Every finding on record at Poplar Hill Health and Rehab

Based on observations and staff interviews, the facility staff failed to prepare food in a sanitary manner in one of one facility kitchens.The findings include:On 05/12/2026 at approximately 11:30 an observation of OSM (other staff member) #3 kitchen aide in the facility's kitchen revealed she was placing covers on approximately 20 cups of a beverage for the resident's lunch. Further observations of OSM #3 failed to evidence she was wearing a hairnet.On 05/12/2026 at approximately 11:30 an observation of a ladder cart in the facility's kitchen revealed trays of approximately 12 plated slices of cake on each tray next to the kitchen steamer and in front of a food preparation table. Further observation of the cart failed to evidence covering over the cart of the individual slices of cake.On 5/12/26 at approximately 12:34 p.m. an observation of lunch trays being delivered to resident rooms on the 200 unit revealed the trays served with cake were uncovered, at approximately 12:45 p.m. an observation of lunch trays being delivered to resident rooms on the 300 unit revealed the trays served with cake were uncovered and at approximately 12:53 p.m. an observation of lunch trays being delivered to resident rooms on the 400 unit revealed the trays served with cake were uncovered.On 05/13/2026 at approximately 9:19 a.m. an interview was conducted with the facility's Dietary Manager regarding the observation stated above of OSM #3 not wearing a hair net and the cake not being covered. She stated the use of hair nets is to prevent hair from falling into the food and contamination of the residents' food. She further stated OSM #3 should have been wearing a hairnet. Regarding the cake not being covered she stated it should have been covered to prevent contamination.On 05/13/2026 at approximately 11:13 a.m. an interview was conducted with OSM #3 regarding the observation of not wearing a hairnet. She stated the purpose for the hair net to hair from falling into the food and contaminating the food. She stated that she forgot to put one on when she entered the kitchen.The (Name of Dietary and Healthcare Food Services Company) policy Dress Code documented in part, 7. Dietary employees should wear a hairnet covering that covers all hair completely.The (Name of Dietary and Healthcare Food Services Company) policy Handling, Serving and Transporting Foods documented in part, Procedure: 7.When serving room trays, every food item must be covered until it reaches the resident (i.e drinks, desserts, salads).On 05/13/2026 at approximately 1:57 p.m. the Administrator and Director of Nursing were made aware of the above findings.No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, the facility staff failed to follow professional standards of care for one of eight residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to follow standard of care for resident with persistent complaints of decreased blood pressure (BP), dizziness, and gastrointestinal (GI) (1) symptoms and little to no improvement in symptoms and no evidence of discussion or implementation of an alternative plan of care. On the most recent minimum data set (MDS), quarterly assessment with an assessment reference date (ARD) of 1/8/2026, the patient's BIMS (brief interview for mental status) score was assessed at 15, indicating the resident was cognitively intact for making daily decisions. The resident admission demographic information documented R1 being their own responsible party and two alternates as emergency contacts. -A review of Attending Physician's notes on 3/6/2026 at 17:15 (5:15 PM), documents in part, Patient is seen today for a medical exam. Repeat labs (laboratory tests) in approximately 20 days (around 3/26) to include CBC (2) and iron panel for anemia follow-up -A review of NP (nurse practitioner)'s note on 3/9/2026 at 11:45 AM, documents in part, Patient is seen today for evaluation of nausea and vomiting. Gastroparesis (3): Diabetic gastroparesis evaluated today. Abdominal ultrasound ordered to rule out gastric outlet obstruction. Nausea with vomiting, unspecified: Continue with Ondansetron (4) HCl 4 mg by mouth every 6 hours as needed for nausea/vomiting. -A review of the NP's note on 3/10/2026 at 11:19 AM, documents in part, Pt (patient) reports still feeling nauseous (no emesis), but slight improvement from yesterday. Pt reports Zofran (5) helps when taken, but it has only been administered once so far. c/w (continue with) Zofran for symptom management. f/u (follow up) on abd(abdominal) US (ultrasound). VS (vital signs) ordered BID (twice a day) x2 days. START CBC/BMP (basic metabolic panel) (6) to r/o (rule out) active infection or electrolyte imbalance. - 3/15/2026 at 15:17 (3:17 PM), Nursing Note: she has low BP (blood pressure) which was mentioned on TAR/MAR (treatment administration record/medication administration record), encouraged to drink more fluid, she rested on bed whole time, let the next upcoming nurse to continue monitor and update. Review of the TAR/[DATE]/15/2026 does not document a BP. - 3/15/2026 at 22:30 (10:30 PM), Nursing Note: patient complained of nausea and dizziness during the shift. -A review of the Attending Physician's note on 3/16/2026 at 6:43 PM, the resident's BP was 120/74. The note also documents the additional following blood pressures:On 3/3/2026- BP 138/92; On 3/4/2026- BP 126/84; On 3/5/2026- BP 125/72; On 3/6/2026, BP 120/74. -A review of the NP's note on 3/24/2026 at 12:37 PM, documents the resident's blood pressure: 110/68. Patient was seen per nursing request for coughing and lab orders. Nausea with vomiting, unspecified: Zofran has not been effective. Ordered abdominal ultrasound to rule out cholecystitis (7) and biliary tract obstruction (8).-abd (abdominal) US (ultrasound) w/no acute findings. Pt (patient) reports N/V (nausea/vomiting) has been going on for a few weeks now. Would like to do labs including CBC (complete blood count), CMP (comprehensive metabolic panel) (9), lipase (10), and TSH (thyroid stimulating hormone) (11), however, pt refused labs even after education.-HOLD iron (new med and pt denies being on it before) and START Pepcid-if no relief, will need GI (gastrointestinal) appt.(appointment)-3/24 pt reports some improvement today but gave limited details. -A review of the NP's note on 3/26/2026 at 8:30 AM, documents in part, Persistent nausea and vomiting. Nausea with vomiting, unspecified: Zofran has not been effective. Ordered abdominal ultrasound to rule out cholecystitis and biliary tract obstruction. -A review of a late entry note entered by LPN #4, for 3/25/2026 at 15:30 (3:30PM), documents: OT (occupational therapist) reported that the client was observed lowering herself to the ground and complained of dizziness. Upon assessment client denied hitting her head and was alert and responsive. No visible injuries noted on examination. Vital signs were obtained and blood pressure was noted to be low. (bp-95/54, hr (heartrate)-69, rr (respiration rate)-16, temp (temperature)-97.9, pain -0/10). Assistance was provided with another nurse to get her back in bed. Encouraged fluids to client and Patient refused oral intake. Patient did not eat breakfast or lunch either. Will continue to encourage fluids, reassess vital signs every hour, and reassess safety status. At approximately 1615 (4:15 PM), I checked on resident's roommate; resident was observed in bed sleeping at that time. At approximately 1640 (4:40 PM) I returned to the room to perform treatment on roommate and notes residents' bed was empty. Resident was then observed lying on the floor. I immediately sought assistance from another nurse. Upon initial assessment residents lower extremities appeared pale and scaly, and skin was cold to touch with lips having a bluish tent.At 1645 (4:45 PM) I called 911 while additional nursing staff arrived and initiated CPR (cardiopulmonary resuscitation) (10). I retrieved crash cart and oxygen; oxygen therapy and chest compressions were started immediately. At approximately 1650 (4:50 PM) EMS (emergency medical service) arrived and continued CPR efforts. At 1712 (5:12 PM) I called and notified the Director of Nursing. At 1717 (5:17PM) time of death was pronounced by EMS 1101 via phone with Dr. [doctor's name]. Family was then notified of time of death. -Additionally, a review of the blood pressure graphing documents an ongoing decrease in R1's systolic blood pressure beginning on 3/1/2026. -A review of the physician's orders documented three orders for abdominal ultrasounds ordered on the 3/10/2026, 3/16/2026 and 3/18/2026. Review of the clinical record failed to evidence completion of an abdominal ultrasound on 3/12/2026 and failed to evidence completion or refusal of the additional ultrasounds ordered. -Neuro Check Assessment Form documented in part, 3/26/2026 at 1:15 AM, BP- 81/50; 3/26/2026 at 5:15 AM, BP- 80/51. The assessment failed to evidence notification of the physician of the blood pressure. -Review of R1's comprehensive care plan failed to evidence documentation of R1 refusing care or treatments. Review of the clinical record failed to evidence that alternatives to treatment were discussed with R1, regarding the lack of improvement in symptoms or options available for interventions outside of the facility. There was no evidence of the additional ultrasounds being completed or refused and no evidence of referral to GI that was documented in the NP notes frequently. On 5/12/2026 at 1:15 PM, an interview was conducted with LPN (license practical nurse) #4 . When asked what do you remember about R1 symptoms on 3/25/2026, the nurse stated, R1 had a recent room change, and staff on that unit had worked with her for three days. He stated she had been refusing meals, not drinking a lot. He stated she was just lying in bed and had always been in bed since working with her. On 5/12/2026 at 1:37 PM, an interview was conducted with the NP. When asked, what was the POC (plan of care) for R1 due to her persistent symptoms, not responding to treatment and refusing care? The NP stated R1could make her own decision. She stated R1 had been nauseated and was being seen for that. NP stated I wanted to do blood work but she was refusing despite educating her. The NP further stated that the goal was to send her to a (GI) gastrointestinal doctor but R1 would only agree to think about it and the GI appointment was never scheduled. The NP stated one ultrasound was ordered and it was negative for acute findings. The NP stated that the criteria to send R1 to a GI doctor were negative labs but R1 refused the blood work. When asked if there was a discussion about IV (intravenous) (12) fluids, the NP stated there was no indication to give IV fluids. NP states R1 was being encouraged to take in more fluids and that day she was drinking. When asked, the NP stated that she did not have any discussions with the family about refusals of treatment or encouraging R1 to accept care. The NP was asked to describe the timeline of R1's decline; the NP stated that R1 was first seen in 2/2026. The NP stated that they didn't expect her to pass despite having a lot of comorbidities. The NP stated the biggest problem was R1 refusing treatment. She stated that her nausea was improving, and the diabetes was fairly controlled. The NP stated that R1 seemed pretty much the same during the time that she worked with her. On 5/12/2026 at 2:17 PM, an interview was conducted with the DON (director of nursing). When asked if there were any changes in R1's symptoms on 3/25/2026 or 3/26/2026, the DON stated, not that she is aware of. She stated she knew the R1 was having belly issues and was getting an ultrasound and taking Zofran for it. On 5/13/2026 at 8:17 AM, an interview was conducted with the Attending Physician. He stated that R1 was alert and oriented, her vital signs were stable, she was not cooperative and refused bloodwork. When asked what would the bloodwork shown, He stated that could not be predicted but what was needed was a baseline. When asked what should nursing have done about R1's complaint of not feeling well, dizziness along with the decrease in her blood pressure, he stated the NP should have been contacted for any alarming signs or symptoms. He stated alarming signs would be anything that is not baseline, which include loss of consciousness, drop in blood pressure or severe fever and with a decrease in blood pressure it should be repeated in ten minutes until it is at baseline. On 5/13/2026 at 8:40 AM, an interview was conducted with the Medical Director (MD). When asked if there is a resident who is refusing the POC (plan of care) for treatment and has a blood pressure that is decreasing for two weeks, what intervention should be taken? The MD stated, talk to them and explain the risk of not adhering to POC. When asked, would you discuss code status or end of life? The MD stated if they are declining I would discuss code status but if a resident is alert and oriented, they can make their own decision, and you cannot force the patient. The MD stated those types of conversations would be in the provider's note. 5/13/2026 at 10:10 AM, Administrator and Director of Nursing were made aware of the concern for R1. No further information was provided prior to exit. References:1. Gastrointestinal- Your digestive or gastrointestinal (GI) tract includes the esophagus, stomach, small intestine, large intestine or colon, rectum, and anus. https://medlineplus.gov/gastrointestinalbleeding.html2. CBC- A complete blood count (CBC) is a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets.3. Gastroparesis- is a condition that reduces the ability of the stomach to empty its solid contents. https://medlineplus.gov/ency/article/000297.htm4.Ondansetron- https://medlineplus.gov/druginfo/meds/a601209.html5. Zofran-https://my.clevelandclinic.org/health/drugs/18477-ondansetron-solution6. BMP- A basic metabolic panel (BMP) measures eight different substances in your blood. It provides important information about your body's fluid balance, your metabolism (the process your body uses to make energy from food you eat), and how well your kidneys are working. https://medlineplus.gov/lab-tests/basic-metabolic-panel-bmp/7.Cholecystitis-Acute cholecystitis is sudden swelling and irritation of the gallbladder. Chronic cholecystitis is swelling and irritation of the gallbladder that continues over time. https://medlineplus.gov/ency/article/000264.htm; https://medlineplus.gov/ency/article/000217.htm8. Biliary tract obstruction-A bile duct obstruction occurs when a blockage or narrowing in your bile ducts prevents bile from flowing as it should. https://my.clevelandclinic.org/health/diseases/bile-duct-obstruction9. CMP- A comprehensive metabolic panel (CMP) is a routine blood test that measures 14 different substances in a sample of your blood. https://medlineplus.gov/lab-tests/comprehensive-metabolic-panel-cmp/10. Lipase- A lipase blood test shows how much of the pancreatic enzyme lipase you have in your blood. https://my.clevelandclinic.org/health/diagnostics/lipase-blood-test11. TSH- A TSH test is a blood test that measures this hormone. https://medlineplus.gov/lab-tests/tsh-thyroid-stimulating-hormone-test/12. IV- means giving medicines or fluids through a needle or tube (catheter) that goes into a vein. https://medlineplus.gov/ency/patientinstructions/000496.htm

Based on observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens.The findings include:On 05/12/2026 at approximately 12:00 p.m. an observation in the facility's kitchen revealed Dietary Manager plating lunch for the residents. The lunch menu consisted of whole chicken leg quarters, whole mixed vegetables, cubed potatoes, chopped chicken, pureed chicken, mash potatoes and pureed mixed vegetables. Observations of the serving utensils being used by the Dietary Manager to plate the food revealed she was using a green handle scoop for whole mixed vegetables, cubed potatoes, chopped chicken, ground chicken, pureed chicken, mash potatoes and pureed mixed vegetables. Continued observations revealed the Dietary Manager placed one scoop of each of the food items list above on each of the residents' lunch plates.The facility's Diet Spreadsheet for lunch on 05/12/2026 documented in part, Week 3. Tuesday. Regular. Lunch. Seasoned diced potatoes. Portion Size: 4 oz (four ounce) spdl (spoodle - type of portion control serving spoon), Four Way Mixed Vegetables. Portion Size: 4 oz spdl. Ground Baked Chicken Breast w/(with) Thick Gravy. Portion Size: #8 (number eight) scp (scoop). Pureed Baked Chicken Quarter. Portion Size: #8 scp., Mashed Potatoes & (and) Gravy. Portion Size: #8 scp.The kitchen's Scoop Size Chart reference sheet revealed pictures of different colored scoop handles indicating the following: [NAME] handle Scoop #6 - 5 OZ, Grey handle Scoop #8 - 4 OZ, Beige handle Scoop #10 - 31/4 OZ, [NAME] handle Scoop #12 - 2 OZ, Blue handle Scoop #16 - 2OZ.On 05/13/2026 at approximately 9:19 a.m. an interview was conducted with the facility's Dietary Manager regarding portion control. She was asked to describe the procedure for ensuring residents receives the correct portion of food for each meal. She stated the Scoop Size Chart that is posted above the steam table is referred to make sure the residents receive the correct portion according to the Diet Spreadsheet. She further stated the correct size scoops were not used for the resident's lunch on 05/12/2026 and the residents did not receive the correct portion of food.The (Name of Dietary and Healthcare Food Services Company) policy Portion Control documented in part, Policy: Portion size is determined by the nutritional needs of the residents, federal and state regulations that specify the food groups, and portion sizes that must be served according to the facility menu. Procedure: 2. Serve portions according to the menu spreadsheet.On 05/13/2026 at approximately 1:57 p.m. the Administrator and Director of Nursing were made aware of the above findings.No further information was provided prior to exit.

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of four facility units, the 400 Unit.The findings include:On 05/12/2026 at 12:00 p.m. the holding temperatures for the resident's food for lunch were obtained by the Dietary Manager in the facility's kitchen at steam table with the following results: whole chicken leg quarter-168 F (degrees Fahrenheit), whole mixed vegatables-187 F, diced potatoes- 159 F, Chopped chicken-160 F, ground chicken-166 F, pureed chicken-158 F, mashed potatoes-177 F, pureed mixed vegatables-172 F. On 05/12/2026 at 12:48 p.m., a test tray consisting of all the food item listed below was placed on a cart with other meal trays for residents and taken to the 400 Unit. At 1:10 p.m., the last lunch tray was served to a resident on the 400 Unit. The Dietary Manager was then asked to remove the covers from the two test plates and proceeded to take the temperatures of the food. Two surveyors observed Dietary Manager obtaining the food temperatures. The whole chicken leg quarter-127 F, whole mixed vegatables-112 F, diced potatoes- 123 F, pureed chicken-127 F, mashed potatoes-118 F, pureed mixed vegatables-122 F. The test tray was sampled by two surveyors and the Dietary Manager for appropriate holding temperatures and palatable taste. When asked to describe the taste of the food she stated the whole mixed vegetables and cubed potatoes were cold and not palatable.The (Name of Dietary and Healthcare Food Services Company) policy Safe Food Handling Practices documented in part, Policy: All food must be purchased, prepared and distributed in a clean, safe manner while promoting safe food handling in compliance with state and federal guidelines. Procedure: Hot foods are served at 135 degrees or higher and cold foods are served at 41 degrees or lower.On 05/13/2026 at approximately 1:57 p.m. the Administrator and Director of Nursing were made aware of the above findings.No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to follow medication orders for administration for one of eight residents in the survey sample, Resident #5. The findings include:For Resident #5 (R5), the facility staff failed to hold medication according to the ordered parameters. The physician orders for R5 documented in part, Metoprolol Succinate ER (extended release) (1) Oral Tablet Extended Release 24 Hour 25 MG (milligram) (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN (hypertension) hold for SBP (systolic blood pressure) <100 or HR (heart rate) <60. Start Date: 04/24/2026. Review of the eMAR (electronic medication administration record) for R5 dated 4/1-4/30/2026 documented the Metoprolol Succinate ER administered on 4/25/2026 at 9:00 AM with a heart rate documented at 55. On 5/13/2026 at 9:20 AM, an interview was conducted with licensed practical nurse (LPN) #2 who stated that when administering medication that contained administration parameters they checked the vital signs first and then went to the order to review if the medication needed to be held or given. She reviewed the eMAR for R5 and stated that according to the order for the Metoprolol it should have been held on 4/25/2026 because the heart rate was below 60 which was in the order. LPN #2 stated that the nurse should have documented that the medication was held and notified the nurse practitioner. The facility policy Medication Administration revised 9/25, documented in part, .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . On 5/13/2026 at 1:53 PM, the Regional Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Reference:(1) Metoprolol is used to treat high blood pressure, angina (chest pain) and heart failure. Metoprolol also is used to improve survival after a heart attack . Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure . This information was obtained from the website: Metoprolol: MedlinePlus Drug Information

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide care and services to meet professional standards for one of eight residents, Resident #4.The findings include: The facility staff failed to meet professional standards by administering medications as ordered for Resident #4 (R4).R4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to paroxysmal atrial fibrillation (A-fib), HTN (hypertension), CHF (congestive heart failure) and DM (diabetes mellitus).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for transfer, hygiene, bathing/dressing and set up for eating. A review of the comprehensive care plan dated 9/8/23 revealed, FOCUS: Resident has decreased Cardiac Output due to A-fib and HTN. Resident is at risk for is for unstable Blood Glucose Level due to Diabetes. INTERVENTIONS: Administer cardiac medications per MD (physician) order. Administer medications as prescribed.A review of the physician orders dated 7/14/24 revealed, Apixaban Oral Tablet (1) 5 MG (Apixaban) Give 1 tablet by mouth two times a day. Metoprolol Tablet (2) 25 MG, Give 1 tablet by mouth two times a day. Ordered to be administered at 9:00 AM.A review of the physician orders dated 10/11/24 revealed, Cartia XT Oral Capsule Extended Release 24 Hour 180 MG (Diltiazem HCl Coated Beads) (3) Give 1 capsule by mouth one time a day. Ordered to be administered at 9:00 AM.A review of the physician orders dated 3/4/25 revealed, Furosemide Tablet (4) 20 MG Give 1 tablet by mouth one time a day. Ordered to be administered at 8:00 AM.A review of the physician orders dated 12/16/25 revealed, 'Metformin HCl Oral Tablet (5)500 MG, Give 1 tablet by mouth two times a day. Ordered to be administered at 9:00 AM.A review of the medication time audit report for 2/3/26 revealed these medications (Apixaban, Metoprolol, Cartia, Furosemide and Metformin) were administered on 2/3/26 at 3:24 PM.There was no progress note documenting delay in administration.The LPN (licensed practical nurse) who administered the medications on 2/3/26, is no longer employed at the facility.Medication Administration was observed on 5/13/26 at 7:45 AM with LPN (licensed practical nurse) #1. Asked the process for medication administration, LPN #1 stated, check the order, right patient, drug, dose, route, time and then document it.An interview was conducted on 5/13/26 at 11:30 AM, an interview was conducted with the DON (director of nursing). When asked about the process for administration of medications, the DON stated, the medications are to be administered within one hour before or after the administration time and documented in PCC (point click care) MAR (medication administration record). Asked about the delay in medications administered on 2/3/26 for R4, the DON stated that this LPN was giving the medications on time and waiting until the end of his shift to document. He was not following the facility standard of care. Asked what is the process if medications are administered outside the time frame, the DON stated, there should be a written progress note explaining that the medications were given on time and he did not document them as administered until the end of his shift. Asked if this LPN's medication administration on 2/3/26 was following the standard of practice, the DON stated, no this was not following standards of practice.On 5/13/26 at 2:00 PM, the regional administrator and the director of nursing were made aware of the findings. A review of the facility's Lippincott Manual of Nursing Practice policy revealed, Departure from Standard of Care- Failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. (6)No further information was provided prior to exit. References:Apixaban-anticoagulant and thrombin inhibitor. [NAME] 2019 Drug Guide for Nurses, page 25.Metoprolol-antihypertensive. [NAME] 2019 Drug Guide for Nurses, page 243.Diltiazem-antianginal, antihypertensive. [NAME] 2019 Drug Guide for Nurses, page 112.Lasix-loop diuretic. [NAME] 2019 Drug Guide for Nurses, page 167.Metformin-antidiabetic. [NAME] 2019 Drug Guide for Nurses, page 235.Lippincott Manual of Nursing Practice 12th Edition-page 15.

Based on resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for one of eight residents, Resident #4.The findings include: The facility staff failed to provide ADL specifically incontinence care for a dependent resident, Resident #4 (R4).R4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to paroxysmal atrial fibrillation, HTN (hypertension), CHF (congestive heart failure) and DM (diabetes mellitus).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for transfer, hygiene, bathing/dressing and set up for eating. A review of the comprehensive care plan dated 9/8/23 revealed, FOCUS: Resident has an alteration in self-care related to Co-morbidities. She frequently refuses showers, to get out of bed and at times refuses to be changed. INTERVENTIONS: Assist with dressing, bathing, incontinent care, bed mobility and transfers. Educate resident on the risks vs benefits of not being changed timely.A review of the ADL reveals missing evidence of incontinence care being provided on following shifts and dates: Day shift: 1/15, 1/16, 1/17, 1/18, 1/19, 1/20, 1/22, 1/23, 1/25, 1/26, 1/29, 2/5, 2/15, 3/3, 3/5, 3/10, 3/11, 3/12, 3/20, 3/26, 4/9, 4/30 and Evening shift: 1/14, 1/18, 1/23, 1/24, 1/25, 2/3, 3/16, 5/4; night shift: 1/14, 1/15, 1/16, 1/17, 1/31, 2/11, 2/19, 2/28, 3/7, 3/25, 3/31, 4/8 and 4/30.An interview was conducted on 5/13/26 at 7:20 AM with CNA (certified nursing assistant) #1. Asked about the incontinence care rounding process, CNA #1 stated, resident rounding is every one-two hour to provide incontinence care and reposition the residents. Ask if there is evidence of this care, CNA #1 stated, there is documentation in the ADL form. Asked if there was no documentation, is there evidence the care was provided, CNA #1 stated, no, there is not. 5/13/26 at 9:40 AM an interview was conducted with CNA #2, who stated, the resident is on my assignment most days. Incontinence care is documented every shift in PCC (point click care). Asked if there is no evidence of incontinence care, CNA #2 stated, if it is not documented, it is not done. There is work being done to reduce call bell response time and to make sure care is documented.On 5/13/26, at 11:30 AM, an interview was conducted with the DON (director of nursing). When asked about the incontinence care being provided, the director of nursing stated, there is a performance improvement plan (PIP) on call bells and incontinence care. DON was asked to provide the PIP.The PIP dated 4/6/2026 documented the following: Timely call bell response with incontinent care. Providing timely call bell response with incontinent care and general care services. Other residents could be affected by this practice.All licensed nursing staff were re-educated by the SDC on timely call bell response and timely incontinent care.The Supervisors/Designees will randomly audit call bell response and incontinent care for (4) weeks. The results of these reviews will be presented to QAPI (Quality Assurance Performance Improvement) for review and recommendations. Completion date:5/6/2026.Review of staff educational sign-in sheets for the call bells and incontinence care in-services dated 4/6/26 through 4/8/26 documented 59 staff members educated. The facility Incontinence policy was attached to the education sign-in sheets. Education and training were reviewed and verified by multiple staff interviews. Implementation of the education was verified with resident interviews and observations. No concerns were identified.A review of the facility's Incontinence policy revealed, Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.On 5/13/26 at 2:00 PM, the regional administrator and the director of nursing were made aware of the findings of past non-compliance. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to assist in arrangement of follow up vision services for one of eight residents in the survey sample, Resident #5. The findings include:For Resident #5 (R5), the facility staff failed to evidence arrangement of a follow-up ophthalmology (1) appointment. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 4/8/26, R5 scored two out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were severely impaired for making daily decisions. The assessment further documented R5 having diagnoses that included but were not limited to aphasia (2) and cerebral infarction (3). The progress notes for R5 documented in part,- Effective Date: 03/31/2026 23:19 (11:19 PM) Type: [Name of wound care practice] skin and wound note . Per nursing anf [sic] primary NP (nurse practitioner) request, wound team consult to new skin rash to face. Upon assessment, Pt noted to have Herpes Zoster (4) (shingels) [sic] rash on left forehead, left face, and left nose bridge, and left eye, herpes zoster ophthalmicus (HZO) with Viral Conjunctivitis (5). Please initiate the wound treatment plan listed in the wound plan section. Calamine zinc 8-8% external lotion (6) to left forehead, leave open to air, avoid putting in the eye. ophthalmologist consult STAT (now), PO (by mouth) Valacyclovir (7) 7 days. Discussed with primary NP for POC (plan of care). Also, pt needs to be on isolation r/t (related to) drainage. Shingles is contagious until the blisters have completely dried and scabbed over. Direct contact with the fluid can spread the virus .- Effective Date: 03/31/2026 14:38 (2:38 PM) Type: Health Status Note. Note Text: spoke w/resident's daughter and she is going to schedule eye appt/transport for resident- resident has shingles on his face, possibly in eye. Was seen by NP and Wound NP and orders placed. resident moved to isolation room.- Effective Date: 04/09/2026 17:03 (5:03 PM) Type: Follow Up Visit - [Name of nurse practitioner] .shingles treatment discussed w/ ID (infectious disease). No further medications necessary. Rash has resolved. PERRLA (pupils equal, round, reactive to light and accommodation) (8) noted. unclear how his vision is at this time . Review of the visit summary note from the retina specialist who examined R5 on 4/1/2026 documented in part, .Imp/Plan (impression/plan): 1. Herpes Zoster Ophthalmicus OS (left eye), oral acyclovir and lubrication- refer to [Name of ophthalmologist] . Review of the clinical record failed to evidence a follow up appointment set up, offered or discussed with R5's family for R5 to see the ophthalmologist that they were referred to on 4/1/2026. On 5/13/2026 at 9:20 AM, an interview was conducted with licensed practical nurse (LPN) #2 who stated that R5's eye had started by being pinkish red with clear drainage and they were treated with eye drops. She stated that R5 had been rubbing the eye and when the rash developed started scratching the rash which caused the blisters to break open and crust over. LPN #2 stated that the nurse practitioner and the wound nurse practitioner had both assessed R5 on 3/31/2026 and diagnosed shingles at that time. She stated that they had started medication, put R5 on contact isolation and R5's family had taken them to the eye doctor the next day. LPN #2 stated that normally family members scheduled appointments for the residents, but she assisted as needed. She stated that R5 had not been back to the eye doctor for follow up and normally she would get a copy of the physician's note from the office and coordinate with the family to set up the appointment needed. On 5/13/2026 at 11:18 AM, an interview was conducted with the Director of Nursing who stated that they had not set up a follow up appointment with the ophthalmologist because the nurse practitioner had said that R5 did not need it. She stated that she was not sure why the nurse practitioner did not think R5 needed the follow up appointment. On 5/13/2026 at 12:00 PM, an interview was conducted with the nurse practitioner who stated that when she saw R5 her priority was getting them to the eye doctor right away. She stated that she did not think it was dire for R5 to follow up because she had been checking his eyes and the resident reports that he has vision in the eye. She stated that if the family wanted R5 to go they would send him but typically the family sets up appointments. She stated that when she examines a resident's eyes, she makes sure that a resident is reporting no changes in their vision and she is checking the pupils for equal size, reaction to light and accommodation. She stated that R5 could nod yes or no to answer some questions and had nodded appropriately to some questions, but she could not say that the resident was 100% cognitively intact. The facility provided letter to residents and families dated 2/25/2025 documented in part, . Appointments & Transportation. All appointments should be scheduled by yourself or a family member. [Name of facility] is not responsible for transportation. If you have questions, concerns or need assistance, please contact your Unit Manager or Social Services. We understand that appointments and outings are an important part of maintaining quality of life, and we are always happy to support you and your loved ones . On 5/13/2026 at 1:53 PM, the Regional Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Reference:(1) Ophthalmologists are medical doctors. They are the only eye doctors with medical degrees, either MD or DO (doctors of osteopathic medicine) . Ophthalmologists must complete many more years of medical training than optometrists and opticians . As a result, an ophthalmologist is the most qualified among eye care professionals to diagnose and treat a wide range of eye diseases, beyond the routine eye and vision care provided by an optometrist . This information was obtained from the website: https://www.aao.org/eye-health/tips-prevention/what-is-ophthalmologist(2) Aphasia is a language disorder that makes it hard for you to read, write, and say what you mean to say. Sometimes it makes it hard to understand what other people are saying, too. Aphasia is not a disease. It's a symptom of damage to the parts of the brain that control language . This information was obtained from the website: Aphasia | MedlinePlus(3) A stroke occurs when blood flow to a part of the brain stops. A stroke is sometimes called a brain attack.If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. A stroke can also occur if a blood vessel inside the brain bursts, leading to bleeding inside the head . This information was obtained from the website: Stroke: MedlinePlus Medical Encyclopedia(4) Shingles (herpes zoster) is an infection that causes a painful rash. It is caused by the varicella-zoster virus (VZV). This is the same virus that causes chickenpox. After you have chickenpox, the virus stays in your body. It may not cause problems for many years. But as you get older, the virus may become active again and cause shingles . This information was obtained from the website: Shingles | Herpes Zoster | MedlinePlus(5) Conjunctivitis is the medical name for pink eye. It involves inflammation of the outer layer of the eye and inside of the eyelid. It can cause swelling, itching, burning, discharge, and redness. Causes include:Bacterial or viral infectionAllergiesSubstances that cause irritationContact lens products, eye drops, or eye ointmentsPink eye usually does not affect vision. Infectious pink eye can easily spread from one person to another. The infection will clear in most cases without medical care, but bacterial pink eye needs treatment with antibiotic eye drops or ointment . This information was obtained from the website: Conjunctivitis | Pink Eye | MedlinePlus(6) What are the treatments for shingles? There is no cure for shingles. Antiviral medicines may help to make the attack shorter and less severe. They may also help prevent PHN. The medicines are most effective if you can take them within 3 days after the rash appears. So if you think you might have shingles, contact your provider as soon as possible. Pain relievers may also help with the pain. A cool washcloth, calamine lotion, and oatmeal baths may help relieve some of the itching . This information was obtained from the website: https://medlineplus.gov/shingles.html(7) Valacyclovir is used to treat certain viral infections including, It is in a class of medications called antivirals. It works by stopping the spread of the herpes virus in the body.herpes labialis (cold sores)varicella infections including herpes zoster (shingles) and chicken pox)genital herpes (a sexually transmitted infection)Valacyclovir helps treat and control outbreaks of genital herpes but should be used with safe sexual practices. Valacyclovir will not cure genital herpes . This information was obtained from the website: Valacyclovir: MedlinePlus Drug Information(8) Clinicians need to check the pupils during the physical assessment to evaluate cranial nerves II and III. Cranial nerve II (optic) controls visual acuity/afferent input, while Cranial nerve III (oculomotor) controls pupil constriction and dilation. The PERRLA test is used to examine the pupils: Pupils, Equal, Round, Reactive to, Light, Accommodation . This information was obtained from the website: How to Do A Neurological Assessment: 5-Step Neuro Exam

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to notify the medical provider of changes in condition one of eight residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to notify the medical provider of change in condition on 3/26/2026.On the most recent minimum data set (MDS), quarterly assessment with an assessment reference date (ARD) of 1/8/2026, the patient's BIMS (brief interview for mental status) score was assessed at 15, indicating the resident was cognitively intact for making daily decisions.The resident admission demographic information documented R1 being their own responsible party and two alternates as emergency contacts. R1 diagnoses include but are not limited to hypertension (1), peripheral vascular disease (2) and diabetes mellitus (3). The progress notes for R1 documented in part, -A review of the Attending Physician's note on 3/16/2026 at 6:43 PM, the resident's BP (blood pressure) was 120/74. -A review of the NP's (nurse practitioner) notes on 3/24/2026 at 12:37 PM, documents the resident's blood pressure:110/68. -A review of a late entry note entered by LPN #4, for 3/25/2026 at 15:30 (3:30PM), documents: OT (occupational therapist) reported that the client was observed lowering herself to the ground and complained of dizziness. Upon assessment client denied hitting her head and was alert and responsive. No visible injuries noted on examination. Vital signs were obtained and blood pressure was noted to be low. (bp-95/54, hr (heartrate)-69, rr (respiration rate)-16, temp (temperature)-97.9, pain -0/10). Assistance was provided with another nurse to get her back in bed. Encouraged fluids to client and Patient refused oral intake. Patient did not eat breakfast or lunch either. Will continue to encourage fluids, reassess vital signs every hour, and reassess safety status. -Neuro Check Assessment Form documented in part, 3/25/2026 at 1:15 AM, BP- 81/50; at 3:45 PM, BP -100/63; at 5:15 PM, BP-100/61; 3/26/2026 at 5:15 AM, BP- 80/51. The assessment failed to evidence notification of the physician of the blood pressure. On 5/13/2026 at 8:17 AM, an interview was conducted with the Attending Physician. When asked what nursing should have done about R1 complaint of not feeling well, dizziness along with the decrease in her blood pressure, he stated the NP should have been contacted for any alarming signs or symptoms. He stated alarming signs would be anything that is not baseline, which include loss of consciousness, drop in blood pressure or severe fever and with a decrease in blood pressure it should be repeated in ten minutes until it is at baseline. A review of the facility's Notification of Changes policy, revised 1/26, revealed the policy purpose is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: life-threatening conditions. 5/13/2026 at 10:10 AM, Administrator and Director of Nursing were made aware of the concern for R1. No further information was provided prior to exit. References: Hypertension- Blood pressure is the force of your blood pushing against the walls of your arteries. https://medlineplus.gov/highbloodpressure.htmlPeripheral Vascular Disease- Is a condition of the blood vessels that supply the legs and feet. It occurs due to narrowing of the arteries in the legs. This causes decreased blood flow, which can injure skin, muscles, nerves and other tissues heart. https://medlineplus.gov/ency/article/000170.htmDiabetes Mellitus- Diabetes, also known as diabetes mellitus, is a disease in which your blood glucose, or blood sugar, levels are too high. https://medlineplus.gov/diabetes.html

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for two of eight residents in the survey sample, Residents #3, and #5. The findings include:1. For Resident #3 (R3), the facility staff failed to ensure the medication Ciprofloxacin (an antibiotic) was available for administration 3/23/26 through 3/25/26. A review of R3's clinical record revealed a physician's order dated 3/23/26 for Ciprofloxacin 500mg (milligrams)- one tablet two times a day for five days for a urinary tract infection. R3's March 2026 MAR (medication administration record) documented the same physician's order. A nurse's note dated 3/23/26 documented, Ciprofloxacin Oral Tablet 500 MG (milligrams). Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 5 Days. Waiting for pharmacy to deliver medication. A nurse's note dated 3/24/26 documented, Cipro not available. Mistakenly signed it. Pharmacy will deliver later. A nurse's note dated 3/25/26 documented, Ciprofloxacin Oral Tablet 500 MG. Give 1 tablet by mouth two times a day for UTI for 5 Days. Checked med (medication) bank, med not available, notified unit manager. A nurse's note dated 3/25/26 documented, Ciprofloxacin Oral Tablet 500 MG. Give 1 tablet by mouth two times a day for UTI for 5 Days. Pharmacy called and they said they sent medication but medication not on hand, unit manager notified. A nurse's note dated 3/26/26 documented, Complete antibiotic timeout under assessment one time only for Antibiotic timeout for 1 Day. RESIDENT RECEIVED FIRST DOSE TODAY. The med bank was a machine in the facility that contained various medications. A review of the med bank list revealed the machine should have contained at least ten tablets of Ciprofloxacin 250mg. On 5/13/26 at 9:48 a.m. an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated that if a medication is not available, the nurse should obtain the medication from the med bank and call the pharmacy. LPN #1 stated that if the medication is not in the med bank, the nurse should call the pharmacy and have them deliver the mediation stat on a delivery separate from the two routine daily deliveries. On 5/13/26 at 2:00 p.m. the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled, Medication Administration failed to document the facility process for obtaining medications that are not available. The facility Corrective Action Plan dated 4/8/26 documented, Problem Identified: Medication not available. Address how corrective action will be accomplished for resident(s) found to have been affected: Notification to provider when medication is not available and the process of obtaining medication when it is not available. Address how corrective action will be accomplished for resident (s) having potential to be affected by the same issue needing to be addressed: Other residents could be affected by this practice. Address what measures will be put in place or system changes made to ensure that the identified issue does not occur in the future: All licensed nurses were re-educated by the SDC (Staff Development Coordinator) on proper method of following up on medications not available and notifying provider/RP (Responsible Party). Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. The Unit Managers will run missed medication and not available medication reports, follow up until resolved for 5x week for (4) weeks. The results of these reviews will be presented to QAPI (Quality Assurance Performance Improvement) for review and recommendation. The documented completion dated was 5/6/26. All credible evidence was reviewed and verified during the survey. PAST NON-COMPLIANCE 2. For Resident #5 (R5), the facility staff failed to ensure medication was available for administration. The physician orders for R5 documented in part, Erythromycin Ophthalmic Ointment 5 MG/GM (milligram/gram) (Erythromycin (Ophth)) (1), Instill 1 centimeter in left eye, four times a day for Shingles for 7 Days. Order Date: 4/1/2026. Review of the eMAR (electronic medication administration record) for R5 dated 4/1-4/30/2026 documented the Erythromycin ophthalmic ointment started on 4/1/2026 with missed doses on 4/3/2026 at 9:00 AM and 12:00 PM. The eMAR documented the medication not available for those doses. The progress notes for R5 documented in part, - Effective Date: 03/31/2026 23:19 (11:19 PM) Type: [Name of wound care practice] skin and wound note . Upon assessment, Pt noted to have Herpes Zoster (2) (shingels) [sic] rash on left forehead, left face, and left nose bridge, and left eye, herpes zoster ophthalmicus (HZO) with Viral Conjunctivitis (3) . ophthalmologist consult STAT (now) . - Effective Date: 03/31/2026 14:38 (2:38 PM) Type: Health Status Note. Note Text: spoke w/resident's daughter and she is going to schedule eye appt/transport for resident- resident has shingles on his face, possibly in eye. Was seen by NP and Wound NP and orders placed. resident moved to isolation room. - Effective Date: 04/01/2026 12:56 (PM) Type: Pharmacy Note Text: Call placed to pharmacy to have the Erythromycin ointment sent STAT (now). Pharmacy stataed [sic] it will be sent stat . - Effective Date: 04/03/2026 09:00 (9:00 AM) Type: eMAR - Administration Note. Note Text: Erythromycin Ophthalmic Ointment 5 MG/GM. Instill 1 centimeter in left eye four times a day for Shingles for 7 Days. Medication on order, not administered. NP (nurse practitioner) & RP (responsible party) notified. - Effective Date: 04/03/2026 14:04 (2:04 PM) Type: eMAR (electronic medication administration record)- Administration Note. Note Text: Erythromycin Ophthalmic Ointment 5 MG/GM. Instill 1 centimeter in left eye four times a day for Shingles for 7 Days. Medication on order, not administered. NP & RP notified. Review of the visit summary note from the retina specialist who examined R5 on 4/1/2026 documented a copy of a prescription for Erythromycin ointment into the left eye, four times a day. On 5/12/2026 at 1:38 PM, an interview was conducted with the nurse practitioner who stated that the erythromycin eye ointment was ordered by the eye doctor for R5. She stated that it was an eye antibiotic used to reduce the risk of infection due to R5 having drainage to the eye and they were doing everything they could to preserve vision in the eye. She stated that her expectation would be for R5 to receive the full dosing of the medication. On 5/13/2026 at 9:20 AM, an interview was conducted with licensed practical nurse (LPN) #2 who stated that after the nurse practitioner had diagnosed R5 with shingles he had gone to the eye doctor the next day who had ordered the erythromycin ointment. She stated that she was not aware of any problems getting the medication to the facility and was not sure why R5 missed the 9:00 AM and 12:00 PM doses of the medication on 4/3/2026 but it came in a small tube, and they may have run out. LPN #2 stated that when medications were not available, staff were to check the cart twice, then check the pyxis (back up medication system) for availability and notify the pharmacy. She stated that they also notified the nurse practitioner and the responsible party. On 5/13/2026 at 11:18 AM, an interview was conducted with the Director of Nursing who stated that she had to clarify the erythromycin ointment order when it first came back from the eye doctors office because it was missing some details, but she was not aware of any delays getting the medication started. She stated that the pharmacy came in twice a day to deliver medications and medications were delivered that evening if entered by 12:00 PM and they could also order the medication stat. On 5/13/2026 at 1:53 PM, the Regional Administrator and the Director of Nursing were made aware of the concern. No further information was provided prior to exit. Past non-compliance Reference: (1) Ophthalmic erythromycin is used to treat bacterial infections of the eye. This medication is also used to prevent bacterial infections of the eye in newborn babies. Erythromycin is in a class of medications called macrolide antibiotics. It works by killing bacteria that cause infections . This information was obtained from the website: Erythromycin Ophthalmic: MedlinePlus Drug Information (2) Shingles (herpes zoster) is an infection that causes a painful rash. It is caused by the varicella-zoster virus (VZV). This is the same virus that causes chickenpox. After you have chickenpox, the virus stays in your body. It may not cause problems for many years. But as you get older, the virus may become active again and cause shingles . This information was obtained from the website: Shingles | Herpes Zoster | MedlinePlus (3) Conjunctivitis is the medical name for pink eye. It involves inflammation of the outer layer of the eye and inside of the eyelid. It can cause swelling, itching, burning, discharge, and redness. Causes include: Bacterial or viral infection Allergies Substances that cause irritation Contact lens products, eye drops, or eye ointments Pink eye usually does not affect vision. Infectious pink eye can easily spread from one person to another. The infection will clear in most cases without medical care, but bacterial pink eye needs treatment with antibiotic eye drops or ointment . This information was obtained from the website: Conjunctivitis | Pink Eye | MedlinePlus

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 22 residents in the survey sample, Resident #35. The findings include: The facility failed to provide a bagged lunch for Resident #35 to take with him to the dialysis appointment or offer additional food prior to going to dialysis. Resident #35 was admitted with diagnoses that include but are not limited to: ESRD (end stage renal disease. Resident #35's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/7/23, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section O-Special Procedures: coded the resident as dialysis-yes. A review of the comprehensive care plan dated 12/12/19 and revised on 6/30/23, revealed, FOCUS: Resident has end stage renal disease and receives hemodialysis via left arm AV (arterio-venous) graft, 3 times a week on Monday, Wednesday and Friday. Resident is at increased nutritional risk related to requiring a therapeutic diet, food preferences for foods that contradict diet order, ESRD on hemodialysis, Heart Failure and Type 2 diabetes mellitus. Resident has nutritional risk related to related to heel pressure injury. INTERVENTIONS: Prepare and send meal with [NAME] as well as any other items he may need. Encourage to follow ordered diet to reduce risks of fluid overload/deficit and nutritional concerns. Revised 6/17/20: Dialysis no longer allows resident to take food into the center. Resident usually has a big breakfast each morning, monitor for the need to offer food prior to going out at 10 am and immediately upon returning from dialysis. Revised on 10/13/20: Currently foods are not allowed at dialysis due to COVID precautions. Provide snacks upon return as requested. Revised 6/30/23: Educate Resident / Representative regarding nutritional needs and requirements. Offer Juven supplement twice daily to promote wound healing. A review of the physician's order dated 1/20/22, revealed, Dialysis every Mon-Wed-Fri at 11:00am pick up at 10:30am. A review of the nursing progress note dated 7/7/23 at 4:27 PM, revealed, Last meal eaten: breakfast. Meal / snack was sent with the Resident. A review of the progress notes from 4/1/23-7/31/23 revealed no additional documentation of meal sent with resident. An interview was conducted on 7/31/23 at approximately 10:00 AM with Resident #35. Resident #35 was sitting in a wheelchair in his room, waiting for dialysis transport. When asked if he had a bagged lunch from the facility or if food was provided by the dialysis center, Resident #35 stated, No, they do not give us food at the dialysis center. I have only been given lunch from this place once. Two sandwiches, since then no food. I do not get back till close to supper time and I have missed my lunch completely. Inside Resident #35's dialysis bag were one bag of hard candy and one bag of gummy candy. When asked about the candy, Resident #35 stated, That is all I have to take to eat during dialysis. An interview was conducted on 7/31/23 at 10:30 AM with OSM (other staff member) #3, the chef/manager and OSM #4, the dining services manager. When asked if brown bag lunch was provided to Resident #35 for his dialysis appointments, OSM #3 stated, No, we do not provide a brown bag lunch. OSM #4 stated, Our process is to provide him with food when he returns from dialysis. When asked about the timing of his return and supper time, OSM #4 stated, he gets back around 4:30-4:45 PM, it is close to when we are serving supper. When asked if he had missed a meal for his dialysis days, OSM #4 stated, yes. An interview was conducted on 8/1/23 at 8:20 AM, with LPN (licensed practical nurse) #3. When asked if a lunch was provided to Resident #35 for his dialysis appointment, LPN #3 stated, No, we are not sending a lunch with him. On 8/1/23 at approximately 4:15 PM, ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the findings. On 8/2/23 at 8:00 AM, ASM #2 stated, they have talked with the dialysis facility and they will be sending a brown bag lunch with him starting today. According to the facility's Care of Resident with End Stage Renal Disease policy, Residents with end-stage renal disease (ESRD) will be cared for according to current recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff may include: The nature and clinical management of ESRD, including infection prevention and nutritional needs. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 22 residents in the survey sample, Residents #38, #39, #242 and #35. The findings include: 1. For Resident #38, the facility staff failed to implement the comprehensive care plan for administering pain medications per the physician orders. The comprehensive care plan dated, 5/27/2023 documented in part, Focus: (R38) is at risk for acute pain due to her osteoarthritis, limited ROM (range of motion) to her neck and kidney stones. The Interventions documented in part, Pain patches to neck and knee per MD (medical doctor) order. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the Aspercreme Pads to the back of the resident's neck. She proceeded to the other side of the bed and pulled back the covers off the resident's left knee. The Aspercreme pad was still on the resident's left knee, dated 7/31/2023. RN #3 stated she could not just remove the patch and apply the new one as there was an order to remove it after 12 hours of being on. RN #3 went and spoke with the unit manager and left a message for the nurse practitioner. The physician orders dated, 7/17/2023, documented, Lidocaine External Patch 4% (Lidocaine) (1), Apply to L (left) knee topically one time a day for OA (osteoarthritis) and remove per schedule. The July 2023 MAR (medication administration record) documented the above order. The Lidocaine External Patch was to be applied at 9:00 a.m. and removed at 2059 (8:59 p.m.). An interview was conducted with LPN #2, the unit manager, on 8/2/2023 at 8:33 a.m. When asked the purpose of the care plan, LPN #2 stated, It's their life, their plan of care. LPN #2 was asked if it should be followed, LPN #2 stated, yes. When asked who is responsible for implementing the care plan, LPN #2 stated, it's everyone that is responsible for implementing the care plan. The facility policy, Baseline Care Assessment and Comprehensive Care Plan, documented in part, 6. The interdisciplinary team, in conjunction with the resident, resident's family, surrogate or representative should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment .7. The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment .11. The care plan includes treatment objective that have measurable outcomes with timetables and specific approaches to meet the defined needs. The policy did not address the implementation of the care plan. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 4, the vice president of post-acute services, were made aware of the above concern on 8/2/2023 at 9:58 a.m. No further information was provided prior to exit. 2. For Resident #39 (R39), the facility staff failed to develop a care plan for the use of side rails. Observation was made of R39 on 8/1/2023 at 8:21 a.m. The resident was in bed, with both side rails up. The Side Rail and Entrapment Evaluation dated 7/6/2023 documented in part, Resident's care plan addresses use of side rails and interventions to minimize injury or entrapment. A Y, indicating, yes, was documented. The comprehensive care plan dated, 7/7/2023, failed to evidence documentation for the use of side rails. An interview was conducted with LPN #2, the unit manager, on 8/2/2023 at 8:33 a.m. When asked the purpose of the care plan, LPN #2 stated, It's their life, their plan of care. LPN #2 was asked if it should be followed, LPN #2 stated, yes. When asked who is responsible for implementing the care plan, LPN #2 stated, it's everyone that is responsible for implementing the care plan. When asked if a resident uses side rails, should that be on the care plan, LPN #2 stated, yes, and after reviewing R39's care plan LPN #2 stated she didn't see the use of side rails on the care plan. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM # 4, the vice president of post-acute services, were made aware of the above concern on 8/2/2023 at 9:58 a.m. No further information was provided prior to exit. 29843 3. For Resident #242 (R242), the facility staff failed to implement the care plan to place a fall mat on the floor to the left side of the bed while he was lying in bed. R242 was admitted to the facility with a diagnosis that included but was not limited to convulsion (1). R242's admission MDS (minimum data set) was not due at the time of the survey. The facility's admission assessment for R242 dated 07/24/2023 documented in part, Mental Status: Alert & (and) Oriented x3 (times three - person, place, time). On 08/01/23 at approximately 1:30 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. On 08/01/23 at approximately 3:20 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. The physician's order for R242 documented in part, Fall mat in place to left side of bed when resident is in bed. Order Date: 07/31/2023. The comprehensive care plan for R242 documented in part, Focus. (R242) is at risk for falls characterized by history of falls, CVA (cerebral vascular accident) with left sided weakness related to: impaired balance, poor coordination. Date Initiated: 07/24/2023. Under Interventions it documented in part, Fall mat in place to left side of bed when resident is in bed Date Initiated: 07/31/202. On 08/02/23 at approximately 8:33 a.m., an interview was conducted with LPN (licensed practical nurse) #2. When asked to describe the purpose of a resident's care plan she stated that it is the resident's life, the resident's plan of care. After reviewing R242's care plan for the use of the fall mat and informed of the above observations, she was asked if the care plan was being followed. LPN #2 stated no. On 08/02/2023 at approximately 9:40 a.m., ASM (administrative staff member) #2, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The term seizure is often used interchangeably with convulsion. A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. This information was obtained from the website: Seizures | MedlinePlus. 42183 4. For Resident #35, the facility staff failed to implement the comprehensive care plan for dialysis care, specifically offering food prior to dialysis. Resident #35 was admitted with diagnosis that included but not limited to: ESRD (end stage renal disease). Resident #35's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/7/23, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section O-Special Procedures: coded the resident as dialysis-yes. A review of the comprehensive care plan dated 12/12/19 and revised on 6/30/23, revealed, FOCUS: Resident has end stage renal disease and receives hemodialysis via left arm AV (arterio-venous) graft, 3 times a week on Monday, Wednesday and Friday. Resident is at increased nutritional risk related to requiring a therapeutic diet, food preferences for foods that contradict diet order, ESRD on hemodialysis, Heart Failure and Type 2 diabetes mellitus. Resident has nutritional risk related to related to heel pressure injury. INTERVENTIONS: Prepare and send meal with (Name) as well as any other items he may need. Encourage to follow ordered diet to reduce risks of fluid overload/deficit and nutritional concerns. Revised 6/17/20: Dialysis no longer allows resident to take food into the center. Resident usually has a big breakfast each morning, monitor for the need to offer food prior to going out at 10 am and immediately upon returning from dialysis. Revised on 10/13/20: Currently foods are not allowed at dialysis due to COVID precautions. Provide snacks upon return as requested. Revised 6/30/23: Educate Resident / Representative regarding nutritional needs and requirements. Offer Juven supplement twice daily to promote wound healing. A review of the physician's order dated 1/20/22, revealed, Dialysis every Mon-Wed-Fri at 11:00am pick up at 10:30am. An interview was conducted on 7/31/23 at approximately 10:00 AM, with Resident #35. Resident #35 was sitting in a wheelchair in his room, waiting for dialysis transport. When asked if he had a bagged lunch from the facility or if food was provided by the dialysis center, Resident #35 stated, No, they do not give us food at the dialysis center. I have only been given lunch from this place once. Two sandwiches, since then no food. I do not get back till close to supper time and I have missed my lunch completely. Inside the resident's dialysis bag were one bag of hard candy and one bag of gummy candy. When asked about the candy, Resident #35 stated, That is all I have to take to eat during dialysis. An interview was conducted on 8/2/23 at 8:40 AM, with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is their life and it is used to identify a plan of care, it should be followed. When asked who is responsible for implementing the care plan, LPN #2 stated, any aspect of the care plan is to be implemented by the nurse, aides and the interdisciplinary team. When asked if the care plan had been followed regarding Resident #35's nutrition related to dialysis, LPN #2 stated, no, it has not been implemented. We are sending a bag lunch with him today and will revise the care plan today. On 8/1/23 at approximately 4:15 PM, ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the findings. According to the facility's Baseline Care Assessment and Comprehensive Care Plan policy, The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications per the physician order for one of 22 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to remove a lidocaine patch per the physician orders. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the Aspercreme Pads to the back of the resident's neck. She proceeded to the other side of the bed and pulled back the covers off the resident's left knee. The Aspercreme pad was still on the resident's left knee, dated 7/31/2023. RN #3 stated she could not just remove the patch and apply the new one as there was an order to remove it after 12 hours of being on. RN #3 went and spoke with the unit manager and left a message for the nurse practitioner. The physician orders dated, 7/17/2023, documented, Lidocaine External Patch 4% (Lidocaine) (1), Apply to L (left) knee topically one time a day for OA (osteoarthritis) and remove per schedule. The July 2023 MAR (medication administration record) documented the above order. The Lidocaine External Patch was to be applied at 9:00 a.m. and removed at 2059 (8:59 p.m.). An interview was conducted on 8/1/2023 at 3:38 p.m. with LPN (licensed practical nurse) #2, the unit manager. When asked the process for applying and removing a Lidocaine patch, LPN #2 stated they are applied in the mornings and removed after 12 hours. LPN #2 was asked why is that done that way, LPN #2 stated it's per the physician orders and to prevent irritation of the skin where the patch was applied. When asked if it is signed off as removed on the evening shift and the day shift nurse finds it still in place the next morning, is that following the physician orders, LPN #2 stated, no. An interview was conducted with LPN #4, the nurse that signed off the removal of the lidocaine patch on 7/31/2023, on 8/1/2023 at 3:34 p.m. The above MAR was reviewed with LPN #4. When asked if she took the patch off last night LPN #4 stated she did. It was reviewed with LPN #4 that the resident had two patches prescribed. LPN #4 stated she took one off of her neck. The observation made on 8/1/2023 at 8:42 a.m. was reviewed with LPN #4. LPN #4 stated, I guess I didn't take it off as I was so busy last night. The facility policy, Medication Administration, documented in part, 3. Medications will be administered in accordance with the orders, including any required time frame. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 8/1/2023 at 4:01 p.m. (1) Lidocaine External Patch 4% is in a class of medications called local anesthetics. It works by stopping nerves from sending pain signals. Never wear them for more than 12 hours per day (12 hours on and 12 hours off). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a603026.html

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to implement fall interventions for one of 22 residents in the survey sample, Resident #242. The findings include: For Resident #242 (R242), the facility staff failed to place a fall mat on the floor to the left side of the bed while he was lying in bed. R242 was admitted to the facility with a diagnosis that included but was not limited to convulsion (1). R242's admission MDS (minimum data set) was not due at the time of the survey. On 08/01/23 at approximately 1:30 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. On 08/01/23 at approximately 3:20 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. The physician's order for R242 documented in part, Fall mat in place to left side of bed when resident is in bed. Order Date: 07/31/2023. The comprehensive care plan for R242 documented in part, Focus. (R242) is at risk for falls characterized by history of falls, CVA (cerebral vascular accident) with left sided weakness related to: impaired balance, poor coordination. Date Initiated: 07/24/2023. Under Interventions it documented in part, Fall mat in place to left side of bed when resident is in bed Date Initiated: 07/31/202. On 08/02/2023 at approximately 8:33 a.m., an interview was conducted with LPN (licensed practical nurse) #2. After informed of the above observations, review of the physician's orders and care plan LPN #2 stated that the fall matt should have been put in place. On 08/02/2023 at approximately 9:40 a.m., ASM (administrative staff member) #2, administrator, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) The term seizure is often used interchangeably with convulsion. A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. This information was obtained from the website: Seizures | MedlinePlus.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen areas. The findings include: The facility staff failed to date and/or dispose of opened food. On 7/31/23 at 9:15 AM, an observation was conducted in the main kitchen. In the freezer, one of two five-pound frozen hash browns packed in a plastic bag had been torn open. There was no label on the bag of the date it was opened or expiration date. An interview was conducted on 7/31/23 at 9:20 AM with OSM (other staff member) #1, the chef/dietary supervisor. When asked to review the opened hash brown bag, OSM #1 stated, They must have just opened this with breakfast service. It should not be open like this. I will remove it. The ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the finding on 8/1/23 at 4:15 PM. The facility's Infection Control Sanitation/Safety Guidelines policy dated 8/2013, revealed the following, Storage: The objective is to maintain high-quality food at approved temperatures and conditions to ensure retention of quality and safe conditions. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide services to attempt to restore bladder and bowel continence for one of 22 residents in the survey sample, Resident #25. The findings include: For Resident #25 (R25), the facility staff failed to provide evidence of attempting to restore her bladder and bowel function after admission to the facility. R25 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/26/23, R25 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being frequently incontinent of both bowel and bladder. On the admission MDS (8/28/22) and the quarterly assessments (11/21/22 and 2/21/23) since her admission, she was also coded as being frequently incontinent of bowel and bladder. On all of these MDS assessments, R25 was coded as being independent for walking in her room. On 7/31/23 at 3:05 p.m., R25 was seated on the wheelchair in her room. When R25's incontinence was discussed and when asked if the facility staff had taken any steps to restore bladder or bowel continence since her admission, R25 stated: No, they haven't. She stated she takes herself to the bathroom, but she sometimes needs help changing her brief [due to bowel or bladder incontinence episodes]. On 8/1/23 at 8:48 a.m., R25 was observed independently walking in her room. A review of R25's clinical record failed to reveal evidence of the facility staff's attempt to restore R25's continence of bowel or bladder, or rationale of why it wasn't attempted. On 8/1/23 at 4:01 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. On 8/2/23 at 8:59 a.m., ASM #2 stated: We don't really have anything to provide. She stated the facility staff had focused more on the resident's mobility than on bowel and bladder incontinence. A review of the facility policy, Fecal Incontinence, revealed, in part: Residents with fecal incontinence will receive the appropriate treatment and services to restore as much normal bowel function as possible .Incontinence is not considered a normal part of the aging process .The resident will be evaluated for presence of fecal incontinence on admission/readmission and with each .MDS assessment. Consideration of factors impacting will be reviewed. A review of the facility policy, Assessment and Management of Urinary Function, revealed, in part: Policy: To ensure each resident has an evaluation of urinary function and if urinary incontinence is identified, a determination is made of the type of urinary incontinence and appropriate treatment and services are implemented to restore as much bladder function as possible .When urinary function evaluation identifies urinary incontinence, a further evaluation will be completed .to determine appropriate treatment and/or interventions. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to identify and monitor targeted behaviors for the use of [CONDITION(S)] medications for two of 31 residents in the survey sample, Residents #40 and #6. The findings include: 1. The facility staff failed to identify and monitor targeted behaviors for the use of [MEDICATION(S)] (used to treat [CONDITION(S)], [CONDITION(S)], and in combination with other medications to treat depression) (1) for Resident #40. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder (state of mild to severe apprehension, often without specific cause, resulting in body changes such as quickened heartbeat and sweat.) (2), mood disorder (a mood disorder, feeling sad or irritable, affects a person's everyday emotional state.) (3), depression (a dejected state of mind with feelings of sadness, discouragement, and hopelessness, often accompanied by reduced activity and ability to function, apathy and sleep disturbance) (4), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.) (5). The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 12/28/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as being independent or requiring supervision of one staff member for all of his activities of daily living. In Section N - Medications, the resident was coded as receiving an anti-psychotic medication for all seven days of the look back period. The physician order dated, 1/23/2022, documented, [MEDICATION(S)] Tablet 25 MG (milligrams); Give 1 tablet by mouth at bedtime for BPSD (behavioral and psychological symptoms of dementia) (6) r/t (related to) Dementia. A physician order dated, 10/14/2020, documented, [MEDICATION(S)] Tablet 25 MG; Give 25 mg by mouth in the morning for BPSD r/t dementia. The physician orders dated, 8/3/2019, documented, Observe for absence of behaviors to indicate effectiveness of [CONDITION(S)] medication. Document Y if none observed. Document N, if behaviors observed and record in nurses' notes, every shift. The MARs (medication administration records) for November, December of 2021 and January 2022, were reviewed. The above orders were documented on the MARs. The MARs documented the behavior monitoring. For all three months, a check mark was documented in each block for each shift, not a Y or N. The comprehensive care plan dated, 5/8/2021 and revised on 8/22/2019, documented in part, Focus: (Resident #40) is at risk for ineffective coping related to [CONDITION(S)], depression, mood disorder, anxiety and utilizes [CONDITION(S)] medications. The Interventions documented in part, Monitor for behaviors every shift and record accordingly in EMR (electronic medical record). Contact family members if (Resident #40) becomes agitated (recently tapered off of other antipsychotic medications [this intervention was dated 11/26/2018]. Provide 1:1 assistance during episodes of ineffective coping. Allow (Resident #40) to vent feelings and offer support. Review of the progress notes to include physician notes and nurse's notes was conducted. The attending physician note dated, 11/29/2021, documented in part, [CONDITION(S)]: controlled with [MEDICATION(S)] and [MEDICATION(S)] (sleeping pill). Has failed other options. Failed tapers. Unable to get THC (The main, active ingredient in marijuana is THC [short for delta-9-tetrahydrocannabinol]) (7). Depression controlled with current rx (medications). No more [CONDITION(S)]. The social services note dated, 1/5/2022 documented in part, Resident does not do well with change and the smallest change, such as Bingo time changing and can cause major distress for the resident. The Care Plan Meeting notes dated 1/12/2022, documented in part, Resident was also upset because the resident's shower was late yesterday. Resident becomes upset if anything changes. The psychiatric nurse practitioner notes dated 11/23/2021 documented in part, Mental Status Exam: Attitude: Cooperative, Pleasant, Friendly. Appearance: Appropriate, Alert. Behavior: No agitation, good eye contact, no psychomotor [CONDITION(S)]. Mood: good. Affect: Mood congruent. Thought Content: no hallucinations, no delusions, no illusions. The psychiatric nurse practitioner note dated, 12/30/2021, documented in part, Mental Status Exam: Attitude: Cooperative, pleasant, friendly. Appearance: appropriate, alert. Behavior: no agitation, good eye contact, no psychomotor [CONDITION(S)]. Speech: Coherent, fluent, spontaneous. Mood: good. Affect: mood congruent. Thought content: no hallucinations, no delusions, no illusions. The psychiatric nurse practitioner note dated, 1/21/2022, documented in part, Mental Status Exam: Attitude: Cooperative, pleasant, friendly. Appearance: appropriate, alert. Behavior: no agitation, good eye contact, no psychomotor [CONDITION(S)]. Speech: Coherent, fluent, spontaneous. Mood: good. Affect: mood congruent. Thought content: no hallucinations, no delusions, no illusions. An interview was conducted with LPN (licensed practical nurse) #5 on 1/26/2022 at 3:25 p.m. When asked what Resident #40's behaviors are, LPN #5 stated he has commanding behaviors. He wants things very specific if it's not done for him, he becomes demanding. He will scream at staff if he doesn't want something. Once you give him what he wants he calms down. An interview was conducted with RN (registered nurse) #1, the unit manager, on 1/26/2022 at 3:32 p.m. When asked what is the targeted behavior for Resident #40 for the use of [MEDICATION(S)], RN #1 stated she would have to look and get back with the surveyor. At 3:52 p.m. RN #1 stated (Resident #40) is on it for behavioral disturbances such as aggressiveness, agitation. He's been on it long term and when they tried to decrease it he became verbally abusive. An interview was conducted with RN #1 on 1/27/2022 at 9:20 a.m. The MARs were reviewed with RN #1. When asked what the check marks indicate, RN #1 stated a check mark would equal a yes. When asked how nurses know what the resident's behavior is that they are monitoring, RN #1 stated all nurses are oriented to all units. There is nothing in place that would give the nurse the information. When asked is there anywhere the nurse can review what the behaviors are for each resident, RN #1 stated, It is our responsibility to read the psych (psychiatric) notes and you are given information in report at the change of shift. The care plan above was reviewed with RN #1. When asked what ineffective coping was, RN #1 stated she was not sure. When asked what the targeted behavior for Resident #40 is, RN #1 stated, I've never seen them but I've heard he can be verbally abusive. When asked if it would be helpful for the nurse to have that information on the MAR that they are signing off on, RN #1 stated, Yes. An interview was conducted with LPN #3, the MDS coordinator, on 1/27/2022 at 10:19 a.m. When asked what ineffective coping was, LPN #3 stated, It may be he is having difficult time dealing with his disease process. The care plan above was reviewed with LPN #3. When asked if she saw the targeted behaviors in Resident #40's care plan, LPN #3 stated, No, you didn't miss them, they aren't there. When asked if the targeted behaviors for the use of an antipsychotic medication be on the care plan, LPN #3 stated, yes. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 1/27/2022 at 10:29 a.m. The MARs were reviewed with ASM #2. When asked what the check marks indicated on the MAR, ASM #2 stated, The way you have to answer this in the system, the check marks would be equivalent of a yes. If they check no, it should force them to satisfy it and document the behavior noted. This system was in place before I came. When asked how the nurse can tell what the targeted behavior is for each resident, ASM #2 stated, For each resident you would want it to be specific to them. The behaviors aren't documented. When asked how then are the nurses monitoring for targeted behaviors for the use of the [CONDITION(S)] medication, ASM #2 stated, It needs to be more specific. The facility policy, Psychoactive Medication Management and Behavior Monitoring documented in part, Policy: To optimize the therapeutic psychoactive medications by observation of behaviors and to minimize adverse effects Targeted behaviors to be observed are specific to the psychoactive medication being administered and individualized to the patient. Monitoring of behaviors should occur at least daily, and targeted behavior is identified in the care plan. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 9.htm. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 43. (3) This information was obtained from the following website: https://medlineplus.gov/mooddisorders.html (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 160. (5) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (6) This information was obtained from the following website: www.ncbi.[NAME].nih.gov (7) This information was obtained from the following website: https://medlineplus.gov/ency/patientinstructions/ 6.htm 2. The facility failed to specify and monitor target Resident # 6's behaviors for the use of [MEDICATION(S)] [1]. Resident#16 was admitted to the facility with diagnoses that included but were not limited to Alzheimer's disease [1] and dementia with behavioral disturbances [2]. Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/29/2021, coded Resident # 6 as scoring an eleven on the staff assessment for mental status (BIMS) of a score of 0 - 15, eleven- being moderately impaired for making daily decisions. Section N documented Resident # 6 receiving antipsychotic and antidepressant medications. The POS (physician's order sheet) for Resident # 6 documented in part, [MEDICATION(S)] Tablet. Give 25MG (milligrams) by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCES. Order Date: 12/30/2021. Start Date: 12/30/2021. The comprehensive care plan for Resident # 6 dated 03/01/2019 documented in part, Focus: [Resident # 6] uses antipsychotics r/t (related to) dementia with behavioral disturbances. Date Initiated: 03/01/2019. Under Interventions/Tasks it documented in part, Monitor/record occurrence of for target behavior symptoms Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Date Initiated: 03/01/2019. The eMARs [electronic medication administration records for Resident # 6 dated 12/01/2021 through 01/26/2022 documented side effect monitoring for the use of [CONDITION(S)] medications. The eMARs failed to evidence monitoring of behaviors. The progress notes for Resident # 6 dated 12/01/2021 through 01/26/2022 failed to evidence monitoring of behaviors. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN [registered nurse] #1, unit manager. After reviewing the Resident # 6's physician's orders as stated above, the facility's progress notes dated 12/01/2021 through 01/26/2022 and the eMAR dated 12/01/2021 through 01/26/2022, RN # 1 was asked to identify what specific behaviors were being monitored and to provide documentation evidencing behavior monitoring. RN # 1 stated that they did not specify specific behaviors on the eMAR nor could they provide documentation of behavior monitoring. On 01/27/2022 at 10:30 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. After reviewing the Resident # 6's physician's orders as stated above, the facility's progress notes dated 12/01/2021 through 01/26/2022 and the eMAR dated 12/01/2021 through 01/26/2022, ASM # 2 was asked to identify what specific behaviors were being monitored and to provide documentation evidencing behavior monitoring. ASM # 2 stated that they did not specify specific behaviors on the eMAR nor could they provide documentation of behavior monitoring. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. References: [1] [MEDICATION(S)] is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 9.html. [2] A brain disorder that seriously affects a person's ability to carry out daily activities) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. [3] Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety [CONDITION(S)], agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 17/.

Based on clinical record review and staff interview, it was determined that the facility staff failed to obtain daily weights according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Resident # 5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four on the brief interview for mental status (BIMS), indication the resident is severely impaired of cognition for making daily decisions. The POS [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 5 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 day and/or greater than 5LBS (five pounds) in 1 week - reweigh immediately notify MD (medical doctor) loss/gain. Date Order: 03/26/2021. Start Date: 03/27/2021. The comprehensive care plan for Resident # 5 with a revision date of 05/07/2021 documented. FOCUS: [Resident # 5] is at increased nutritional risk r/t requiring a therapeutic diet, PMH (past medical history) of T2DM (type two diabetes mellitus), diabetic foot wound, HF (heart failure), Alzheimer's disease, dementia, chronic pain syndrome. She chooses to follow own eating plan that may contradict physician-ordered plan. Current BMI is 47.4 (obese classification). Revision on: 05/07/202. Under Interventions it documented in part, Monitor weight, notify MD/RP (medical doctor/responsible party) of weight change 5 % (five percent) x (times) 30 days, 7.5 (seven and a half) % x 90 days, 10% x 180 days, if indicated, anticipate variations and investigate causative factors upon occurrence. Date Initiated: 02/17/2021. The eTAR (electronic treatment record) for Resident # 5 dated November 2021 through January 2022 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 day and/or greater than 5LBS (five pounds) in 1 week - reweigh immediately notify MD (medical doctor) loss/gain. Start Date: 03/27/2021. Further review of the eTARs revealed a blank on 11/24/2021, 12/17/2021, 12/23/2021, 12/25/2021, 12/29/2021, 12/30/2021, 01/08/2022 and on 01/14/2022. The facility's Weights and Vitals Summary sheet for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. The facility's progress notes for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. When asked why Resident # 5's weight was being monitored RN # 3 stated, For congestive heart failure to ensure there is no fluid build-up around their heart. After reviewing Resident # 5's the comprehensive care plan dated 05/07/2021, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 3 stated, It wasn't done. If it's blank I can't say it was done. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for four of 31 residents in the survey sample, Residents #51, #8, #5, and #6. The findings include: 1. The facility staff failed to offer non-pharmacological interventions and document the location of pain prior to the administration of pain medications per the comprehensive care plan for Resident #51. Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13 on the BIMS (brief interview for mental status) score, indicating the resident is capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for most of her activities of daily living such as bathing, eating, transfers and dressing. In Section J - Health Conditions, the resident was coded as having pain in the past five days. The resident was coded as having almost constant pain and the pain was coded as being severe in nature. The comprehensive care plan dated, 6/9/2017 and revised on 8/24/2021, documented in part, Focus: (Resident #51) has potential for pain related to S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interventions documented in part, Anticipate (Resident #51)'s need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause for each pain episode. Remove/limit cases where possible. Monitor/record pain characteristics as patient complains of pain and PRN (as needed), Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset, Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. Provide non-pharmacological interventions for pain relief prior to administering PRN medications such as change in position, cool compress or heat, diversional activities such as tv, snack, drink, others as desired. The November 2021 MAR (medication administration record) documented the above physician orders. On 11/21/2021 at 1:25 a.m., 11/23/2021 at 12:00 a.m. and 11/29/2021 at 10:00 p.m. the [MEDICATION(S)] was administered. The location of the pain was documented as 3. There was no chart code for 3 for location. On 11/23/2021 at 2:07 p.m. the [MEDICATION(S)] was administered, documented for non-pharmacological interventions was y. A y was documented also at that time for the location of pain. The December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/16/2021 at 11:40 p.m., the [MEDICATION(S)] was administered. It was documented, a 0 in the box for the non-pharmacological interventions. The January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was administered on 1/5/2021 at 2:33 p.m. A N/A was documented in the box for non-pharmacological interventions and for the location of the pain. On 1/8/2022 at 12:05 p.m., 1/9/2022 at 10:32 a.m., 1/10/2022 at 12:02 a.m. and 11:18 a.m., 1/16/2022 at 9:55 a.m., there was a y documented in the box for non-pharmacological interventions. On 1/17/2022 at 6:15 a.m. the box for non-pharmacological interventions was blank. Review of the nurse's notes from 11/1/2021 through 1/127/2022 failed to reveal further explanation of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with RN (registered nurse) #1, the unit manager, on 1/27/2022 at 9:20 a.m. When asked the purpose of the care plan, RN #1 stated it was the plan of care for the resident, how to care for the resident. When asked should the care plan be implemented and followed, RN #1 stated, yes. An interview was conducted with LPN (licensed practical nurse) #1, the unit manager, on 1/27/2022 at 9:41 a.m. The above information was shared with LPN #1. When asked if that was following the comprehensive care plan, LPN #1 stated, no. The facility policy, Baseline Care Assessment and Comprehensive Care Plan documented in part, The care plan must describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being in accordance with the comprehensive assessment .8. The care planning process must include the resident with information so that he/she can participate in goals and wishes regarding treatment. 9. When there appears to be a conflict between a resident's right and the residents health or safety, the facility must accommodate both the resident's rights and the residents health, including exploration of alternative care through the care planning process in which the resident participates. 10. The care plan must reflect current standards of professional practice. 11. The care plan includes treatment objectives that have measurable outcomes with time tables and specific approaches to meet the defined needs. A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care.(6) ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 1/27/2022 at 1:33 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 114. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 266. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 72. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html (6) Fundamentals of Nursing Lippincott Williams & Wilkins 2007 Lippincott Company Philadelphia pages 65-77. 2. The facility staff failed to implement Resident # 8's comprehensive care plan for checking the placement of a wander guard. Resident # 8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) out of 15 on the brief interview for mental status (BIMS). A score of 0 indicates the resident severely impaired of cognition for making daily decisions. Section P Restraints and Alarms coded Resident # 8 for a wander guard Used daily. The POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Date Order: 08/06/2021. Start Date: 08/06/2021. The comprehensive care plan for Resident # 8 dated 08/03/2021 documented. FOCUS: [Resident # 8] is an elopement risk/wanderer AEB (as evidenced by) impaired safety awareness. Date Initiated: 11/08/2021. Under Interventions it documented in part, WANDER ALERT: Wander guard to wheelchair. Check placement every shift. Date Initiated: 11/08/2021. The eTAR (electronic treatment record) for Resident # 8 dated January 2022 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Start Date: 08/06/2021. Further review of the eTAR revealed blanks on 01/17/2022 on the night shift and on 01/23/2022 on the evening shift. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 8's the comprehensive care plan dated 08/03/2021, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 1 stated, It wasn't done. If it's blank I can't say it was done. RN # 1 was asked if Resident # 8's comprehensive care plan was implemented. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to implement Resident # 5's comprehensive care plan for obtaining physician ordered daily weights. Resident # 5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four out of 15 on the brief interview for mental status (BIMS), with four indicating the resident is severely impaired of cognition for making daily decisions. The POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If weight greater than 3LBS (three pounds) in 1 (one) day and/or greater than 5LBS (five pounds) in 1 (one) week - reweigh immediately notify MD (medical doctor) loos/gain. Date Order: 03/26/2021. Start Date: 03/27/2021. The comprehensive care plan for Resident # 5 with a revision date of 05/07/2021 documented. FOCUS: [Resident # 5] is at increased nutritional risk r/t requiring a therapeutic diet, PMH (past medical history) of T2DM (type two diabetes mellitus), diabetic foot wound, HF (heart failure), Alzheimer's disease, dementia, chronic pain syndrome. She chooses to follow own eating plan that may contradict physician-ordered plan. Current BMI is 47.4 (obese classification). Revision on: 05/07/202. Under Interventions it documented in part, Monitor weight, notify MD/RP (medical doctor/responsible party) of weight change 5 % (five percent) x (times) 30 days, 7.5 (seven and a half) % x 90 days, 10% x 180 days, if indicated, anticipate variations and investigate causative factors upon occurrence. Date Initiated: 02/17/2021. The eTAR (electronic treatment record) for Resident # 5 dated November 2021 through January 2022 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 (one) day and/or greater than 5LBS (five pounds) in 1 (one) week - reweigh immediately notify MD [medical doctor] loss/gain. Start Date: 03/27/2021. Further review of the eTARs revealed a blank on 11/24/2021, 12/17/2021, 12/23/2021, 12/25/2021, 12/29/2021, 12/30/2021, 01/08/2022 and on 01/14/2022. The facility's Weights and Vitals Summary sheet for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. The facility's progress notes for Resident # 5 dated November 2021 through January 2022 failed to evidence weights for the same dates as listed above. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 5's the comprehensive care plan dated 05/07/2021, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN # 1 stated, It wasn't done. If it's blank I can't say it was done. RN # 1 was asked if Resident # 5's comprehensive care plan was implemented. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to implement Resident # 6's comprehensive care plan for behavior monitoring. Resident#16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/29/2021, coded Resident # 6 as scoring an eleven on the staff assessment for mental status (BIMS) of a score of 0 - 15, with 11 indicating the resident is moderately impaired for making daily decisions. Section N documented Resident # 6 receiving antipsychotic and antidepressant medications. The POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 25MG (milligrams) by mouth at bedtime related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCES. Order Date: 12/30/2021. Start Date: 12/30/2021. The comprehensive care plan for Resident # 6 dated 03/01/2019 documented in part, Focus: [Resident # 6] uses antipsychotics r/t (related to) dementia with behavioral disturbances. Date Initiated: 03/01/2019. Under Interventions/Tasks it documented in part, Monitor/record occurrence of for target behavior symptoms Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. Date Initiated: 03/01/2019. The eMARs (electronic medication administration records) for Resident # 6 dated 12/01/2021 through 01/26/2022 documented side effect monitoring for the use of [CONDITION(S)] medications. The eMARs failed to evidence monitoring of behaviors. The progress notes for Resident # 6 dated 12/01/2021 through 01/26/2022 failed to evidence monitoring of behaviors. On 01/27/2022 at approximately 9:20 a.m., an interview was conducted with RN (registered nurse) # 1, unit manager. After reviewing Resident # 6's the comprehensive care plan dated 03/01/2019, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 1 was asked if Resident # 6's comprehensive care plan was implemented for behavior monitoring. RN # 1 stated no. On 01/27/2022 at approximately 1:30 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the findings. No further information was provided prior to exit. REFERENCES [1] A brain disorder that seriously affects a person's ability to carry out daily activities) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. [2] Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety [CONDITION(S)], agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 17/.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notice of hospital transfer for one of 31 residents in the survey sample, Resident #45. Resident #45 transferred to the hospital on 10/11/21. The facility staff failed to provide written notice of the transfer to the resident representative or ombudsman. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's quarterly minimum data set assessment with an assessment reference date of 11/22/21 coded the resident's cognition as severely impaired. Review of Resident #45's clinical record revealed a nurse's note that documented the resident was transferred to the hospital on 10/11/21 for a left knee wound. Further review of Resident #45's clinical record failed to reveal evidence that written notice of the transfer was provided to Resident #45's representative or the ombudsman. On 1/26/22 at 2:11 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the nurses notify residents' representatives of hospital transfers via phone but not via written notice. On 1/26/22 at 2:03 p.m., an interview was conducted with OSM (other staff member) #3 (the social services director) in regards to providing written notice of transfer to the ombudsman. OSM #3 stated she populates the facility discharge list and faxes it to the ombudsman each month. OSM #3 stated that Resident #45's 10/11/21 transfer was not classified as a discharge because the resident returned on 10/12/21 so the resident's name was not on the list faxed to the ombudsman. In regards to written notice to the representative, OSM #3 stated she provides written notice of transfer to the representative via certified mail but she only started this process in November 2021. On 1/26/22 at 5:33 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Facility Initiated Transfer and Discharge documented, H. Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .8. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman . No further information was presented prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide adequate supervision and assistive devices to prevent accidents for five of 29 residents in the survey sample, Resident # 11, #12, #8, #1 and #10. 1. Resident #11 had four falls in three months on: 1/9/17, 2/15/17, 3/24/17 and 3/26/17. The facility staff failed to evaluate the effectiveness of interventions in place after each fall and failed to implement new interventions to prevent further falls. On 3/26/17, Resident #11's last fall, the resident sustained [REDACTED]. 2. Resident #12 had five falls in six months on: 12/25/16, 5/4/17, 5/18/17, 6/8/17 and 6/18/17. The facility staff failed to evaluate the effectiveness of the interventions in place after each fall and failed to implement new interventions to prevent further falls. On 6/18/17, Resident #12's last fall, the resident sustained [REDACTED]. 3 The facility staff failed to ensure a safe transferr for Resident #8. On 2/12/17 Resident #8 had a fall and was assessed as requiring a Hoyer lift for transferss. On 6/28/17 during an observation the facility staff transferred Resident #8 using the wrong mechanical lift. 4. Resident # 1 sustained a fall during a transfer on 6/25/17. The facility failed to evaluate the effectiveness of the interventions in place after Resident #1's fall on 6/25/17 and failed to implement new interventions to prevent further falls. 5. The facility staff failed to ensure safe storage of Resident #10's lancets (a short pointed blade used to obtain a drop of blood (1)). Resident #10's lancets were observed stored at the bedside with the residents diabetic supplies and were not secured in a locked cabinet or medication cart. The findings include; 1. Resident #11 had four falls in three months on: 1/9/17, 2/15/17, 3/24/17 and 3/26/17. The facility staff failed to evaluate the effectiveness of interventions in place after each fall and failed to implement new interventions to prevent further falls. On 3/26/17, Resident #11's last fall, the resident sustained [REDACTED]. Resident #11 was admitted to the facility on [DATE] with a readmission on 11/9/16 with [DIAGNOSES REDACTED]. Resident #11's most recent comprehensive MDS (minimum data set) was an admission assessment with an ARD (assessment reference) date of 11/16/16. Resident #11 was coded as scoring a five out of a possible 15 on the BIMS (brief interview for mental status) in Section C, Cognitive Patterns, indicating that Resident #11 was severely cognitively impaired in daily decision making. Section G, Functional Status, coded Resident #11 as requiring extensive assistance of one to two people for transfers, walking, toileting, personal hygiene as well as having impairment to her upper extremities. Resident #11 was further coded in Section J, Health Conditions, as having a fall with a fracture prior to entry into the facility. Resident #11 was observed on the following occasions: - 6/27/17 at 11:00 a.m., during the initial facility tour, Resident #11 was sitting in a chair at the foot of her bed, a bedside table and the call bell were within reach. Resident #11 stated she gets tired sitting in the chair all day. No motion monitors/alarms were observed in the bed or on the resident's chair. - 6/28/17 at 7:30 a.m. Resident #11 was sitting in a chair at the foot of her bed. The call bell within reach. Resident #11 stated she had just received her shower and was waiting on breakfast. No motion monitors/alarms were observed in the bed or on the resident's chair. - 6/29/17 at 7:00 a.m. Resident #11 was lying in her bed and was observed attempting to get herself out of bed. The bed was in a standard position. Resident #11 stated her back was in pain from lying in bed too long. Resident #11 was observed attempting to swing her legs out of the bed to get up. The call bell light outside the room was engaged; several aides passed by the doorway and did not stop to respond to the light. This surveyor walked to the end of the hallway, and within five minutes the call light was turned off. At 7:30 a.m., this surveyor returned to Resident #11's room with RN (registered nurse) #1, an MDS coordinator. Resident #11 was still lying in her bed, in the same position. When asked if someone had helped her, Resident #11 stated someone came into the room and asked her if she needed the bathroom, then left without taking her to the bathroom. At this time, RN #1 offered to take Resident #11 to the bathroom. There were no motion monitors/alarms observed in the bed or on the resident's chair. A review of Resident #11's clinical record revealed, in part, the following incident reports: - 1/9/17 Incident Description: Nursing Description: Found resident sitting on floor in room @0800 (8:00 a.m.). Fecal matter noted on floor. Resident Description: Resident stated had to go to the bathroom and got up in a hurry and slid on floor. Did not hit head. Immediate Action Taken: Description: Assessed for injuries. Assisted resident to bathroom. Crackles noted in L (left) lower lobe. Resident stated of (sic) pain on 1 (one) side of back (name of doctor) notified. Resident Taken to Hospital: N (no). Other Info: Incontinent of stool while attempting to go to bathroom. Notes: 1/9/2017 Mobility monitor (a motion alarm used on a bed or chair to alert staff when a resident attempts to get up without assistance) on and functioning. A corresponding progress note, completed and electronically signed by LPN (licensed practical nurse) #2 on 1/9/2017, documented the following; Assessed for injury. Assisted to bathroom with help of 2 (two). Stated of (sic) L (left) mid back pain. (Name of doctor) notified and new order for Stat (immediate) CXR (chest x-ray). There was no further mention of mobility monitors in place. This documentation was also documented in a nursing progress note. - 2/15/17 1:17 (1:17 a.m.) Incident Description: Nursing Description: This writer was notified by the CNA (certified nursing assistant) that the resident was on the floor. Upon entering the room. The resident was sitting on her bottom, with her feet out in front of her, in between her wheelchair and her bed. No visible injuries. Resident Description: When asked, the resident stated she was trying to go to the restroom. Resident also stated she bumped her head on her wheelchair, but denies any pain. Immediate Action Taken: Description: This writer assessed resident for injuries. No injuries noted. ROM (range of motion) performed and ROM WNL (within normal limits). Assisted resident back into bed. Resident Taken to Hospital? N (no). This documentation was also documented in a nursing progress note. - 3/24/17 15:45 (3:45 p.m.). Incident Description: Nursing Description: resident finished toileting, stood to pull pants up and became unsteady, fell to floor and landed on buttocks, this writer present at time with head turned to speak to CNA about residents (sic) mattress sliding out lost balance (sic). Immediate Action Taken: Description: assisted up and assessed. This documentation was also documented in a nursing progress note. - 3/26/2017 08:30 (8:30 a.m.) Incident Description: Nursing Description: pt (patient) was attempting to reposition self on side of bed to put on shoe on (sic) and slid onto floor on buttocks with bed items (mattress topper and blankets) pt sitting upright on buttocks on top of mattress topper and blankets. I was trying to put on my shoe. Immediate Action Taken: Description: assessment done and range of motion, pt reeducated to ask staff for assistance for transfers and adl's (activities of daily living), rp (responsible party) and md (medical doctor) notified, (name of doctor) in building and notified. (Name of doctor) preformed (sic) physician exam on pt. Injuries Report Post Incident: No injuries Observed Post Incident. Notes: new order for left rib x-ray. This documentation was also documented in a nursing progress note. A review of Resident #11's clinical record revealed the following X-Ray report: Date 3/27/17. Examination: XR (X-Ray) Ribs 2V (views) LT (left). Indication: Pain. Impression: There is a minimally displaced fracture of the anterior (front) aspect of the left 10th rib. The incident reports did not provide any evidence that new interventions were initiated following each fall to prevent Resident #11 from sustaining further falls. A review of Resident #11's physician progress notes [REDACTED]. Fall precautions. Tfr (transfer) only w (with)/ assist. Bed alarm and chair alarm on. 3/27/17 Assessment/Plan: 3. Assessment Frequent falls. 5/25/17 Assessment/plan: Frequent falls. due to her (Resident #11) deconditioned status and rapid shifts in position, we continue to encourage slow supported movement. A review of Resident #11's physician order summaries dated November 30, 2016 and May 1, 2017 did not document any fall prevention orders. When asked for the physician order summaries for the months between November 2016 and May 2017 ASM (administrative staff member) #2, the director of nursing, stated that because Resident #11 was a long term care resident the physician reviewed the orders every 60 days. ASM #2 further stated that these were the only physician order summaries available. Further review of Resident #11's physician orders did not reveal any orders for motion alarms to be used on the bed or chair. A review of Resident #11's nursing progress notes did not provide documentation that any alarms were in place following the 1/9/17 incident. A review of Resident #11's Kardex (an information system for CNAs) dated 11/9/16 (the date of admission) documented, in part, the following: Resident Care: For her (Resident #11) comfort, ensure mobility pad (a bed alarm) is flat, w/o (without) bulky connections, folds etc. under (name of Resident #11) at bedtime. A review of Resident #11's fall risk assessments revealed fall risk assessments were completed weekly from 11/10/16 through 1/17/17. The scores were not completed to indicate Resident #11's level of risk for falls. Further review of Resident #11's fall risk assessments revealed that between 2/1/17 and 2/28/17 and between 2/28/17 and 5/16/17, Resident #11 was assessed as a high risk for falls. A review of Resident #11's comprehensive care plan dated 11/9/16 revealed, in part, the following documentation; Focus. (Name of Resident #11) has impaired visual function r/t (related to) Macular Degeneration, legally blind. Date Initiated: 11/22/2016. Revision on: 11/22/2016. Focus: (Name of Resident ) is high risk for falls r/t (related to) weakness, vision problems, hx (history) of falls with injury. 5/24/17 Family identified risk of mattress topper slipping off bed if both mattresses are not covered with the bottom fitted sheet. Date initiated: 11/22/2016. Revision on 5/24/2017. Interventions/ Tasks: Anticipate and meet (name of Resident #11's) needs. Date Initiated: 11/22/2016. Educate (name of Resident #11)/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 11/22/2016. Revision on: 11/22/2016. Encourage (name of Resident #11) to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date Initiated: 11/22/2016. Revision: 11/22/2016. Ensure that (name of Resident #11) is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Date Initiated: 11/22/2016. Revision on: 11/22/2016. Follow facility fall protocol. Date Initiated: 11/22/2016. Revision: 11/22/2016. (Name of Resident #11's) call light is within reach when in room and encourage her to use it for assistance as needed. Date Initiated: 11/22/2016. Revision on: 11/22/2016. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). Date Initiated: 11/22/2016. There was no evidence that Resident #11's comprehensive care plan was updated following her falls that occurred on 1/9/17, 2/15/17, 3/24/17 and 3/26/17. On 6/9/17 at 9:00 a.m. an interview was conducted with RN (registered nurse) #1, an MDS coordinator. RN #1 was asked to describe the process followed when a resident falls, RN #1 stated, If a resident has a fall it is documented in the progress notes, a risk report is completed and the care plan is reviewed and revised to review the current interventions. We have to put in a new intervention for each fall. We discuss the falls in our stand up meetings and (name of administrator) always asks if the care plan has been updated. The expectation is that it (updated care plan) is being done. RN #1 was then asked specifically about Resident #11 and evidence was requested to show that Resident #11's care plan was updated with new interventions, following each fall, to prevent further falls. On 6/29/17 at approximately 10:00 a.m. a meeting was conducted with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. ASM #1 and ASM #2 were made aware of the above concern for harm for Resident #11. ASM #1 and ASM #2 were asked if they were aware of any interventions that were put into place and implemented after each of Resident #11's falls to prevent further falls. ASM #1 and ASM #2 were unable to say what had been done. A policy was requested for fall prevention at this time. ASM #1 and ASM #2 were asked to provide any documentation that would evidence attempts by the facility after each fall to protect Resident #11 from further falls. On 6/9/17 at 10:12 a.m. an interview was conducted with RN #6, an MDS coordinator. RN #6 reviewed Resident #11's care plan with this writer and stated that there were no revisions done following each of Resident #11's falls. When asked if it should have been done, RN #6 stated yes. On 6/29/17 at 10:30 a.m. an interview was conducted with LPN (licensed practical nurse) #2, a floor nurse caring for Resident #11. LPN #2 was asked to describe the process followed by staff when a resident falls. LPN #2 stated, I check the surroundings, check for injuries/ movement, check to see if they hit their head, and notify the RP (responsible part) and MD (medical doctor). LPN #2 stated, I would complete the risk management incident report, follow the questions. LPN #2 was asked if she would consider implementing any new interventions, LPN #2 stated, I might consider interventions but I would ask the unit manager, they would have a better understanding. I might initiate alarms if the resident didn't have alarms and make sure the environment was safe. LPN #2 was asked if she would initiate a fall alarm if the resident was a fall risk. LPN #2 stated, Not typically. LPN #2 was asked about Resident #11 and her falls and whether or not she was aware of any interventions put into place to reduce Resident #11's risk for falls. LPN #2 stated, I have not been made aware of any. When asked if Resident #11 had any alarms in place, LPN #2 stated she didn't think so. LPN #2 was asked about the fall that occurred in January 2017 where she documented that an alarm was in place. LPN #2 stated she didn't remember, but if she wrote that there was an alarm it must have been in place. LPN #2 was asked if she was aware of Resident #11's risk for falls. LPN #2 stated that she had not been made aware of the risk or of any interventions. LPN #2 further stated, This is not discussed as a team, so I don't know. The unit manager on Resident #11's hall was not available for an interview on 6/29/17. On 6/29/17 at 1:15 p.m. a meeting was conducted with ASM #1, the administrator, ASM #2, the director of nursing. ASM #1 and ASM #2 stated that they did not have any further information regarding Resident #11's falls. The care plan had not been reviewed/revised and there were no interventions put into place following each fall. A review of the facility document, Fall Resident Assessment and Investigation revealed, in part, the following documentation; Purpose: To provide a comprehensive, consistent approach to assess residents at risk for falls and to implement interventions to reduce risks for recurrence and injury. Policy: 7. The fall investigation form will be utilized in reviewing and revising the residents care plan to minimize the recurrence of falls or injury. 8. The interdisciplinary team will review incident at the next clinical meeting for completeness of documentation and evaluated for trends. Residents that have recurrent falls (more than 2 falls per month or a fall with a significant injury - fracture ) will be evaluated for other causative factors or treatment interventions. No further information was provided prior to the end of the survey process. 2. Resident #12 had five falls in six months on: 12/25/16, 5/4/17, 5/18/17, 6/8/17 and 6/18/17. The facility staff failed to evaluate the effectiveness of the interventions in place after each fall and failed to implement new interventions to prevent further falls. On 6/18/17, Resident #12's last fall, the resident sustained [REDACTED]. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE], (after an overnight only stay in the hospital emergency room for evaluation), with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), an annual assessment, with an assessment reference date of 5/18/17, coded the resident as being severely impaired to make daily cognitive decisions. Resident #12 was coded as requiring limited assistance of one staff member for moving in the bed and dressing, extensive assistance of one staff member for transfers and toileting, and as independent after set up assistance was provided for eating. Resident #12 was not coded for any impairment in her range of motion. In Section J - Health Conditions, the resident was coded as having had two falls without injuries. The Fall Risk assessment dated , 10/9/16, documented the following: Reason for Assessment - recent fall Date of admission - less than 90 days History of Falls within Last 3 months - #2. 1-2 times Medication Use - antiseizure, antihypertensive, NSAID (non -steroidal anti-inflammatory drug) narcotics, psychotropic, anti-Parkinson's Medication Usage - takes 3 or more of these medications currently or within last 7 days. Systolic Blood Pressure - no drop between lying & standing Memory/Recall - disoriented x (times) 1 Vision - adequate with or without glasses Continence - Continent complete control in past 7 days. Behavior in last 7 days - no behavior exhibited in last 7 days Confined to Chair - not Gait Analysis - unable to independently come to a standing position Predisposing Conditions - Parkinson's disease Response based on number of predisposing condition - 1-2 present. There was no risk score or documentation of the resident's fall risk. The nurse's note dated, 12/25/16 at 8:13 p.m. documented, Pt (patient) wheeled self into bathroom unassisted and attempted to put self onto toilet unassisted. pt (sic) sitting on buttocks on floor, sitting upright holding onto grab rail with both hands. pt (sic) stated 'I couldn't hold on too long', 'I fell on my butt.' Pt assessed and toileted with staff assist, pt reeducated to get staff assistance with transfers, pt denies pain or discomfort, ROM (range of motion) W/N/L (within normal limits) without c/o (complaint of) pain or discomfort, no s/s (signs and symptoms) of distress, resp (respirations) even/non-labored, skin intact. will cont (continue) to monitor for changes. The Fall Incident Report dated, 12/25/16 documented in part, Immediate Action Taken - pt assessed and toileted with staff assist, pt reeducated to get staff assistance with transfers. The review by the director of nursing (DON) on 12/26/16 documented, Resident is impulsive in her actions and has been observed frequently by this writer attempting to transfer herself from her wheelchair to the bed, bed to wheelchair, and even wheelchair to bathroom without calling for staff assistance. Resident has unsteady gait/balance. The Fall Risk assessment dated , 2/15/17, documented in part, Score - 16. Category - High Risk (for falls). A nurse's note dated, 5/4/17 at 3:35 p.m. documented, Found on floor in room. Assess for injury. Skin intact. No outward rotation of hips noted. Able to move all extremities well. Denies pain. The Fall Incident Report dated, 5/4/17 documented in part, Found resident lying on L (left) side on floor with head against visitor leg. Mobility alarm in place. Works intermitten (sic). New alarm applied. Assess for injuries. Able to move all extremities well. No outward rotation of hips. Skin intact. Denies pain. Resident did not have brakes on w/c (wheelchair). Resident Description - Stated wheelchair tip over Other info (information) Gets up and down from w/c, was bending over and standing up, the w/c did not have brakes on and w/c moved backwards and resident went to sit down and missed w/c. Notes: Did not have brakes on w/c, and moved backwards while bend over and fell to floor. Mobility alarm changed due to alarm only working internitten (sic). The Fall Risk assessment dated , 5/18/17, documented in part, Score - 22. Category - High Risk. A nurse's note dated, 5/18/17 at 6:05 p.m. documented, Resident observed leaning forward in wheelchair rearranging items in bottom dresser drawer, this writer began to ask resident to sit back, resident continued to lean forward when wheelchair slid from under resident. Educated to not lean forward, use call light for any assistance. The Fall Incident Report dated, 5/18/17 documented in part, Resident observed in wheelchair leaning forward rearranging items in bottom dresser drawer, this writer began to ask resident to sit back when resident continued to lean forward and wheelchair slid from under resident Other info - Resident often displays impulsive behaviors and suffered from parkinsonian [DIAGNOSES REDACTED]/tremors. Resident was attempting to arrange items in her bottom dresser drawer when she slid out of her wheelchair. Resident has poor balance and is unable to judge her movements. The Fall Incident Report dated, 6/8/17 documented in part, Housekeeping stated that she was walking by pt's room and pt was lying on the floor. Pt found lying on her left side, head against the wall. Pt states, I tapped my head on the wall, I was trying to pick this thing from the floor .Other info - Impulsive/determines (sic) behavior, did not call for assistance, unsteady balance. A nurse's note dated, 6/18/17 at 9:12 p.m. documented, Pt fell on to floor witnessed by roommate; roommate stated that pt was 'looking at papers and some dropped and she went to pick them off the floor and fell out of her wheelchair on to the floor.' Pt stated, 'I fell , I was picking up my papers.' Pt laying on right side on floor, wheelchair next to pt, papers on floor. pt c/o (complained of) right hip, back and coccyx pain, immobilized pt, MD (medical doctor) notified, new order to send pt to ER (emergency room ) for eval (evaluation), called 911, pt sent out to ER via 911, rp (responsible party) notified, ER notified The Fall Incident Report dated, 6/18/17, documented in part, Pt fell on to floor witnessed by roommate; roommate stated that pt was 'looking at papers and some dropped and she went to pick them off the floor and fell out of her wheelchair onto the floor. Resident description - I fell , I was picking up my papers. Immediate action taken - pt laying on right side on floor, wheelchair next to pt papers on floor .Notes - x-ray revealed broken 7th and 8th right lateral rib fractures. The x-ray results dated, 6/20/17, documented in part, There is a fracture of the ninth and 10th lateral fibs, with slight displacement, possibly involving the eighth lateral rib as well. Impression: Right-sided lateral rib fractures as mentions. The comprehensive care plan dated,5/5/16 and revised on 6/28/17, documented in part, Focus: (Resident #3) is at risk for injury r/t (related to) falls characterized by multiple risk factors related to: unstable health condition, non-compliance with mobility aide use, visual deficit, new surroundings and psychotropic medication. (Resident #12) had an actual fall on 8/14/16. (Resident #12) had a fall on 9/14/16. (Resident #12) sustained a fall on 10/1/16, resulting in a skin tear to left elbow. The following were added to the care plan after this surveyor asked for information on the falls. (Resident #12) had an actual fall on 5/18/17. (Resident #12) had an actual fall on 6/18/17. The Interventions documented in part, 5/5/16 -Apply bed and chair mobility monitors at all times to enhance safety. Encourage resident to ask for assistance when walking with walker and not to walk independently. 10/2/16 - Ensure that nursing staff continues to monitor and remind (Resident #12) to ask for assistance when wishing to transfer. 5/5/16 - Maintain locked brakes on wheelchair when resident is sitting in it. 7/12/16 - Place objects that resident frequently uses within resident's reach. 5/5/16 - Reinforce need to call for assistance. 8/22/16 - Staff to continuously remind (Resident #12) not to lean over in her chair r/t poor safety awareness. The last update to Resident #12's care plan was dated, 10/2/16. There were no updates after her falls on 12/25/16, 5/4/17, 5/18/17, 6/8/17 and 6/18/17. The physician orders dated, 6/20/17 documented the order for the rib x-rays and Tramadol (non-narcotic used to treat moderate to severe pain (1)) 50 mg (milligrams); give 1 tablet by mouth every 6 hours as needed for pain. The June 2017 MAR (medication administration record) documented Resident #12 received Tramadol three times on 6/20/17 for a pain score of 10 (scale of one to ten, ten being the worse pain ever in). Resident #12 was documented as receiving the Tramadol on 6/21/17 once for a pain level of seven. The resident was documented as receiving the Tramadol on 6/22/17 for a pain level of five and one of eight. On 6/29/17 at 9:16 a.m. an interview was conducted with RN (registered nurse) #3. When asked who is responsible for updating the care plans, RN #3 stated, The unit managers. An interview was conducted with RN #1, the MDS coordinator, on 6/29/17 at 10:10 a.m. When asked who is responsible for updating the care plan with new interventions after a resident has a fall, RN #1 stated, The clinical coordinator (unit manager) updates the care plan with the fall and new interventions. RN #1 was asked to review Resident #12's fall care plan. When asked if she saw any documentation regarding Resident #12's falls on 12/25/16, 5/4/17, 5/18/17, 6/8/17 and 6/18/17, RN #1 stated she did not see those falls on the care plan. An interview was conducted with CNA (certified nursing assistant) #4 on 6/29/17 at 9:25 a.m. CNA #4 was asked how she knows what a resident's transfer status is and what safety devices a resident requires. CNA #4 stated, There is a sheet in the resident's closet that tells us their mobility status. Sometimes they list the safety devices, it sometimes depends what the therapist has written on it. When asked about residents not on therapy caseload, CNA #4 stated, I guess the nurse writes on it. The closet for Resident #12 was viewed with CNA #4. The Care Card was blank. It didn't have the resident's name or anything documented on it. CNA #4 was asked how staff knows what to do for a resident, if there is no information on the Care Card, CNA #4 stated, I would ask another CNA who is familiar with the resident. An interview was conducted with CNA (certified nursing assistant) #3 on 6/29/17 at 10:40 a.m. When asked how she knows what safety devices a resident requires, CNA #3 stated, It's in the Kardex in (name of computer program). The Bedside Kardex Report for Resident #12 with an admission date of [DATE] and a print date of 6/29/17, documented, Dressing - (Resident #12) is to wear hose daily. Transferring - Use lifting device, draw sheet etc. to reduce friction. Resident Care - Heel lift boots bilaterally when in bed. May need to face (Resident #12) or decrease ambient noise if she is having difficulty hearing or understanding. Staff to continuously remind (Resident #12) not to lean over in her chair r/t her poor safety awareness. Eating - (Resident #12) is to have her lower partial dentures put in every am and out every pm. Monitor - Vitals All (BP (blood pressure) P (Pulse) R (respirations) T (temperature). There was no documentation for a mobility alarm. An interview was conducted with LPN (licensed practical nurse) #2 on 6/29/17 at 10:50 a.m. When asked how the staff identify a resident who is at risk for falls, LPN #2 stated, They have a yellow band on and there is a list in the computer of what they need. When asked how the CNA's know what devices a resident needs, LPN #2 stated, There is a falling leaf outside the door. LPN #2 and this surveyor identified the leaf at the doorway to Resident #12's room. LPN #2 was asked to look at the care card in Resident #12's closet. LPN #2 stated, Well that needs to be filled in. An orange dot with M/M was noted next to Resident #12's name outside her door. When asked what that indicated, LPN #2 stated, I don't know but I will find out. A second interview was conducted with LPN #2 who cared for Resident #12 for one of her falls, on 6/29/17 at 11:09 a.m. When asked what happened on 5/4/17, LPN #2 stated, She gets up and down in her chair. She fidgets. She takes off her alarms and plays with them. LPN #2 stated, I found out what the M/M on the orange dot was, it's her mobility monitor she has. LPN #2 was asked if she put any new interventions in place at the time of the 5/4/17, fall to prevent further falls. LPN #2 stated no, she hadn't. An interview was conducted with RN #4, the care manager for Resident #12, on 6/29/17 at 11:55 a.m. When asked who updates the care plans, RN #4 stated, I'm supposed to do that. It's been a struggle to do so. The care plan for Resident #12 was reviewed with RN #4. RN #4 was asked if Resident #12's care plan had been updated with new interventions to prevent further falls after each fall on 12/25/16, 5/4/17, 5/18/17, 6/8/17 and 6/18/17. RN #4 stated, No, I don't see it there. When asked if the care plan should have been updated, RN #4 stated, Yes, Ma'am. When asked should interventions be put in place to prevent further falls, RN #4 stated, Yes, it should be updated. She is my special person. She has a mobility alarm. I go in to her room a lot and she's very busy. Her business increases with her roommate but her family doesn't want her moved. RN #4 was informed Resident #12 has had five falls in six months with the last fall resulting in a fracture and increased pain, and was asked if something should have been put in place to prevent further falls. RN #4 stated, Yes, we should have done something. The facility policy, Fall Resident Assessment and Investigation documented in part, 7. The fall investigation will be utilized in reviewing and revising the residents care plan to minimize the recurrence of falls or injury. 8. The interdisciplinary team will review incident at the next clinical meeting for completeness of documentation and evaluated for trends. Residents that have recurrent falls (more than 2 falls per month or a fall with a s

Based on observation, clinical record review, staff interviews, and facility documentation review the facility staff failed to ensure adequate supervision and safe coffee temperatures to prevent an avoidable accident for one resident (Resident #9) in the survey sample of 27 residents, Resident #9 sustained second degree burns after spilling hot coffee on her right thigh; and during the survey the coffee served to residents on both facility units was identified at temperatures sufficient to cause tissue injury, also hot water from a water dispensing machine, accessible to residents was identified at a temperature sufficient to cause tissue injury to residents resulting in the identification of immediate jeopardy. On 6/10/16, Resident # 9 spilled hot coffee onto her right leg resulting in first and second degree burns. On 7/20/16 at 7:00 a.m. the temperatures of the coffee being served to residents was checked. The temperature of the coffee in the urn located on the Cherry Blossom Unit registered 160 degrees Fahrenheit (F). The coffee in the urn on the Willow Unit measured 170 degrees Fahrenheit (F). An observation of coffee being delivered to residents on both of these units was conducted, the last cup of coffee was delivered at 7:50 a.m., the temperature of the test cup of coffee was obtained and was 143 degrees Fahrenheit resulting in identification of an immediate jeopardy situation. On 7/21/16 at 1:50 p.m. at the request of the surveyor, the temperature of hot water from a water dispensing machine for residents, was obtained by RN (Registered nurse) # 1. The temperature of the hot water was 173.8 degrees Fahrenheit, resulting in continued identification of an immediate jeopardy situation. The findings include: Resident # 9 was admitted to the facility on [DATE], readmitted on [DATE], and readmitted again on 6/29/16 with [DIAGNOSES REDACTED]. The most recent MDS, (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/3/16 coded Resident # 9 as understood by others and able to understand others. Resident # 9 was coded as scoring 3 of a possible 15 on the Brief Interview for Mental Status (BIMS) in Section C, Cognitive Patterns, indicating the resident was not cognitively intact. Review of Section G Functional status documented under G0110 H that Resident # 9 was able to eat with Supervision oversight and Setup help only. Further review under section D 0400 Functional Limitation in Range in Motion documented that Resident # 9 had no impairment in her upper extremity. Section K Swallowing/Nutritional Status under K0300 Weight Loss - Loss of 5 % or more in the last month or loss of 10 % or more in the last 6 months was coded as 0 indicating No. Review of an Occupational Therapy Evaluation & Plan of Treatment, dated 9/9/15, documented the use of adaptive equipment as needed and sippy cup with handle to increase independence with self-feeding. Staff interview and observations during the days of the survey revealed that Resident # 9 did use the sippy cup to consume beverages. Observation on the days of the survey revealed that Resident # 9 was independent with feeding after setup. A Rehabilitation Screening was completed after Resident # 9 was readmitted to the facility on [DATE] the recommendations are as follows: Physical Therapy: Pt (patient) is not a rehab (rehabilitation) candidate at this time. Occupational Therapy: No skilled OT (occupational therapy) services indicated. Speech Language Pathology: No skilled ST (speech therapy) services indicated at this time. Resident # 9 was unable to be interviewed due to her cognition level. CDC (Centers for Disease Control) DEFINITION OF TYPES OF BURNS: (2) First-Degree Burns: First-degree burns involve the top layer of skin. Sunburn is a first degree burn. Signs: · Red · Painful to touch · Skin will show mild swelling Second-Degree Burns: Second-degree burns involve the first two layers of skin. Signs: · Deep reddening of the skin · Pain · Blisters · Glossy appearance from leaking fluid · Possible loss of some skin Third-Degree Burns: A third-degree burn penetrates the entire thickness of the skin and permanently destroys tissue. Signs: · Loss of skin layers · Often painless. · Skin is dry and leathery · Skin may appear charred or have patches that appear white, brown, or black On 7/20/16 at 12:15 p.m. Resident # 9 was sitting up in bed, lunch tray was in the room on the tray table and a sippy cup (3) was observed. The sippy cup contained juice. On 7/21/16 at 8:10 a.m. Resident # 9 was eating breakfast with a sippy cup on the tray and again the cup contained juice. Review of a nurse's note dated 6/10/16 at 14:28 (2:28 p.m.) documented, This writer was called to resident's room at 7:30 a.m. by the CNA (certified nursing assistant) assigned to her, according to her; resident has spilled hot coffee on her right thigh. The CNA was instructor (sic) to leave the brief open and not to put anything tight on her. Resident keeps yelling and screaming. New order received to start Hydrocortisone cream 0.5% (4) and Tylenol (5) Extra strength Q (every) 6 PRN (as needed). Name of physician notified and name of RP (responsible party) notified. This note was signed by LPN (licensed practical nurse) # 9. Review of the care plan with a Focus of ADL (activities of daily living) Self Care Performance Deficit initiated 5/22/12 and revised most recently on 6/16/16 (after the incident on 6/10/16), documented under Interventions -- EATING: ms. (sic) (name of Resident # 9) is able to hold cup, feed self, eat finger foods independently. (Name of Resident # 9) uses sippy cup for all liquids. (Name of Resident # 9) is to have direct supervision with all hot liquids. During an interview on 7/20/16 at 9:10 a.m. with ASM (administrative staff member) # 2, interim director of nurses, a request was made for the facility investigation for this incident. During an interview on 7/20/16 at 12:45 p.m. with CNA (certified nurse assistant) # 8, CNA # 8 stated, (Name of Resident # 9) has used a sippy cup for long time and now after the burn must have supervision when drinking hot liquids. CNA # 8 was the CNA assigned to Resident # 9 on the morning of the incident (6/10/16). CNA # 8 stated that she heard Resident # 9 yelling and screaming. CNA # 8 stated it was not unusual for the resident to yell and scream. That is how she calls for help and had been doing so all morning. When this happens staff would go in and talk to the resident and calm her down. CNA # 8 stated that when she went into the room Resident # 9 was upset (Resident # 9) was on fluid restriction and she (Resident # 9) wanted something to drink. CNA # 8 stated that she (CNA # 8) asked Resident # 9 what she wanted to drink and offered her water, juice, or coffee. Resident # 9 stated that she wanted coffee. CNA # 8 then went to the kitchen to get Resident # 9's sippy cup. After she got the sippy cup she (CNA # 8) went to the pantry and put coffee into the sippy cup replacing the lid and then returned to Resident # 9's room and put the sippy cup with the coffee on the over bed table within the Resident's reach. Resident # 9 had been yelling and screaming all morning. A short time later, about 5 minutes after she (CNA #8) had taken the coffee to the Resident she was yelling and screaming again. When CNA # 8 went into the room CNA # 8 saw that she (Resident # 9) had spilled the coffee on herself. CNA # 8 immediately laid her (Resident # 9) down and removed the sheets. The area was red right away. CNA # 8 immediately called the nurse and he came in and looked at it. CNA # 8 further stated that Resident # 9 never had any problem with spilling things and she (Resident # 9) only needed to be supervised occasionally. CNA # 8 stated that they now know she (Resident # 9) must be supervised when she has any hot liquids. During an interview on 7/20/16 at 12:55 p.m. with CNA # 3, CNA # 3 stated that they were passing trays. Resident # 9 usually screams and hollers a lot but this time it was more than normal so they checked on her right away. They were in the room in less than a minute. They, (CNA # 8 and CNA # 3) saw the wet sheets, laid her back and removed the sheets and dried her off. One could tell right away that she was burned. CNA # 3 laid her back and dried her. Right when it happened they did not see any blisters. They called for the nurse to come in and he did right away. They were concerned about transfers as Resident # 9 was a Hoyer lift transfer and the strap would go right over the reddened area. But when they came to transport her to dialysis they (transport staff) transported her by stretcher. During an interview on 7/20/16 at 2:20 p.m. with LPN (license practical nurse) # 9, LPN # 9 stated that the aide came and told him that the resident had spilled coffee on herself. He told the aides to not put anything on the reddened area until he called the doctor. When he first saw the area it was just reddened. He thinks maybe a day or so later there was a blister. Several days later they did not see any improvement with the hydrocortisone cream so when the doctor came in to see her he changed the treatment. Physician order dated 6/10/16 documented: Hydrocortisone Cream 0.5 % Apply to Right thigh topically every shift for Redness/Blisters. Signed 6/14/16 this order was discontinued on 6/14/16 and signed the discontinued order on 6/21/16 Another physician order for [REDACTED]. Signed 6/21/16. Review of the clinical record documented that Resident # 9 received Tylenol Extra Strength on the following dates 6/14/16, 6/15/16, 6/17/16, 6/22/16, 6/23/16, and 6/24/16. Review of the nurses' notes indicated that the pain was generalized and that the medication was effective. During an interview on 7/20/16 at 3:05 p.m. with LPN (licensed practical nurse) # 2, LPN # 2 stated that Resident #9 can tell you if she has pain. On 6/14/16 the physician wrote an order for [REDACTED]. Signed 6/14/16 On 6/16/16 the physician ordered: Resident is to have direct supervision with all hot liquids. Do not leave any hot liquids within reach, every shift. Signed on 6/21/16 During an interview on 7/21/16 at 1:50 p.m. with LPN # 9, LPN # 9 stated, The area was initially just red then a blister appeared, not exactly sure when the blister appeared, maybe the following day, but initially it was just red. Review of the incident report documented the same information as the nurse's note written by LPN # 9 on 6/10/16. (Note: Subjective, Objective, Assessment, Plan (S.O.A.P. NOTES (7)) Review of the physician progress (written by ASM (administrative staff member) # 4, Resident # 9 ' s attending physician) notes dated 6/14/16 at 0710 AM: S. Asked by nurse to eval (evaluate) Pt. (patient) spilled coffee on inside of R. (right) thigh 3d (days) ago. Treated w (with)/hydrocortisone cream and has developed 4 in (inch) x 4 in red [DIAGNOSES REDACTED]tous abrasion over site. Pt (patient) denies pain . Using hydrocortisone area . O. Inner R. thigh w (with)/6in x 6 in [DIAGNOSES REDACTED]tous red patch w/clear margins and old scaled dead skin that has been peeled away .A. 1. Stage 2 burn (second degree) inner R. thigh w/o (without) signs of infection .P.1. Wound is healing well. Change to Silvadene cream bid, wound care. Review of physician progress notes [REDACTED]. Pt. (patient) tx (treatment) w (with)/Silvadene cream for spilled coffee on R. thigh. Asked by nurse last night to look at wound today. Developed eschar (8) and dry scaly skin over inner side of R. thigh. Pain under good control. No redness, no bleeding, no spitting out .O.R. inner thigh w/6 in x 6 in burn w/clear edges and brown eschar throughout entire wound .A. 1. Burn R. thigh now w/eschar development .P .4. Need wound care eval (evaluation) for eschar on R. leg. Will likely need debridement. Refer to Wound Clinic. Cont. (continue) w/ current wound care. Review of the clinical record documented on 6/20/16 at 12:56: New order received for wound clinic consult, appointment scheduled for Monday 6/27/16 at 2pm, pickup at 1 pm by (name of transport company) at 1pm .Call made to (name of RP (responsible party)), message left for RP to call back. During an interview on 7/21/16 at 3:38 p.m. with ASM # 4, (Resident # 9's attending physician), ASM # 4 stated that the area was just a red irritated spot on the leg so he started treatment right away with Hydrocortisone cream as he did not want to delay treatment. He stated that on his very next rounds he assessed the area (he did not remember the exact time frame). When he did assess the wound he changed the treatment to Silvadene. The wound is improving; the eschar was the size of a silver dollar and now is the size of a dime. During an interview on 7/20/16 at approximately 3:00 p.m. with RN (registered nurse) # 1 Resident # 9's wound care was discussed. RN # 1 stated that wound care was done two times a week on Monday and Thursday on the 3 to 11 shift. When this was discussed further RN # 1 stated that it might be possible to do the wound care on Thursday (7/21/16) before Resident # 9 went to dialysis. On 7/21/16 at approximately 8:15 a.m. RN # 1 was reminded of the request to see Resident # 9's wound care. RN # 1 stated that she would tell staff caring for Resident # 9, to notify this surveyor when the care was being completed. This attempt was not successful and the surveyor was not notified. During an interview on 7/22/16 at 6:21 a.m. with LPN # 12, LPN # 12 stated, I remember it was just red then a blister about the size of a half dollar. I did not feel that it was improving and I knew that Silvadene Cream was good for burns so when the Doctor (ASM # 4) came in on rounds on the morning of 6/14/16, I grabbed him. He looked at the burn and changed the treatment to Silvadene cream. During an interview on 7/22/16 at 6:30 a.m. with LPN # 13, LPN # 13 stated, I do not remember when I first saw the burn - I had been off a few days and I do not believe I saw the burn until 6/14/16 and at that time it was just a big bubble and then in the next few days it popped. The first I remember we were applying Silvadene cream and a dressing. During an interview on 7/22/16 at 8:50 a.m. with OSM (other staff member) # 7, the pharmacist, when OSM # 7 was asked about the uses of Hydrocortisone Cream OSM # 7 stated, It is for skin irritations, rashes, for non-descript skin irritation, eczema-it is used for tons of things. When asked if it would be specifically used for burns/blisters, OSM # 7 stated, It could be used for irritation/swelling, but it would be out of my scope of practice to say if it could be used on burns. On 7/20/16 at 6:50 a.m., an investigation of the coffee temperatures was conducted by two members of the survey team. The kitchen was entered and it was found that coffee is brewed in the kitchen and put into urns. The urns are moved to the Unit nourishment rooms. At 7:00 a.m. the nourishment rooms were observed to have their urns in place and the survey team requested that the temperatures of the coffee in each urn be measured. The urn located on the Cherry Blossom Unit registered 160 degrees Fahrenheit (F). The urn on the Willow Unit measured 170 degrees F. The survey team members requested that a cup of coffee be poured for each of them and when they tried to drink the coffee they scalded their tongues. (The cup of coffee that was poured for the survey team was poured by LPN (licensed practical nurse) # 2.) At 7:15 a.m. on 7/20/16 when the two survey team members tasted the coffee CNA # 11 was asked to do the same. CNA (certified nurse's assistant) # 11 stated, It's hot for sure. It's too hot to drink right now. CNA # 11 further stated that staff pours the coffee, then puts lids on and then the coffee sits for 5 minutes. The survey team followed the staff as they distributed the coffee and when the last cup was delivered the coffee was temped again and the coffee registered 143 degrees. OSM (other staff member) # 9, dietary staff, was the staff that took the temperatures.) During an interview on 7/20/16 at 7:05 a.m. with CNA # 10, CNA # 10 was asked how staff knows which Residents get hot beverages. CNA # 10 stated it is on their meal ticket. The nurse will tell the CNAs if a resident is not allowed to drink a hot beverage without supervision. When asked if a resident wanted hotter coffee what would be done, CNA # 10 stated you heat it up for 30 seconds or a minute in the microwave. During an interview on 7/20/16 at 7:10 a.m. with CNA # 11, CNA # 11 was asked what one would do if a resident requested another cup of coffee or wanted the current cup reheated. CNA # 11 stated that one should not heat it up but should get another cup from the pantry. When asked if any residents on her hall required supervision with drinking hot liquids, CNA # 11 stated not on this hall. CNA # 11 could identify a resident on another hall that required supervision and gave the name of Resident # 9. Staff finds out who needs supervision or assistance through report. Also, they would use their judgment. At approximately 7/20/16 8:06 a.m. a request was made of ASM (administrative staff member) # 1, the administrator, for all incidents for June and July 2016. Later it was determined that the survey team needed to review incidents since the last survey and on 7/21/16 at 2:45 p.m. a request was made of ASM # 1, ASM # 2, the interim director of nurses, and ASM # 3, the quality assurance staff member, for this information. Review of the facility incident reports revealed there had been no other reported burns since the last survey ending on date 7/23/15. On 7/20/16 at 9:13 a.m., the team leader placed a telephone call to the supervisor at the Office of Licensure and Certification, State Department of Health, and informed the supervisor of their findings/concerns. A return call was received at 9:40 a.m. supervisory staff confirmed Immediate Jeopardy for failure to ensure an environment free from accidents and hazards; hot coffee of sufficient temperature to cause tissue injury was available and served to residents. During an interview on 7/20/16 at approximately 10:00 a.m. with ASM (administrative staff member) # 1, the administrator, ASM # 2, the interim director of nurses, and ASM # 3, the quality assurance staff member, the concern for the first and second degree burns that Resident # 9 received due to hot coffee being spilled was revealed. At this time a request was made for the facility policy on hot beverages. The observation of the coffee in the nourishment room with coffee in the urn at a temperature of 170 degrees (F) was also revealed. ASM # 1, ASM # 2, and ASM #3 were informed that the facility was in immediate jeopardy at a level four pattern, which constituted Substandard Quality of Care, as one resident (Resident #9) had already been harmed with second degree burns by a hot coffee spill, and the temperatures of coffee currently being served to residents had and could harm other residents in the facility. The facility management team was informed an acceptable plan of correction would need to be presented. On 7/20/16 at approximately 11:30 a.m. ASM # 3 stated that there was no policy on hot beverages, ASM # 3 stated that one was being written. A copy of this policy was presented on 7/20/16 at 4:25 p.m. On 7/20/16 at 5:30 p.m., ASM (administrative staff member) # 1, the administrator, ASM # 2, the interim director of nurses, and ASM # 3 the quality control staff member, presented an initial plan of correction for the removal of immediate jeopardy to the survey team. This plan included the following points: 1. Coffee and hot water holding containers were removed from resident nourishment rooms and unsupervised common areas. Testing completed on coffee temperature beginning at 167 degrees. Without a lid, temperature dropped to 147 in 6 minutes. Placed lid on cup and waited 7 minutes and coffee temperature was 136 degrees and palatable to the tester. 2. All residents have the potential to be affected by this deficient practice 3. Dietary staff were educated to take temperature of coffee and hot water in holding containers prior to delivering to nourishment rooms or common areas. Temperature is not to exceed 145 degrees in holding containers. Policy created on 07/20/2016 and all staff will be educated to policy, which includes no reheating hot beverages. Fresh pours from the holding containers will not be served above 130 degrees. Creamer and/or ice can be added to reduce the temperature. 4. Dietary staff will maintain a temperature log of coffee and hot water holding container temperatures prior to delivering holding containers to nourishment room or common areas. Dietary Manager of designee will monitor temperature logs daily for 2 weeks and then weekly thereafter. All findings will be reviewed and reported at Quarterly QA. 5. 07/20/16 Communication to Staff: Personal education provided to all staff scheduled on Day/Evening/Night Shift on 7/20/16. Education will be provided on a daily basis to all staff scheduled by Management Staff or Designee. Administrator or designee will monitor staff in need of education daily. Phone calls, emails, or shift message may be utilized to reach staff that work less frequently. Signage posted in Nourishment Room of maximum hot beverage temperature of 130 degrees and instructions on how to reduce temperature with ice or chilled creamer. Thermometers provided in Nourishment Rooms to validate temperature if necessary. Temperature Testing: Director of Dining Services conducted multiple temperature and taste tests with coffee poured from holding container to cup to include covering container, adding ice, and/or creamer. State Surveyors participated and validated the temperature palatability. Supporting Documentation: Attached literature utilized to determine safer serving temperatures to reduce the risk of burn injuries in a nursing facility setting. To confirm that staff had been educated per the PoC the survey team interviewed staff on all facility nursing units to ensure that the education was completed and understood. There were no issues with staff understanding. The interviews are as follows: On 7/20/16 at 5:20 p.m., CNA (certified nurse's assistant) # 14 was interviewed regarding hot beverage temperatures. CNA # 14 stated that staff was not allowed to reheat beverages in the microwave. If a resident requests a hotter beverage, the staff must get a new hot beverage from the nourishment room. The temperature was not to be hotter than 130 degrees (F). CNA # 14 stated that each hall had a thermometer and they were to take the temperature before giving the beverage to a resident. On 7/20/16 at 5:20 p.m., CNA# 17 was interviewed regarding hot beverage temperatures. She stated: Our coffee was too hot. We will be setting it back out at a lower temperature from now on. We are not allowed to reheat it in a microwave. We can add ice to get the temperature down to 130 degrees (F). On 7/20/16 at 5:30 p.m. RN (registered nurse) # 7 was interviewed regarding hot beverages. RN # 7 stated that beverages that were to be served to residents' could be no hotter than 130 degrees (F). RN # 7 had the thermometer in her pocket at the time of the interview. On 7/20/16 at 5:30 p.m. LPN (licensed practical nurse) # 8 was interviewed regarding hot beverages. LPN # 8 stated that beverages hotter than 130 degrees (F) were not to be served to Residents. LPN # 8 stated that each unit had thermometer to measure the temperature. On 7/20/16 at 5:35 p.m., CNA # 16 was interviewed regarding hot beverage temperatures. She stated: Our coffee was too hot. We are not allowed to reheat it in a microwave. We can add ice to get the temperature down to 130 degrees F. On 7/20/16 at 5:40 p.m., CNA # 13 was interviewed regarding hot beverage temperatures. She stated: Our coffee was too hot. We will be setting it back out at a lower temperature from now on. We are not allowed to reheat it in a microwave. On 7/20/16 at 5:42 p.m., CNA# 8 was interviewed regarding hot beverage temperatures. She stated that the staff is no longer allowed to reheat beverages in the microwave, and that the hot beverage temperatures are not to exceed 145 degrees in the urn and 130 when served to residents. On 7/20/16 at 5:45 p.m., CNA # 12, and RN # 2 were interviewed regarding hot beverage temperatures. They stated that CNAs cannot reheat beverages in the microwave. If a resident requests a hotter beverage, the staff must get a new hot beverage from the nourishment room. They stated that if a beverage is too hot, the staff must remove the top to let the beverage get cooler. On 7/20/16 at 5:47 p.m., CNA# 15 was interviewed regarding hot beverage temperatures. She stated that the staff is no longer allowed to reheat beverages in the microwave, and that the hot beverage temperatures are not to exceed 145 degrees in the urn and 130 when served to residents. On 7/20/16 at 5:30 p.m. and ASM # 1, the administrator, ASM # 2, the interim director of nursing, and ASM # 3, were informed that the plan of correction was approved and the immediate jeopardy abated. On 7/21/16 at 1:50 p.m. a member of the survey team was able to obtain hot water from a machine on Magnolia Unit. The machine, Pure Water Resource, dispensed both hot and cold water. The water was noted to be steaming; the cup was not secure as the water came out of the machine. The survey team member asked RN (registered nurse) # 1, to check the temperature of the water. RN # 1 placed a new, clean cup on the machine to catch dispensed water. The two red dots on the machine were pressed and hot water was dispensed. The stream was fast and the cup started to slide off the machine and RN # 1 caught the cup. RN # 1 obtained a temperature from the newly acquired hot water; the temperature was 173.8 degrees Fahrenheit. RN # 1 stated the water was too hot. When asked what the purpose of the machine was RN # 1 stated it replaced the old water fountain and was a hydration station for the residents and to be used by residents. On 7/21/16 at 2:16 p.m. the team leader contacted the supervisory staff regarding the above concern. Supervisory staff confirmed at 2:32 p.m. that the IJ situation from the previous day was not abated and that facility administrative staff should be notified. Administrative staff to include ASM # 1, the administrator, ASM # 2, the interim director of nursing, and ASM # 3, the quality assurance staff member, was asked to meet with the survey team at 2:45 p.m. and were informed of the new finding, that the IJ was not abated, and that a PoC addressing the new finding would be necessary. During an interview on 7/21/16 at 2:45 p.m. with ASM (administrative staff member) # 1,the administrator, ASM # 1, and ASM # 3, quality assurance staff member, Administrative staff members were informed of the finding of the Water Cooler being able to dispense hot water at a temperature of 173 degrees Fahrenheit; therefore the Immediate Jeopardy was not abated. Administrative staff was informed that there needed to be a permanent solution and the Plan of Correction needed to be amended. A request was made for any incidents since the last survey (7/23/15 to today 7/21/16) for any incidents of Residents being burned. During an interview on 7/21/16 at 3:13 p.m. with OSM (other staff member) # 8, the Pure Water Resource Representative, OSM # 8 stated that he sent an email to corporate requesting instructions on how to permanently disable the hot water function. OSM # 8 stated it would likely take 24 hours to get the instructions and as soon as the instructions are received a technician will be sent to make the modification. In the meantime the water cooler can be made inoperative by totally removing the power cord. Shortly after this conversation with OSM # 8, (7/21/16 at approximately 3:20 p.m.) ASM (administrative staff member) # 1, the administrator, produced the power cords stating that they would be locked in her office. Two members of the survey team went out to inspect the water coolers and found that when you pressed the hot water buttons no hot water, or any water came out. On 7/21/16 at 4:36 p.m., an updated PoC was presented by ASM (administrative staff member) # 1, the administrator, ASM # 2, the interim director of nurses, and ASM # 3 the quality control staff member, for the removal of immediate jeopardy. This plan included the following points: Updated POC appears in italic & underlined. 1. Coffee and hot water holding containers were removed from resident nourishment rooms and unsupervised common areas. Testing completed on coffee temperature beginning at 167 degrees. Without a lid, temperature dropped to 147 in 6 minutes. Placed lid on cup and waited 7 minutes and coffee temperature was 136 degrees and palatable to the tester. Water Cooler located in resident hallway dispensed hot water at a temperature of 173 degrees on 07/21/16. Water Cooler was immediately turned off and upon notification to Administrator and after speaking to the Vendor, the power cords were removed and placed in Administrator's office. 2. All residents have the potential to be affected by this deficient practice 3. Dietary staff were educated to take temperature of coffee and hot water in holding containers prior to delivering to nourishment rooms or common areas. Temperature is not to exceed 145 degrees in holding containers. Policy created on 07/20/2016 and all staff will be educated to policy, which includes no reheating hot beverages. Fresh pours from the holding containers will not be served above 130 degrees. Creamer and/or ice can be added to reduce the temperature. Vendor was immediately contacted and spoke to Administrator and Medical Facilities Inspector Team Lead. Vendor advised contacting Manufacturer to get written instructions on how to permanently disable hot water function. Email sent to Administrator to confirm. Service Technician scheduled to service water cooler and make modifications on 07/22/16. 4. Dietary staff will maintain a temperature log of coffee and hot water holding container temperatures prior to delivering holding containers to nourishment room or common areas. Dietary Manager of designee will monitor temperature logs daily for 2 weeks and then weekly thereafter. All findings will be reviewed and reported at Quarterly QA. 5. 07/20/16 & 07/21/16 Attachments: 1. Hot Beverage Policy 2. Hot Liquids Temperature Monitoring Form 3. Copy of sign that will be placed next to each hot beverage containers with instructions not to serve beverages above 130 degrees and instructions on how to lower the beverage temperature and to check the beverage temperature with the provided thermometer. 4. Education provided and the sign-in sheets 5. Copy of email from vendor to Administrator (from water cooler vender) The survey team confirmed that the power cords were removed from the water coolers. At 4:36 p.m. on 7/21/16 the survey team shared with the administrative staff that the immediacy was abated. On 7/22/16 at 7:45 a.m., a CNA was observed taking the temperature of coffee from the urn in the kitchenette. The coffee was temped at 129. The CNA then placed the covered coffee out on a table in the hallway until 8:00 a.m. when meal trays arrived. At 8:08 a.m., right before Resident #24 received

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure 1 of 27 residents; Resident #20, was free of a significant medication error. The facility staff failed to ensure the resident was continued on his antidepressant medication [MEDICATION NAME], when Resident #20 was admitted on [DATE]. The error of Resident # 20 not receiving the [MEDICATION NAME] was not discovered until 3/5/16, at which time the medication was restarted. Resident #20 was without his antidepressant medication for approximately 2 weeks after having been abruptly stopped. On 3/8/16 the resident attempted suicide. The findings include: Resident #20 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident was admitted with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was the admission comprehensive assessment with an ARD (Assessment Reference Date) of 2/29/16. The resident was coded as being severely cognitively impaired in ability to make daily life decisions, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident's mood score was a 4 out of a possible 27. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, and toileting; limited assistance for hygiene and ambulation; independent for eating; and was at times incontinent of bowel and bladder. A review of the clinical record revealed the following: On 2/22/16 the resident was admitted to the facility, with hospital discharge papers that included medications the resident was taking. The medications were listed as follows: Discharge Medications New medications: [REDACTED] [MEDICATION NAME] ([MEDICATION NAME] an antibiotic (1)) 500 mg (milligrams) tab (tablet) Q (every) 12 hours [MEDICATION NAME] (used to treat high blood pressure (2)) 20 mg tab, take 100 mg every other day. Continued Medications [MEDICATION NAME] Acid (Vitamin C used to replace loss of Vitamin C (3)) 500 mg (milligram) daily Aspirin (used to decrease the risk of blood clotting (4)) 81 mg daily Atorvastatin (used to treat high cholesterol (5)) 10 mg QPM (every evening) [MEDICATION NAME] ([MEDICATION NAME] XL an antidepressant (6)) 150 mg tab ER (extended release) BID (twice daily) Carvdilol ([MEDICATION NAME]) (used to treat heart failure (7)) 6.25 mg BID (twice daily) [MEDICATION NAME]/Salmeterol ([MEDICATION NAME] Diskus used to prevent symptoms of asthma and [MEDICAL CONDITION] (8)) 250/50) 1 puff INH (inhalation) BID [MEDICATION NAME] (used to treat [MEDICAL CONDITION] (9)) 10 mg BID Montelukast ([MEDICATION NAME]) (used to treat asthma (10)) 10 mg daily Mu-Vits-Min ([MEDICATION NAME] Silver) (used to replace / boost vitamins and minerals (11)) 1 tablet daily Tamsulosin ([MEDICATION NAME]) (used to treat enlarged prostate (12)) 0.4 mg QPM Zinc (used to replace / boost zinc in the body (13)) 50 mg tablet, take 100 mg BID Discontinued Medications [MEDICATION NAME] 100 mg daily A review of the admission orders [REDACTED]. A review of the clinical record revealed the following: On 3/2/16 at 11:47 a.m., the Director of Social Services (OSM #10 - Other Staff Member) wrote a note that documented, .Resident occasionally presents with sad facial expression which is easily altered with conversation. Resident states his two children and spouse are very supportive in his care On 3/5/16 at 6:25 p.m., LPN #15 (Licensed Practical Nurse) documented, After lunch Pt (patient) stated, I don't feel good. Pt unable to voice complaint and requested to call daughter. Pt also made repeated comments stating I am ready to go home to my Lord. Daughter in to facility. Pt continued to tell daughter that he did not feel well but could not tell her why. Daughter stated that Pt does have Hx (history) of depression. Daughter concerned that Pt may have UTI (urinary tract infection) D/T (due to) confusion. New order received from (name of doctor) 1) Urinalysis (UA). Family at bedside and made aware of new order. VSS (vital signs stable) at this time. Will cont (continue) to monitor. On 3/5/16 at 9:31 p.m., LPN #16 documented, Urine culture pending at this time; UA without bacteria or leukocytes. MD (medical doctor) aware. On 3/5/16 at 9:32 p.m., LPN #16 documented, Spoke with daughter regarding pt.'s worsening depression; daughter requesting that pt.'s antidepressant be increased. Upon review of pt.'s orders, no antidepressant was on medication list. Clarification received from MD (medical doctor) to restart [MEDICATION NAME] XL ER 150 mg po (by mouth) BID as pt. had been on this prior to admission to (name of facility.) First dose to be administered tonight. On 3/7/16 at 2:47 p.m., RN #4 (Registered Nurse) documented, patient c/o (complained of) being tired, 120/70 (blood pressure), 96% stat (sic) (saturation) O2 (oxygen) at 2L (liters) prior 92%, pulse 68 resp (respirations) 20. monitor for any changes. patient made comfortable in bed to rest. On 3/7/16 at 10:45 p.m., LPN #17 documented, Pt receiving skilled services r/t (related to) RLE (right lower extremity) [MEDICAL CONDITION]. A+OX2 (alert and oriented to two spheres) and forgetful at times. no c/o (complaints of) pain or discomfort. RLE remains red and warm to touch with dry scabs, wife was in this evening, call bell within reach, will continue to monitor. On 3/8/16 at 1:14 a.m., LPN #6 documented, Behavior Demonstrated: Routine rounding on pt, observed pt in room with fork from his dinner, digging into his (L) (left) AC (antecubital) and left side of neck. Redness noted to neck. (L) AC with epidermis broken about 2-3cm (centimeters). Verbalized am tryna (sic.) kill myself, am tired of all this old age. Intervention: Pressure applied to wound, bleeding stopped and wrapped with 4x4 with gauze. BP (blood pressure) 127/89, p (pulse) 86, T (temperature) 98.0, r (respirations) 20 at 94 (% oxygen saturation) RA (on room air) Evaluation: Pt sent to ER (emergency room ) and EC#1 (emergency contact) notified, MD notified. On 3/8/16 at 8:00 a.m., LPN #6 documented, UA (urinalysis) results received: no bacteria noted. Placed in MD's folder for review . This was the last note documented in this clinical record. A review of the hospital record dated 3/8/16 documented, The patient is a [AGE] year old male who is seen in the Emergency Department for suicide attempt. Patient has a history of [MEDICAL CONDITIONS]. He was recently admitted for [MEDICAL CONDITION] and was discharged to local skilled nursing facility. Patient states that since the time of discharge he has felt short of breath and uncomfortable. This has led him to have suicidal thoughts. Patient states, I don't want to be here anymore and describes an incident where he tried to use a fork to stab himself in the neck. He describes disappointment at being unable to penetrate the skin of his neck and so he instead stabbed himself in the arm with the fork. He was able to penetrate the tissues of his elbow with a fork. This got the attention of the workers at the skilled nursing facility who sent him to the emergency department for evaluation. Patient states he has had intermittent chest discomfort, though he denies any chest discomfort at the time of ER evaluation. He repeatedly expresses suicidal thoughts and disappointment that his attempt at harming himself did not result in death. Patient's daughter states that patient has been on [MEDICATION NAME] for a long time, however after transfer to skilled nursing his [MEDICATION NAME] was overlooked and he did not receive it for about 2 weeks. Daughter states this was only restarted 2 days ago. Daughter states the patient's mood has degenerated since being taken off his antidepressant. Further review of the hospital record revealed an emergency room physical dated 3/8/16 that documented, Procedure performed: Laceration repair. Indication: Left arm laceration. Wound was irrigated with 500 cc of saline by technician staff. Local anesthesia was performed with 3 cc of 1% [MEDICATION NAME] without [MEDICATION NAME]. The wound was closed with #7 simple interrupted sutures, 5-0 nylon. Patient tolerated this well. Total closed length was 3 cm. An interview was conducted with LPN #6 on 7/21/16 at 8:57 a.m. She stated that on 3/8/16 she went in to check on the resident. She stated he was sitting on the side of the bed trying to dig in his arm with a fork, stating he wanted to die. She stated she put pressure on it, called 911 and notified the doctor. She stated that it was reported to her that the resident was depressed and not himself, but she was not told anything about [MEDICAL CONDITION]. Regarding the admission medications, she stated another nurse started the admission and did the meds (medications), and that she just finished the admission after change of shift. She stated she did not check the meds that the other nurse had entered. A review of Corrective Counseling / Behavioral Accountability Record from LPN #6's employee file documented, On 2-22-16, did not perform 24 (hour) check on admission of (name of resident) (LPN #6) will ensure that all chart checks will be completed on her scheduled shift. On 7/21/16 at 2:13 p.m., an interview was conducted with LPN #15. She stated that she could not recall much about the resident. She stated the daughter would not let her leave the room so she could take care of other patients, so she called (LPN #16) to assist. On 7/21/16 at 2:21 p.m., an interview was conducted with LPN #16. She stated that on 3/5/16 (LPN #15) had called her to the unit to assist with this resident so that LPN #15 could care for her other residents. She stated that the family felt that something was wrong. She stated his vital signs were normal, but that the resident stated he felt like he was crawling out of his skin. She stated the daughter felt he was acting unusual. She stated that recent blood work was normal. She stated a UA was done and that it was normal too. She stated she reviewed his meds and that there was nothing new. She stated the daughter asked about increasing the antidepressant, and that she reviewed the resident's meds and noted that the [MEDICATION NAME] was never ordered on admission. She stated she was unaware of the resident's statements about wanting to go home to be with the Lord. She stated if LPN #15 had told her that, she would have notified the social worker and doctor, and put the resident on suicide watch. On 7/21/16 at 11:30 a.m., an interview was conducted with the social worker, OSM #10. She stated that anytime someone is suicidal, the social worker should be informed, to see if they have a plan and don't want to live anymore and find out if there is a desire, plan, or if they just mean that they are ready when their time comes. On 7/21/16 at 11:57, OSM #10 returned to the surveyor, after reviewing the record, and stated that she was not notified of the comment that the resident was ready to go home to be with the Lord, but that she should have been notified. She stated that after this incident, that she had incorporated training on suicide prevention into the annual abuse trainings that were provided in March, 2016 for all staff. A copy of an email that was sent from the (former) DON (Director of Nursing, Administrative Staff Member (ASM) #3, the current corporate QA nurse) to all of the facility nurses staff, dated 3/8/16 documented, We've had a med error that resulted in a negative outcome to a patient from not complying with process of a second check of medications and not completing 24 hour chart audit for new orders. Admitting nurse must compare discharge summary to med list and note second check on admission orders [REDACTED]. Record 24 hour check on all new orders noted in last 24 hours. If there aren't any new orders than no notation is needed, as long as they were noted on the night they were received. There should be few of these as most orders are entered by the nurse, vs (versus) the MD/NP/PA (medical doctor/nurse practitioner/physician's assistant). As of tonight, please be sure that all new admission orders [REDACTED]. Leave a copy of the transfer summary and other summary in my box at the Willow and CB Nurses Stations. This process will be monitored and reported out at monthly QA meetings. The facility enacted a plan of correction which contained the following 5 points: 1. MD was immediately notified of medication transcribing error on 3/5/16 once discovered. Missing medication order was discovered when resident started exhibiting new behaviors of depression. Order obtained from MD to restart antidepressant medication on 3/5/16. RP (responsible party) notified that resident had not been receiving medication since resident arrived to facility on 2/22/16. Resident received dose on 3/5/16. When nurse found Resident inflicting self-harm on 3/8/16, resident was immediately assessed and treated and sent to the ER (emergency room ) for medical treatment and psychological evaluation. MD (medical doctor) and RP (responsible party) were notified. 2. All Residents with depression not receiving their prescribed medications and / or having [MEDICAL CONDITION] have the potential to be affected by this deficient practice. 3. All Nurses educated via email on 3/8/16 of medication transcription error from Discharge Summary upon admission to facility. Policy 6110-118. Management of Physician Order Sheet, etc., was provided for education of requirement for double check. Staff were educated by Social Services via scheduled Mandatory Abuse and Suicide Policy throughout March 2016. Nurse responsible for second check was counseled with verbal written warning. 4. For 30 days, all new admission orders [REDACTED]. Follow up audits of 25% of new Admissions were completed for next 60 days by DON or designee. Social Services educated to review high risk progress notes during scheduled work hours. All results and findings will be presented and reviewed at the Quarterly QA meeting. 5. 4/15/16. During the survey, a current resident (Resident #22) was identified as having made statements on 7/20/16 of [MEDICAL CONDITION]. A review of his record revealed immediate action by facility staff and notification of the physician. Resident #22 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent comprehensive MDS was the admission MDS with an ARD of 5/17/16. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident scored a 0 on the Mood summary (Section D of the MDS). The resident required extensive care for bathing; limited assistance for transfers, dressing, and toileting; was independent for eating; and was occasionally incontinent of bladder and had an ostomy for bowel. Interviews conducted with LPN #6 on 7/21/16 at 8:57 a.m., LPN #5 on 7/21/16 at 11:35 a.m., LPN #9 on 7/21/16 at 1:50 p.m., LPN #15 on 7/21/16 at 2:13 p.m., and LPN #16 on 7/21/16 at 2:21 p.m., revealed staff were aware of the procedures for ensuring admission orders [REDACTED] A review of the facility policy, Management of Physician Order Sheet, Physician order for [REDACTED]. Admitting nurse will review and validate accuracy of orders, and acknowledge as second check. The night nurse will complete triple check of admission orders [REDACTED]. Once a physician signs a physician order sheets, a new medication and or treatment cannot be added. New orders are written on Physician's Interim/Telephone or noted via fax form. All ordered medications must have a [DIAGNOSES REDACTED]. 2. For the first ninety days, the physician order sheet must be signed every thirty days, and thereafter only every sixty days. 3. A Licensed Nurse transcribes orders into electronic medical record, with inclusion of the date of order, drug name, dosage, time or frequency, and route of administration Treatments can be done with a specific time, or if can be identified as needing to be done during a shift, example is 7-3, or 3-11. A second Licensed Nurse must also review the orders for accuracy and completeness of the transcription process and write reviewed with date time and signature. 4. The Licensed Nurse performs this verification process every 30 days. This process is completed by examining current orders and Telephone Orders that have been written from the date of the Nurse signature on the preceding POS. 5. All new telephone orders that are transcribed prior to physician signature on POS must be added to the printed POS. 6. It is the responsibility of the 11-7 shift to review these POS, as a second check to be sure all information is accurate. The nurse should initial each sheet to identify that this second check has occurred. [MEDICATION NAME] ([MEDICATION NAME]) is indicated for the treatment of [REDACTED]. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Advise patients regarding the following issues and to alert their prescriber if these occur while taking [MEDICATION NAME]. Suicidal Thoughts and Behaviors: Instruct patients, their families, and/or their caregivers to be alert to the emergence of anxiety, agitation, panic attacks, [MEDICAL CONDITION], irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Advise families and caregivers of patients to observe for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. What else do I need to know about antidepressant medicines? · Never stop an antidepressant medicine without first talking to a healthcare provider. Stopping an antidepressant medicine suddenly can cause other symptoms. This information was obtained from the website: <http://druginserts.com/lib/rx/meds/[MEDICATION NAME]-1/> On 7/21/16 at 12:40 p.m., the Administrator (ASM #1) and the Corporate QA nurse (ASM #3) were made aware of the concerns. COMPLAINT DEFICIENCY PAST NON-COMPLIANCE References: (1) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 6.html>> (2) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 2.html>> (3) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 3.html>> (4) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 8.html>> (5) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 5.html>> (6) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 3.html>> (7) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 2.html>> (8) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 3.html>> (9) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 8.html>> (10) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 4.html>> (11) Information obtained from <http://www.webmd.com/drugs/2/drug-9881-5249/[MEDICATION NAME]-silver-oral/multivitamins-includes-[MEDICATION NAME]-vitamins-chewable---oral/details#uses <http://www.webmd.com/drugs/2/drug-9881-5249/[MEDICATION NAME]-silver-oral/multivitamins-includes-[MEDICATION NAME]-vitamins-chewable---oral/details>> (12) Information obtained from <<https://medlineplus.gov/druginfo/meds/a 2.html>> 13) Information obtained from <<https://medlineplus.gov/minerals.html>>

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to follow professional standards of practice for 3 of 27 residents in the survey sample; Resident #20, #16, and #6. 1. For Resident #20, the facility staff failed to accurately transcribe admission medication orders from the hospital discharge summary. The facility staff failed to transcribe the antidepressant [MEDICATION NAME] when Resident #20 was admitted on [DATE], thus in effect, causing the resident to stop the medication immediately, without tapering or monitoring. On 3/8/16 the resident attempted suicide. 2. The facility staff failed to clarify the physicians order for treatment of [REDACTED]. 3. The facility staff failed to clarify an order for [REDACTED].>The findings include: 1. For Resident #20, the facility staff failed to accurately transcribe admission medication orders from the hospital discharge summary. The facility staff failed to transcribe the antidepressant [MEDICATION NAME] when Resident #20 was admitted on [DATE], thus in effect, causing the resident to stop the medication immediately, without tapering or monitoring. On 3/8/16 the resident attempted suicide. Resident #20 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident was admitted with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was the admission comprehensive assessment with an ARD (Assessment Reference Date) of 2/29/16. The resident was coded as being severely cognitively impaired in ability to make daily life decisions, scoring a 4 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident's mood score was a 4 out of a possible 27. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, and toileting; limited assistance for hygiene and ambulation; independent for eating; and was at times incontinent of bowel and bladder. A review of the clinical record revealed the following: On 2/22/16 the resident was admitted to the facility, with hospital discharge papers that included medications the resident was taking. The medications were listed as follows: Discharge Medications New medications: [REDACTED] [MEDICATION NAME] ([MEDICATION NAME] an antibiotic (1)) 500 mg (milligrams) tab (tablet) Q (every) 12 hours [MEDICATION NAME] (used to treat high blood pressure (2)) 20 mg tab, take 100 mg every other day. Continued Medications [MEDICATION NAME] Acid (Vitamin C used to replace loss of Vitamin C (3)) 500 mg (milligram) daily Aspirin (used to decrease the risk of blood clotting (4)) 81 mg daily Atorvastatin (used to treat high cholesterol (5)) 10 mg QPM (every evening) [MEDICATION NAME] ([MEDICATION NAME] XL an antidepressant (6)) 150 mg tab ER (extended release) BID (twice daily) Carvdilol ([MEDICATION NAME]) (used to treat heart failure (7)) 6.25 mg BID [MEDICATION NAME]/Salmeterol ([MEDICATION NAME] Diskus used to prevent symptoms of asthma and [MEDICAL CONDITION] (8)) 250/50) 1 puff INH (inhalation) BID [MEDICATION NAME] (used to treat [MEDICAL CONDITION] (9)) 10 mg BID Montelukast ([MEDICATION NAME]) (used to treat asthma (10)) 10 mg daily Mu-Vits-Min ([MEDICATION NAME] Silver) (used to replace / boost vitamins and minerals (11)) 1 tablet daily Tamsulosin ([MEDICATION NAME]) (used to treat enlarged prostate (12)) 0.4 mg QPM Zinc (used to replace / boost zinc in the body (13)) 50 mg tablet, take 100 mg BID Discontinued Medications [MEDICATION NAME] 100 mg daily A review of the admission orders [REDACTED]. A review of the clinical record revealed the following: On 3/2/16 at 11:47 a.m., the Director of Social Services (OSM #10 - Other Staff Member) wrote a note that documented, .Resident occasionally presents with sad facial expression which is easily altered with conversation. Resident states his two children and spouse are very supportive in his care On 3/5/16 at 6:25 p.m., LPN #15 (Licensed Practical Nurse) documented, After lunch Pt (patient) stated, I don't feel good. Pt unable to voice complaint and requested to call daughter. Pt also made repeated comments stating I am ready to go home to my Lord. Daughter in to facility. Pt continued to tell daughter that he did not feel well but could not tell her why. Daughter stated that Pt does have Hx (history) of depression. Daughter concerned that Pt may have UTI(urinary tract infection) D/T (due to) confusion. New order received from (name of doctor) 1) Urinalysis (UA). Family at bedside and made aware of new order. VSS (vital signs stable) at this time. Will cont (continue) to monitor. On 3/5/16 at 9:31 p.m., LPN #16 documented, Urine culture pending at this time; UA without bacteria or leukocytes. MD (medical doctor) aware. On 3/5/16 at 9:32 p.m., LPN #16 documented, Spoke with daughter regarding pt.'s worsening depression; daughter requesting that pt.'s antidepressant be increased. Upon review of pt.'s orders, no antidepressant was on medication list. Clarification received from MD (medical doctor) to restart [MEDICATION NAME] XL ER 150 mg po (by mouth) BID as pt. had been on this prior to admission to (name of facility.) First dose to be administered tonight. On 3/7/16 at 2:47 p.m., RN #4 (Registered Nurse) documented, patient c/o (complained of) being tired, 120/70 (blood pressure), 96% stat (sic) O2 (oxygen) at 2L (liters) prior 92%, pulse 68 resp (respiration) 20. monitor for any changes. patient made comfortable in bed to rest. On 3/7/16 at 10:45 p.m., LPN #17 documented, Pt receiving skilled services r/t (related to) RLE (right lower extremity) [MEDICAL CONDITION]. A+OX2 (alert and oriented to two spheres) and forgetful at times. no c/o (complaint of) pain or discomfort. RLE remains red and warm to touch with dry scabs, wife was in this evening, call bell within reach, will continue to monitor. On 3/8/16 at 1:14 a.m., LPN #6 documented, Behavior Demonstrated: Routine rounding on pt, observed pt in room with fork from his dinner, digging into his (L) (left) AC (antecubital) and left side of neck. Redness noted to neck. (L) AC with epidermis broken about 2-3 cm (centimeters). Verbalized am tryna (sic.) kill myself, am tired of all this old age. Intervention: Pressure applied to wound, bleeding stopped and wrapped with 4x4 with gauze. BP (blood pressure) 127/89, p (pulse) 86, T (temperature) 98.0, r (respirations) 20 at 94 (% oxygen saturation) RA (on room air) Evaluation: Pt sent to ER (emergency room ) and EC#1 (emergency contact) notified, MD notified. On 3/8/16 at 8:00 a.m., LPN #6 documented, UA (urinalysis) results received: no bacteria noted. Placed in MD's folder for review . This was the last note documented in this clinical record. A review of the hospital record dated 3/8/16 documented, The patient is a [AGE] year old male who is seen in the Emergency Department for suicide attempt. Patient has a history of [MEDICAL CONDITIONS]. He was recently admitted for [MEDICAL CONDITION] and was discharged to local skilled nursing facility. Patient states that since the time of discharge he has felt short of breath and uncomfortable. This has led him to have suicidal thoughts. Patient states, I don't want to be here anymore and describes an incident where he tried to use a fork to stab himself in the neck. He describes disappointment at being unable to penetrate the skin of his neck and so he instead stabbed himself in the arm with the fork. He was able to penetrate the tissues of his elbow with a fork. This got the attention of the workers at the skilled nursing facility who sent him to the emergency department for evaluation. Patient states he has had intermittent chest discomfort, though he denies any chest discomfort at the time of ER evaluation. He repeatedly expresses suicidal thoughts and disappointment that his attempt at harming himself did not result in death. Patient's daughter states that patient has been on [MEDICATION NAME] for a long time, however after transfer to skilled nursing his [MEDICATION NAME] was overlooked and he did not receive it for about 2 weeks. Daughter states this was only restarted 2 days ago. Daughter states the patient's mood has degenerated since being taken off his antidepressant. Further review of the hospital record revealed an emergency room physical dated 3/8/16 that documented, Procedure performed: Laceration repair. Indication: Left arm laceration. Wound was irrigated with 500 cc of saline by technician staff. Local anesthesia was performed with 3 cc of 1% [MEDICATION NAME] without [MEDICATION NAME]. The wound was closed with #7 simple interrupted sutures, 5-0 nylon. Patient tolerated this well. Total closed length was 3 cm. An interview was conducted with LPN #6 on 7/21/16 at 8:57 a.m. She stated that on 3/8/16 she went in to check on the resident. She stated he was sitting on the side of the bed trying to dig in his arm with a fork, stating he wanted to die. She stated she put pressure on it, called 911 and notified the doctor. She stated that it was reported to her that the resident was depressed and not himself, but she was not told anything about [MEDICAL CONDITION]. Regarding the admission medications, she stated another nurse started the admission and did the meds, and that she just finished the admission after change of shift. She stated she did not check the meds that the other nurse had entered. A review of Corrective Counseling / Behavioral Accountability Record from LPN #6's employee file documented, On 2-22-16, did not perform 24 (hour) check on admission of (name of resident) (LPN #6) will ensure that all chart checks will be completed on her scheduled shift. On 7/21/16 at 2:13 p.m., an interview was conducted with LPN #15. She stated that she could not recall much about the resident. She stated the daughter would not let her leave the room so she could take care of other patients, so she called (LPN #16) to assist. On 7/21/16 at 2:21 p.m., an interview was conducted with LPN #16. She stated that on 3/5/16 (LPN #15) had called her to the unit to assist with this resident so that LPN #15 could care for her other residents. She stated that the family felt that something was wrong. She stated his vital signs were normal, but that the resident stated he felt like he was crawling out of his skin. She stated the daughter felt he was acting unusual. She stated that recent blood work was normal. She stated a UA was done and that it was normal too. She stated she reviewed his meds and that there was nothing new. She stated the daughter asked about increasing the antidepressant, and that she reviewed the resident's meds and noted that the [MEDICATION NAME] was never ordered on admission. She stated she was unaware of the resident's statements about wanting to go home to be with the Lord. She stated if LPN #15 had told her that, she would have notified the social worker and doctor, and put the resident on suicide watch. On 7/21/16 at 11:30 a.m., an interview was conducted with the social worker, OSM (other staff member) #10. She stated that anytime someone is suicidal, the social worker should be informed, to see if they have a plan and don't want to live anymore and find out if there is a desire, plan, or if they just mean that they are ready when their time comes. On 7/21/16 at 11:57, OSM #10 returned to the surveyor, after reviewing the record, and stated that she was not notified of the comment that the resident was ready to go home to be with the Lord, but that she should have been notified. She stated that after this incident, that she had incorporated training on suicide prevention into the annual abuse trainings that were provided in March, 2016 for all staff. A copy of an email that was sent from the (former) DON (Director of Nursing, Administrative Staff Member (ASM) #3, the current corporate QA nurse) to all of the facility nurses staff, dated 3/8/16 documented, We've had a med error that resulted in a negative outcome to a patient from not complying with process of a second check of medications and not completing 24 hour chart audit for new orders. Admitting nurse must compare discharge summary to med list and note second check on admission orders [REDACTED]. Record 24 hour check on all new orders noted in last 24 hours. If there aren't any new orders than no notation is needed, as long as they were noted on the night they were received. There should be few of these as most orders are entered by the nurse, vs (versus) the MD/NP/PA (medical doctor/nurse practitioner/physician's assistant). As of tonight, please be sure that all new admission orders [REDACTED]. Leave a copy of the transfer summary and other summary in my box at the Willow and CB Nurses Stations. This process will be monitored and reported out at monthly QA meetings. A review of the facility policy, Management of Physician Order Sheet, Physician order for [REDACTED]. The night nurse will complete triple check of admission orders [REDACTED]. Once a physician signs a physician order sheets, a new medication and or treatment cannot be added. New orders are written on Physician's Interim/Telephone or noted via fax form. All ordered medications must have a [DIAGNOSES REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) is indicated for the treatment of [REDACTED]. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Advise patients regarding the following issues and to alert their prescriber if these occur while taking [MEDICATION NAME]. Suicidal Thoughts and Behaviors: Instruct patients, their families, and/or their caregivers to be alert to the emergence of anxiety, agitation, panic attacks, [MEDICAL CONDITION], irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. Advise families and caregivers of patients to observe for the emergence of such symptoms on a day-to-day basis, since changes may be abrupt. What else do I need to know about antidepressant medicines? · Never stop an antidepressant medicine without first talking to a healthcare provider. Stopping an antidepressant medicine suddenly can cause other symptoms. This information was obtained from the website: <http://druginserts.com/lib/rx/meds/[MEDICATION NAME]-1/> On 7/21/16 at 12:40 p.m., the Administrator (ASM #1) and the Corporate QA nurse (ASM #3) were made aware of the concerns. References: (1) Information obtained from <https://medlineplus.gov/druginfo/meds/a 6.html> (2) Information obtained from <https://medlineplus.gov/druginfo/meds/a 2.html> (3) Information obtained from <https://medlineplus.gov/druginfo/meds/a 3.html> (4) Information obtained from <https://medlineplus.gov/druginfo/meds/a 8.html> (5) Information obtained from <https://medlineplus.gov/druginfo/meds/a 5.html> (6) Information obtained from <https://medlineplus.gov/druginfo/meds/a 3.html> (7) Information obtained from <https://medlineplus.gov/druginfo/meds/a 2.html> (8) Information obtained from <https://medlineplus.gov/druginfo/meds/a 3.html> (9) Information obtained from <https://medlineplus.gov/druginfo/meds/a 8.html> (10) Information obtained from <https://medlineplus.gov/druginfo/meds/a 4.html> (11) Information obtained from <http://www.webmd.com/drugs/2/drug-9881-5249/[MEDICATION NAME]-silver-oral/multivitamins-includes-[MEDICATION NAME]-vitamins-chewable---oral/details#uses> (12) Information obtained from <https://medlineplus.gov/druginfo/meds/a 2.html> 13) Information obtained from <https://medlineplus.gov/minerals.html> COMPLAINT DEFICIENCY 2. The facility staff failed to clarify the physicians order for treatment of [REDACTED]. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's most recent MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 6/23/16. Resident #16 was coded as having a BIMS (brief interview of mental status) of 14 out of a possible 15, indicating that Resident #16 was cognitively intact. Resident #16 was also coded as not having any pressure ulcers since admission. A review of Resident #16's clinical record revealed a physician order dated 6/16/2016, the date of admission, that documented, in part, the following: Cleanse Stage II pressure ulcer to L (left) buttock with WC (wound cleanser), pat dry, apply allevyn (a type of wound dressing). Change Q3 (every 3) days and as needed. Apply barrier cream to periwound every evening shift. Order Status: Active. Order Date: 6/16/16. A review of Resident #16's admission assessment revealed, in part, the following documentation: 2. if skin not intact: IDENTIFY AND DOCUMENT all skin impairments. 23) Coccyx: other (specify) excoriation. On 7/21/16 at 1:30 p.m. an interview was conducted with LPN (licensed practical nurse) #1, a floor nurse who had conducted Resident #16's skin assessment on admission. LPN #1 was asked if she remembered conducting the admission assessment for Resident #16, LPN #1 stated that she did. LPN #1 was asked to describe the skin on Resident #16's buttocks. LPN #1 stated that it was moist and red, but without open areas. LPN #1 was asked whether or not she was aware that the physician had ordered treatment for [REDACTED]. LPN #1 stated, I was aware of the orders on admission but she did not have a Stage II, her buttocks were excoriated. LPN #1 was asked what she did about the order; LPN #1 stated that she did nothing. LPN #1 was asked was she supposed to follow the orders prescribed for Resident #16, LPN #1 stated that she was but in this case there was no need for the treatment, I should have called the physician for clarification of the order. On 7/21/16 at 2:25 p.m. RN (registered nurse) #2, the care manager (unit manager) was observed while assessing Resident #16's wound. There were no open wounds on Resident #16's buttocks; there was a circular area of approximately 2 cm (centimeters) that appeared scaly and dry. RN #2 was asked if the wound was a Stage II pressure ulcer, RN #2 stated that it was not, that it was an old area of excoriation. RN #2 was asked what the nursing staff should have done in regards to the orders for a Stage II pressure ulcer when Resident #16 did not have a Stage II pressure ulcer. RN #2 stated, The nurses should have discontinued the order. On 7/21/16 at 3:45 p.m. ASM (administrative staff member) #1, the administrator, was made aware of the above findings. Policies were requested for order verification and clarification. No further documentation was provided prior to the end of the survey process. (1) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ 3. The facility staff failed to clarify an order for [REDACTED].>Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with assessment reference date 4/5/16, she was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). Resident #6 was coded as having no concerns related to pain during the look back period. A review of Resident #6's clinical record revealed the following physician's orders, both written 12/22/15: - [MEDICATION NAME] (1) Tablet 5-325 mg (milligrams) ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 4 hours as needed for pain. - [MEDICATION NAME] (1) Tablet 5-325 mg (milligrams) ([MEDICATION NAME]-[MEDICATION NAME]) Give 2 tablet (sic) by mouth every 4 hours as needed for pain. A review of the MARs (medication administration records) for Resident #6 revealed that [MEDICATION NAME] had not been administered during the months of May, June, or July 2016. A review of the comprehensive care plan dated 2/9/16 revealed, in part, the following: Administer [MEDICATION NAME] (pain reliever) as per orders. Give 1/2 hour before treatments of care .(Name of Resident #6) prefers to have pain controlled by: medication, treatment. On 7/21/16 at 12:00 p.m., RN (registered nurse) #4 was interviewed regarding the above referenced orders for [MEDICATION NAME]. When asked how many tablets should be given to the resident if the resident experienced pain, RN #4 stated she would have to ask the resident how severe her pain was. When asked why the two orders are exactly alike except for the number of tablets to be administered, RN #4 stated: Well you have both so if you give one pill, you click on that one, and if you give two pills, you click off the other one. When asked if the orders specify the circumstances under which one tablet would be administered as opposed to two tablets, or vice versa. She stated: You would just know how many to give. Most of the residents can tell you how many they need. She further stated: There is no need to specify the number on the order. On 7/21/16 at 12:15 p.m., RN #1, a unit manager, was interviewed regarding the above referenced orders for [MEDICATION NAME]. RN #1 stated: They are kind of confusing. You can't put in a range for orders in this computer system. They probably should have some kind of qualifier or description of when to give one tablet or when to give two. RN #1 stated that the order is exactly the same, except for the number of pills, and that the order needs to be clarified with the physician. On 7/21/16 at 4:55 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the interim director of nursing, and ASM #3, quality assurance nurse, were informed of these concerns. Policies regarding order clarification were requested. Review of the facility policy entitled Management of Physician Order Sheet, Physician order for [REDACTED]. The night nurse will complete triple check of admission orders [REDACTED] No further information was provided prior to exit. (1) [MEDICATION NAME] is indicated for the relief of moderate to moderately severe pain. This information is taken from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3af57f54-117e-43fc-b0ae-21ef772d854e According to Fundamentals of Nursing, Lippincott, Williams and Wilkins 2007 page 169, After you receive a written medication order, transcribe it onto a working document approved by your health care facility .read the order carefully, concentrate on copying it correctly, check it when you're finished. Be sure to look for order duplications that could cause your patient to receive a medication in error / -*