Every finding on record at Riverside Health and Rehab

Based on facility policy review, record review, and interviews, the facility failed to notify Resident (R)3's representative of changes to R3's treatment plan, specifically the insertion of a midline intravenous catheter and initiation of intravenous antibiotic therapy.Review of the facility policy titled, Physician and Other Communication/ Change in Condition with a revision date of 05/05/23, revealed, Procedures: 5. The patient/ resident and patient's/ resident's family member/ legal representative will be notified of any changes in medical condition or treatment plan as indicated by HIPAA directives.Review of R3's face sheet revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, cerebral infarction (stroke), flaccid hemiplegia affecting his left side (paralysis on the left side), hypernatremia (elevated sodium levels), hyperkalemia (elevated potassium levels), dysphagia (difficulty swallowing), epilepsy (seizure disorder), Type 2 diabetes, and urinary tract infection (UTI). Review of R3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/26 revealed R3 had a Brief Mental Status Score (BIMS) of 15/15, which indicated he had no cognitive deficits. R3 had functional impairments on both sides of his body and was dependent on others for most activities of daily living (ADLs), including toileting, dressing, and bathing. R3 was always incontinent. Review of R3's care plan revealed a focus of taking an antibiotic through a peripherally-inserted central catheter (PICC) related to a diagnosis of UTI. The goal was for R3 to receive therapeutic treatment from medication without complications. Review of R3's orders revealed an order for the insertion of a peripheral intravenous catheter on 06/24/26. The order stated a midline catheter should be inserted if the peripheral intravenous catheter could not be inserted. A second order was for ertapenem 1 gram intravenously once a day for UTI. This order started on 06/25/26 and ended 06/28/26. Review of R3's progress notes did not reveal a note indicating R3's representative was contacted when the orders for the insertion of the intravenous catheter and for intravenous antibiotics for UTI were received on 06/24/26. A note dated 06/30/26 at 03:13 PM by Licensed Practical Nurse (LPN)4 revealed, Resident's RP called to provide an update regarding the resident's hospitalization. The POA reported that the resident is currently admitted to the ICU. He also voiced concerns regarding communication from the community about the resident's change in condition. During an interview on 08/18/26 at 10:38 AM with R3's representative, he revealed he was not notified of his father's UTI diagnosis, of the start of the intravenous antibiotic medication, or of the PICC insertion.During an interview on 08/18/26 at 4:01 PM with LPN4, she confirmed R3's representative was not notified of the orders for the initiation of intravenous antibiotic therapy for UTI, which included having to insert an intravenous catheter. She stated they typically call Resident representatives when new intravenous medications and/ or antibiotics are ordered. She revealed she understood why R3's representative was upset he was not notified of the new intravenous medication orders. During an interview on 08/18/26 at 4:50 PM with the Director of Nursing (DON), she revealed they have reviewed the situation that happened with R3. She stated their action plan is to ensure family notification of Resident changes. She revealed they held an immediate care plan with R3's representative.

Based on observation, interview, record review, and facility policy, the facility failed to fully investigate an allegation of staff to resident abuse. Specifically, the facility did not conduct a record review related to the alleged violation to acknowledge that the incident occurred. There were no clinical progress notes, incident reports, or Care Plan updates, for 1 of 5 residents reviewed for abuse, Resident (R)7. This failure has the potential to result in continued psychosocial harm or place the resident at risk for further abuse. Findings include:Review of the undated facility policy titled, Organizational Ethics, Abuse, Neglect, and Misappropriation of Property, states, III. Prevention: 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to abuse or neglect. Component IV: Investigation 5. E. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. Guidelines for Investigation: H. Social Service will provide support services to resident/patient and implement an interdisciplinary care plan.Review of the facility policy titled, Care Plan Process, Person Centered Care, with a complete revision date of May 5, 2023, states, Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates. 11. The person-centered care plan includes: E. Interventions, discipline-specific services, and frequency.Review of the facility policy titled, Social Services, with a complete revision date of June 9, 2023, states, Allegations of Abuse, Neglect, or Exploitation: Abuse may result in increased psychosocial needs displayed by behavioral or psychosocial outcomes including, but not limited to, the following: .including aggressive or disruptive behavior toward a specific person. Document psychosocial well-being related to allegations of abuse or neglect to ensure no psychosocial harm. Monitor and document for a minimum of 72 hours. Care Plan: Social Services will develop or revise resident/patient care plans if the resident's mental or psychosocial needs or preferences change as a result of an incident of abuse, neglect, or exploitation. Will add a care plan to monitor for the next 90 days at minimum for any psychosocial impact or unmet needs.Review of R7's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, contracture, muscle weakness, need for assistance with personal care, cognitive communication deficit, restlessness and agitation, and depression.Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/26 reveals she had a Brief Interview of Mental Status (BIMS) of 12 out of 15, indicating she had moderate cognitive impairment. Review of R7's Progress notes did not include any information pertaining to the alleged incident that was investigated by the abuse coordinator.Review of R7's Care Plan did not include any information pertaining to the alleged incident that was investigated by the abuse coordinator.Review of R7's Electronic Health Record (EHR) did not include an incident report, or social services assessments or reports that provided any information pertaining to the alleged incident that was investigated by the abuse coordinator.During an interview on 06/11/26 at 11:15 AM, R7 revealed that a CNA hit her in the face twice; she was not aware of her name. I told her she wasn't going to be hitting and jerking on me. She was handling me rough and I told her to stop. I was in the wheelchair, and she kept pushing me back and I would push back against her and I hit at her. She called the nurse because I wouldn't let her help me. I saw her the night before last, but she doesn't help me anymore, but she will roll her eyes at me when she sees me. Social Services did not come to assist her after the incident, but she states she feels safe and doesn't feel threatened. The doctor came and assessed her that day. She indicates that her left leg hurts sometimes but they give her pain medication for that. She stated she wanted to call her daughter that night and one of the nurses helped me at the desk to call her. During an interview on 06/11/26 at 1:46PM, the Director of Social Services revealed, If there were speculation of abuse I would report to administration right away, separate residents, and if need be, I would call local law enforcement. We would assess the resident and contact Emergency Medical Services (EMS) if needed. My role would be to evaluate if there needs to be a room change and provide daily checks each day after the incident to see how they are doing emotionally and/or mentally. I would also follow up if a mental health referral is needed. If I was involved in the situation then I would put in a progress note. Anything after the incident, I would document and usually update the care plan if it was a behavioral issue. I don't see any progress notes related to R7, and I don't recall any incidents with her. She is usually a quiet resident. Information about the incident would have been provided in the morning rounds, that is where we would discuss hospitalizations, deaths, changes of condition, new residents, grievances, falls, and resident radar. It's a 24-hour report about anything that may have changed with the residents in the facility. I wasn't involved in the alleged situation with R7, and I didn't know that happened.During an interview on 06/11/26 at 2:07 PM, the Assistant Director of Nursing (ADON) revealed in the morning meetings we discuss grievances, complaints, schedules for staff, nursing staff rundown or significant events. I am not involved in the investigation process, if there were allegations of abuse, we would notify the social worker, and we must notify the administrator. During an interview on 06/11/26 at 2:15 PM, the Facility Administrator (FA) stated, Morning meetings are at 9AM to discuss discharges and admissions, and anything clinical that happened the previous day. Rounds and IDT team meetings help determine any new information about the residents. They discuss what is going on and what we will be investigating. The clinical regional nurse, and DON, assist with investigations and the staff development coordinator will also assist if they have to reeducate the staff. Incidents are reported by the nursing department for every incident. After incidents, we usually update the care plan, and this would be completed by MDS or nursing management. Social Services will assist if someone may need therapy or a room change initiated, and they would also be responsible for psychosocial treatment, and they could update their care plan if needed.During an interview on 06/11/26 at 2:23 PM, the MDS Coordinator revealed she receives updates about resident status through email or morning meetings, or by stopping by a unit and information can be relayed that way also. The Care Plan is established to identify what needs to happen to the residents. The DON and Social Services are involved with any changes. The MDS Coordinator stated she would look to see if there have been any changes or updates to the MDS about R7 and let the surveyor know. The MDS Coordinator did not provide any information following this interview.During an interview on 06/11/26 at 3:13 PM, the FA revealed the incident didn't happen with nursing, that is why there wouldn't be any incident reports or notes about the incident. Nurses stated they didn't know anything about it until he informed them the next day after I had received a call from her daughter. Because I notified them of the situation, I can't say that it would be classified as an incident. An allegation of abuse is not seen as an incident, because it was provided initially by the daughter.

Based on review of the facility policies, observations, and interviews, and facility policy the facility failed to ensure proper cleaning of kitchen equipment (deep fryer, stove and 2 of 2 ovens), failed to ensure that kitchen staff hair was completely covered with a hair net and or/cap, and facial hair was covered with a hair net or beard guard. In addition, the facility failed to ensure dietary staff correctly demonstrated the calibration technique to ensure the temperature readings on the thermometers. Findings include:Review of the facility policy titled, Sanitation & Food Safety in Food and Nutrition Services last revision 10/15/25 revealed, The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. 1. Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness. (Refer to Exhibit 2E, Major Food Borne Illnesses in section J of this manual. 4.The CDM monitor food safety and sanitation of the Food and Nutrition Department daily. 5.The CDM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. Cleaning tasks are initialed as they are completed. (Refer to sample cleaning schedule) 9.The CDM provides a cleaning schedule for each area and piece of equipment in the kitchen.Review of facility policy titled, Nutrition Orientation and Competency Policies and Procedure, revised 07/21/23 revealed, Calibrating the thermometer: 1. Check the thermometer for proper calibration at least weekly or more often if it has been dropped. Record on the Calibration Record Form. Safe Food Handling and Preparation: 6. Keep hair restrained with a hair net or cap when in the kitchen.Review of facility policy titled, Safe Food Preparation last revised 06/20/23 revealed, Procedures: 2. All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use. 9. Hands do not touch areas of utensils, dishware, or silverware where the food or mouth is placed. 10. Avoid touching ready-to-eat foods that are not subsequently cooked with bare hands. Use tongs or gloves instead. When gloves are worn, they are clean, without tears, and changed between tasks and whenever you leave the kitchen, they also are changed after sneezing, coughing, or touching hair or face. 11. Anyone working in, visiting, or inspecting the kitchen during normal food production hours is expected to wear appropriate clothing, shoes and hair restraint. An initial tour observation of the Main Kitchen and interview with the Kitchen Manager (KM) on 04/19/26 at 10:30 AM revealed the following items: a stove, a deep fryer and two ovens with excessive amounts of grease and food residue buildup. During the subsequent interview with the KM, she stated, I have a log of the cleaning schedule for the stove/grill, but not for the other kitchen equipment like the ovens and the deep fryer. The daily cleaning schedule states the stove/grill was cleaned this morning, but I wouldn't consider it to be clean from the appearance today. We do not have a cleaning log or have a schedule to clean the ovens or deep fryer. I do not know the last time the ovens or deep fryer were cleaned, but I will get it cleaned today.During an observation and interview with Dietary Staff (DS1) on 04/19/26 at 10:41 AM revealed a male kitchen staff member with a beard, but without a beard cover, in the main kitchen plating meals. During the interview, DS1 stated, I am not required to wear a hair net or beard cover because I do not have hair, as he rubbed his hands down his beard.During an observation and interview with the Kitchen [NAME] (KC) on 04/19/26 at 10:50 AM revealed a female kitchen staff member wearing a purple bonnet hair cover that was not fully covering approximately 5 inches of her hair. During the interview with the KC, she stated I can wear this on my head. The rules state I just need to have my hair covered with anything that covers my hair.During a second observation on 04/20/26 at 4:25 PM, the stove, a deep fryer, and two ovens were observed with excessive amounts of grease and food residue buildup.During an observation and interview with KC2 on 04/20/26 at 4:35 PM, revealed a male cook with a beard but without a beard cover in the main kitchen prepping meal trays without gloves. During the interview with KC2 he stated because I don't really have a beard, I do not have to wear a beard cover. I don't wear gloves in the kitchen we are required to wash our hands upon entering the kitchen, but we are told not to wear gloves because it can cause cross contamination.During an observation and interview with KC3 on 04/20/26 at 4:45 PM, KC3 was observed entering the facility kitchen with a dirty uniform on. KC3 was observed taking food temperatures without calibrating the thermometer for temperature testing. KC3 was observed scratching her face and neck and putting her hands in and out of her pockets, while bare handedly, handling food pans, and only stopping to wash her hands, once. During an interview, when asked, Do you have to calibrate the thermometer before taking food temperatures? And if so, how do you calibrate the thermometer? KC3 responded by stating, Yes, I calibrate the thermometer before taking food temperatures by turning the thermometer off and on. During a second interview on 04/20/26 at 5:15 PM, the KM revealed, The expectations are that all kitchen staff are to wear clean uniforms, hair restraints and wash their hands, upon entering the kitchen. Hair restraints include hair nets, head wraps or any hair covering and beard covers to ensure no hair is exposed in the kitchen. We are instructed by management to never use gloves in the kitchen, as it could cause cross contamination, so frequent hand washing is required. The KM stated, When testing the temperature of the food on the tray line, the thermometer should be calibrated after each food item is temped. All cooks and dietary staff have been trained in cleaning and the operation of all kitchen equipment to include the ovens, stove, dishwasher and thermometers.During an interview on 04/20/26 at 6:00 PM, the Administrator revealed, The facility does not have a cleaning schedule for all kitchen equipment, such as the deep fryer and ovens. We have put a cleaning schedule in place today and have completed kitchen staff training on the proper cleaning of all kitchen equipment. The expectations are that all kitchen staff are trained the cleaning of all kitchen equipment properly.

Based on observation, interview, and facility policy, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 2 residents reviewed. Specifically, Resident (R)42 did not receive rehabilitative services although recommended by the Occupational Therapist. Findings include:Record review of facility policy titled, Activities of Daily Living [ADLs], Optimal Function last revision 05/05/23, revealed, The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Procedures: 1. Facility staff recognize and assess an inability to preform ADL's or a risk for decline in any ability to perform ADLs by reviewing the most current comprehensive or most recent quarterly assessment; 3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address identified limitations in ability to perform ADLs. 7. Facility staff revises the approaches and interventions as appropriate.Review of R42's face sheet revealed that the facility admitted R42 on 02/28/25 with diagnoses including but not limited to: spastic hemiplegia affecting the right dominant side; contracture of unspecified joints; other abnormalities of gait and mobility; other lack of coordination; muscle wasting and atrophy; generalized muscle weakness; hemiplegia and hemiparesis as sequelae of cerebral infarction; and vitamin D deficiency.Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/01/26, revealed that R42 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating that R42 was moderately cognitively impaired.Review of R42's care plan dated 04/15/26, with a target completion date of 07/16/26, revealed the following: impaired mobility and ADLs, with a need for assistance related to cognitive and functional decline status post intracerebral hemorrhage (ICH); spastic hemiplegia affecting the right dominant side; need for assistance with personal care; muscle wasting and atrophy; and generalized weakness. Review of R42's quarterly Therapy Screening Form dated 03/10/26 indicated the following: difficulty performing ADLs, including grooming; joint limitations and contractures. Occupational Therapist comments stated, PT having difficulty with completing grooming and hygiene tasks. PT with right digit contracture. Occupational Therapy (OT) recommended.Review of R42's Rehabilitation Therapy Funding Information Form dated 03/11/26 revealed the following: [NAME] text: Therapy recommended OT, Diagnosis/Reason for Service grooming and Hygiene, Right hand contracture, Not Approved by Facility Administrator 'Not at this time, Coinsurance Medicaid, does state cover Therapy if No Medicare B - yes. Administrator's signature dated 3/13/26. During an observation and interview on 4/20/26 at 3:23 PM, R42 was sitting on the side of his bed looking distressed. The fingers on R42's right hand were contracted with his pinky finger digging into the palm of his hand. R42 was unable to move his fingers from that set position. During the interview R42 stated I want to go back to therapy. I was getting better, my fingers were straightening out, and I wasn't in so much pain. I don't know why I was taken out of therapy staff just said I was no longer approved to go. I can't get better and be able to go home if I don't have my therapy. Therapy was helping me to be able to take care of myself so I can get out of this place and go home. I can't leave until I can take care of myself. Because they took me out of therapy now my fingers are contracting back in this stuck position. Sometimes, I cry from the pain and no medicine will help. Sometimes I am up all night in pain. I tell the staff, but they don't care telling me you already know you are not approved for additional therapy services but won't tell me why. I have Medicaid so I don't know why I am not allowed to finish my therapy. I feel trapped in this place.During an interview on 4/21/26 at 11:15 AM, the Director of Rehabilitation (DR) stated, R42 came off OT on 02/17/26 when he was released from the hospital. Pain levels were 7 out of 10 and remained, pain levels never changed. He hasn't gotten better or worse. For him to be screened in the facility it must be recommended by the Occupational Therapist. Residents are screened quarterly. [R42's] last screening was 3/10/26. OT's outcome was [R2] was recommended for continued OT services. Recommendation based on the resident's right-hand contracture and a decline in ADLs such as grooming and hygiene. I completed the referral on 3/11/26 and sent it to the administrator for funding approval but it was denied on 3/13/26. If the funding form is not approved by the administrator there is nothing more i can do to assist the residents with therapy services.During an interview on 4/21/26 at 11:45 AM, the Administrator stated he received an OT funding referral from the DR on 3/11/26. After he observed, evaluated, and interviewed the resident himself he saw no need to continue OT services and denied the funding form. The Administrator stated in reviewing the Rehabilitation Therapy Funding Information Form he did not see a reason for service and denied the form stating, Not approved, not at this time. Review the Therapy screening form with the Administrator. The screening form stated the Occupational Therapist recommendations, showing the areas the resident was deficient in Difficulty performing ADLs such as grooming and Joint limitations, comments: pt having difficulty with completing grooming and hygiene task, pt with right digit contactor.The Administrator stated I do not have access to this information in my system, just received the residents Rehabilitation Therapy Funding Information Form without a diagnosis or reason for services. The Therapy Screening was reviewed with the Administrator and revealed that the form stated the reason for services, and diagnosis of a decline in grooming, hygiene, and right-hand contracture. He then replied, I did not see that there. For future references I will request the Therapy Screening Forms with the Rehabilitation funding form to better evaluate the funding approvals for therapy services.

Based on observation and interview, the facility failed to ensure food stored in the refrigerator was labeled and dated; failed to ensure dietary equipment was clean; failed to ensure dry storage bins were free of a Styrofoam cup directly touching the flour and sugar instead of a scoop; and failed to ensure dirty dishes and trays were not stored in the dietary prep area. This deficient practice had the potential to affect 128 of 147 residents who received meals prepared in the facility and had the potential to affect the spread of food borne illness. Findings include: A request for a kitchen cleaning and service policy was requested on 04/14/25 at 3:45 PM and on 04/15/25 at 11:30 AM. The policy was not provided prior to the survey exit. During the initial kitchen tour on 04/13/25 at 8:30 AM, with the Dietary [NAME] (DA) the following observations were made: The reach in refrigerator contained food items of gravy, roast beef, a block of opened cheese, and three packages of opened sliced sandwich meat, that were not dated or labeled. The large bins that contained sugar and flour contained a Styrofoam cup inside the bin. The Styrofoam cup was in direct contact with the flour and sugar. In the prep area of the kitchen, there was a six-tiered rack that held dirty trays, and on the floor were crumbs and scraps of paper. The oven's cooktop and the sides of the oven had the appearance of thick grease and food debris. During the second kitchen tour on 04/13/25 at 4:00 PM, with the Dietary Manager (DM), the following observations were made: The large bins containing dry goods containers of sugar and flour still contained a Styrofoam cup inside the bin. The oven's cooktop and sides of the oven still had the appearance of thick grease and food debris. During an interview with the Dietary [NAME] (DA) on 04/13/25 at 9:15 AM, she stated she arrived to discover dirty pots, pans, and trays left by the previous staff that prepared dinner on 04/12/25. She stated she was not aware of the Styrofoam cups in the dry food bins that appeared to be used as scoops. She stated there should be a proper scoop available for the dry food bins. During an interview with the Dietary Manager (DM) on 04/16/25 at 10:45 AM, she provided a cleaning schedule for cleaning the appliances, floors, and dirty kitchen ware. She stated that the staff should have labeled and dated the food in the reach in refrigerator, that it was not acceptable to have the Styrofoam cup in the flour and sugar bins, and the oven should have been cleaned.

Based on observation, interview, record review, and review of facility policy, the facility failed to implement therapy recommendations for the use of hand splints for three of three residents (Resident (R)40, R102, and R15) reviewed for contractures out of a total sample of 34. This failure had the potential to increase limited range of motion, deformities, and pain. Findings included: Review of the facility's policy titled, Restorative Nursing Policies and Procedures, revised 10/25/24, revealed, . The Nurse completes the Restorative monthly summary to include overall status in the program, progress toward care plan goals, and program recommendation. Documentation must be completed as per state specific guidelines . documents on all programs during look back of Minimum data set (MDS) . Patients/Residents in a Joint Mobility/Splint Program are reassessed on a regular basis (quarterly), and as needed (significant change). The plan of care is reviewed by the interdisciplinary team and revised as needed. Reassess as per nursing assessment and follow trigger guidelines . appropriate candidates for the Nursing Restorative (range of motion) ROM Program may include, but are not limited to, patients/residents with the following conditions: Contractures . 1. Review of R40's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R40 was readmitted to the facility on [DATE], with diagnoses that included but was not limited to: cerebral palsy, quadriplegia, unspecified and contracture, unspecified joint. Review of R40's Care Plan, located in the EMR under the RAI tab and initiated on 05/08/24, revealed, . [R40] has, requires assistance with ADL's [activities of daily living] r/t [related to] Cerebral Palsy . LUE [Left Upper extremities] d/t [due to] contracture. Review of R40's Occupational Therapy (OT) Discharge Summary, provided by the facility and dated 03/05/25, revealed, . Discharge Recommendations: LHS [Left right hand splint] three hours a day as tolerated to prevent worsening contractures . Review of R40's EMR, including Orders, Medication Administration Records (MARs), Treatment Administration Records (TARs), and Care Plan tabs revealed no orders or treatments for R40's left hand contracture per OT discharge recommendations. The Care Plan had not been updated to reflect the OT discharge recommendations for the use of a left hand splint. During an observation and interview on 04/13/25 at 10:49 AM, R40 was resting in his room. A blue hand splint was noted on the resident's dresser. R40 stated that while on therapy services, therapy staff would place the splint on his left hand, but since I do not have therapy anymore, no one puts it on me. R40 confirmed that he was unable to put the brace on without assistance. 2. Review of R102's Face Sheet, located in the EMR under the Face Sheet tab, revealed R102 was admitted to the facility on [DATE], with diagnoses that included contracture, unspecified joint. Review of R102's Occupational Therapy Discharge Summary, provided by the facility and dated 03/04/25, revealed, . Discharge Recommendations: Continue use of RHS [right hand splint] with nursing staff . It was recorded R102 was to use the splint three hours per day as tolerated to prevent worsening contractures. Review of R102's Care Plan, located in the EMR under the RAI tab and dated 03/04/25, revealed, . [R102] has (L) hand splint . [R102] requires assistance with ADL's R/T COPD, Muscle wasting and atrophy . R hand contracture . The care plan did not address use of the right hand splint. Review of R102's EMR, including Orders, MARs, and TARs tabs revealed no order or treatments for R102's right hand contracture per OT discharge recommendations. During an observation on 04/13/25 at 12:36 PM and 04/14/25 at 1:49 PM, R102's right hand was noted to be contracted inwards at the wrist at a 90-degree angle. R102's splint was observed laying on the resident's bedside table at each observation. During an interview on 04/14/25 at 3:49 PM, the Rehabilitation Director stated the tracking and placement of splints had been a concern. The Rehabilitation Director stated that once a resident was discharged from rehabilitation services, orders were not implemented related to the therapist's recommendations. During an interview on 04/14/25 at 4:10 PM, the Director of Nursing (DON) confirmed that there had been a communication failure between nursing and therapy. The DON stated her expectation was for orders to be placed to reflect therapy recommendations. During an interview on 04/15/25 at 10:20 AM, the Regional Director of Rehabilitation revealed she was aware of the disconnect between the therapy department and nursing and the concern was currently being addressed. 3. Review of R15's Face Sheet, located under the Resident tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE], with diagnoses that included but was not limited to: epilepsy, right hand contracture, and aphasia following cerebral infarction. Review of R15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated the resident was severely cognitively impaired. The assessment indicated the resident had functional limitation in range of motion to the upper extremity on one side and that R15 was dependent on staff for self-care and mobility and did not reject care. Review of R15's Physician Orders, located under the Resident tab of the EMR and dated 07/12/23, indicated, [R15] splint to right hand daily with hand hygiene. Review of R15's Care Plan, initiated 07/01/21 and located in the Care Plan tab of the EMR, revealed the resident was at risk for skin impairment related to impaired mobility, incontinence, orthotic use, contracture. Interventions, dated 12/27/24, revealed, orthotic as ordered. An additional intervention, dated 04/15/25, was to splint to right hand daily. Review of R15's Observations, located under the Resident Documents tab of the EMR and dated 01/01/25, revealed a Therapy Screening Form, which was documented by the Occupational Therapist (OT), that R15, currently has towel roll used in hand contracture with nursing . Review of R15's Observations, located under the Resident Documents tab of the EMR and dated 03/18/25, revealed a Therapy Screening Form, which was documented by the OT, that R15 . was at baseline. Review of R15's Observations, located under the Resident Documents tab of the EMR and dated 04/14/25, revealed a Therapy Screening Form, which was documented by the OT, that R15 had joint limitations/contractures and . would benefit from new R [right] palm guard. During an observation on 04/13/25 at 12:14 PM, R15 was asleep in bed with her right hand in a fist. No splinting was observed in place. During an additional observation on 04/14/25 at 3:30 PM, R15 was observed in bed with her right hand in a fist without splinting. During an interview on 04/14/25 at 4:12 PM, the DON stated that the facility kept a book on the nursing floor to identify the ambulation needs of the residents. She stated that the information was also verbalized to the staff. The DON confirmed they needed to do a better job documenting. She stated that her expectation was that if there was a need for splinting for a resident, there would be a physician order in place with directions on how to use it. During an interview on 04/15/25 at 9:20 AM, the Regional Director of Rehab (RDR) stated that R15 required the use of a small right-handed palm guard. During an observation on 04/15/25 at 9:28 AM, R15 was observed in bed with her right hand in a fist, with no splinting in place. During an interview on 04/15/25 at 9:30 AM, Licensed Practical Nurse (LPN)3 stated that she was not aware if R15 required a splint or not but confirmed the resident was not currently using one. During an additional interview on 04/15/25 at 9:39 AM, the RDR stated that OT had rescreened R15 on 04/14/25 and had noted she did not have a splint or palm guard in use. She stated that after searching, the facility staff could not find one in her room for use. The RDR stated that the last assessment had been completed on 03/18/25, and that the assessments were completed by the OT. At 10:31 AM, the RDR confirmed there should be better communication between nursing and therapy. During an additional interview and resident observation on 04/15/25 at 11:00 AM, the DON confirmed R15 was in bed and not actively wearing a splint or palm guard to her right hand. The DON stated that the use of the splint could help prevent decline or pain. She again confirmed that she would want to see a care plan and physician order for the splinting. During an interview on 04/15/25 at 11:24 AM, the OT stated that she evaluated new residents on caseload, new or old, and did quarterly screening for residents with contractures. OT stated that since R15 had a contracture, she would see her quarterly. OT confirmed R15 had a right-handed contracture and had been treated with passive range of motion last year and had a palm guard that she was tolerating. OT stated that R15 had not had any changes since last year according to the nursing staff. She stated that after speaking with nursing, the facility staff could not find her palm guard and told her they were using a towel. OT stated that she believed that R15 should wear the palm guard daily because it was a flatter design.

Based on observations, interviews, and review of facility policy, the facility failed to ensure staff properly handled soiled linen. Specifically, Licensed Practical Nurse (LPN)1 carried unbagged soiled linen out of one of one resident's room (Resident (R) 102) and placed the linen in the soiled linen cart. Failure to properly handle soiled linen can lead to cross contamination. Findings include: Review of the facility's policy titled, Laundry, dated 05/2006 revealed, Soiled linens are handled minimally . collection bags, carts or other containers should be strong and large enough to contain the contents of the soiled linens . personnel is instructed in the proper disposition of linens . Review of R102's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R102 was readmitted to the facility on [DATE], with diagnoses that included but was not limited to: urinary tract infection (UTI) and dysphagia. Review of R102's Physician Orders, located in the EMR under the Resident tab, revealed, . [R102] is on Enhanced Barrier Precautions, r/t [related to] Enteral Feeding tube . During an observation and interview on 04/13/25 at 12:39 PM, revealed Licensed Practical Nurse (LPN)1 exited R102's room after providing activities of daily living (ADL) care. LPN1 was carrying a large bundle of unbagged soiled linen and placed the linen in the laundry cart which was located 60 to 75 feet away from R102's room. Interview with LPN1 immediately after this observation confirmed that she did not bag the soiled linen per facility policy and failed to follow facility's procedures for handling soiled linen. During an interview on 04/13/25 at 12:40 PM, Certified Nurse Aide (CNA)1 confirmed soiled linen is to be placed in a clear bag prior to exiting a resident's room per facility policy and procedures to reduce the spread of infections. CNA1 stated soiled linen which is unbagged is not to exit a resident's room. During an interview with the Infection Preventionist (IP) on 04/14/25 at 10:04 AM, revealed her expectation is that all staff should adhere to the facility's soiled linen policy.

Based on observation and interview, the facility failed to dispose of garbage in a sanitary manner in the kitchen. Specifically, the garbage container was overflowing with garbage on the floor. This deficient practice had the potential to affect 128 of 147 residents who received meals prepared in the kitchen. Findings include: During the initial kitchen tour on 04/13/25 at 8:30 AM, with the dietary cook (DA), the following observation was made: The garbage container near the food preparation area was uncovered and overflowing with garbage of paper towels and gloves on the floor. During an interview with the Dietary Manager (DM) on 04/16/25 at 10:45 AM, she stated that it was unacceptable, and that garbage should be contained or emptied before it overflowed.

2. Review of R108's Face Sheet, located in the EMR under the Profile tab, revealed R108 readmitted to the facility on [DATE], with diagnoses that included but was not limited to: End Stage Renal Disease, urinary tract infection, diabetes mellitus, and essential hypertension. Review of R108's quarterly MDS, with an ARD of 02/28/25 and located in the EMR under the RAI tab, revealed R108 had a BIMS score of 15 out of 15, which indicated R108 was cognitively intact. Review of R108's Physician's Orders, located under the Orders tab of the EMR, revealed no order for self-administration of medication. During an interview and observation on 04/14/25 at 1:00 PM, R108 was observed lying in bed. A medication cup containing eight medications was noted on her overbed table. R108 was asked why her medications were left and had not been taken. R108 stated, I had fallen asleep and forgot to take them. R108 picked up her medications and took them. During an interview on 04/14/25 at 1:09 PM, LPN2 confirmed that she had administered R108 medications and did not observe the resident taking them. The surveyor asked LPN2 to verify the medications that were left. LPN2 stated, Vitamin C, Aspirin, Vitamin B, Vitamin B 12, Iron Pill, Keppra, Methocarbamol, Metoprolol and Neurontin. LPN2 stated R108 had not been assessed for self-administration and it was not facility policy to leave medications unattended. During an interview on 04/15/25 at 3:03 PM, the DON confirmed R108 had not been assessed for self-administration of medications. The DON stated it was her expectation that medications are not left unattended with any residents. She stated nursing staff were to monitor all residents taking medications. Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident's ability to self-administer medications for two of two residents (Resident (R)77 and R108) reviewed for self-administration of medications out of a total sample of 34. This had the potential to cause medication administration errors and adverse consequences. Findings include: Review of the facility's policy titled, Pharmacy Services Policies and Procedures, revised on 04/17/24, revealed, . The resident may choose to self-administer medication(s) according to applicable state and federal law and regulation upon completion of an assessment by the Interdisciplinary Care Team (lDT). 1. Review of R77's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed R77 was admitted to the facility on [DATE], with diagnoses including but not limited to: congestive heart failure. Review of R77's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R77's Physician Orders, located in the Orders tab of the EMR, revealed R77 was to receive: Amlodipine (a calcium channel blocker to treat hypertension), five mg once a day, Amiodarone (an antiarrhythmic), 200 mg once a day, Atorvastatin (a statin), 10 mg once a day, Docusate sodium (a laxative), 100 mg twice a day, Diazepam (a benzodiazepine), two mg three times a day, Loratadine (an antihistamine), 10 mg once a day, Magnesium oxide (a minerals/electrolyte), 500 mg once a day, Methenamine hippurate (an anti-infective), one gram once a day, Metoprolol tartrate (a beta blocker to treat hypertension), 25 mg twice a day, Famotidine (an H2 blocker (acid reducer)), 20 mg twice a day, Actobacillus acidophilus (a probiotic), 1.5 mg (250 million cell) twice a day, Ergocalciferol (vitamin d2, a dietary supplement), 1,250 mcg (50,000 unit) once a day on Monday, and Cyanocobalamin (vitamin B-12, a dietary supplement), 500 mcg once a day. During an observation and interview on 04/14/25 at 9:10 AM, Licensed Practical Nurse (LPN) 2 placed a medicine cup containing 13 pills on R77's bedside table and left the room prior to R77 consuming the medications. R77 was observed to have a half bottle of Tums on his bedside table. LPN2 stated, We're not allowed to leave meds at the bedside, but [R77] likes to take his meds with his breakfast. So, I go pass the next room's meds and come back to check on [R77] to make sure he took all his meds. He likes to do things his way. He has that bottle of Tums whenever he needs them, but I don't think he takes them regularly. I'll have to look to see if he has an order for them. He orders a lot of his own meds from Amazon. I know he doesn't have an assessment to self-administer his own meds, but like I said, [R77] likes to do things his way. During an interview on 04/14/25 at 9:35 AM, R77 stated, The Tums just sit there, and I take them as an emergency in case the Pepcid doesn't work. I bought them on Amazon. The doctor has seen them on my bedside table every time they come to see me and have never said a word about them. I haven't had one in four months. I dropped most of them on the floor and that's why they're gone. During an observation and interview on 04/14/25 at 10:20 AM, Registered Nurse (RN)1 stated, The nurses don't leave meds at the bedside. We don't have any residents that are assessed to self-administer their own meds. [LPN2] should have watched R77 take his meds or return with them when he was ready to take them. We do have a few residents that order their own meds from Amazon. We make rounds checking for meds in rooms, remove them, and educate them. RN1 entered R77's room, informed R77 that he was not allowed to have medications in his room, and she would need to remove them. RN1 informed R77 that they could call the doctor to get orders for the medications to be left at the bedside. During an interview on 04/14/25 at 10:24 AM, the Director of Nursing (DON) stated, Nurses are not supposed to leave meds at bedside with any resident. [LPN2] knows that is the policy and she will be reeducated immediately. The DON stated, We don't have any residents that self-administer their own meds. We do have a few residents that try to order their own over the counter meds from Amazon and we must monitor for that. We remove the meds and reeducate them that they are not allowed to because other residents could come and take them.

Based on observation, interview, record review, and review of facility policy, the facility failed to: 1.) promote the resident's right to dignity for 128 of 147 residents who ate food from the kitchen when meals were served in Styrofoam containers, and 2.) protect the resident's right to physical privacy during medication administration for one of 34 sampled residents (Resident (R)77), reviewed for resident rights. These failures had the potential to affect the dignity and psychosocial wellbeing of the residents. Findings include: A request for a meal service policy was requested on 04/14/25 at 3:45 PM and on 04/15/25 at 11:30 AM. The policy was not provided prior to the survey exit. 1. During an observation of meal service on 04/13/25 at 9:15 AM, residents received their breakfast trays served on Styrofoam containers. During an interview on 03/13/25 at 9:30 AM, the [NAME] stated she arrived at work to find dirty pots, pans, and dishes from the previous evening meal service and did not have enough time to wash dishes prior to serving the breakfast meal. The [NAME] stated she also served resident meals in Styrofoam containers for the breakfast and lunch meals on Saturday 04/12/25, because she was running behind schedule. During an interview on 04/16/25 at 10:45 AM, the Dietary Manager (DM) stated that serving meals to residents in Styrofoam containers was not acceptable and that the evening kitchen staff on 04/12/25 should have cleaned and prepared the kitchen for the morning meal service. Review of the facility's undated policy titled, Resident Rights revealed, . The facility protects and promotes the rights of each resident in our care . Each resident has the right to privacy with regard to accommodations, treatment, communications, personal care, visits and meetings of family and resident groups. 2. Review of R77's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R77 was admitted to the facility on [DATE], with diagnoses that included but was not limited to: congestive heart failure and neuromuscular dysfunction of bladder. Review of R77's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R77's Physician Orders, located in the Orders tab of the EMR, revealed R77 was to receive insulin glargine (a long-acting insulin) 100 unit/mL, 28 units once a day and Renacidin (citric ac-gluconolact-mag Carb, a sterile irrigating solution), 1980.6 mg-59.4 mg-980.4mg/30mL; 30 ml irrigation to his suprapubic catheter for 10 minutes and drain once a day. During an observation on 04/14/25 at 9:10 AM, Licensed Practical Nurse (LPN)2 entered R77's room, left the door wide open, approached R77, and did not close the privacy curtain. R77 could be seen from the hallway. LPN2 raised R77's shirt above his abdomen and administered R77 his long-acting insulin to the lower left quadrant, while R77 lowered the waistband of his pants to access his suprapubic catheter. LPN2 then administered the Renacidin irrigation solution into the catheter tube. R77 used one hand to hold both the tube and the top sheet up for privacy. R77 used other hand to pour the irrigation solution. During an interview on 04/14/25 at 9:25 AM, LPN2 stated, I had to leave [R77]'s door open so that I could watch my unlocked med cart and laptop screen. [R77] held up the top sheet so no one could see. But normally I would pull the privacy curtain to give them their privacy. During an interview on 04/14/25 at 10:20 AM, Registered Nurse (RN)1 stated, All the staff know that you must provide patient privacy. My expectation is that nurses lock their med carts and minimize their laptop screens so that they can provide privacy. That's what [LPN2] should have done. During an interview on 04/14/25 at 10:24 AM, the Director of Nursing (DON) stated, All the staff know to always provide privacy during all patient care no matter what it is. That is my expectation too, with no exceptions. [LPN2] . should have provided privacy.

Based on observation and interview, the facility failed to post current nurse staffing information daily. Specifically, the facility had a nurse staffing posting displayed in a common area accessible to residents and visitors; however, the information was not current for the date reviewed. This practice has the potential to mislead all residents and visitors regarding staffing levels and may impact transparency and trust in the facility's operations. Findings include: Review of the facility's 24 Hour Posting of nursing staffing data on 04/13/25 at 9:00 AM, located in the facility front lobby revealed, Riverside Health and Rehab .Census 147 .date 04/10/25 . During an interview on 04/13/25 at 10:13 AM, the Assistant Administrator confirmed the posting was dated 04/10/25 and should have been dated 04/13/25. He further stated that the staffing data was to be current, accurate, and posted daily. During an interview on 04/13/25 at 10:22 AM, the Director of Nursing (DON) confirmed that the 24-hour posting nurse staffing data should reflect the current date.

Based on interviews, record review and review of the facility policy, the facility failed to provide adequate supervision for Resident (R)3, who successfully eloped from the facility. On 11/18/24 at 3:15 PM, the Administrator was notified that the failure to provide adequate supervision to prevent an elopement constituted Immediate Jeopardy (IJ) at F689. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F689. On 11/19/24, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 11/07/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility's policy titled, Elopement, with a revision date of 11/01/17 states, to safely and timely redirect patients/residents to a safe environment. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: depression, cognitive communication deficit, acquired absence of left leg above knee, and unspecified psychosis not due to a substance or known physiological condition. Review of R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R3 had moderate cognitive impairment. Review of R3's Decisional Making Capacity Form located in his Electronic Medical Record revealed an undated document with R3's name on it. There was a slash across the form. Review of the Facility's 5 Day Reportable revealed R3 was taken from the facility on 11/04/24 between 1:00 PM - 2:00 PM. R3 was last seen sitting in his wheelchair on the front porch of the facility after lunch, which is his usual routine. On 11/04/24 at 5:30 PM, R3 was noted to not be available for his afternoon medications or dinner. Staff assumed R3 was visiting friends in the facility. R3 was not reported as potentially missing to the Administrator or the Police within 30 minutes as required by the facility's policy. An attempt was made to interview R3 on 11/18/24 at 11:38 AM with no success. A second attempt was made to interview R3 on 11/19/24 at 9:15 AM and 11:00 AM, with no success. Observations of R3 during these times revealed a wanderguard bracelet in place to R3's ankle. During an interview with the Medical Records Clerk on 11/18/24 at 11:57 AM, she stated she is responsible for setting up transport for appointments. She stated on the day of the appointment, she called the transport company to verify because she noted the original resident who was to be transported was still in the facility. She was told that the call had been completed, meaning transport had taken someone. She stated she notified transport that no one had been taken because the intended resident was still in the building. At that time, she was told that an investigation would be taking place. During an interview with the Central Supply Clerk on 11/18/24 at 12:09 PM, she stated, I was covering the Receptionist's lunch break at approximately 12:30 PM - 1:00 PM that day. I did notice 2 transport vans, 1 black and 1 gray, but did not see anyone get into the vans. She stated she was not made aware of R3 being missing until the next morning when she returned to work. She stated the process for residents leaving for appointments is typically a resident with a wheelchair will sit in the lobby and wait for transport. However, if they need a stretcher, transport comes to their room to get them. During an interview with Licensed Practical Nurse (LPN)1 on 11/18/24 at 12:13 PM, she stated, I got on the [med] cart around 1:00 PM. I did not receive a report, the keys to the cart were left in the book. I started giving medications so I could catchup on anything that may have been late. I believe it was around dinner time when a Certified Nursing Assistant (CNA) stated [R3's] tray was still in his room, untouched. I knew this was unusual because he goes to other units looking for food. She stated she then made the Director of Nursing (DON) and Unit Manager (UM) aware and went on about her night. LPN1 said, There was no code white or sense of urgency to look to see if anyone knew where [R3] was. During a telephone interview on 11/18/24 at 12:47 PM, the DON stated, [R3] left the facility with transport, instead of the resident that was intended to go. [R3] normally sits outside in the lobby but has never attempted to wander away from the facility. The Assistant DON (ADON) was supposed to go with the intended resident to the appointment, however, she left before him. Once it was noted that the intended resident was still in the building, transport was called and stated they had taken someone from the facility. Code [NAME] was not initiated because it was unknown that a resident was truly missing at that time. Later that day, the police notified the facility that [R3] was at a local Waffle House and a facility staff member went and picked him up. During an interview on 11/18/24 at 1:30 PM, the ADON stated, I agreed to escort the original attendee to the appointment. She was sitting in the lobby of the facility with the original attendant and said she would meet him in there, so she left the facility to head to the doctor's office, which is approximately 18 minutes/13 miles away. The ADON stated she asked the Unit Manager (UM) to text or call when he (the intended resident) was picked up. The DON called and asked her to make a new appointment for him since there was an issue with transportation, but she was not made aware of what the issue was. When the ADON left the facility around 1:40 PM on 11/04/24, R3 was not outside of the facility at that time. She stated that when she was sitting at the doctor's office, there were no residents outside, nor was there a van. Since she was not made aware of the incident, she did not know to look for R3. During an interview with the Administrator on 11/18/24 at 2:07 PM, she stated, I was not made aware of the incident until Tuesday. I believe it was around 2:00 AM on 11/05/24 when [R3] returned to the facility with a staff member. [R3] told the workers at Waffle House that he was ready to go home. The workers then called the police and [R3] told the police his name and that he lived at Riverside. The police called the facility, and a staff member went and picked him up. When asked what her expectations were, the Administrator stated, If I had known he was missing or that transport had stated they had taken someone, I would have immediately locked the building down and completed a headcount, but unfortunately, that was not done. During an interview with the Administrator on 11/19/24 at 10:30 AM, she indicated that the form with the slash meant the resident has decisional making capabilities, but she would defer to the Social Services Director (SSD) for further clarification. During an interview with the SSD on 11/19/24 at 12:30 PM, he stated that the slash meant the resident does have decision making capacity, but there was not any documentation from a Physician to confirm it. He stated that he dropped the ball and R3's medical record is confusing because of conflicting information. During a follow-up interview with the Administrator and Administrator in Training present on 11/19/24 at 1:15 PM, she stated that part of their audits was to ensure all residents were safely located in the building and residents who wish to be outside have now been provided with a courtyard that does not have access for them to be able to wander away from the facility unknown. On 11/19/24 the facility provided an acceptable IJ Removal Plan, which included the following: -What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Resident #1 left facility via transport van without staff knowledge. The resident was out of the facility without staff knowledge for more than two hours. Staff re-educated on physically checking on every resident at least every two hours on 11/7/24. Resident #1 is without injury and elopement risk assessment repeated on 11/7/24 with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for. AOC date is 11/07/24. -How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents who socialize on the front porch or along the walkway may be affected by this alleged deficient practice. -How the corrective action will be monitored to ensure the deficient practice will not recur: (include re-education) 1. Elopement drill conducted 11/7/24. 2. Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch- 11/7/24 3. Re-education for staff on Elopement Policy and Process and Abuse, Neglect, or Mistreatment starting 11/7/24. 4. Elopement risk assessments completed on residents who reside in the facility on 11/7/24. 5. A review of residents who are assessed as an elopement risk was completed on 11/7/24 and care plans updated as appropriate. 6. Safe area (courtyard) provided for residents to socialize. Residents informed 11/7/24. 7. Adhoc QAPI- 11/7/24. 8. Continue a midnight census every night as a daily audit. 9. ADON/designee will audit for elopement assessments completed and accurate within 24 hours or admission/readmission five times weekly for 4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. 10. ADON/designee will audit 24-hour report and new nurses' notes (facility activity report) for documentation of elopement risks five times weekly x 4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. -What quality assurance program will be put into place: Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.

Based on interviews, record reviews and review of the facility policy, the facility neglected to identify and acknowledge that Resident (R)3 was missing from the facility. The facility further failed to implement emergency protocol in a timely manner in order to locate the missing resident. On 11/18/24 at 3:15 PM, the Administrator was notified that the facility neglected to acknowledge a resident was missing from the facility and implement emergency protocol timely for locating the missing resident, which constituted IJ at F600. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F600. On 11/19/24, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 11/07/24. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings Include: Review of the facility policy titled, Elopement, with a revision date of 11/1/17 states, to safely and timely redirect patients/residents to a safe environment. Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE], with diagnoses including but not limited to: depression, cognitive communication deficit, acquired absence of left leg above knee, and unspecified psychosis not due to a substance or known physiological condition. Review of R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/30/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating R3 had moderate cognitive impairment. Review of R3's Elopement Risk Observation dated 11/07/24 revealed, Resident is not oriented to person, place and time. Resident is confused. Does not have safe decision-making capabilities. Wanderguard placed on right ankle. Review of R3's Decisional Making Capacity Form located in his Electronic Medical Record revealed an undated document with R3's name on it. There was a slash across the form. Review of the Facility's 5 Day Reportable revealed R3 was taken from the facility on 11/04/24 between 1:00 PM - 2:00 PM. R3 was last seen sitting in his wheelchair on the front porch of the facility after lunch, which is his usual routine. On 11/04/24 at 5:30 PM, R3 was noted to not be available for his afternoon medications or dinner. Staff assumed R3 was visiting friends in the facility. R3 was not reported as potentially missing to the Administrator or the Police within 30 minutes as required by the facility's policy. An attempt was made to interview R3 on 11/18/24 at 11:38 AM with no success. A second attempt was made to interview R3 on 11/19/24 at 9:15 AM and 11:00 AM, with no success. Observations of R3 during these times revealed a wanderguard bracelet in place to R3's ankle. During an interview with the Medical Records Clerk on 11/18/24 at 11:57 AM, she stated she is responsible for setting up transport for appointments. She stated on the day of the appointment, she called the transport company to verify because she noted the original resident who was to be transported was still in the facility. She was told that the call had been completed, meaning transport had taken someone. She stated she notified transport that no one had been taken because the intended resident was still in the building. At that time, she was told that an investigation would be taking place. During an interview with the Central Supply Clerk on 11/18/24 at 12:09 PM, she stated, I was covering the Receptionist's lunch break at approximately 12:30 PM - 1:00 PM that day. I did notice 2 transport vans, 1 black and 1 gray, but did not see anyone get into the vans. She stated she was not made aware of R3 being missing until the next morning when she returned to work. She stated the process for residents leaving for appointments is typically a resident with a wheelchair will sit in the lobby and wait for transport. However, if they need a stretcher, transport comes to their room to get them. During an interview with Licensed Practical Nurse (LPN)1 on 11/18/24 at 12:13 PM, she stated, I got on the [med] cart around 1:00 PM. I did not receive a report, the keys to the cart were left in the book. I started giving medications so I could catchup on anything that may have been late. I believe it was around dinner time when a Certified Nursing Assistant (CNA) stated [R3's] tray was still in his room, untouched. I knew this was unusual because he goes to other units looking for food. She stated she then made the Director of Nursing (DON) and Unit Manager (UM) aware and went on about her night. LPN1 said, There was no code white or sense of urgency to look to see if anyone knew where [R3] was. During a telephone interview on 11/18/24 at 12:47 PM, the DON stated, [R3] left the facility with transport, instead of the resident that was intended to go. [R3] normally sits outside in the lobby but has never attempted to wander away from the facility. The Assistant DON (ADON) was supposed to go with the intended resident to the appointment, however, she left before him. Once it was noted that the intended resident was still in the building, transport was called and stated they had taken someone from the facility. Code [NAME] was not initiated because it was unknown that a resident was truly missing at that time. Later that day, the police notified the facility that [R3] was at a local Waffle House and a facility staff member went and picked him up. A telephone interview with the Lead Customer Service Supervisor of the Transport Driver on 11/18/24 at 1:24 PM, she stated, Driver asked and [R3] signed the letters BJ, so she took him. She stated that she is unaware of the drivers needing to go into the facility to verify who they are taking. She stated, I will reach out to our upper management to see if they will be putting a process in place so this doesn't happen again. During an interview on 11/18/24 at 1:30 PM, the ADON stated, I agreed to escort the original attendee to the appointment. She was sitting in the lobby of the facility with the original attendant and said she would meet him in there, so she left the facility to head to the doctor's office, which is approximately 18 minutes/13 miles away. The ADON stated she asked the Unit Manager (UM) to text or call when he (the intended resident) was picked up. The DON called and asked her to make a new appointment for him since there was an issue with transportation, but she was not made aware of what the issue was. When the ADON left the facility around 1:40 PM on 11/04/24, R3 was not outside of the facility at that time. She stated that when she was sitting at the doctor's office, there were no residents outside, nor was there a van. Since she was not made aware of the incident, she did not know to look for R3. During an interview with the Administrator on 11/18/24 at 2:07 PM, she stated, I was not made aware of the incident until Tuesday. I believe it was around 2:00 AM on 11/05/24 when [R3] returned to the facility with a staff member. [R3] told the workers at Waffle House that he was ready to go home. The workers then called the police and [R3] told the police his name and that he lived at Riverside. The police called the facility, and a staff member went and picked him up. When asked what her expectations were, the Administrator stated, If I had known he was missing or that transport had stated they had taken someone, I would have immediately locked the building down and completed a headcount, but unfortunately, that was not done. Multiple attempts were made to contact the staff member who returned R3 to the facility, for interview, with no success. During a telephone interview with R3's brother on 11/19/24 at 9:26 AM, he stated, The police called my mother stating my brother was at a Waffle House. My mother then told them to call me. When the police called, I told them that my brother is supposed to be at Riverside Nursing Home, so I don't know how he got to the Waffle House. The facility did not tell us all what happened, someone just called to say they were putting an ankle monitor on him. During an interview with the Administrator on 11/19/24 at 10:30 AM, she indicated that the form with the slash meant the resident has decisional making capabilities, but she would defer to the Social Services Director (SSD) for further clarification. During an interview with the SSD on 11/19/24 at 12:30 PM, he stated that the slash meant the resident does have decision making capacity, but there was not any documentation from a Physician to confirm it. He stated that he dropped the ball and R3's medical record is confusing because of conflicting information. During a follow-up interview with the Administrator and Administrator in Training on 11/19/24 at 1:15 PM, she stated that part of their audits was to ensure all residents were safely located in the building and residents who wish to be outside have now been provided with a courtyard that does not have access for them to be able to wander away from the facility unknown. On 11/19/24 the facility provided an acceptable IJ Removal Plan, which included the following: -What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Resident #1 left facility via transport van without staff knowledge. The resident was out of the facility without staff knowledge for more than two hours. Staff re-educated on physically checking on every resident at least every two hours on 11/7/24. Resident #1 is without injury and elopement risk assessment repeated on 11/7/24 with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for. AOC date is 11/07/24. -How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents who socialize on the front porch or along the walkway may be affected by this alleged deficient practice. -How the corrective action will be monitored to ensure the deficient practice will not recur: (include re-education) 1. Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch- 11/7/24 2. Re-education for staff on Abuse, Neglect, or Mistreatment starting 11/7/24. 3. Re-education for staff on physically checking on residents at least every two hours on 11/7/24. 4. Continue a midnight census every night as a daily audit. 5. Safe area (courtyard) provided for residents to socialize. Residents informed 11/7/24. 6. Adhoc QAPI- 11/7/24. 7. ADON/designee will audit midnight census five times weekly x4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved. -What quality assurance program will be put into place: Results of the monitoring will be presented.

Based on review of facility policy, record review, interviews, and observations, the facility failed to conduct smoking assessments for 4 out of 10 residents (Resident (R)84, R116, R133, and R75) who smoke. Additionally, the facility failed to provide proper safety protocols for 10 out of 10 residents (R80, R84, R116, R595, R60, R133, R75, R93, R37, and R103) who smoke. On 03/13/24 at 4:32 PM, the Administrator was notified that the failure to conduct assessments on residents who smoke and failing to provide proper safety protocols for residents who smoke constituted Immediate Jeopardy (IJ) at F689. On 03/13/24 at 4:32 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/10/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 03/13/24, the facility provided an acceptable IJ Removal Plan. On 03/14/24 the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of E. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F689, constituting substandard quality of care. Findings Include: Review of the facility's Admission Handbook with a revision date of 05/22/20 revealed the following, Smoking Policy. Unless otherwise noted in a separate policy, this facility is a smoke-free environment . All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person. Violations of this policy endanger the health and safety of others at the facility . Review of the facility's policy titled Smoking Policy for Residents and Visitors with an effective date of 08/31/07, revealed, . our nursing facility discourages smoking due to complications that may arise due to medications, illnesses and smoking accidents. Further, we have the added responsibility of ensuring all residents, visitors and staff is free from all fire and smoking hazards . Accordingly, the following smoking policy has been implemented in our Facility and shall be enforced for ALL resident admitted after August 14, 2006 . This Facility is a smoke-free environment and, as such, there are NO designated smoking areas inside the building or on its premises for either residents or visitors. All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc.) in their rooms or on their person. Residents' smoking materials will be kept in assigned lockers adjacent to the exit door to the garden area between Units 100 and 200. The keys for the lockers will be controlled by the medication nurse on the back hall of Unit 200 and kept in the medication cart. During an observation on 03/13/24 at approximately 9:45 AM, R80, R84, and R116 were across the street from the facility smoking. R80 was in a motorized wheelchair, R116 was in a manual wheelchair, and R84 did not have any assistive devices for ambulation. Further observation revealed no protective equipment and no staff were present to supervise and/or provide assistance. During an interview on 03/13/24 at approximately 10:00 AM, the Assistant Business Office Manager (ABOM), who was working the receptionist desk, stated, There were residents trying to smoke. But we put a stop to it. the residents that do smoke have to sign out on a leave of absence. They sign out at the nurses station. During an interview on 03/13/24 at 10:05 AM, with the group of residents smoking, revealed: R80 stated, We use to smoke on property, but they made it no smoking on property. So we come across the street. It's not really safe cause we have to cross the street and the cars zoom by like a bat out of hell. We have to watch out for the traffic. I haven't had any assessment and I keep my cigarettes and lighter on me all the time. There are about eight of us who come out here to smoke. They lock the front doors at seven, so we can't smoke after that. R84 stated, The cars come barreling through here and it is not safe. R116 stated, I keep my cigarettes and lighter on me all the time. During an interview on 03/13/24 at 10:40 AM, Licensed Practical Nurse (LPN)3 stated, I have one smoker [R84]. The resident keeps their own smoking supplies. They sign out and they can go on their own. The smoking situation is new and we are adjusting. [R84] doesn't usually sign out because she is independent. I don't know if they had assessments. During an interview on 03/13/24 at 10:43 AM, LPN12 stated, [R133] tries to buy cigarettes from other residents and sometimes his family brings him some. I am not sure if the residents have had assessments. LPN12 identified the following residents who smoke: R595, R60, and R133. During an interview on 03/13/24 at 10:50 AM, LPN13 stated, I got one smoker on my hall [R93]. He goes out at least four times on my shift. I don't know if he's had an assessment. I hope he had one done. I don't know what he does with his smoking supplies. I am from [another state] and when I worked there we kept it (smoking materials) in a lock box, I don't know what they do here. Investigation identified the following residents that smoke: 1. Review of R80's Face Sheet revealed, R80 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory disease, sepsis, paraplegia, chronic obstructive pulmonary disease with acute exacerbation, shortness of breath, morbid obesity, asthma, and cognitive communication deficit. Review of R80's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/23, revealed R80 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of R80's Physician Orders dated 02/12/24 revealed an order for 2L oxygen PRN via NC. Review of R80's Electronic Medical Record (EMR) revealed, a Smoking Policy with an effective date of 08/31/07 signed by R80 on 01/31/24. Review of R80's Smoking Risk (Acuity) dated 03/01/24 revealed, R80 smokes cigarettes every few hours. Further review of the Smoking Risk revealed, R80 is a moderate problem for Inappropriately Provides Smoking Materials to Others and Mobility. The Smoking Risk evaluated R80 at a score of 4.0 indicating R80 was a safe smoker. Review of R80's Care Plan with a start date on 02/20/24 revealed the following problems: [R80] requires oxygen therapy PRN R/T COPD. Problem start date 09/05/23 [R80] is a former smoker, smoking cessation patch offered. Problem start date 01/27/22 [R80] is at risk for complications related to Asthma and COPD. Problem start date 01/27/22 [R80] at risk for falling R/T Paraplegia, lack of coordination, muscle wasting, and weakness. 2. Review of R84's Face Sheet revealed R84 was admitted to the facility on [DATE] (latest return on 12/19/23), with diagnoses including but not limited to: Type 2 diabetes, cognitive communication deficit, disorientation, acute respiratory disease, muscle weakness, abnormalities of gait and mobility, osteoarthritis, shortness of breath, major depressive disorder, lack of coordination, difficulty in walking, and cognitive social or emotional deficit. Review of R84's Quarterly MDS with an ARD of 03/02/24, revealed R84 had a BIMS score of 99 indicating the resident was unable to complete the interview. Review of R84's Physician Orders revealed the following orders: Seroquel (quetiapine) tablet; 50 mg; amt: 1.5 tablet; oral At Bedtime 09:00 PM 09/12/2023 and tramadol - Schedule IV tablet; 50 mg; amt: ONE TABLET; oral Special Instructions: ONE TAB TID PRN FOR KNEE PAIN As Needed PRN 1, PRN 2, PRN 3 03/05/2024 Review of R84's EMR revealed no Smoking Risk (Acuity) was completed. Review of R84's Care Plan with a start date of 09/11/23 revealed the following problems: [R84] has cognitive impairment and communication deficit, memory problems: Symbolic dysfunction, short/long term memory problems Impaired ability to make decisions R/T Following CVA. [R84] at risk for falling R/T R side weakness . 3. Review of R116's Face Sheet revealed R116 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic kidney disease, acute kidney failure, altered mental status, type 2 diabetes, nicotine dependence, cognitive communication deficit, unsteadiness on feet, lack of coordination, muscle wasting and atrophy, and muscle weakness. Review of R116's Quarterly MDS with and ARD of 01/11/24, revealed R116 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R116's EMR revealed no Smoking Risk (Acuity) was completed. Review of R116's Care Plan revealed the following problems: Problem start date 07/25/22 [R116] has cognitive impairment AEB memory problems: short/long term memory problems. Impaired ability to make decisions. Impaired communication. Problem start date 07/07/22 [R116] is at risk for falling R/T orthostatic hypotension. 4. Review of R595's Face Sheet revealed R595 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 diabetes, panic disorder, heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Review of R595's Admission MDS with an ARD of 02/29/24, revealed R595 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R595's Smoking Risk (Acuity) dated 03/08/24, revealed R595 smokes cigarettes more than once per hour. Further review of the Smoking Risk revealed, R595 is a minimal problem for Smokes in Unauthorized Areas and Mobility. R595 is a moderate problem for General Awareness and Orientation-Including Ability to Understand the Facility Safe Smoking Policy, General Behavior and Interpersonal Interaction and Capability to Follow Facility Safe Smoking Policy. The Smoking Risk evaluated R595 with a score of 8.0, indicating R595 to be a safe smoker. Review of R595's Care Plan revealed the following problems: Problem start date 03/10/24 Resident at risk for falling R/T impaired mobility. Problem start date 03/10/24 Resident is limited in physical mobility R/T impaired mobility and weakness. 5. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: undifferentiated schizophrenia, acute respiratory failure, muscle weakness, tremor, internuclear ophthalmoplegia bilateral, elevated blood-pressure reading, nicotine dependence, cognitive communication deficit, and convulsions. Review of R60's Quarterly MDS with an ARD of 12/15/23, revealed R60 had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. Review of R60's Smoking Risk (Acuity) dated 03/09/24, revealed R60 smokes cigarettes more than once per hour. R60 scored a 0.0 on indicating R60 is a safe smoker. Review of R60's EMR revealed a Smoking Policy with an effective date of 08/31/07, signed by the resident on 01/09/23 and 08/04/23. Review of R60's Care Plan revealed the following problems: problem start date 09/26/22 [R60] appears to have recall deficit related to: short term recall - long term recall - poor decision making. Problem start date 12/22/21 [R60] requires assistance with ADL's due to Anemia, weakness and TBI . Problem start date 10/11/18 [R60] has the dx of bipolar and schizophrenia and is at risk for behaviors including yelling out, seeing things that aren't there, insomnia, puts self on floor when angry bout going home, crying, and decline in mood. Combative at times with staff and aggressive with another resident . Non compliant with smoking policy. Problem start date 09/26/18 [R60] at risk for falling R/T left sided weakness, tremors and Psychotropic meds. 6. Review of R133's Face Sheet revealed R133 was admitted to the facility on [DATE], with diagnoses including but not limited to: schizophrenia, chronic bronchitis, wheezing, bipolar disorder, nicotine dependence, cough, mental disorder due to known physiological condition, lack of coordination, cognitive communication deficit, muscle wasting and atrophy, and muscle weakness. Review of R133's Quarterly MDS with an ARD of 02/14/24 revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Review of R133's Physician Orders revealed the following orders: albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 Puffs; inhalation Special Instructions: Inhale 2 puffs into the lungs every 4 hours as needed for shortness of breath/wheezing As Needed PRN 1, PRN 2, PRN 3 02/06/2024, ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg(2.5 mg base)/3 mL; amt: 3mL; inhalation Special Instructions: 3mL q4 PRN for SOB/wheezing As Needed PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6 01/26/2024, Ativan (lorazepam) - Schedule IV solution; 2 mg/mL; amt: 2mg; injection Special Instructions: 2mg BID PRN As Needed PRN 1, PRN 2 12/15/2023, Breo Ellipta (fluticasone furoate-vilanterol) blister with device; 100-25 mcg/dose; amt: 1 puff; inhalation Special Instructions: Rinse and spit after each use Once A Day 09:00 AM 02/07/2024, and Seroquel (quetiapine) tablet; 50 mg; amt: 1 tab; oral Three Times A Day 09:00 AM, 01:00 PM, 09:00 PM 01/18/2024. Review of R133's Smoking Risk (Acuity) dated 11/09/23 revealed, R133 scored a 12.0 indicating R133 was an unsafe smoker. Further review of the Smoking Risk revealed the following: Potentially Unsafe Smoker - Follow Facility Policy - Clinical Judgement - Resident is not capable of even supervised smoking. Smoking will result in danger to self or others. True - Withhold smoking materials. Review of R133's Care Plan revealed the following problems: problem start date 02/12/24 [R133] is at risk for respiratory distress R/T bronchitis. Problem start date 11/16/23 [R133] is at risk for falling R/T neyrocognitive disorder. Problem start date 11/16/23 [R133] is at risk for further cognitive impairment R/T Neurocognitive disorder. Problem start date 11/10/23 [R133] is at risk for having mood and behaviors changes R/T Schizophrenia. Problem start date 11/10/23 '[R133] wanders and/or is an elopement risk. Requites wander guard. 7. Review of R75's Face Sheet revealed R75 was admitted to the facility on [DATE] with diagnoses including but not limited to: Wernicke's encephalopathy, tremor, delirium, Type 2 diabetes, reduced mobility, delusional disorders, difficulty in walking, and major depressive disorder. Review of R75's Quarterly MDS with an ARD of 12/12/23 revealed a BIMS score of 12 out of 15, indicating R75 was moderately cognitively impaired. Review of R75's EMR revealed no Smoking Risk (Acuity) was completed. 8. Review of R93's Face Sheet revealed R93 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic osteomyelitis, cough, and sepsis Review of R93's Quarterly MDS with an ARD of 12/27/23, revealed a BIMS score of 14 out of 15 indicating the resident was cognitively intact. Review of R93's Smoking Risk (Acuity) dated 03/01/24, revealed R93 smokes cigarettes every few hours. Further review of the Smoking Acuity revealed R93 was a minimal problem for Inappropriately Provides Smoking Materials to Others and Mobility. R93 scored a 2.0 indicating R93 is a safe smoker. Review of R93's Care Plan revealed the following problems: problem start date 05/21/21 [R93] has behaviors which include cursing at staff, refusing to obtain weight, and makes false acquisitions regarding meal/portion preferences and medication administration. Problem start date 04/01/21 [R93] at risk for falling . 9. Review of R37's Face Sheet revealed R37 was admitted to the facility on [DATE] with diagnoses including: cerebral palsey, acute upper respiratory infection, acute bronchitis, pneumonia, contracture, cough, bipolar disorder, nicotine dependence, and acquired absence of right leg below knee. Review of R37's Quarterly MDS with an ARD of 12/13/23 revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Review of R37's EMR revealed a Smoking Policy with an effective date of 08/31/17 signed by the resident on 01/29/24. Review of R37's Smoking Risk (Acuity) dated 03/01/24, revealed R37 smokes cigarettes and vape a couple times per day. Further review of the Smoking Risk revealed, R37 is minimal risk for Smokes in Unauthorized Areas, Inappropriately Provides Smoking Materials to Others, and Begs or Steals Smoking Materials From Others. R37 is a moderate problem for Mobility. R37 scored a 5.0 on the Smoking Risk indicating R37 is a safe smoker. Review of R37's Care Plan revealed the following problems: problem start date 09/27/23 [R37] is a risk for self harm related to: SUD, Poor support system, loneliness as evidence by: Statements of despair, helplessness, hopelessness, Suicide behavior (talk). Problem start date 09/19/23 [R37] is at risk for cognitive decline and behaviors R/T cerebral palsy, Bipolar with use of psychotropics. Problem start date 09/05/23 [R37] is a former smoker and occasionally staff has caught resident smoking despite encouragement and education. Problem start date 10/14/21 [R37] is unable to make daily decisions without cues/supervision R/T decreased safety awareness. Problem start date 09/27/21 [R37] chooses to smoke an e-cigarette. 10. Review of R103's Face Sheet revealed R103 was admitted to the facility on [DATE] with diagnoses including but not limited to: acute hematogenous osteomyelitis, difficulty walking, spastic hemiplegia, and cognitive communication deficit. Review of R103's Quarterly MDS with and ARD of 12/30/23 revealed a BIMS score of 13 out of 15 indicating the resident was cognitively intact. Review of R103's EMR revealed a Smoking Policy with an effective date of 08/31/07 signed by R103 on 08/07/23. Review of R103's Smoking Risk (Acuity) dated 03/01/24 revealed R103 smokes cigarettes a couple times per day. Further review of the Smoking Risk revealed R103 is a moderate problem for Mobility. R103 scored a 2.0 indicating R103 is a safe smoker. Review of R103's Care Plan revealed the following problems: problem start date 03/07/24 Resident at risk for falling R/T unsteady gait. Problem start date 05/15/23 He is at risk of having mood and behavior needs as evidence by periods of (type of behavior, socially inappropriate, physically aggressive, verbally aggressive, refusing care). Problem start date 05/10/22 [R103] may have c/o pain r/t left arm and hand contracted. Problem start date 05/04/22 [R103] is at risk for falling R/T traumatic amputation of 2 or more toes, seizures, resident removes wheel chair arm rest per preference. During an interview on 03/13/24 at 2:13 PM, R75 states, I smoked about a month and a half ago. I kept my cigs in my room and I borrowed someone's lighter. During an interview and observation on 03/13/24 at 2:25 PM, R133 states, I smoked yesterday, across the street. I get lucky and get one every now and again. I buy cigarettes from other residents. Observation revealed an oxygen tank in R133's room. During an interview and observation on 03/13/24 at 2:31 PM, R103 states, I smoked yesterday and I had to cross the street. I don't like crossing that street. I went out to smoke on Sunday, when I was crossing the street to come back, someone almost hit me with their van. I get my cigarettes and lighter from who ever is out there smoking. I buy my own cigarettes whenever I get some money. Observation revealed R103 in a manual wheelchair and both of R103's hands were contracted. During an interview and observation on 03/13/24 at approximately 2:35 PM, three additional residents were observed smoking across the street. During an interview on 03/13/24 at 2:37 PM, while smoking, R60 states, It ain' t too safe crossing that street. I smoked yesterday. I keep my cigarettes and lighter in my room. During an interview and observation on 03/13/24 at 2:40 PM, while smoking, R93 states, I smoke three to four times a day. I don't like crossing the street because of traffic and the parking lot. It's hard to get out here because the wheels on my walker get stuck. I keep all my smoking supplies in my walker. Observation revealed R93 sitting on his walker smoking. R93 pulled up the seat on the walker, revealing a pack of cigarettes and a lighter. During an interview and observation on 03/13/24 at 2:44 PM, while smoking, R37 states, I smoke about three to four times a day. I don't like crossing the street cause I got hit by a car when I was younger. I keep my cigarettes and lighter in my dresser drawer. Observation revealed R37 smoking, in a mechanical wheelchair, R37's left hand was contracted. During an interview on 03/13/24 at 3:17 PM, the Administrator and Director of Nursing (DON) revealed, residents have to sign out and leave the building to smoke. The DON stated her expectation is that they do not smoke. When they leave here we don't know what they are doing. We were not aware that the residents were keeping smoking materials in their room. When we see them in the facility, we will take the smoking items. The Administrator revealed, the lighter goes to the nurses station and the cigarettes we throw away. It usually goes with the nurse in their cart. We do not know how many smokers are in the facility. We were not aware that residents were sharing and borrowing cigarettes from other residents. The DON concluded, if it is a resident that we know smokes, we will do an assessment. On 03/13/24 the facility provided a removal plan, which included the following: Residents currently residing in the facility were asked by facility leadership if they currently are smokers on 3/13/24. Those self-identified as smokers will have a smoking acuity (assessments) completed by a licensed nurse on 3/13/24. The Administrator will review on 3/13/24 with the residents, that have self-identified as smokers, the admission policy including the smoking policy which states the facility is a nonsmoking facility and any smoking materials must be turned into a nurse for secured storage. Residents who had smoking materials have turned in those smoking materials to the administrator for storage in a secured area on 3/13/24. Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 3/13/24. A Review of the Release of Responsibility for leave of absence forms was completed by the Director of Nursing. resident who are currently signed out were located in the facility and reeducation was provided to residents who sign themselves out regarding signing back in upon return and notifying the nurse when leaving the facility and returning on 3/13/24. Facility Staff and residents who sign themselves out via leave of absence form will be reeducated by Director of Nursing/Designee on the following: - Residents who identify as smokers will have the Smoking Acuity (Assessment) completed upon admission by a licensed nurse. - Residents will sign in and sign out with the nurse or facility representative at the nurse's station when they leave the building. - Residents check in with charge nurse or facility representative upon return. - Residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. If residents do not surrender smoking materials upon reentry, appropriate discharge planning by Social Services will occur if smoking materials are identified. Any staff not receiving this education on 3/13/24 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will validate in clinical morning meeting Monday-Friday that Smoking Acuity (assessment) has been completed for newly admitted residents identifying as a smoker. The Director of Nursing will randomly interview a minimum of 2 staff and 3 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with leave of absence sign in/out process. Director of Nursing/designee will review sign out logs twice a shift for 5 days then daily for 3 additional weeks, then monthly for 2 additional months to validate residents remain complaint with signing in and out of the facility. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 3/13/24 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 3/13/24 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months.

Based on observations, manufacturer's recommendation review, and interviews, the facility failed to: 1) provide the date medications were opened in 3 of 4 medication administration carts, 2) failed to ensure that the medication carts were free of loose pills in 2 of 4 medication carts and 1 of 2 narcotic lockboxes, and 3) failed to remove expired medications and biologicals in 2 of 2 medication storage rooms, 1 of 1 treatment supply room, and 1 of 1 central supply room reviewed for medication storage. Findings include: The facility was not able to provide a policy on medication storage. During an observation on 03/14/24 at 09:20 AM, of the medication storage room on Hall 300, with Licensed Practical Nurse (LPN)8 revealed the following: 1. 1 pack of IV3000 10cmx12cm lot 2051 with expiration date of 2023-12-1. 2. 2 single alcohol pads with no expiration date, lying open in cabinet drawer. 3. The following items were contained in one Ziploc bag: 2 - BD Vacutainer push button blood collection set REF 367342 0.6x19mmx305mm 23Gx3/4x12 and 3 - 8 IV Extension set w/non bonded needle free valve REF DYNDTC5081. One item in the bag had a dried reddish colored substance on it contaminating the entire bag. 4. 1 open Luer Lock Disposable syringe without needle ref Lot 171220 opened and not sealed. 5. 1 bag of IV caps not in the original packaging. 6. The refrigerator revealed one syringe in an open package, not labeled or sealed. During an interview on 03/14/24 at 9:49 AM, LPN8 revealed that she was unaware of why the syringe was in the refrigerator, but it may have been used for gabapentin, and that she usually uses and tosses the syringes afterwards. When shown an unlabeled bag of small green containers she identified them as caps for IV but stated that she was not sure of how original packaging looks for them to be stored correctly. LPN8 confirmed the items from the medication storage room and treatment supply room and discarded them. During an observation on 03/14/24 at 10:14 AM, of the treatment supply room on Hall 300 revealed the following: 1. 13 packs of one fluid ounce (oz.) hydrogen peroxide 3% USP 1 fl oz (30 ml) stored in box labeled non-woven drain sponges. 2. 1 urological catheter strap REF DYND 16800 lot 91122040001 package open not sealed. 3. 2 - 1 single use system with antiseptic oral rinse with an expiration date of 2023-01-18. 4. 1 Yankauer with bulb tip no control vent REF DYND5013 - packaged stained with yellowish substance. 5. 1 Calcium alginate dressing 0.35x12 (1.0x30cm) lot 20112124 with an expiration date of 2023-12-28. During an observation on 03/14/24 at 10:26 AM, of the central supply room on Hall 200 revealed the following: 1. 1 case of suture removal trays with an expiration date of 2023-01-31. 2. 1 pack/100 cotton tip wood applicator opened and not sealed for sanitation. 3. 1 Monject 1 ml tuberculin syringe lot 706523 with an expiration date of 2022-02-28. During an interview on 03/14/24 at 10:26 AM, the Central Supply Clerk confirmed the items and discarded them. During an observation on 03/14/24 at 10:40 AM, in medication storage room on Hall 200, revealed the following: 1. 1/2 round pink pill loose in bottom of narcotic lock box located in the refrigerator. 2. Refrigerator temperature log revealed only one temperature check for the month of March 2024. 3. The floor was not swept and dirty with spills. During an observation on 03/14/24 at 2:19 PM, of medication cart on Hall 400 Cart B revealed the following: 1. 1 oblong off white pill labeled US 250 at the bottom of 2nd drawer of the cart. 2. The 2nd Lockbox on cart was unable to be opened for observation. During an interview on 03/14/24 at 2:25 PM, LPN11 confirmed the items and discarded them. During an observation on 03/14/24 at 2:50 PM, of medication cart A on Hall 100 revealed the following: 1. 1 sharps container on cart with 3 unidentifiable needles laying on top of container. 2. 2nd drawer revealed the following loose pills in bottom of drawer: 1 oval orange pill labeled 673, 1 oval white pill labeled 6, 1 round white pill labeled Z, 1/2 round white pill (unable to see label). 3. 3rd drawer revealed 1 Lantus Solostar 100 units/ml pen with no open date and a manufacturer's warning label instructing the medication expires 28 dates after opening, with no open date the expiration date could not be determined. 4. 1 container of Evencare G3 blood glucose test strips lot (10) 16822013008 with an expiration date of 2023-10-11 and 1 container of Evencare G2 glucose control solutions lot (10) 16821072101201 with an expiration date of 2023-07-08. During an interview on 03/14/24 at 2:55 PM, LPN5 revealed that she was not aware of the loose pills found at the bottom of the drawer or when the Lantus pen was opened. LPN5 revealed that she is a PRN (as needed), and this is her first day back. LPN5 confirmed the items and discarded them. During an observation on 03/14/24 at 3:00 PM, of medication cart B on Hall 100 revealed the following: 1. 1 Novalog flexpen 100 unit/ml with no open date and a manufacturer's warning label instructing the medication expires 28 dates after opening, with no open date the expiration date could not be determined. During an interview on 03/14/24 at 03:05 PM, LPN9 confirmed that there was no open date for the medication and that the pen would be discarded. LPN 9 confirmed the items from the medication cart and discarded them. During an interview on 03/15/24 at 10:36 AM, the Director of Nursing (DON) revealed that the medication storage rooms are managed by the unit managers and the Central Supply Clerk, and that these rooms are checked monthly. The DON revealed that the medication carts on each unit are managed by the nursing staff working on the cart. The DON states that her expectation is that the nurses check the medication carts daily to ensure there they are free of expired medications, loose pills at the bottom of the drawers, and that there are no open medications that are not labeled before they start administrating medications at the beginning of their shift.

Based on observation, interviews and record review, the facility failed to provide sufficient Registered Nurse (RN) staffing on a 24-hour basis to ensure all residents receive adequate care. Finding include: Review of the facility policy titled Staffing with a complete revision date of 11/01/17 states, The Facility 's Leadership will provide a sufficient number of staff to successfully implement patient/resident-focused functions. 2. Nursing: A. 1. Based on facility assessment, determines care needs that are consistent with patient/residents needs, provides sufficient numbers of licensed nurses and other nursing staff (RNs, LPNs/LVNs, Nurses Aides) on a 24-hour basis. 3. Except when waived, uses the services of a RN for at least eight (8) consecutive hours seven (7) day a week. Review of the Staffing Daily Posting dated December 2023, revealed six days that the facility did not have Registered Nurse (RN) coverage for 8 consecutive hours. The dates include: 12/06, 12/07, 12/17, 12/18, 12/20, and 12/21. Review of the Staffing Daily Posting dated January 2023, revealed nine days that the facility did not have RN coverage for 8 consecutive hours. The dates include: 01/04, 01/10, 01/12, 01/14, 01/17, 01/18, 01/19, 01/27, and 01/28. Review of the Staffing Daily Posting dated February 2023, revealed thirteen days that the facility did not have RN coverage for 8 consecutive hours. The dates include: 02/01, 02/02, 02/03, 02/05, 02/07, 02/09, 02/10, 02/11, 02/14, 02/15, 02/21, 02/28, and 02/29. Durning an interview on 03/15/24 at 9:29 AM, Certified Nurse Assistant (CNA)1 stated, It depends on the days and the number of call in/out by staff, determine the number of residents I have to care for. It is the same for the weekends. CNA1 reported that if we do not have enough staff on the halls that is when we (CNAs) have to team up to provide care to our residents and we do the best we can. Durning an interview on 03/15/24 at 9:47 AM, Licensed Practical Nurse (LPN)1 stated, We communicate the residents' concerns during our huddle and if there are any concerns that is when I inform the CNAs. If an emergency arises with the resident, I will inform the RN on duty or I will contact the Director of Nursing (DON) for assistance or directions. During an interview on 03/15/24 at 10:00 AM, the DON stated, Based on the residents' concerns, we use this as a teaching moment. After an emergency, we will do a huddle and use this incident as a teaching moment in order to determine the competency needed to meet each resident's needs each day and during an emergency. The DON stated, That's unheard of, we must have a licensed nurse (RN) on duty, but if there is no RN on duty, I or the Assistant Director of Nursing (ADON) will step in to assist until one comes in. The DON, ADON will get on the floor to assist. I will stay until 7:00 PM when the second shift comes in.

Based on interview and record review, the facility failed to provide clean linen/washcloths to residents throughout the facility. Findings include: The facility did not provide a policy on linens/laundry. Review of Resident Council Meeting Minutes for the months of September 2023, October 2023, November 2023, December 2023, January 2024, and February 2024, all revealed concerns regarding lack of linens/wash clothes. During an observation on 03/12/24 at 10:31 AM, revealed room [ROOM NUMBER], linens on both residents' beds were stained with food and dirty. During an observation on 03/12/24 at 10:47 AM, revealed room [ROOM NUMBER], linens on resident's bed was stained and dirty. During an observation on 03/12/24 at 10:50 AM, revealed room [ROOM NUMBER], smelled of urine. Linens on the bed were soiled with what appeared to be a yellow liquid, food and dirty. During an observation on 03/12/24 at 11:05 AM, revealed room [ROOM NUMBER], linen on bed B was dirty, stained with food, and dried blood. During an observation on 03/12/24 at 11:15 AM, revealed room [ROOM NUMBER], there were no linens on bed A and the linen on bed B was dirty and stained. During an observation on 03/12/24 at 11:27 AM, revealed room [ROOM NUMBER], linen on residents bed was soiled with unknown substance and stained with food. During an observation on 03/12/24 at 12:03 PM, revealed room [ROOM NUMBER], there were no linens on on bed A, resident was laying directly on mattress, and the linens on bed B was dirty and stained. During an observation on 03/12/24 at 12:12 PM, revealed room [ROOM NUMBER], there were no linens on bed B. During an observation on 03/13/24 at 12:37 PM, revealed room [ROOM NUMBER], linens on both resident's bed was still stained with food and dirty. During the Resident Council Meeting on 03/13/2024 at 2:02 PM, which included Resident (R)14 and R00. R14, who was the Resident Council President, and R00 stated that linen/laundry had been a major issue discussed. The facility runs out of linen daily, often having residents go weeks without clean linen including washcloths. R14 stated this had been an on going issue that was brought up at every meeting, yet nothing had been done to fix it, no one would tell the residents when the issue would be resolved or what they (staff) were doing/going to do to resolve the issue. R14 stated the Director of Nursing (DON) kept telling us (residents) to try to be more patient, these issues are being addressed, we (staff) understand your (resident) concerns but this is a process and that would be all the answers we (residents) would get and nothing else. During an interview on 03/13/24 at 2:38 PM, the DON stated laundry was a major issue, partly because it was done outside of the facility. The facilities' laundry should be done around the clock or at least on every shift and it has not been done that way for some time now. The facility's laundry was not being picked up and returned in a timely manner and when it was returned it was only a portion of what was picked up. The contract the facility had with the outsourced company will be terminated at the end of the month. Starting 04/01/24 all laundry services will be conducted in-house. The DON also stated that they fully understood every concern addressed by the resident council and staff were doing their best to resolve those concerns. These matters unfortunately will take some time to resolve.

Based on record review, interviews, and review of facility policy, the facility failed to implement interventions outlined in Resident's (R)53's Care Plan, for 1 of 5 residents reviewed. 50085 Findings include: Review of the facility policy titled, Care Plan Process, Person-Centered Care, revised 05/05/23, revealed, Policy Statement: The facility will develop and implement a base line and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of the facility policy titled, Fall Management revised 05/05/23 states, 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Procedures included with this policy: 2. The fall risk evaluation assists in identifying the appropriate preventative interventions that will be recorded on the patient/resident's care plan. 3. The facility provides assistive devices based on individual resident needs to facilitate mobility and prevent falls. 6. The care plan reflects individualized interventions that are reassessed and revised as needed. Review of R53's Face Sheet revealed R53 was admitted to the facility on [DATE] with the latest return date of 09/01/23, with diagnoses including, but not limited to: falls, encephalopathy, seizures, anxiety disorder due to known physiological condition, bipolar disorder, dizziness and giddiness, weakness, and confusional arousals. Review of R53's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/23, revealed R53 had a Brief Interview of Mental Status (BIMS) score of 99, suggesting R53 chose not to participate. Review of R53's undated Care Plan revealed R53 is at risk for falling related to end of life care, seizures, medication, impaired mobility, muscle weakness and atrophy, cognition. Long term goal: R53 will remain free from injury. Intervention/Approach: Fall mats in place while resident is in bed, call light within reach. During an observation on 03/12/24 at 11:17 AM, R53 was in bed asleep, fall mats were on the floor but not positioned properly. During an observation on 3/14/24 at 11:33 AM, revealed fall mats were inappropriately placed on bilateral sides of bed. The right fall mat was located diagonally underneath the bed. The left fall mat was near the left wall, away from the bed, with a folding chair on top of it. During an interview on 03/14/24 at 11:39 AM, Licensed Practical Nurse (LPN)3 revealed she is aware that R53 has a history of falls, and her last fall was a month ago. LPN3 indicated the call light should be within reach, the bed is always in the lowest position, and fall mats should be beside the bed. LPN3 verified the right fall mat positioned diagonally under R53's bed and the left fall mat away from the bed near the doorway with a folding chair on top of it. During an interview on 03/14/24 at 11:45 AM, the Director of Nursing (DON) stated her expectation is that staff are adhering to the care plan and R53 is free from falls. The DON reports that R53, at times places herself on the floor and that is listed on the care plan. The DON stated that she will address the fall mats not being in place.

Based on review of facility policy, record reviews, and interviews, the facility failed to ensure Resident (R)30 or his personal representative received discharge notification, upon discharge to the hospital, in writing and in a language they could understand. The facility further failed to ensure the state Ombudsman received a copy of the notification in timely manner, for 1 of 3 residents reviewed for hospitalization s. Findings include: Review of the undated facility policy titled, Discharge Notification, under Policy: To specify the limited conditions under which a skilled nursing facility or nursing facility may initiate transfer or discharge of a resident, the documentation that must be included in the the medical record, and who is responsible for making the documentation. Additionally, these requirements specify the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting. Number 7 states: Notice before transfer. A. Before a facility transfers or discharges a resident, the facility must: 1) 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. 2) The facility must also send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the residents' medical record. Review of R30's Face Sheet revealed, the facility admitted R30 with diagnoses including, but not limited to: osteomyelitis of vertebra, sacral and sarcococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions and stage four pressure ulcers. Review of R30's Electronic Medical Record (EMR), revealed a hospital stay for R30 from 03/02/24 and returning on 03/06/24. No documentation could be found to ensure R30 or the resident representative received notification of discharge to the hospital in a timely manner. Further review of EMR revealed no documentation to ensure the state ombudsman received notification within a timely manner. During an interview on 03/13/24 at 2:48 PM, the Director of Nursing (DON) confirmed that the medical record did not contain a copy of the transfer paperwork given to the resident or the resident representative. The DON however, did provide a sheet of paper that states, to the Ombudsman Intaker, and reads, Attached is the admission and discharge report for January 2024 (and March 2024 for February 2024). Please let me know if more information is needed. No resident information (names, date of discharge, etc) was included in the documentation provided.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)30 was afforded the right to formulate an advance directive for 2 of 3 residents reviewed for Advance Directives. Findings include: Review of the undated facility policy titled, Advance Directive, states, The facility recognizes the resident's right to formulate an advance directive. Procedures: 1. The facility recognizes the following advanced directives: A. Do-Not-Resuscitate (DNR) identifications and orders. B. Living Will, or similar declaration. C. Power of Attorney for Health Care, or similar declaration. D. Organ Donations. E. POLST, MOLST, and MOST. 2. Upon admission to the facility, the Admission Coordinator will: A. Provide each resident or his/her legal representative with a copy of the facility's policy and state requirements for advanced directives. Obtain the resident or his/her legal representative's signature on a acknowledgement confirming receipt of this information. B. Interview each resident or/his/her legal representative/family members to determine whether the resident has executed an advance directive, and if not, determine if the resident wishes to formulate an advance directive. C. If the resident has executed an advanced directive, obtain copies and: 1) Place them in the medical record (Advanced Directives section) 2) Place them in the financial record (contained in the Business Office) 3) Provide a copy to the Social Services Director 4) Provide a copy to the attending physician. 3. Upon admission to the facility, the Social Services Director will: A. Review the medical record/advance directives, interview patient/resident or his/her legal representative/family member and inform them of their rights to complete advanced directives. B. Assist a patient/resident who wants to, and can, execute an advance directive in obtaining and completing the necessary forms. C. Obtain any needed orders. D. Maintain executed copies and disseminate as appropriate. E. For facilities with an electronic medical record, add a copy of the executed advance directive and patient face sheet to the centrally maintained binder that contains same for all patients/residents with advance directives. Review of R30's Face Sheet revealed, the facility admitted R30 with diagnoses including, but not limited to: osteomyelitis of vertebra, sacral and sarcococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions and stage four pressure ulcers. Review of R30's Electronic Medical Record (EMR) on 03/13/24 at 1:55 PM, revealed no documentation of advance directives. Further review of the EMR on 03/13/24 at 2:10 PM, revealed no documentation to ensure R30 or his personal representative was afforded the right or opportunity to formulate an advance directive. During an interview on 03/13/24 at 2:30 PM, the Director of Nursing (DON) stated she was unable to locate the advance directive for R30. 47812

Based on record review and interview, the facility failed to obtain laboratory tests as ordered for one of six sampled residents reviewed for unnecessary medication. Laboratory test results, including an Urinalysis with Culture and Sensitivity (UA/C&S) were not reported to the physician in a timely manner, resulting in a delay in treatment and subsequent hospitalization for Resident #198. The findings included: Resident #198 was admitted to the facility with [DIAGNOSES REDACTED]. Record review at 11:43 AM on 3-29-17 revealed 12-5-16 physician's orders [REDACTED]. Further review revealed that the resident was seen in the emergency room for an evaluation of aggressive behavior on 12-6-16 and discharged back to the facility on antibiotic therapy for an Urinary Tract Infection [MEDICAL CONDITION]. A 12-8-16 physician's orders [REDACTED]. Review of Nurses Notes at 12:34 PM on 3-29-17 revealed that the lab was drawn and urine specimen obtained and sent to the lab on 12-12-16. There was no mention of receipt or notification of the physician of the lab results in the Nurses Notes. Review of the Nurses Notes and physician visit notes revealed the resident was sent to the emergency roiagnom on [DATE] for evaluation of altered mental status and aggressive behavior. The physician's note stated, It was determined he (she) was delirious due to an [MEDICATION NAME] faecalis UTI . Review of the lab reports revealed that they had been faxed to the facility at 7:58 PM on 12-19-16 and showed an [MEDICATION NAME] Faecalis UTI. The reports were not initialed by the physician until 1-5-17. During an interview on 3-30-17, when asked about processing of lab orders, Licensed Practical Nurse (LPN) #4 (on 400 Hall where Resident #198 lived) stated that when physician's orders [REDACTED]. S/he stated, Nursing staff is responsible to check the lab book and get the results back. The LPN noted that s/he would look for the results of the UA on the same day sent and look for the C&S on the second day and daily thereafter. S/he stated s/he would start calling the lab on the second day if the results had not been received. Review of the lab tracking book revealed incomplete information related to when results were received, when the physician was notified, when the responsible party was notified, whether results were abnormal, and if there were new orders based on the results. During an interview at 10:20 AM on 3-30-17, the Director of Nurses (DON) reviewed the record and verified that the urine specimen had been obtained and sent to the laboratory on 12-12-16. Further review with the DON revealed that the lab results were not reported to the facility until 12-19-16, the day the resident was admitted to the hospital with [REDACTED]. During an interview at 1:48 PM on 3-30-17, the DON verified that the lab results had been signed by the physician on 1-5-17 and there was nothing in Nurses Notes or Progress Notes related to physician awareness of lab results. The DON reviewed the pages from the lab book and verified that the tracking had not been completed as required. S/he stated, The Unit Manager should check the lab book daily. If not received, they should call and get the results.

Based on observation and interviews the facility failed to provide medically related social services to Resident #8, s/he was not provided glasses timely (1 of 3 resident reviewed for social services). The findings included: Resident #8 admitted to the facility with [DIAGNOSES REDACTED]. In an interview with the surveyor on 07/22/2015 at 10:40 AM Resident #8 stated that s/he was afraid to walk outside his/her room because s/he could not see and s/he was afraid of falling. S/he stated s/he was waiting for a prescription for glasses. Review of Resident #8's medical record revealed a nurse's note dated 05/11/2015 at 1:30 PM that stated, Resident was questioning repeatedly about getting his/her glasses. Resident stated that s/he should have gotten his/her glasses because s/he was 1st one in line. Agitation increased when explained that answer had to be researched. Resident was not satisfied agitation continued to increase Xanax 0.25 mg (milligrams) given for anxiety. 2:30 PM Anxiety decreased resident made aware that awaiting on physician to send prescription. Review of the Social Work notes revealed no information related to the resident's eyeglasses. Review of the medical record revealed a Request for Eye Evaluation dated 11/11/2014 that indicated, .New Bifocal RX Given Today. On 06/09/2015 Resident #8 was seen for an eye evaluation. In an interview with the surveyor on 07/22/2015 at approximately 9:45 AM the Social Service Director stated that s/he would check on Resident #8's prescription with the social work assistant who was out and might know about the glasses. I am new and not familiar with what's going on with this resident. The Social Service Director provided the following communication between the facility social service department and the company who did the eye evaluation: 07/08/2015 at 8:01 AM .I am ordering a couple pairs of glasses from our recent optometry services. Secondly, I have a patient (Resident #8) who was seen and wants glasses, but s/he did not have the order form with the amount. How do I go about getting him/her glasses?. 10:07 AM (Resident #8's) consent form is attached to this email. I do not know why one was not left with the others. 07/22/2015 10:07 AM Here is the correspondence along with the consent for glasses. 10:15 AM Thanks. for your response. It was my understanding s/he needed a new script.??? 10:28 AM I apologize - usually, glasses are ordered through us so I sent the consent form. The script was not updated in the database from the last time (Resident #8) was seen on 11/11/14. I have sent an email to the OD and the tech that did the clinic that day and asked them to update the script and get back to me as soon as possible. The authorization to provide Resident #8's eyeglasses was signed by the Administrator on 07/22/2015.

Based on observations, record review and interviews the facility failed to provide the necessary care and services to maintain the highest physical well-being for Resident #1 who was not adequately monitored regarding a change in condition on 07/08-07/09/2015 (1 of 11 residents sampled). The findings included: Resident #1 was noted with an elevated blood sugar on 07/08/2015 at 10:30 PM, the physician was notified and orders were received and followed. An hour later (11:30 PM) the resident's blood sugar was still elevated at 436, the physician was not notified and the blood sugar was not addressed. There was no evidence the resident was monitored until sometime the next day when s/he was noted to have a change in mental status. The Nurse practitioner was called around 11:00 AM on 07/09/2015 to see the resident. Following the Nurse Practitioner's visit there was not evidence the resident was monitored. Sometime between 7-7:30 PM the resident became unresponsive and was seen by the physician and Nurse Practitioner who sent her/him to the emergency room . Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission and Quarterly Minimum (MDS) data set [DATE] and 06/15/2015 coded the resident with a BIMS (Brief interview of Mental Status) of 15. The resident required extensive assistance for all activities of daily living, except eating. Review of Resident #1's medical record revealed a hospital discharge summary dated 07/17/2015 that stated, .admitted to MSICU (medical surgical intensive care unit) on 7/9 for worsening respiratory distress, intubated on admission.was intubated and with a CXR (chest x-ray) showing LLL (left lower lobe) consolidation and food found in the back of her/his throat on presentation, was treated for [REDACTED].not extubated until 7/12 due to continued infiltrates on CXR. transferred from MICU to the floor after extubation 7/13. Review of the Nurse's Notes from 07/08 - 07/09/2015 revealed the following: 07/08/2015 5:15 AM Noted [MEDICAL CONDITION] mask no on resident. [MEDICAL CONDITION] mask in resident's hand. Educated importance of [MEDICAL CONDITION] mask - resident states 'I don't like that mask' and refused to allow nurse to place back on politely. 02 @ 3 LPM (liters per minute) started via nasal canula after refusal. 10:30 PM BS (blood sugar) 510 mg/dl with confusion noted. Rt (right) wrist with c/o (complaint) itching. Noted no redness or open areas. Nurse Practitioner notified with N.O. (new order) give [MEDICATION NAME] 25 mg (milligrams) po (by mouth) now and if itching unreleaved give another [MEDICATION NAME] 25 mg 1 po in 1 hr (hour) - Place resident on MD board for evaluation tomorrow R/T (related to) right wrist. Give 12 units [MEDICATION NAME] SSI for BS 510 mg/dl. 10:31 PM [MEDICATION NAME] 25 mg 1 po given for c/o itching along with Levimer 70 units and [MEDICATION NAME] 12 units SQ (subcutaneous) for BS 510 mg/dl. 11:31 PM continues with c/o itching to rt. wrist [MEDICATION NAME] 25 mg po administered. 11:45 PM RP (responsible party) . notified of resident BS results at 10:30 PM 510 mg/dl and BS results 436 now and rt. wrist itching with order for [MEDICATION NAME] assured RP that writer will monitor for s/sx (signs/symptoms) of hypo/[MEDICAL CONDITION] and effectiveness of [MEDICATION NAME] and that [MEDICAL CONDITION] is placed. 07/09/2015 1:00 AM resting in bed with eyes closed with no s/sx of itching or s/sx hypo/[MEDICAL CONDITION] untimed note N.O. (new order) for PA/Lat CXR (chest x ray) for cough with 2 views, D/C (discontinue) [MEDICATION NAME] 1 q (every) 6 hours for wheezing, [MEDICATION NAME] cream to wrist QID (4 times a day) x 7 days. CBC (complete blood count), BMP (basic metabolic profile), UA (urinalysis) labs for morning, hold 2 PM [MEDICATION NAME] and Klonopin for increased lethargy. RP notified. 11:30 PM N.O. receive to increase Levemor to 80 U (units) BID (twice a day), Zpack 250 mg 2 po x 1 dose today, then 250 mg - po daily x 4 days. Prednisome 40 mg po daily x 5 days. Transfer to emergency room per MD. ADON notified @ 7:30 PM. RP aware. Review of the physician's orders [REDACTED]. 07/08/2015 @ 10:31 PM (1) BS 510 mg/dl - NP (nurse practitioner) notified with order to give 12 units [MEDICATION NAME] 100/ml insulin Pen (2) [MEDICATION NAME] 25 mg 1 po now - itching; [MEDICATION NAME] 25 mg 1 po in 1 hr if itching continues. Place resident for evaluation on MD Board for Nurse Practitioner to evaluate rt. wrist 07/09/2015 @ 12:05 PM (1) PA/Lat CXR. (cough) with 2 views (2) D/C [MEDICATION NAME] (3) [MEDICATION NAME] HHN 1 Q 6 hrs for wheezing (4) [MEDICATION NAME] cream to R (right) wrist QID x 7 days. (2%) allergic [MEDICAL CONDITION]. 1300 (1:00 PM) CBC, BMP, UA (AMS) untimed Hold 2 PM [MEDICATION NAME] and Klonopin on 7/9/15 due to lethargy 7:30 PM Send to. ER (emergency room ) to eval (evaluate) and treat. In a telephone interview with the surveyor on 07/27/2015 at approximately 3:20 PM Licensed Practical Nurse #1 stated s/he was told at report that Resident #1's blood sugar was elevated during the night and that s/he was given Levimer and [MEDICATION NAME] for a rash on her/his wrist. I saw Resident #1 round 7:30 AM (07/09/2015) s/he was not herself, didn't want to get up. S/he stated s/he notified the Nurse Practitioner sometime after that and that the Nurse Practitioner came around noonish to see the resident and wrote order. S/he left to see other residents and came back with the doctor around 7:00 PM. When LPN #1 was asked how Resident #1 was at lunch time s/he stated, Alert, drowsy and lethargic. LPN #1 stated the resident just got bad all of a sudden. In an interview with the Nurse Practitioner at 11:30 AM on 07/27/2015 s/he stated that s/he was in the building and was notified about the resident's mental status around 11:00 AM on 07/09/2015. S/he stated that when she saw the resident soon after that s/he was talking to me, sleepy, not feeling good. She had a cough and was alert/oriented. I discussed her condition with husband by telephone. Later that night the doctor came, we were making rounds, went to see her and she was not responsive at all we worked with her and notified EMS. The NP stated s/he would have expected the staff to monitor the resident closely. S/he also stated s/he would have expected the staff to call about the 436 blood sugar done on 07/08. That's in our parameters to treat.

Based on record review, observation and interviews, the facility failed to maintain clinical records in a manner in accordance with accepted professional standards and practice that are complete and accurately documented. Resident #2's clinical record failed to show when his/her behaviors of chewing on inedible objects started; failed to contain a psycho consult conducted on 09/15/2014; failed to document pressure ulcer measurement and treatments in a consistent and professional manner (Resident #2, #13, #14); Resident #20 with missing Respiratory and Nursing notes related to an incident on 02/03/2015; Resident #15 no nursing notes or physician's orders relate to a hospital admission on 02/15/2015; Resident #9 with documentation on the wrong medical record; Resident #10 with orders documented incorrectly (7 of 24 resident sampled for accuracy of clinical records). The findings included: Resident #2 was observed by the surveyor on 2/23/2015 at approximately 3:10 PM in bed positioned with his/her head turned toward the window, the lights were low, the call bell not in reach of the resident was noted by the surveyor hanging on the wall. Resident #2 called the surveyor into the room and stated s/he would like some water. The surveyor walked to the nurse's station and asked Licensed Practical Nurse (LPN) #1 to assist her/him in identifying the resident's call bell. At 3:21 PM LPN #1 and the surveyor observed Resident #2's call bell hanging on the wall out of the resident's reach and 2 pieces of a snap with small pieces of cloth/threads at the resident's left shoulder. LPN #1 asked Resident #2 if s/he did that (removed the snaps)? S/he responded, Yes. LPN #1 attached the call bell to the resident's bed and asked him/her if s/he had been chewing on it (the call bell), Resident #2 stated, No. The surveyor was unable to confirm if the call bell had been chewed or how the snaps had been removed. LPN #1 confirmed the residents behaviors of chewing on inedible objects. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes documented instances on 10/01/2014 at 4:30 PM, 10/23/2014 Day Shift, 11/18/2014 8:30 AM, 11/20/2014 5:00 PM and 11/29/2014 6:00 PM of Resident #2 chewing on oxygen tubing or the bed /call light control. Further review of the medical record revealed no documentation in the physician's progress notes or psych consult notes related to Resident #2's behavior of chewing inedible items. There were no Social Service Notes addressing the resident's behavior of chewing on inedible items. On 02/24/2015 at approximately 7:30 AM the Director of Nursing provided a psych consult note dated 09/15/2014 that was provided by the Social Service Director and not in the resident medical record. Review of Resident #2's Care Plan dated 10/02/2014 identified Resident #2 with behavioral symptoms not directed to others such as chewing on non-edible items, i.e. call light; 10/3/2014: throwing bell; 10/27/2014: Biting on bed control box; 11/15/2014: Chewed through remote control for bed function; no ingestion of parts; no adverse effects. Goal Target Date: 03/17/2015. In an interview with the surveyor on 02/25/2015 at approximately 7:25 AM Registered Nurse #1 stated that Resident #2 was on the 300 Unit when s/he first came in (September 2014) and s/he was given a cowbell to ring because s/he chewed the call bell, no September documentation regarding chewing behaviors was found in the nurse's notes. In an interview with the surveyor on 02/25/2015 at approximately 8:41 AM the Maintenance Director stated that s/he changed Resident #2's call light on November 1, 2014 and told the nurses that it didn't work because Resident #2 had chewed on it. I could see teeth marks. The Maintenance Director could not provide information prior to the November 2014 incident stating, I was on medical leave from May to October 2, 2014. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Cooperate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] coded Resident #15 as having a Brief Interview for Mental Status of 15 requiring the assistance of one for activities of daily living. Her/his height was 63 inches and s/he weighed 89 pounds on admission. Review of the Nurse's Notes revealed no documentation after 12/14/2014. Review of the Medication Administration Record [REDACTED]. There was no physician's order in the closed medical record regarding the resident's decline or discharge to the hospital/emergency room . Resident #20 admitted to the facility with [DIAGNOSES REDACTED]. Her/his 01/22/2015 Admission Minimum Data Set coded her/him with a Brief Interview for Mental Status of 13. A review on 02/24/2015 of Resident #20's medical record revealed a hospital history and physical dated 02/03/2015 that stated, .Over the last few days, s/he has had some low-grade fever and some cough which is minimally productive. S/he has been more short of breath. Her/his daughter went to visit her/him today and her/his oxygen concentrator was not plugged in. The patient was found to be hypoxic with sats (saturation) down in the 50's and ashen appearing. S/he continued to be tachypneic, which s/he is now and so s/he was put on [MEDICAL CONDITION] I reviewed her/his chest x-ray. It does not show any specific infiltrates or effusions. Assessment and Plan: .is a [AGE] year-old. with advanced disease who comes in with several days of shortness of breath and low-grade fever. Her/his condition may be exacerbated by the fact that s/he has been off [MEDICATION NAME] for a few days and was off her/his oxygen when s/he was found today. 12. Expect s/he will need at least 1 night in the intensive care unit. Will follow her/him closely. Further review of Resident #20 medical record revealed no SBAR Communication Form, no nurse's notes or respiratory therapy notes related to the incident of 02/03/2015. In an interview with the surveyor on 02/25/2015 at 12:35 PM the Director of Nursing confirmed the original SBAR, the Respiratory Therapy note and the nursing note for the incident on 02/03/2015 with Resident #20 was not on the resident's medical record. The facility admitted Resident #9 with a [DIAGNOSES REDACTED]. A review of the Quarterly Material Data Set (MDS) for 11/25/14 coded Resident #9 as having a Brief Interview of Mental Status (BIMS) of 7 and requiring extensive assistance for Activity of Daily Living (ADLs). Resident #9 was coded as needing assistance for eating. A review of Resident #9's medical record on 2/23/15 at 12:15 PM, revealed that documented on the Care Plan Conference Summary sheet under the special request topic was that Resident #9 was allergic to PNC and [MEDICATION NAME]. It was noted at the bottom of the sheet under resident's name was documented on a sheet with the name of another resident. A review of Resident #9's profile sheet and Medication Administration Record [REDACTED]. A review of the MAR for May 2015, revealed that [MEDICATION NAME] was placed on 5/3/14. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 2/25/15 at approximately 10:10 AM, revealed that the person who did the care plan conference sheet is no longer here. S/he stated that the social worker used to do these. An interview was conducted with the Activity Director on 2/25/15 at approximately 2:15 PM, revealed that the care plan conference sheet in Resident #9's chart was filed in the wrong chart. It was supposed to be for another resident with the same first initial and last name. The facility admitted Resident #10 with a [DIAGNOSES REDACTED]. Medical record review on 2/23/15 at 10:00 AM, revealed that a Quarterly Minimum Data Set was conducted on 2/11/4 coding the resident as having a Brief Interview of Mental Status of 13, but requiring extensive assistance with activity of daily living (ADL) care. A review of the physician's orders for January 2015 on 2/23/15 at 10:00 AM, revealed that the order for Accu-checks was marked through and hand written off to the side to check blood glucose levels AC/HS Daily and off to the side of the special instructions is written No SSI (sliding scale insulin). There are 8 times that the route is marked through and hand written to the side with a different route and 1 time the frequency is marked trough and hand written to the side. A review of the February orders revealed that the Accu-checks were ordered bid (3 times) a week and the sliding scale coverage was in place. Upon further review of the physician's orders, there were no documentation's that the sliding scale insulin had been reinstated. A review of the MAR for February revealed that Resident #10 did not receive any insulin during the month. A review of the physicians progress notes dated 1/22/15 documented blood sugars well controlled. Continue [MEDICATION NAME] 30 units daily. I will reduce Accu-checks to bid (twice daily) three times weekly. A review of the care plan for Resident #10 revealed that Diabetes Mellitus was identified as a problem and that an approach was to administer medications, as ordered. Evaluate/record/report effectiveness/adverse side effects. Also, monitor blood glucose, as ordered. An interview was conducted with the Unit Manager for Unit 100 on 2/25/15 at 11:10 AM, revealed that the corrections made on the January/February physicians orders were not made correctly. S/he also stated that upon review of the physician's orders s/he did see where the order for the sliding scale insulin had been discontinued in January, but did see where the sliding scale insulin was continued on the February orders. Prior to leaving the facility the Unit Manager for Unit 100 called the physician and received a clarification order to continue sliding scale insulin with a decrease in Accu-checks to twice daily three times weekly. Cross refer to F-314 Resident's #2, #13 and #14 had no consistent measurements or treatments for their pressure sores documented in their medical records. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on in editable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow and the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and was knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-514 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observations and interviews the facility administration failed to use its resources to maintain Resident #2's well being. Resident #2 had identified behaviors of chewing on inedible items that was not address effectively and efficiently (1 of 3 residents sampled with behaviors). The finding included: Cross refer to 483.10(b)(11) Notification of Changes (injury/decline/room/Etc.,) F-157 was identified at Immediate Jeopardy with a scope and severity of J related to the failure of the facility to notify Resident #2's physician of his/her behavior of chewing on inedible objects such as the call light control, bed control and oxygen tubing. Cross refer to 483.15(g)(1) Provision of Medically Related Social Services, F-250 was identified at Immediate Jeopardy and Substandard Quality of Care with a scope and severity of J related to the failure of the facility to provide medically related social services. Resident #2 with known behaviors of chewing on inedible objects was not provided services to maintain his/her well being. Cross refer to 483.20(k)(3)(ii) Services By Qualified Persons/per Care Plan, F-282 was identified at Immediate Jeopardy with a scope and severity of J related to the failure of the facility to implement Resident #2's care plan related to his/her behavior of chewing his/her bed/call light control and oxygen tubing. Cross refer to 483.25(f)(1) Treatment/services for Mental/psychosocial Difficulties, F-319 was identified at Immediate Jeopardy and Substandard Quality of Care with a scope and severity of J related to the failure of the facility to provide psychosocial services to Resident #2. Cross refer 483.25 (k) Free of Accident Hazards/supervision/devices, F-323 was identified at Immediate Jeopardy and Substandard Quality of Care with a scope and severity of J. The facility failed to ensure that Resident #2 with behaviors of chewing on inedible objects received appropriate treatment and services to correct the identified problem. Cross refer 483.75(l)(1) Records-Complete/accurate/accessible, F-514 was identified at Immediate Jeopardy with a scope and severity of J related to the failure of the facility to maintain clinical records in a manner in accordance with accepted professional standards and practice that are complete and accurately documented. Resident #2's clinical record failed to show when his/her behaviors of chewing on inedible objects started and the progression of the behavior; failed to contain a psycho consult conducted on 09/15/2014. Resident #2 was observed by the surveyor on 2/23/2015 at approximately 3:10 PM in bed positioned with his/her head turned toward the window, the lights were low, the call bell not in reach of the resident was noted by the surveyor hanging on the wall. Resident #2 called the surveyor into the room and stated s/he would like some water. The surveyor walked to the nurse's station and asked the Unit Manager for the 400 unit to assist her/him in identifying the resident's call bell. At 3:21 PM the Unit Managter and the surveyor observed Resident #2's call bell hanging on the wall out of the resident's reach; 2 pieces of a snap with small pieces of cloth/threads at the resident's left shoulder. The Unit Manager asked Resident #2 if s/he did that (pulled the snaps off) and s/he stated, Yes. The Unit Manager attached the call bell to the resident's bed and asked him/her if s/he had been chewing on it (the call bell), Resident #2 stated, No. The surveyor was unable to confirm if the call bell had been chewed or how the snaps had been removed. The Unit Manager confirmed the residents behaviors of chewing on inedible objects. In an interview with the surveyor on 02/25/2015 at approximately 7:25 AM Registered Nurse #1 stated that Resident #2 was on the 300 Unit when s/he first came in and s/he was given a cowbell to ring because s/he chewed the call bell. In an interview with the surveyor on 02/25/2015 at approximately 8:41 AM the Maintenance Director stated that s/he changed Resident #2's call light and told the nurses that it didn't work because Resident #2 had chewed on it. I could see teeth marks. The Maintenance Director could not provide information prior to the November 2014 incident stating, I was on medical leave from May to October 2, 2014. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Cooperate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on in editable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow and updated the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and was knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-490 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observation and interviews, the facility failed to provide medically related social services to maintain Resident #2 well being, his/her behavior of chewing on inedible objects was not not addressed (1 of 15 residents reviewed for social service needs.) The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes documented instances on 10/01/2014 at 4:30 PM, 10/23/2014 Day Shift, 11/18/2014 8:30 AM, 11/20/2014 5:00 PM and 11/29/2014 6:00 PM of Resident #2 chewing on oxygen tubing or the bed /call light control. Review of Resident #2's Social Service Notes from 09/08/2014 through 12/17/2014 revealed entries related to the resident's yelling out for the staff but no documentation of the resident chewing on the bed/call bell control or oxygen tubing. There were no psych consults in the resident's medical record. Review of Resident #2's Care Plan dated 09/16/2014 listed category: Behavioral Symptoms: Mr. (NAME REDACTED) . exhibits behavioral symptoms evidenced by yelling out help and yelling for staff as well as repeatedly pressing call bell. 10/14/2014: Nearby pt. (patients) c/o (complain of) unmet sleep need r/t (related to) this resident's continued yelling through the night. Long term target date: 03/17/2015 . Approaches: 10/14/2014 - Seek permission from resident's family to move him/her to a room where his/her through the night yelling is less likely to keep other awake. The discipline to address indicated Licensed Nurse. 09/16/2014 - Medicate as indicated and monitor effects. Psych/physician consult as needed. The discipline to address indicated Nursing, Social Service 09/16/2014 - Provide 1:1 as needed. The discipline to address indicated Social Service. 09/16/2014 - Provide time to calm down and reassure his needs/safety as needed. The discipline to address indicated All staff, Social Service . In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing (DON), Administrator and Corporate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. The Social Service Director provided a psych consult note dated 09/15/2014 to the Director of Nursing. The DON stated the information was provided by the Social Service Director and that it was found in the Social Service Director's file. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on in editable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-250 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observation and interviews, the facility failed to provide appropriate supervision to 5 of 12 residents reviewed for accidents/hazards. Resident #2 with known behaviors of chewing on inedible objects was noted with his/her call bell out of reach and 2 pieces of a snap and small pieces of cloth/threads in his/her bed; Resident's A, B, C, #7 observed with bed that did not lock). The findings included: Resident #2 was observed by the surveyor on 2/23/2015 at approximately 3:10 PM in bed positioned with his/her head turned toward the window, the lights were low, the call bell not in reach of the resident was noted by the surveyor hanging on the wall. Resident #2 called the surveyor into the room and stated s/he would like some water. The surveyor walked to the nurse's station and asked the Unit Manager for the 400 Unit to assist her/him in identifying the resident's call bell. At 3:21 PM the Unit Manager and the surveyor observed Resident #2's call bell hanging on the wall out of the resident's reach; 2 pieces of a snap with small pieces of cloth/threads at the resident's left shoulder. The Unit Manager asked Resident #2 if s/he pulled the snaps off and s/he stated, Yes. The Unit Manager attached the call bell to the resident's bed and asked him/her if s/he had been chewing on it (the call bell), Resident #2 stated, No. The surveyor was unable to confirm if the call bell had been chewed or how the snaps had been removed. The Unit Manager confirmed the residents behaviors of chewing on inedible objects. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from September 2014 through February 2015 documented the following: 10/01/2014 4:30 PM Provide Resident with plastic teething ring to chew on to deter him from chewing on call light. Resident stated this was a good thing he enjoyed the teething ring to chew on. 10/05/2014 5:00 PM Resident bell taken away because s/he is constantly ringing and bothering the other residents . 10/22/2014 Night Shift .Pt (patient) is total care extensive assist due to quadriplegia. Yell for help during time while awake, like company . 10/23/2014 Day Shift .Resident was noted to be chewing on his/her O2 tubing, tubing changed and resident educated on not chewing on tubing. 11/18/2014 8:30 AM Res (resident) is still chewing on his/her O2 tubing and call bell at intervals - redirection is not helping it only lasts for a short while. We will continue to monitor resident chewing on items in his/her reach. 11/20/2014 5:00 PM .O2 via nasal cannula @ 2 L (liters) remain in progress. Resident continues to chew on tubing . 11/26/2014 (untimed) .Resident did not chew on his/her O2 tubing this tour very quiet . 11/29/2014 6:00 PM .Resident noted chewing on O2 tubing. Instructed not to chew on tubing s/he may puncture it . Review of Resident #2's Care Plan dated 10/02/2014 identified Resident #2 with behavioral symptoms not directed to others such as chewing on non-edible items, i.e. call light; 10/3/2014: throwing bell; 10/27/2014: Biting on bed control box; 11/15/2014: Chewed through remote control for bed function; no ingestion of parts; no adverse effects. Goal Target Date: 03/17/2015. In an interview with the surveyor on 02/25/2015 at approximately 7:25 AM Registered Nurse #1 stated that Resident #2 was on the 300 Unit when s/he first came in and s/he was given a cowbell to ring because s/he chewed the call bell. S/he was not sure what happened with the chewing after s/he went to the 400 unit. In an interview with the surveyor on 02/25/2015 at approximately 8:41 AM the Maintenance Director stated that s/he changed Resident #2's call light and told the nurses that it didn't work because Resident #2 had chewed on it. I could see teeth marks. The Maintenance Director could not provide information prior to the November 2014 incident stating, I was on medical leave from May to October 2, 2014. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Cooperate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. On 2/22/15 beginning at approximately 4:00 AM, initial tour of the facility was conducted on the 100 Unit. During the tour, random observations were made of residents who received incontinence care. The observations revealed at approximately 4:20 AM, Certified Nursing Assistant (CNA) #6 provided incontinence care to resident A. The CNA turned the resident from side to side to remove the brief. When the CNA turned the resident the bed was not locked and it moved each time the resident was turned. At approximately 4:30 AM, CNA #6 was observed providing incontinence care to resident B. The CNA pushed the resident away from him/her to the edge of the opposite side of the bed. The resident's left leg was hanging over the side of the bed. As the CNA pushed the resident away from him/her the bed moved with the resident. At approximately 4:35 AM, CNA #6 provided incontinence care to resident C. During the incontinence care the resident's bed moved from side to side as the CNA pushed or pulled the resident to provide the care and change the brief. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the his/her Quarterly Minimum (MDS) data set [DATE] coded him/her as having a Brief Interview for Mental Status (BIMS) of 8 requiring limited assistance for all activities of daily living. Observations made of his/her bed on 02/24/2015 revealed on 2 occasion that the bed would not lock. The Maintenance Director inspected all bed identified as not locking on 2/25/15 at approximately 11:00 AM and stated that the mechanisms were loose on all identified beds and the beds are moving with ease. S/he stated, my assistant does all of my bed checks and may not know to check the locks on the beds. Since the assistant had been doing them, I have only seen maybe one rolling bed. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on ineditable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations and interviews revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and was knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-323 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observation and interviews, the facility failed to notify Resident #2 physician of his/her behavior of chewing on inedible objects such as the call light control, bed control and oxygen tubing. Resident #15 admitted with weight concerns was noted as having a poor appetite for 3 days and thrush with physician notification not made timely (2 of 15 residents sampled for notification). The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes documented instances on 10/01/2014 at 4:30 PM, 10/23/2014 Day Shift, 11/18/2014 8:30 AM, 11/20/2014 5:00 PM and 11/29/2014 6:00 PM of Resident #2 chewing on oxygen tubing or the bed /call light control. The resident's Care Plan dated 10/02/2014 identified Resident #2 with behavioral symptoms not directed to others such as chewing on non-edible items, i.e. call light; 10/3/2014: throwing bell; 10/27/2014: Biting on bed control box; 11/15/2014: Chewed through remote control for bed function; no ingestion of parts; no adverse effects. Goal Target Date: 03/17/2015. In an interview with the surveyor on 02/25/2015 at approximately 7:25 AM Registered Nurse #1 stated that Resident #2 was on the 300 Unit when s/he first came in September (2014) and s/he was given a cowbell to ring because s/he chewed the call bell. In an interview with the surveyor on 02/25/2015 at approximately 8:41 AM the Maintenance Director stated that s/he changed Resident #2's call light on November 1, 2014 and told the nurses that it didn't work because Resident #2 had chewed on it. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Corporate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. There was no documentation that Resident #2's physician was notified of his/her chewing behaviors. In a telephone interview with the surveyor on 03/03/2015 the physician confirmed s/he was unaware of the resident's behavior. In a telephone interview with the surveyor on 03/03/2015 the Nurse Practitioner stated s/he was told once in September (2014) about the resident chewing on his/her remote control/bed control. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] coded Resident #15 as having a Brief Interview for Mental Status of 15 requiring the assistance of one for activities of daily living. Her/his height was 63 inches and s/he weighed 89 pounds on admission. Review of the Nurse's Notes from 11/25/2014 through 12/14/2014 revealed Resident #15's appetite was poor on 12/11, 12/13, and 12/14/2014. The 12/14/2014 at 7:30 PM documentation revealed the resident's daughter express to a nurse her/his concern that her/his mother was not eating or drinking. The nurse responded that s/he had noticed that the resident had thrush and that there was a call to the doctor regarding another issue and the oncoming nurse would let him/her know about the thrush. There was no documentation the physician was called timely related to the resident poor appetite for 3 days and the alleged thrush. The resident was sent out to the emergency roiagnom on the afternoon of 12/15/2014. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on ineditable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors and failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations and interviews revealed the AOC submitted by the facility on 02/25/2015 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-157 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observation and interviews, the facility failed to ensure that Resident #2 with behaviors of chewing on inedible objects received appropriate treatment and services to correct the identified problem (1 of 3 residents sampled with behaviors). The findings included: Resident #2 was observed by the surveyor on 2/23/2015 at approximately 3:10 PM in bed positioned with his/her head turned toward the window, the lights were low, the call bell not in reach of the resident was noted by the surveyor hanging on the wall. Resident #2 called the surveyor into the room and stated s/he would like some water. The surveyor walked to the nurse's station and asked Unit Manager for the 400 Unit to assist her/him in identifying the resident's call bell. At 3:21 PM LPN #1 and the surveyor observed Resident #2's call bell hanging on the wall out of the resident's reach and 2 pieces of a snap with small pieces of cloth/threads at the resident's left shoulder. The Unit Manager asked Resident #2 if s/he did that (removed the snaps)? S/he responded, Yes. The Unit Manager attached the call bell to the resident's bed and asked him/her if s/he had been chewing on it (the call bell), Resident #2 stated, No. The surveyor was unable to confirm if the call bell had been chewed or how the snaps had been removed. The Unit Manager confirmed the residents behaviors of chewing on inedible objects. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes documented instances on 10/01/2014 at 4:30 PM, 10/23/2014 Day Shift, 11/18/2014 8:30 AM, 11/20/2014 5:00 PM and 11/29/2014 6:00 PM of Resident #2 chewing on oxygen tubing or the bed /call light control. Further review of the medical record revealed no documentation in the physician's progress notes or psych consult notes related to Resident #2's behavior of chewing inedible items. There were no Social Service Notes addressing the resident's behavior of chewing on inedible items. On 02/24/2015 at approximately 7:30 AM the Director of Nursing provided a psych consult note dated 09/15/2014 that was provided by the Social Service Director. The psych note indicated the reason for the referral was for delusions. The note stated, .yells out for help frequently . The note did not mention chewing on inedible items. There was no further follow up related to the psych consult. Review of Resident #2's Care Plan dated 10/02/2014 identified Resident #2 with behavioral symptoms not directed to others such as chewing on non-edible items, i.e. call light; 10/3/2014: throwing bell; 10/27/2014: Biting on bed control box; 11/15/2014: Chewed through remote control for bed function; no ingestion of parts; no adverse effects. Goal Target Date: 03/17/2015. In an interview with the surveyor on 02/25/2015 at approximately 7:25 AM Registered Nurse #1 stated that Resident #2 was on the 300 Unit when s/he first came in and s/he was given a cowbell to ring because s/he chewed the call bell. In an interview with the surveyor on 02/25/2015 at approximately 8:41 AM the Maintenance Director stated that s/he changed Resident #2's call light on November 1, 2014 and told the nurses that it didn't work because Resident #2 had chewed on it. I could see teeth marks. The Maintenance Director could not provide information prior to the November 2014 incident stating, I was on medical leave from May to October 2, 2014. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Corporate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on ineditable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations and interviews revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her careplan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and was knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-319 was removed but the citation remained at a lowered scope and severity of D.

Based on record review, observations and interviews the facility failed to implement Resident #2's care plan related to his/her behavior of chewing his/her bed/call light control and oxygen tubing; Resident #18 care plan related to fluid restriction was not followed (2 of 24 resident's sampled for care plans). The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Further review of the Quarterly Minimum Data Set coded Resident #2 as having a Brief Interview for Mental Status (BIMS) of 5. Review of Resident #2's medical record revealed the following care plans for behaviors: Care Plan for behaviors dated 10/02/2014 stated, .has behavioral symptoms not directed to others such as chewing on non-edible items, i.e. call light; 10/3/14: throwing bell; 10/27/2014: Biting on bed control box; 11/15/2014: chewed through remote control for bed function; no ingestion of parts; no adverse effects. Approaches start date: 11/15/2014, change out bed to bed with no loose cords/wires; give resident bed with manuel functions that are out of reach; keep all chewable items (anything that can fit in his/her mouth) out of his/her reach. Approach start date: 10/28/2014 Remove control box if it does not hinder beds function; get resident out of bed each day into chair so s/he may interact with other residents and staff in day room. Approach start date: 10/02/2014 All .to have control over situations, if possible. Approach start date: 10/02/2014 Assess whether the behavior endangers .and/or others. Intervene if necessary . Approach start date: 10/02/2014 Divert . behavior by having call bell and chew items. Approach start date: 10/02/2014 Monitor . for signs of physical complication's related to ingestion of foreign objects . Approach start date: 10/02/2014 Place . in a room near the nurse's station. Approach start date: Remove non-edible but frequently ingested objects from environment. The Care plan documented a goal target dated of 03/17/2015. Care Plan dated 09/16/2014 listed category: Behavioral Symptoms: Mr . exhibits behavioral symptoms evidenced by yelling out help and yelling for staff as well as repeatedly pressing call bell. 10/14/2014: Nearby pt. (patients) c/o (complain of) unmet sleep need r/t (related to) this resident's continued yelling through the night. Long term target date: 03/17/2015 . Approaches: 10/14/2014 - Seek permission from resident's family to move him/her to a room where his/her through the night yelling is less likely to keep other awake. The discipline to address indicated Licensed Nurse. 09/16/2014 - Medicate as indicated and monitor effects. Psycho/physician consult as needed. The discipline to address indicated Nursing, Social Service 09/16/2014 - Provide 1:1 as needed. The discipline to address indicated Social Service. 09/16/2014 - Provide time to calm down and reassure his/her needs/safety as needed. The discipline to address indicated All staff, Social Service . Observation of Resident #2 on all the days of the survey revealed s/he was in a room furthest away from the nurse's station in an electric bed with an air mattress for skin care. Review of his/her medical record revealed s/he had one psych consult on 09/15/2014, with no follow up regarding his/her behaviors. In an interview with the surveyor on 02/24/2015 at approximately 7:30 AM the Director of Nursing, Administrator and Corporate Consultant confirmed Resident #2 chewed on his/her call light and oxygen tubing but thought the problem had been fixed. Resident #18 was noted to have a [DIAGNOSES REDACTED]. Review of Resident #18's February Physician order [REDACTED]. The order start date was noted as 7/31/14 with no end date. Review of Resident #18's Care Plan revealed at risk for volume fluctuation/dehydration related to multiple medical conditions including End- Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT] and fluid restriction was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to follow fluid restriction and coordinate fluid intake with dietary. Review of Resident #18's February Medications Flowsheet revealed the fluid restriction order was not listed. Review of Resident #18's Resident Profile revealed the fluid restriction was not listed. In an interview with the surveyor on 2/24/15 at approximately 3:05 PM, LPN #1 stated that for residents on a fluid restriction the amount they can receive per shift is documented on the Medications Flowsheet. The resident's Certified Nurse Aide (CNA) will let the nurse know how much the resident drinks and the nurse will document the amount on the Medication Flowsheet. In an interview with the surveyor on 2/24/15 at approximately 3:15 PM, the Unit 2 Manager stated that for residents on a fluid restriction the breakdown of the amount that should be given is kept on the resident's Medication Flowsheet. In an interview with the surveyor on 2/24/15 at approximately 3:20 PM, Licensed Practical Nurse (LPN) #1 (Resident #18's assigned nurse) stated that s/he thought Resident #18 was possibly on a fluid restriction. LPN #1 stated that s/he writes down the amount of intake on his/her sheet. LPN #1 stated that the CNA puts the information in the kiosk and monitors the amount of fluid the resident has received. LPN #1 reviewed Resident #18's medical record and stated that s/he did not see a fluid restriction ordered. LPN #1 stated s/he knows Resident #18 is on a fluid restriction but is not sure what it is. In an interview with the surveyor on 2/24/15 at approximately 3:30 PM, Certified Nurse Aide (CNA) #8 (Resident #18's assigned CNA) stated that s/he asks the nurse if a resident is on a fluid restriction. CNA #8 stated that [MEDICAL TREATMENT] resident's are usually on a fluid restriction. CNA #8 stated s/he does not know where the information on fluid restrictions is located and was unable to state the amount of Resident #18's fluid restriction. In an interview with the surveyor on 2/25/15 at approximately 1:35 PM, the Director of Nursing (DON) stated that fluid restrictions should be on the Resident Profile and on the Medication Flowsheet. The DON stated that Resident #18's Resident Profile was updated on 2/24/15 to include the fluid restriction. On 2/23/2015 at approximately 4:15 PM the Administrators, Director of Nursing and Corporate Consultant was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 11/01/2014 related to the failure of the facility to protect Resident #2 from harm related to his/her behavior of chewing on in editable object, failure to address his/her behaviors, failure of the facility to notify the physician of the resident's behavior, failure to follow the resident's care plan related to his/her behaviors, failure of Social Services to address the resident's behaviors; failure to document the resident's behaviors as they occurred. Criterion 1 Resident #2 was placed with 1 on 1 supervision on 2/23/15 at 4:30 pm. This will remain in place for 2 weeks, then be decreased to every 15 minute observations for 1 week, then be decreased to every 2 hours observation for 1 week at which time the Director of Nursing in conjunction with the physician and psychiatrist will determine if the resident can be deemed safe without 1 on 1 supervision. Resident #2 had facility gown with snaps removed and was placed in a tee shirt with no snaps or buttons on 2/23/15 with the approval of the responsible party and consent from Resident #2. Resident #2 had plan of care updated on 2/23/15 and 2/24/15 to reflect the use of tee shirts instead of clothing with snaps or buttons, the implementation of 1 on 1 supervision, the resolution of changing to room closer to nurse's station and the resolution of removing inedible unneeded items from room. The observation of food tray items, such as straws, will be monitored for chewing has been added to the current care plan. The physician of record for Resident #2 was notified of the resident's chewing issue, the placement of clothing with no straps or buttons and the implementation of 1 on 1 supervision on 2/23/15. The contracted psychiatrist was notified of the resident's chewing issue on 2/23/15, and was asked to assess Resident #2 on 2/26/15 at next visit. This treatment plan will be included in the poc (plan of correction). The Social Service Director/Assistant has been made aware of the resident's tendency to chew on inedible items on 2/23/15, and will see Resident #2 five times per week for 4 weeks to assess psychosocial wellbeing. Criterion 2 The Interdisciplinary team, which included the Director of Nursing, Social Services, the Activity Director and Unit Managers has completed a 100% audit on 2/24/15 of all facility residents with identified self-endangering behaviors, specifically residents that attempt to consume inedible items of liquids, to ensure no other potential areas of harm are present. At time of audit, no other facility residents have been identified with specific self-endangering behaviors. A review of incident logs and 24 hour reports of the past 90 days indicates no other issues identified. Criterion 3 On 2/23/15, 2/24/15 and 2/25/15, all facility staff was educated by the Director of Nursing and the Social Service Director on the reporting of self-endangering behaviors to the nursing department for immediate follow up/intervention. On 2/24/15, all facility licensed nursing staff had been educated by the Director of Nursing/Staff Development Coordinator on physician notification of any self-endangering behaviors. On 2/24/15, all facility licensed nursing staff has been educated by the Director of Nursing/Staff Development Coordinator on appropriate and consistent documentation of identified self-endangering behaviors. On 2/24/15, the facility Social Service department has been educated by the National Director of Social Services for the Company on necessary monitoring of identified self-endangering behavior, assurance of meeting psych social needs of identified residents with said behaviors and timely filing of consulting physician progress notes [REDACTED]. Any facility staff members unable to be reached for the above mentioned education will not be allowed to work their next scheduled shift until this education is completed. All above mentioned education will be a part of new employee education. AOC (Allegation of Compliance) date is 2/25/15. Observations, interviews, and review of policy revealed the AOC submitted by the facility on 02/25/2015 was implemented by the facility and was in practice removing the immediacy of the deficient practice. Resident #2 was observed with 1:1 supervision and wearing a tee shirt; his/her care plan was updated to include new interventions and the facility staff was educated regarding the new interventions. Facility staff was educated and was knowledgeable of the policy regarding the notification of behaviors to their supervisors. The facility nursing staff was educated related to notification and documentation of behaviors. Documentation indicated the Social Service Director was inserviced related to the immediate jeopardy. The Administrator was informed of this on 02/25/2015 at approximately 4:45 PM. The Immediate Jeopardy at F-282 was removed but the citation remained at a lowered scope and severity of D.

Based on record review and interviews the facility failed to provide care and treatment for [REDACTED]. The findings included: Resident #20 admitted to the facility with [DIAGNOSES REDACTED]. Her/his 01/22/2015 Admission Minimum Data Set coded her/him with a Brief Interview for Mental Status of 13. A review on 02/24/2015 of Resident #20's medical record revealed a hospital history and physical dated 02/03/2015 that stated, "...Over the last few days, s/he has had some low-grade fever and some cough which is minimally productive. S/he has been more short of breath. Her/his daughter went to visit her/him today and her/his oxygen concentrator was not plugged in. The patient was found to be hypoxic with sats (saturation) down in the 50's and ashen appearing. S/he continued to be tachypneic, which s/he is now and so s/he was put on [MEDICAL CONDITION] I reviewed her/his chest x-ray. It does not show any specific infiltrates or effusions... Assessment and Plan: ...is a [AGE] year-old... with advanced disease who comes in with several days of shortness of breath and low-grade fever. Her/his condition may be exacerbated by the fact that s/he has been off [MEDICATION NAME] for a few days and was off her/his oxygen when s/he was found today... 12. Expect s/he will need at least 1 night in the intensive care unit. Will follow her/him closely..." Further review of Resident #20 medical record revealed no SBAR (Situation-Background-Assessment-Request) Communication Form, no nurse's notes or respiratory therapy notes related to the incident of 02/03/2015. In an interview with the surveyor on 02/25/2015 at 11:10 AM Respiratory Therapist #1 was asked about the incident on 02/03/2014 s/he stated that the Unit Manager for Unit 300 told him/her that the resident appeared to be in respiratory distress and her/his daughter was in the room. "I went in s/he was diaphoretic, her/his heart rate and pulse was up. Her/his SATS in the 70's range. I looked and saw that the nasal cannula was attached to the water bottle connected to concentrator, concentrator not connected to oxygen supply. Put her on a partial non rebreather mask and got her/his SATS around 92-94%, but still respiration high. S/he had pneumonia at the time, I recommended s/he be sent out. Called the Nurse Practitioner, s/he came in and saw her/him and sent her/him to emergency room ." RT #1 stated that s/he wrote a note the day the incident happened and s/he had no idea when it was. S/he stated that Physical Therapy had seen the resident that morning and s/he was changed from a portable tank back to the concentrator at the bedside when s/he returned. In an interview with the surveyor on 02/25/2015 at 11:55 AM Physical Therapy Director #1 stated that s/he had statements from the Physical Therapist who worked with Resident #20 the day of the incident. S/he stated that an inservice was conducted for all her/his staff on 02/04/2015 about the oxygen needs of all residents currently on therapy caseload. "Proper procedure for signing out O2 tanks when getting one for resident, switching resident from portable O2 to concentrator when we take them back to rooms after therapy, and proper positing of concentrator, O2 tank and nasal cannula tubing." In an email dated 02/06/2015 at 8:38 AM PT #1 stated that the resident complained of not feeling well and this was reported to the nurse who stated that the resident was being treated for [REDACTED]. Pt (patient) had breakfast in gym at the table. Pt. was transferred from w/c (wheelchair) to mat. Pt. completed seated activities including reaching forward to complete pipe tree activity with rings. O2 tank was changed 1 time while pt. in gym to full O2 tank. Pt. transferred back to w/c c (with) CGA (complete gait assist)... O2 sats were monitored via finger pulses-ox and remained >90% while in gym on 4 L O2 via NC. Pt. did require verbal cueing for pursed lip breathing and rest breaks c activity. At approximately 10 AM, pt was brought back to room as s/he was not feeling well. S/he was transferred from w/c to bed c CGA. O2 tubing was changed from tank to O2 tubing on O2 concentrator (concentrator was turned on). When therapist left, pt was sitting EOB (edge of bed) with call bell in reach..." In an email dated 02/06/2015 at 12:59 PM Occupational Therapist (OT) #1 stated, "...I entered pt's room @ 11:45 AM. Pt. was in bed with nasal canula in place and was talking on the telephone. Pt. indicated by holding up 1 finger for OT to wait. OT left and returned 2-3 minutes later. Pt's daughter was present and asked OT to take her/her mother's vitals. Floor nurse was at med cart just outside pt's door. When asked for thermometer, nurse stated s/he 'had just taken pt's temp and was 98'. OT got vitals cart from hall and informed charge nurse, that pt was not feeling well and color was not good. Nurse notified RT. OT checked BP and pt's dtr (daughter) had her own pulse oximeter that s/he brought with her/him. Pt's BP was within normal parameters, but lower that usual per her dtr and O2 reading was in low 60's. RT and Unit Manager entered room and OT stepped back to let RT take over. RT attached ear probe and examined concentrator and identified that tubing to humidifier had come apart from humidifier. OT coached pt on deep breathing tech (technique) and RT and nurse continued to monitor oxygen. Pt rebounded to high 80's at rest in bed..." Interviews with the surveyor on 02/25/2015 at approximately 11:50 AM with both PT #1 and OT #1 confirmed their emails dated 02/06/2015, no additional information was obtained concerning the incident. In an interview with the surveyor on 02/25/2015 at 12:35 PM the Director of Nursing confirmed the original SBAR (Situation-Background-Assessment-Request) Communication Form, the Respiratory Therapy note and the nursing note for the incident on 02/03/2015 with Resident #20 was not on the resident's medical record. S/he had a copy of the SBAR along with the facility Patient/Resident Incident/Accident Investigation Worksheet dated 02/03/2015. The DON was unable to provide evidence that the facility conduced an investigation or that witness statements were taken. When asked if all the nursing staff had been inserviced s/he stated that they did a "huddle with staff" about observing equipment.

Based on record review and interview, the facility failed to provide appropriate care to prevent and treat pressure sores for 3 of 3 residents reviewed for pressure sores. Resident #13 was admitted without pressure sores and developed multiple pressure sores. Resident's #2, #13 and #14 had no consistent measurements or treatments for their pressure sores. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review of the Admission physician's orders [REDACTED]. Review of the Physician Telephone orders from 11/19/14 through 2/23/15 related to wound care revealed the following orders: 11/22/14: Clean gluteal crease skin abrasion with wound cleaner or normal saline (NS), pat dry. Apply [MEDICATION NAME] dressing every three days and as needed (prn). 11/24/14: Cleanse sacrum/buttocks with wound cleaner or NS. Apply Santyl, cover with a dry dressing. Change daily and prn. 11/26/14: Clarification from 11/22/14 area noted as skin tear is truly a pressure ulcer. 12/1/14: Discontinue (D/C) santyl on sacrum dressing. Clean sacrum area with wound cleanser or NS. Apply large size [MEDICATION NAME] every three days and prn. 12/2/14: Disregard above wound order. Continue to cleanse sacrum/buttocks with WC/NS, apply santyl. Cover with a dry dressing, change daily and prn. that was written on 11/24/14. (Unstageable wd (wound). 12/4/14: May have airmattress. 12/16/14: Change Sacrum wound dressing, cleanse with wound cleaner then apply santyl to wound bed, cover with calcium alginate then dry dressing every day prn. 12/18/14: [MEDICATION NAME] (antibiotic) 875 milligrams (mg)/125 mg every 12 hours for 7 days for sacral wound. 12/19/14: D/C treatment to sacrum. Clean sacral wound with NS. Apply 1/4 strength Dakins solution soaked gauze. Change daily and prn. 12/19/14: Refer patient to Dr. _____ for wound evaluation. 1/14/15: Apply skin prep to top of left foot blister and right foot blister every shift. Apply skin prep to left knee blister every shift. Discontinue previous sacrum treatment. Cleanse sacral wound with NS, apply soaked gauze with Dakins Solution, pack loosely cover with dry dressing every shift and prn. 1/16/15: Wedge for positioning in partial sidelying while in bed, as patient tolerates. 1/19/15: Protein supplement 30 milliliters (ml) three times a day for wound healing. 1/28/15: Cleanse right heel with NS, apply dime sized santyl ointment and cover with dry dressing twice a day. Float heels in bed at all times as pt tolerates. (Heel wound Stage II). 2/12/15: Apply heels off cushion while in bed. 2/17/15: Wound culture of sacral wound. The resident was noted with an abrasion of the sacral/gluteal area on 11/22/14, seven days after admission. On 11/26/14, four days after the area was observed, the wound was diagnosed as a pressure sore and not an abrasion. Although treatments were changed to the wound on 12/2/14 the wound was found to have deteriorated and was unstageable. An airmattress was ordered on [DATE] (pressure relief). On 12/18/14 an antibiotic was ordered for wound infection. On 12/19/14 Dakins solution was ordered for treatment of [REDACTED]. The resident developed unstageable pressure sores on his/her heels. There was no evidence of the resident's heels being floated until the order of 2/12/15. Review of the Wound Treatment and Progress Record revealed there were no Wound Treatment and Progress Record for November or December. The January wound record contained measurements on 1/14/15 and 1/19/15. The sacral wound measured 6.9 x 3.5 x 5.5 depth, Stage 4. The wound was described to have "some pink granulation, white and yellow with slightly greenish slough". On 1/19/15 the pressure sore was documented to be 6.9 x 3.5 x 5.3 "with pink tissue with slough" On 2/13/15 the sacral wound was noted to be a Stage IV with measurements of 8 cm x 4 cm by 3.8 cm depth. The wound was described as "Pink granulation with green/yellow and black slough, bone is showing and moderate brown and clear drainage. foul odor. Macerated edges surrounding skin integrity". On 2/17/15 the wound was measured to be 7 cm x 4.7 cm x 6.5 cm. It was described as, "green black slough in wound bed. Bone present, mild brown drainage, macerated edges, foul odor". Review of the Nurse's Notes revealed a SBAR (Situation-Background-Assessment-Request) dated 1/4/15. The request stated, "0230 VS (vital signs unstable, temp elevated to 101.7, HR (heart rate) 105, B/P (blood pressure) 96/48. RR (respirations) 22, lethargic MD paged awaiting call back. 0315- T.O. (telephone order send pt to _____(hospital) for further evaluation. Transport called , DON called (Director of Nursing), pt family called, ER (emergency room ) called for report." Under the Assessment area, "Septic ? r/t (related to) wound." Review of the hospital Progress Notes dated 1/9/2015 revealed the resident was seen for a follow-up related to her/his wound. "FU (follow-up) for stage 4 sacral pressure ulcer and unstageable Bilateral Heels." Review of the wound report revealed the pressure sore of the right and left heel were noted on admission to the hospital on [DATE] and were seen on 1/5/15. "Pressure Ulcer 01/05/15 1356 (1:56 PM). Date First Assessed/Time First Assessed 01/05/15 1356. Present on admission to Hospital (Pressure Ulcer): yes. Orientation midline sacral spine. Pressure Ulcer Left lateral heel Date First Assessed/Time First Assessed 01/05/15 1359. Present on admission to Hospital (Pressure Ulcer): yes. Orientation Lateral Heel. Black eschar, unstageable. Pressure Ulcer Right heel Date First Assessed/Time First Assessed 01/05/15 1400 (2:00 PM). Present on admission to Hospital (Pressure Ulcer): yes. Location: Right heel, medial and lateral aspects. The resident was noted on 2/13/15, after hospitalization , to have a 5 cm x 7.5 cm area on the left heel. The Wound Treatment Progress report described the wound to be unstageable, 5 cm x 7.5 cm and covered with "Hard black, crusted Eschar" On 2/17/15 the area remained the same size, unstageable with hard, black, crusty eschar. There was no documentation of the pressure ulcer on the left heel until after the hospitalization . The hospital documented the presence of the wound on admission to the hospital on [DATE]. On 1/27/15 a pressure sore was "discovered" on the right heel. The wound was 3 cm x 1 cm. With no stage or description. The treatment order on 1/27/15 was to cleanse the area with normal saline or wound cleanser, apply dime size santyl ointment and cover with dry dressing twice a day. On 2/13/15 the wound measured 7 cm x 10 cm, covered with eschar, unstageable. The wound was described as "soft detached black, brown eschar. pink tissue present wound edge and middle of heel with yellow green slough present foul odor, moderate brown drainage." On 2/17/15 the measurements and description were the same. There was no documentation of the pressure ulcer on the right heel until after the hospitalization . The hospital documented the presence of the wound on admission to the hospital on [DATE]. Registered Nurse (RN) #1 was interviewed by the surveyor on 2/24/15 at approximately 7:15 AM. The nurse stated the resident was admitted with one small area, covered with a [MEDICATION NAME]. "The order was changed to santyl. It just got worse and worse..." On 2/25/15 the Director of Nurses (DON) was interviewed by the surveyor at approximately 10:30 AM. The DON stated, "We do have a problem with our pressure sores. I saw that when I first came to work here. We are working on it. Our system is broken." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] coded the resident as having a Brief Interview for Mental Status of 5. S/he required extensive assistance for all activities of daily living except eating, which was accomplished by the resident after the food was setup. S/he used his/her right hand to feed himself/herself. Review of Resident #2's pressure sore documentation revealed a pressure ulcer on admission 09/09/2014 to the right hip/buttock that measured 28 centimeters (cm) x 8 cm x 5 cm. Review of the measurements from from October, November, December 2014 and January 2015 was not available or incomplete. Observation of the wound on 02/24/2015 at approximately 9:40 AM revealed a clean wound, with on odors or drainage that appeared to be healing measuring approximately 21.5 cm x 5.5 cm x very little depth. Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] coded the resident as having a Brief Interview for Mental Status of 14. S/he required extensive assistance for all activities of daily living. Review of Resident #14's pressure sore documentation revealed a sacral wound on admission 11/19/2014 that measured 8 centimeters (cm) x 8 cm. The resident was followed by the wound clinic and a wound vac was in place at admission. Further review of the Wound Treatment and Progress Record review revealed no documented measurements until a hospital discharge summary dated 02/06/2015 stated, "...Location Buttocks (type) pressure: (stage) 4: measured 01/30/2015: Length (cm) 6.5 Width (cm) 5 Depth (cm) 3.5. Review of the February 2015 Wound Treatment and Progress Record revealed the wound on 02/07/2015 measured 5 cm x 4.2 cm x 2.8 cm; 02/11/2015 measured 5.1 cm x 4.1 cm x 2.8 cm; 02/15/2015 measured 5.7 cm x 4.9 cm x 3.9 cm. The current treatment to cleanse with normal saline, loosely pack with gauze soaked in Dankins 0.25 5, and cover with dry gauze and place dry dressing each shift was ordered on the discharge summary from the hospital on [DATE]. The wound nurse stated on 02/25/15 that this was the order that came from the hospital.

Based on record review and interviews, the facility failed to ensure Resident #1 and Resident #3 were free of significant medication errors. Resident #1 did not receive [MEDICATION NAME] and Xarelto and Resident #3 did not receive [MEDICATION NAME] and [MEDICATION NAME] as ordered by the Physician, 2 of 4 residents reviewed. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of Resident #1's medical record on 7/23/2014 at approximately 10:30 AM revealed Resident #1 was admitted on [DATE] at 5:35 PM on a Friday. Review of Resident #1's medical record indicated the facility was to continue with ordered medications of Xarelto 15 milligrams (mg) orally with dinner for a [DIAGNOSES REDACTED]. Resident #1's failed to receive ordered Xarelto and [MEDICATION NAME]; no other medications were administered. Review of the SBAR Communication Form and Progress Note dated 4/5/2014 at "0145 AM, pt (patient) called to 'check my trach.' Nurse entered, noted resident in abd (abdominal), labored resps (respirations), SOB (short of breath), 36-42. [MEDICAL CONDITION], 02 4 l (liters), res (respiratory) tx (treatment) given no secretions [MEDICAL CONDITION]. HOB (head of bed) 90 degrees... Dr. notified as of 0155 AM... EMS (emergency medical services) notified... 0225 AM EMS arrived to take pt. to emergency room ..." An interview on 7/23/2014 at approximately 1:57 PM with the Licensed Practical Nurse taking care of Resident #1 on 4/4/2014 and 4/5/2014 stated, "the medications came into the facility at approximately 1:00 AM, by that time a certified nursing assistant has called me to the room." Upon entering the room, "I noticed this resident was short of breath and the heart rate was 130-140." I felt like the resident needed to go out now to the hospital, so I did not give him/her any medications." "I called report to the hospital emergency room , the nurse taking the report did not ask if I had given any medications and I did not tell the nurse that I had not given the medications. But, I did send a copy of the MAR indicated [REDACTED] Review of the emergency room admission history and physical dated 04/05/2014 stated, "...Assessment and Plan: ...a [AGE] year-old gentleman now presenting with acute hypoxic [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] with rapid ventricular response. The etiology of the patient's findings is likely due to withholding of his/her medications after transitioning to his/her rehab facility..." The facility admitted Resident #3 on 3/8/2014 at 5:45 PM with [DIAGNOSES REDACTED]. Review of Resident #3's medical record on 7/23/2014 at approximately 12:00 Noon revealed a Medication Administration Record [REDACTED]. This resident did not receive the 10 PM dosage. Also ordered were [MEDICATION NAME] 0.2 mg 3 times daily orally for Hypertension at 6 AM, 2 PM and 10 PM s/he did not receive the 10 PM dosage. No documentation could be found in Resident #3's medical record where the medications were given for Hypertension. Review of Resident #3's admission Nurse's Notes revealed a blood pressure of 169/83. Review of the facility policy entitled, "Medication Management Program," on 7/23/2014 at approximately 11:15 AM stated under section entitled, "Procedures" Step II: Preparing for the Medication Pass, #5 states, "Medications are administered one (1) hour before or one (1) hour after the designated medication pass time." No documentation could be found on the Medication Administration Record [REDACTED]. During an interview on 7/23/2014 at approximately 2:20 PM with the Director of Nurses (DON) s/he verified that the medications were not given and stated, "If we do not have the medications we cannot give them."

On the day of the complaint inspection, based on record reviews, interviews, observations, and review of facility files, the facility failed to ensure the services they provided to residents met professional standards of quality related to managing resident medication allergies and/or sensitivities for 3 of 7 resident records reviewed (Resident #1, #6, and #7); and failed to ensure that a resident sensitive to a medication did not receive that medication for 1 of 1 resident administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes showed the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). The resident returned to the facility on [DATE]. Review of the hospital discharge summary revealed a primary discharge [DIAGNOSES REDACTED]. "... [MEDICAL CONDITION] was thought to be secondary from Bactrim. The patient was also on [MEDICATION NAME], which could be contributing. .... Nephrology was consulted and confirmed that they suspected Bactrim was the cause of patient's [MEDICAL CONDITION] and not to use Bactrim again..." The hospital physician orders [REDACTED]. The resident's other allergies were also noted: [MEDICATION NAME] G, [MEDICATION NAME], and [MEDICATION NAME]. Review of the Nursing Data Collection Tool completed on the resident's return showed allergies to [MEDICATION NAME], and [MEDICATION NAME]. It did not note the direction to not use Bactrim again. Review of the Physician order [REDACTED]. Review of the readmission History and Physical completed by the physician's assistant on 2/3/11 showed the note "... Bactrim is not to be used in this patient again. ..." Under the section titled Allergies was noted "PCN ([MEDICATION NAME]), [MEDICATION NAME]. She is not to be given Bactrim." Review of the medical record failed to show that Bactrim was added to the resident's list of allergies after her return to the facility on [DATE]. The resident was started on [MEDICATION NAME] for knee and back pain on 3/15/11. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop the [MEDICATION NAME], avoid all Nsaids (non-steroidal anti-[MEDICAL CONDITION] agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the Nurses' Notes on 3/31/11 showed the nephrologist's order was received and confirmed by the facility physician. The [MEDICATION NAME] was discontinued. Review of the medical record showed no update to the resident's allergy list for the Bactrim, sulfa, [MEDICATION NAME], Nsaids, ACE, or ARBs as a result of the nephrologist's directions and facility physician's orders [REDACTED]. Review of the pharmacy consultant monthly reports for 2/9/11, 3/14/11, 4/15/11, 5/16/11, and 6/13/11 showed no documentation alerting the staff of the resident's new allergy listings. Review of the Pharmacy Consultant Agreement showed under Medication Regimen Review (MRRs): "(b) factors to be considered in Conducting MRRs. In conducting the MRR, CONSULTANT shall consider whether: ... (ii) the physician and staff have identified and acted upon, or should be notified about, the resident's allergies and/or potential side effects and significant medication interactions; ..." On 6/28/11, the resident was started on Bactrim DS (double strength) for a raised, hard area on her left inner wrist, suspicious of [MEDICAL CONDITION]. Blood work done on 7/6/11 showed potassium of 7.2 but the specimen was hemolyzed so a repeat potassium was drawn. The repeat potassium result was 6.6 (normal range 3.5 to 5.1). As a result of the elevated potassium level, the resident required treatment with two doses of [MEDICATION NAME] 30 grams on 7/6/11, 15 grams on 7/7/11, and 30 grams on 7/18/11. The resident's medical record was updated to show her allergies and the medications to avoid after the bout of elevated potassium in July 2011. Review of the medical record revealed the Bactrim DS was ordered on [DATE] to be given twice a day for ten days. The resident took the medication for approximately 8 days, not the four days reported. The Bactrim was discontinued on 7/6/11 after the resident's potassium reached 6.6. An interview with the Director of Nurses (DON) on entering the facility revealed she concluded her audit of readmission charts on 7/22/11 and found only one resident whose chart did not reflect all her allergies (#7). Resident #7 arrived at the facility in September 2010. Her [DIAGNOSES REDACTED]. The resident returned to the facility from a hospitalization on [DATE] and again on 7/28/11. Review of the medical record revealed a History and Physical dated 9/7/10 that showed the physician identified the resident's allergies as: shellfish, [MEDICATION NAME], and [MEDICATION NAME]. The History and Physical of 7/28/11 noted allergies to ammonia, [MEDICATION NAME], shellfish, and [MEDICATION NAME]. The monthly cumulative physician orders; hospital discharge documents; and Nursing Data Collection Tools of 9/2/10, 3/5/11, 7/14/11, and 7/28/11 all showed allergies to ammonia water, [MEDICATION NAME], and shellfish. The resident's record was not updated as a result of the DON's audit completed on 7/22/11. A telephone order dated 8/3/11 at 11:45 AM stated: "Order clarification Resident is allergic to [MEDICATION NAME]." Handwritten allergy notices were added to the printed monthly physician's orders [REDACTED]. The medical records of five residents admitted to the facility after 7/22/11 revealed one resident with conflicting allergy medication (#6). Resident #6 arrived at the facility on 7/26/11. His [DIAGNOSES REDACTED]. Review of the hospital discharge information revealed the resident was allergic to [MEDICATION NAME], and Rosuvastatin. The physician's orders [REDACTED]. Continued record review showed an additional allergy to [MEDICATION NAME] on the medical record face sheet, Medication Administration Record, OK per Brian in pharmacy." Review of the medical record failed to show any source for the information that the resident was allergic to [MEDICATION NAME]. The DON was asked to assist in determining the resident's allergy status. She reported that the Admissions Director received the information and documented it in the admission intake notes, which was not part of the permanent medical record. The Admissions Director stated the resident's daughter told her that [MEDICATION NAME] caused confusion in the resident. Review of the facility's Nursing Policies and Procedures Subject: Allergy History revealed the admitting nurse was to obtain the allergy history, document, and communicate findings with the appropriate staff. Allergies were to be recorded on the plan of care, nurse's assessment form, Minimum Data Set, Medication Administration Record, [REDACTED]. An allergy label was to be attached to the front of the chart. Dietary was to be notified of food allergies. The nurse was to advise the physician of any allergies when notifying him of the admission. Any adverse reactions or suspected allergies were to be documented and reported to the physician. A resident's allergies were to be included in the discharge summary and responsible party information at discharge. An interview with the DON at 10:30 AM revealed the floor nurses did the admission paperwork. They followed two separate checklists, one for the physician and one developed by the DON in effect since Spring 2011. The condition alert was done first. Orders from the hospital were then transcribed onto the physician's orders [REDACTED]. Allergies were to be noted on the transcribed physician orders. Cross Refer to F-333 as it related to the failure of the licensed staff to follow facility policy in ensuring all allergies were noted at the time of admission and documentation of any current or newly identified allergies was present and notification to appropriate staff was completed.

On the day of the complaint inspection, based on record review and review of the monthly consulting pharmacy reports, the facility failed to ensure that the pharmacy consultant reported irregularities concerning medication sensitivities for 1 of 1 resident who was administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes indicated the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Again Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition, but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). Review of Resident #1's medical record revealed the facility was alerted by her nephrologist on 1/19/11 and again on 3/31/11 that she should not be given Bactrim. Bactrim was determined to cause hyperkalemia in the resident. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop Naproxen which had been ordered for knee and back pain 3/15/2011, avoid all Nsaids (non-steroidal anti-inflammatory agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the pharmacy consultant's monthly reports for 2/9/11, 3/14/11, 4/15/11, and 6/13/11 showed no documentation alerting the physician or facility staff of the resident's new allergy listings. Bactrim was ordered for Resident #1 on 6/28/11 causing the resident's potassium level to again rise above normal range which required repeated treatment with Kayexalate to bring it down to within normal limits. Cross refer to F-333 as it relates to Resident #1's identified allergy to the medication Bactrim and the pharmacy consultant's failure to address this during monthly review.

On the day of the complaint inspection, based on record review and interviews, the facility failed to ensure that a resident sensitive to a medication did not receive that medication for 1 of 1 resident who was administered Bactrim after the medication was determined to have an adverse effect on her (Resident #1). The findings included: Resident #1, with [DIAGNOSES REDACTED]. The resident developed a urinary tract infection in December 2010 and was started on Bactrim on 12/30/11. Review of the Nurse's Notes showed the resident demonstrated no adverse effects from the medication. On 1/11/11, the nurse practitioner ordered blood work and a urinalysis for the resident. Nurse's Notes on 1/12/11 showed no signs or symptoms of a change in condition but the 12:18 PM note stated the resident was being transferred to the hospital due to a change in condition. The resident left the facility at 12:30 PM. At 2 PM, the laboratory called in a Potassium level of 9.1 (normal range 3.5 - 5.1). Resident #1 returned to the facility on [DATE]. Review of the hospital discharge summary revealed a primary discharge [DIAGNOSES REDACTED]. "... [MEDICAL CONDITION] was thought to be secondary from Bactrim. The patient was also on [MEDICATION NAME], which could be contributing. .... Nephrology was consulted and confirmed that they suspected Bactrim was the cause of patient's [MEDICAL CONDITION] and not to use Bactrim again. ..." The hospital physician orders [REDACTED]. The resident's other allergies were also noted: [MEDICATION NAME] G, [MEDICATION NAME], and [MEDICATION NAME]. Review of the Nursing Data Collection Tool completed on the resident's return showed allergies to [MEDICATION NAME], and [MEDICATION NAME]. It did not note the direction to not use Bactrim again. Review of the Physician order [REDACTED]. Review of the readmission History and Physical completed by the physician's assistant on 2/3/11 showed the note "... Bactrim is not to be used in this patient again. ..." Under the section titled Allergies was noted "PCN ([MEDICATION NAME]), [MEDICATION NAME]. She is not to be given Bactrim." Review of the medical record failed to show that Bactrim was added to the resident's list of allergies after her return to the facility on [DATE]. The resident was started on [MEDICATION NAME] for knee and back pain on 3/15/11. On 3/31/11, the resident saw her nephrologist and returned to the facility with directions to stop the [MEDICATION NAME], avoid all Nsaids (non-steroidal anti-[MEDICAL CONDITION] agents), avoid Bactrim and Sulfa, avoid ACE (Angiotensin-Converting Enzyme Inhibitor) and ARB (Angiotensin Receptor Blocker) agents. A telephone order was written with this direction and signed by the facility physician and the nurse who took the order. Along the bottom of the telephone order was indicated by check marks that the order was sent by facsimile to the pharmacy, it was placed on the physician's orders [REDACTED]. Review of the Nurses' Notes on 3/31/11 showed the nephrologist's order was received and confirmed by the facility physician. The [MEDICATION NAME] was discontinued. Review of the medical record showed no update to the resident's allergy list for the Bactrim, sulfa, [MEDICATION NAME], Nsaids, ACE, or ARBs as a result of the nephrologist's directions and facility physician's orders [REDACTED]. Review of the pharmacy consultant monthly reports for 2/9/11, 3/14/11, 4/15/11, 5/16/11, and 6/13/11 showed no documentation alerting the staff of the resident's new allergy listings. Review of the Pharmacy Consultant Agreement showed under Medication Regimen Review (MRRs): "(b) factors to be considered in Conducting MRRs. In conducting the MRR, CONSULTANT shall consider whether: ... (ii) the physician and staff have identified and acted upon, or should be notified about, the resident's allergies and/or potential side effects and significant medication interactions; ..." On 6/28/11, the resident was started on Bactrim DS (double strength) for a raised, hard area on her left inner wrist, suspicious of [MEDICAL CONDITION]. Blood work done on 7/6/11 showed potassium of 7.2 but the specimen was hemolyzed so a repeat potassium was drawn. The repeat potassium result was 6.6 (normal range 3.5 to 5.1). As a result of the elevated potassium level, the resident required treatment with two doses of [MEDICATION NAME] 30 grams on 7/6/11, 15 grams on 7/7/11, and 30 grams on 7/18/11. The resident's medical record was updated to show her allergies and the medications to avoid after the bout of elevated potassium in July 2011. The facility reported to the State survey and certification agency on 7/21/11 that the resident's allergies had not been updated after the January 2011 hospitalization , resulting in the administration of Bactrim again in June and July 2011. "... The contraindication was not brought forward to the record/MAR (medication administration record). On June 28, 2011, the attending physician ordered Bactrim and Ms. ... (sic) The issue was discovered during our QA process and stopped after four days on July 6, 2011. Ms. ... was tested and found to have elevated potassium (6.6 meq/L). The elevation was treated and resolved with no adverse effects. All of the documentation has been updated and a QA/PI (quality assessment/performance improvement) action plan was initiated on July 13, 2011 and reported to the monthly PI Committee on July 20, 2011. ..." Review of the medical record revealed the Bactrim DS was ordered on [DATE] to be given twice a day for ten days. The resident took the medication for approximately 8 days, not the four days reported. The Bactrim was discontinued on 7/6/11 after the resident's potassium reached 6.6. The facility's action plan for Orders and Allergies From Readmission Discharge Summaries was dated 7/13/11. Review of the facility's Nursing Policies and Procedures Subject: Allergy History revealed the admitting nurse was to obtain the allergy history, document, and communicate findings with the appropriate staff. Allergies were to be recorded on the plan of care, nurse's assessment form, Minimum Data Set, Medication Administration Record, [REDACTED]. An allergy label was to be attached to the front of the chart. Dietary was to be notified of food allergies. The nurse was to advise the physician of any allergies when notifying him of the admission. Any adverse reactions or suspected allergies were to be documented and reported to the physician. A resident's allergies were to be included in the discharge summary and responsible party information at discharge. An interview with the DON at 10:30 AM revealed the floor nurses did the admission paperwork. They followed two separate checklists, one for the physician and one developed by the DON in effect since Spring 2011. The condition alert was done first. Orders from the hospital were then transcribed onto the physician's orders [REDACTED]. Allergies were to be noted on the transcribed physician orders.

On the days of the complaint inspection, based on record reviews, interviews, and review of facility documents, the facility failed to ensure residents received appropriate assistance devices to maintain a resident environment as free of accident hazards as possible for 1 of 2 residents reviewed who had bruising from a known source (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the resident assessments of 4/5/10 and 9/20/10 revealed the resident had memory and communication impairment. The resident did not ambulate and required total care from the staff for transfer, dressing, hygiene, and bathing. When out of bed, the resident used a tray top on her wheelchair for positioning due to leaning. She received anticoagulant therapy with the drug Coumadin. On 11/4/10, the 7:40 AM Nurse's Note stated the nurse was called to the resident's room. "... Nurse noted resident to have a bruise from sternum, over the (L) (left) side of chest, around to the back. ..." The nurse notified the nurse practitioner and the resident's daughter. At 1:45 PM on 11/4/10 (sic), the Nurse's Note said the bruise was "... from sternum to waist area on (L) side and goes around to back. According to the nurse's note, the nurse practitioner ordered An x-ray of the abdomen on right and left side. The note also stated "... resident appears to be in pain leans to (R) (right) side." The facility determined the wheelchair tray top was responsible for the band of bruising around the resident's left side. Review of the resident's blood levels related to her anticoagulant therapy showed elevated PT (prothrombin time) and INR (international normalized ratio) on 11/1/10. The resident's tests were in therapeutic range on 11/4/10 but elevated again on 11/8/10. The physician and nurse practitioner monitored the resident's test results and adjusted the Coumadin dose as necessary, however, the likelihood of continued injury or new bruising remained high for this resident. Review of the Rehabilitation Screen dated 9/9/09 revealed the resident needed positioning in the wheelchair with the lap tray, right side supports, and calf pads. Review of the medical record and an interview with one of the resident's direct caregivers, Certified Nursing Assistant #1, revealed no evidence the side support was in use in November 2010. Review of the medical record showed no interventions put in place to protect the resident from further potential injury from the tray table.