Every finding on record at Rose Linn Care Center

Based on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving care and services for optimal resident outcomes. Findings include:The facility's 7/19/24 Quality Assurance/Performance improvement (QAPI) program will aim for safety and high quality with all clinical interventions and service delivery while emphasizing autonomy, choice and quality of daily life for residents and family by ensuring our data collection tools and monitoring systems are in place. -The mission of [NAME] is to provide the appropriate care for our residents to make their days the best they can be. On 4/24/26 at 11:48 AM Staff 1 (Interim Administrator) acknowledged the QAPI program did not recognize or address the following identified concerns: - Obtaining consent when psychotropic medications were used. - Implementing physician orders regarding wound care, mobility and bowel medications.- Implementing care plans to prevent falls.- Nurse aide performance reviews and required In-Service training. - Lack of appropriate infection control practices related to following CDC guidelines.Refer to F552, F684, F689, F730, F790, F880, and F947

Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 7 randomly selected CNA staff (#s 5, 6, 7, and 8) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff. Findings include:A review of personnel records on 4/24/26 indicated the following employees did not received their annual performance evaluations:-Staff 5 (CNA), hire date was 11/2020 and a performance review was completed in 11/2024.-Staff 6 (CNA), hire date was 8/2023 and a performance review was completed in 8/2024.-Staff 7 (CNA), hire date was 11/2011 and a performance review was completed in 11/2024.-Staff 8 (CNA), hire date was 1/2015 and a performance review was completed in 1/2025.On 4/24/26 at 10:43 AM Staff 1 (Interim Administrator) stated performance reviews were to be completed annually and acknowledged annual performance reviews were not completed for Staff 5, Staff 6, Staff 7 and Staff 8.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 7 of 7 randomly selected staff members (#s 5, 6, 7, 8, 9, 10, and 11) reviewed for in-service training. This placed residents at risk for lack of quality care. Findings include:On 4/24/26 at 9:30 AM Staff 12 (Human Resources/Payroll Director) provided minutes for all-staff meetings and sign in sheets for 4/2025-4/2026. The minutes showed Staff 5, 6, 7, 8, 9, 10, and 11 attended various all-staff meetings, but did not indicate what topics were covered and how many hours of training were provided.On 4/24/26 at 9:39 AM Staff 12 stated staff were expected to attend the all-staff meetings to receive the required trainings. If the staff member was not in attendance, they received a packet of the materials covered. Staff 12 could not produce a record of topics covered and how many hours each CNA had attended or received.On 4/24/26 at 10:43 AM Staff 1 (Administrator) acknowledged the 12 hours of annual in-service trainings for CNAs was not completed.

Based on interview and record review it was determined the facility failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications. Findings include:Resident 8 was admitted to the facility in 3/2026 with diagnoses including depression and dementia.Resident 8's 3/2026 Physician Orders indicated the resident was prescribed sertraline (antidepressant) for depression.Resident 8's 4/2026 MAR revealed the resident received sertraline daily.Review of Resident 8's medical record revealed no indication the resident was informed in advance of the risks and benefits of sertraline.On 4/23/26 at 1:24 PM, Staff 3 (LPN Resident Care Manger) acknowledged Resident 8 was not informed of the risks and benefits for the use of sertraline.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 5 and 40) reviewed for wound care and bowel medications. This placed residents at risk for constipation and worsening skin impairment. Findings include:1. Resident 40 admitted to the facility in 4/3/2026 with diagnoses including bipolar disorder. A review of Resident 40's Physician Orders dated 4/3/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder, medications indicated for constipation on a PRN basis. The Physician Orders also included a bowel routine for Resident 40 which indicated the resident was to receive Milk of Magnesia for no bowel movement after three days, bisacodyl suppository after four days and fleets enema after five days. A review of Resident 40's Care Plan dated 4/6/26 revealed the resident had bowel incontinence and was dependent on staff for all toileting tasks. A review of Resident 40's bowel record indicated the resident had no bowel movement from 4/17/26 to 4/21/26 (five days). A review of Resident 40's 4/2026 MAR revealed no indication the resident received medications for constipation or that her/his bowel routine was followed after three days of no bowel movement. On 4/23/26 at 1:58 PM Staff 13 (LPN) stated Resident 40 had bowel movements daily and was unaware if the resident went consecutive days without a bowel movement. Staff 13 stated Resident 40 did not refuse medications and she did not administer medications indicated for constipation to the resident since her/his admission. On 4/24/26 at 9:53 AM Staff 3 (LPN Resident Care Manager) confirmed the resident went five days without a bowel movement from 4/17/26 to 4/21/26 and did not receive medications for constipation or her/his bowel routine. On 4/24/26 at 11:58 AM Staff 2 (DNS) stated nursing staff were expected to administer Resident 40's medications for constipation on 4/19/26 and to follow her/his bowel routine as ordered on 4/20/26. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses including acute cystitis (sudden bladder infection). A 3/30/26 admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact. A 3/14/26 MAR indicated staff performed daily wound care to Resident 5's left elbow. Wound care orders specified the site did not require a dressing. A 4/12/26 MAR indicated staff performed daily wound care to Resident 5's right elbow. The order indicated staff cleaned the wound with cleanser, dried it and applied a new dressing. During observations from 4/21/26 through 4/23/26 from 8:00 AM to 12:00 PM, Resident 5 was repeatedly observed wheeling herself/himself in the hallway. During these observations Resident 5's left elbow wound was covered with a dressing dated 4/19/26. The dressing on Resident 5's right elbow was peeled off and the wound was exposed. Resident 5 was observed resting her/his arms on the side rails of the wheelchair. Resident 5 was observed bumping her/his elbow on the hallway rails. On 4/23/26 at 12:09 PM, Staff 13 (LPN) stated staff performed daily wound care to Resident 5's right and left elbow. Staff 13 acknowledged Resident 5's left elbow dressing was dated 4/19/26. Staff 13 stated Resident 5 did not require a dressing and removed the dressing. Staff 3 stated she did not perform wound care the previous day and acknowledged the MAR indicated she did perform wound care on that day. On 4/23/26 at 12:17 PM, Staff 13 and Resident 5 returned back into her/his room and she removed Resident 5's right elbow dressing and applied a new dressing. Staff 3 stated she did not perform wound care the previous day and acknowledged the MAR indicated she did perform wound care on that day. On 4/24/26 at 9:08 AM, Staff 3 (LPN, Resident Care Manager) stated she expected staff to follow wound care orders. Staff 3 stated she monitored residents MARs to ensure staff completed wound care. Staff 3 stated she was unaware staff did not complete wound care orders.

Based on observation, interview and record review it was determined the facility failed to provide treatment, services, equipment, and assistance to maintain or improve mobility related to the use of a brace 1 of 1 sampled resident (#30) reviewed for mobility. Findings include:Resident 30 was admitted to the facility in 6/2018 with diagnoses including abnormalities of gait and mobility. A 1/16/26 Quarterly MDS indicated Resident 30 had a BIMS score of 4 indicating the resident was not cognitively intact. The MDS indicated the resident used a walker and wheelchair. The MDS indicated Resident 30 did not use a brace but she/he performed ROM exercises four days a week. A 6/20/25 Referral to Prosthetics and Orthotics indicated Resident 30 required an AFO (ankle foot orthosis) due to ankle weakness and instability and the length of need was lifetime. The referral indicated the current AFO did not fit properly. A 10/23/25 Care Conference indicated Resident 30's AFO fit properly when her/his black shoes were worn. A 3/6/26 Restorative services referral indicated Resident 30 performed functional transfer maintenance. Resident 30 wore a brace for repeated toilet transfers with bathroom grab bars three times a week. A 4/10/26 Care Plan indicated the following restorative services-Transfer program: Staff to perform repetitive toilet transfers with the grab bars and using the right AFO. A 4/2026 MAR indicated staff applied Resident 30's brace daily. Resident 30's medical record indicated staff performed daily restorative services.During observations from 4/20/26 through 4/23/26 from 8:00 AM to 4:00 PM, Resident 30 was repeatedly observed sitting in her/his wheelchair with her/his right foot inverted to the left side. Resident 30 did not wear the recommended shoes to properly fit the brace.On 4/20/26 at 12:25 PM Resident 30 stated she/he did not wear the brace due to increased pain when using the brace. Resident 30 stated staff adjusted the brace in the past to try and make it more comfortable, but it continued to be painful. Resident 30 indicated she/he was never reassessed for proper fit for the brace. On 4/23/26 at 9:07 AM Resident 30 stated staff were not currently offering her/him exercises or use of the brace. On 4/23/26 at 1:01 PM and 1:52 PM, Staff 6 (CNA) stated Resident 30 was able to communicate her/his needs. Staff 6 stated Resident 30's mobility decreased and she/he required maximum assistance to stand up. Staff 6 stated he did not offer Resident 30 transfer programs during the day. Staff stated he did not offer Resident 30 to use the brace because she/he normally refuses. Staff 6 stated Resident 30 stopped using the brace several months ago. Staff 6 stated Resident 30 did not wear because it was painful. Staff 6 stated he was unsure if Resident 30 performed ROM or worked with therapy. On 4/23/26 at 4:25 PM, Staff 11 (CNA) stated Resident 30 was required to use a brace daily. Staff 11 stated Resident 30 did not use the brace because it was tight and painful. Staff 11 stated staff were aware about the brace not fitting properly. Staff 11 stated Resident 30 continued to report pain and discomfort related to her/his brace. On 4/23/26 at 1:59 PM, Staff 18 (PT) stated Resident 30 was not required to use the brace daily. Staff 18 was unsure if Resident 30 was evaluated to stop using the brace. On 4/24/26 at 8:13 AM, Staff 13 (LPN) stated she did not offer the brace to Resident 30. Staff 13 stated she did not document refusals. Staff 13 stated she was unsure why the resident refused to use the brace. Staff 13 stated she was unsure if restorative services were completed daily. On 4/24/26 at 8:35 AM, Staff 3 (LPN Resident Care Manager) stated she expected staff to offer the brace daily. Staff 13 stated she was unaware if Resident 30 refused the brace. Staff 3 stated she expected staff to document refusals daily and notify the provider to assess the use of the AFO. On 4/24/26 at 9:58 AM, Staff 2 (DNS) stated Resident 30's brace was adjusted but not replaced. Staff 2 stated Resident 30 used the AFO intermittently. Staff stated the AFO was assessed for comfort or proper fitting since adjustment. Staff 2 stated the brace was ordered for stability and proper alignment. Staff 2 stated she expected staff to document refusals and notify the provider to assess for use.

Based on observation, interview, and record review it was determined the facility failed to implement care plan interventions to prevent falls for 1 of 4 sampled residents (#60) reviewed for accidents. This placed residents at risk for falls. Findings include:Resident 60 was admitted to the facility in 2/2026 with diagnoses including a stroke and femur fracture.Resident 60's 2/10/26 admission MDS revealed the resident was cognitively impaired.Resident 60's 2/3/26 care plan indicated she/he was a high fall risk which required a one person assist with transfers and to ensure her/his call light was within reach.A 3/18/26 and 4/13/26 Fall Assessment revealed Resident 60 had two unwitnessed falls which was a result of the resident's attempt to self-transfer to the bathroom independently.Observations between 4/20/26 at 8:30 AM and 4/22/26 at 2:48 PM revealed multiple occasions of Resident 60's sitting in her/his wheelchair near the foot of her/his bed and her/his call light draped over the head of her/his bed which was out of reach of the resident. On 4/20/26 at 9:08 AM Staff 5 (CNA) stated Resident 60 was able to use her/his call light appropriately if she/he was able to see it. Staff 5 stated Resident 60 was forgetful at times, and the visual of the call light was often a way to remind her/him to call for assistance.On 4/22/26 at 1:35 PM Staff 6 (CNA) stated if the call light was out of the resident's reach it would be safe for the resident to ambulate around her/his room to reach it.On 4/22/26 at 1:57 PM Staff4 (Resident Care Manager, LPN) acknowledged Resident 60 was a high fall risk and it was not safe for Resident 60 to ambulate in a wheelchair around her/his bed to reach her/his call light.

Based on observation, interview, and record review it was determined the facility failed to properly clean a suprapubic catheter for 1 of 1 sampled resident (#5) reviewed for catheter care. This placed residents at risk for infection. Findings include:Resident 5 was admitted to the facility on [DATE] with diagnoses including acute cystitis (sudden bladder infection). A 3/30/26 admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact. A 3/18/26 MAR indicated staff performed daily care to Resident 5's suprapubic catheter (a tube inserted through the stomach to drain urine from the bladder). Orders specified staff were to clean the site with warm soapy water or other gentle cleanser, pat dry and apply gauze. On 4/23/26 at 1:31 PM, Staff 13 was observed performing care to Resident 5's suprapubic catheter. Staff 13 cleaned the site with warm water and did not use soapy water or a cleanser. Staff 13 acknowledged she did not use soapy water or a cleanser and stated she forgot. On 4/24/26 at 9:08 AM Staff 3 (LPN Resident Care Manager) stated staff were to follow orders related to the suprapubic catheter.

Based on observation, interview and record review it was determined the facility failed to ensure PPE was used when wound care and catheter care was performed for 1 of 1 sampled resident (#5) reviewed for wound care. This placed residents at risk for infection. Findings include:A 2/2024 CDC Implementation of Personal Protective Equipment (PPE) Use In Nursing Homes to Prevent Spread of Multi-drug-resistant Organisms indicated enhanced barrier precautions was required during high-contact activities including device care or wound care. Resident 5 was admitted to the facility on [DATE] with diagnoses including acute cystitis (sudden bladder infection). A 3/30/26 admission MDS indicated Resident 5 had a BIMS score of 1 which indicated the resident was not cognitively intact.A 3/14/26 MAR indicated staff performed daily wound care to Resident 5's left elbow. The order indicated the wound did not require a dressing. A 3/18/26 MAR indicated staff performed daily wound care to Resident 5's suprapubic catheter (a tube inserted through the stomach to drain urine from the bladder). The order indicated staff were to clean the site with warm soapy water or other gentle cleanser, pat dry and apply gauze. A 4/12/26 MAR indicated staff performed daily wound care to Resident 5's right elbow. The order indicated staff cleaned the wound with a cleanser, dried it and applied a new dressing.On 4/22/26 at 2:14 PM, Staff 19 was observed to empty Resident 30's suprapubic catheter bag without using PPE. Staff 19 stated she was unaware the resident was on enhanced barrier precautions. On 4/23/26 at 12:11 PM, Staff 13 stated Resident 5 did not require a dressing. Staff 13 removed Resident 5's left elbow dressing in the hallway. Staff 13 did not use PPE.On 4/23/26 at 12:17 PM, Staff 13 and Resident 5 returned back into her/his room. Staff 13 removed Resident 5's right elbow dressing and applied a new dressing. Staff 13 did not wear PPE. Staff 13 stated PPE was not required because she did not touch the resident's suprapubic catheter. On 4/24/26 at 10:07 AM, Staff 2 (DNS) stated staff were not required to use PPE when changing Resident 5's wounds on her/his left and right elbow because staff were not in close contact with the suprapubic catheter. Staff 2 stated staff were not required to use PPE when the catheter bag was emptied because the resident did not have a urine infection.

Based on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents (#s 114 and 115) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities and the right to an appeal. Findings include: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) indicated notices are valid when all patient specific information required by the notice is included. 1. Resident 114 was admitted to the facility in 9/2024 with diagnoses including diabetes and schizophrenia (mental health disorder). Resident 114's clinical record indicated the resident had Medicare Part A coverage. Resident 114's Profile indicated her/his financial and care POA (Power of Attorney) was Witness 3 (Family). A 9/25/24 facility email was sent to Witness 3 by Staff 9 (Former Social Services Director) that indicated Resident 114 was provided a Notice of Medicare Non-Coverage (NOMNC) form. The NOMNC form contained no information related to Resident 114's effective date of coverage, a date when coverage was to end or the contact information for the Quality Improvement Organization to request an appeal. A 9/28/24 Discharge Summary indicated Resident 114 was ready to discharge to her/his home with outpatient supervision. A 9/30/24 Social Services Note indicated Witness 3 did not sign and return Resident 114's NOMNC form. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) acknowledged Resident 114's NOMNC form was not valid due to incomplete information on the form. 2. Resident 115 was admitted to the facility in 11/2024 with diagnoses including dementia and a thoracic vertebrae (spine) fracture. Resident 115's clinical record indicated the resident had Medicare Part A coverage. A 12/17/24 Discharge Summary indicated Resident 115 completed her/his therapy services and was cleared to discharge. Review of Resident 115's clinical record revealed no Notice of Medicare Non-Coverage (NOMNC) form was provided to the resident. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) confirmed a NOMNC form was needed for Resident 115 and was not provided.

Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed residents at risk for falls with injury. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including dementia. The 8/16/23 revised Care Plan indicated Resident 1 was at risk for falls related to cognitive impairment and required assistance with mobility. Interventions included the use of a Hoyer (mechanical lift) for transfers. The Care Plan also indicated Resident 1 was resistant to care with interventions including to use a calm tone/approach and to not rush during care. A 9/28/23 facility fall investigation indicated Staff 5 (CNA) transferred Resident 1 using a Sara lift (sit to stand transfer device) when the resident's foot slipped and the resident lost her/his balance. The resident hit her/his mouth and sustained a cut on the lower lip with bruising. Resident 1 was care planned for a two-person transfer using a hoyer lift. Staff 5 did not follow the Care Plan and used a Sara lift instead of the Hoyer to transfer the resident. On 6/18/24 at 10:12 AM Staff 5 stated she was familiar with Resident 1. Staff 5 stated on the day of the incident, Resident 1 was to suppose to receive a shower. Staff 5 stated she was scared to use the Hoyer sling on Resident 1 due to her/his aggression when she/he was placed on the sling. Staff 5 further stated stated the facility was out of Hoyer slings at the time and instead of getting three or four staff to assist with transferring Resident 1, she decided to use the sit to stand to transfer the resident. Staff 5 stated Resident 1 did not fall but was guided to the floor. Staff 5 stated Staff 6 (LPN) was present during the entire incident. Staff 5 acknowledged Resident 1 was care planned for two-person assistance with a Hoyer for transfers. On 6/18/24 at 10:27 AM Staff 2 (RNCM) stated she was asked to look at Resident 1 after the fall. Staff 2 stated Resident 1 had a history of being resistant to care if she/he was not approached in a calm manner, and required a two person transfer. Staff 2 stated she asked Staff 5 if she used the sit to stand to transfer Resident 1 and Staff 5 indicated she did. Staff 2 stated she was informed by Staff 5 that Staff 5 transferred Resident 1 by herself. On 6/18/24 at 10:50 AM Staff 3 (CMA) stated she was next door in the medication room when Staff 5 asked for assistance with Resident 1. Staff 3 stated she and Staff 6 went into the room, and Resident 1's feet were off the sit to stand with her/his face leaning on part of the device. Staff 3 stated Staff 3 was present in the room when Staff 5 was told she was not suppose to use the sit to stand to transfer Resident 1, and was not suppose to transfer the resident alone. On 6/18/24 at 11:22 AM Staff 6 stated she was not in the room during Resident 1's fall and did not enter the room until Staff 5 yelled for assistance. Staff 6 stated Staff 5 tried to tell staff she was in the room with her but she was not. Staff 6 stated when she entered the room with Staff 5, the resident's lip was resting against the bar of the sit to stand. Staff 6 further stated Staff 5 was aware she was not supposed to use the sit to stand to transfer Resident 1. On 6/18/24 at 9:30 AM and 12:05 PM Staff 1 (Administrator) stated Staff 5 was terminated as a result of the incident on 9/28/23. Staff 1 acknowledged Staff 5 did not follow the care plan, resulting in Resident 1's fall.

Based on interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled resident (#s 22 and 39) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: 1. Resident 22 admitted to the facility in 12/2022 with diagnoses including dementia and depression. Social Service Hearing and Vision Summaries revealed the following: -2/28/23: Resident 22 had difficulty hearing a speaker at conversational volume when there was background noise but could hear well once background noise was eliminated. Resident 22 was not seen for an audiology appointment since her/his admission. The resident and Witness 1 (Family Member) requested Resident 22 be seen because the resident had hearing aids in the past. Social Services was to schedule an appointment. -5/15/23 and 8/1/23: Resident 22 was in the process to receive hearing aids through an audiology appointment per the resident and Witness 1's request. A 7/27/23 Quarterly MDS revealed Resident 22 had severe cognitive impairment. A 9/5/23 Progress Note revealed Staff 3 (RNCM) spoke with Witness 1 and an audiology appointment was scheduled in 5/2023 but was canceled and a new audiology appointment was made. On 9/5/23 at 11:18 AM Witness 1 stated she requested a hearing aid test to be completed for Resident 22 because she/he was hard of hearing and could not participate in conversations when Witness 1 visited. Witness 1 indicated the facility did not initiate an appointment and Resident 22 was still without hearing aids. Witness 1 further stated this was frustrating and very important because it was difficult for Resident 22 to understand and participate in conversations. On 9/6/23 at 12:45 PM Staff 3 stated he was new to his position and scheduled an audiology appointment for Resident 22 but was unaware this was an issue prior to his conversation with Witness 1 on 9/5/23. On 9/7/23 at 1:46 PM Staff 2 (DNS) and Staff 4 (RN) acknowledged Resident 22 did not have an audiology appointment scheduled timely. Staff 2 and Staff 4 stated staff were expected to communicate to Staff 8 (Social Service Director) to follow up and ensure appointments were made timely. Staff 4 stated Staff 8 was new to her position (two weeks). 48820 2. Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A Hearing Health Progress note dated 7/27/23 revealed Resident 39 needed an appointment with an ENT (Ear, Nose and Throat) specialist to have her/his ears cleaned. A review of Resident 39's medical record revealed no evidence an ENT appointment was scheduled. On 9/7/23 at 1:53 PM Staff 2 (DNS) and Staff 4 (RN) confirmed an ENT appointment was not made for Resident 39 to get her/his ears cleaned.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for medication complications and side effects. Findings include: Resident 6 admitted to the facility in 12/2022 with diagnoses including chronic heart failure and atrial fibrillation (an irregular, often rapid heart rate). A physician order dated 12/19/22 directed staff to administer digoxin (a cardiac stimulant [can cause many adverse side effects, is involved in multiple drug interactions, and can result in toxicity]) one time a day for chronic heart failure. A Pharmacy Recommendation dated 7/1/23 indicated the facility to consider drawing digoxin level because no digoxin level was on file since admission in 12/2022. On 9/7/23 at 11:45 AM Staff 7 (Pharmacy Consultant) stated she completed monthly pharmacy reviews for Resident 6 and requested a digoxin level in 7/2023 but it was not completed. Staff 7 stated she could not locate a digoxin level and would expect the facility to monitor Resident 6's digoxin level to ensure Resident 6 was stable on her/his current digoxin medication. On 9/8/23 at 9:27 AM Staff 2 (DNS), Staff 4 (RN) and Staff 3 (RNCM) acknowledged the 7/1/23 pharmacy recommendation was not followed up on timely and they could not locate any documentation to verify Resident 6 had a base line digoxin level completed.

Based on interview and record review it was determined the facility failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampled residents (#39) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus. Findings include: Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A review of Resident 39's medical record revealed no information regarding her/his COVID-19 vaccination status. On 9/7/23 at 1:52 PM and 9/8/23 at 9:03 AM Staff 2 (DNS) and Staff 4 (RN) confirmed there was no documentation regarding Resident 39's COVID-19 vaccination status.

Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency CNA) adhered to professional standards of practice regarding Staff 17 not following Resident 1's care plan of a two-person assist for transfers. This resulted in Resident 1 sustaining a deep laceration on her/his left knee that required sutures. This placed residents at risk for accidents. Findings include: Resident 1 was admitted in 2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severly cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the Kardex (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was his fault and it was an unfortunate mistake. Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan and he did not ask for another person to assist with the transfer.

Based on interviews and record review it was determined the facility failed to ensure adequate transfer supervision to prevent injury for 1 of 2 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a deep laceration with profuse bleeding across her/his left kneecap and required sutures at the hospital emergency department. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severely cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 (Former Agency CNA) not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the Kardex (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was his fault and it was an unfortunate mistake. Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan, and did not ask for another person to assist with the transfer.

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs for 2 of 2 resident halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Review of Direct Care Staff Daily Report from 6/1/22 through 7/28/22 revealed the facility failed to meet the state required minimum number of CNA staff for 35 of 58 days. The following interviews were completed by residents regarding staffing: 7/26/22 at 12:34 PM Resident 53 stated she/he has waited up to two hours for assistance from staff. Resident 53 stated she/he needed assistance with brief changes and getting back into bed. 7/26/22 at 12:45 PM Resident 20 stated staff took a long time to answer call lights. Resident 20 stated staff would ask what was needed and not return to assist her/him. 7/26/22 at 1:21 PM Resident 28 stated she/he waited up to an hour for the call light to be answered. 7/27/22 at 10:00 AM Resident 50 stated she/he had to wait what seemed like an hour for the call light to be answered. 7/27/22 at 10:40 AM Resident 5 stated the call light could take up to an hour to be answered. The following interviews were completed by staff regarding staffing: On 7/27/22 at 12:26 PM Staff 16 (CNA) stated staffing had been a struggle and at times it was overwhelming to complete her daily assignments. On 7/27/22 at 2:21 PM Staff 9 (CNA) stated residents did not always receive adequate care due to staffing shortages. Staff 9 stated she did not receive her breaks most days and only sat down during lunch time. Staff 9 stated that she was asked to stay late most days to help cover the following shift. Staff 9 also stated Sundays were the most challenging day for staffing needs and CMA's and charge nurses would have to assist with resident care. On 7/28/22 at 11:09 AM Staff 14 (CMA) stated the facility was understaffed most shifts. Staff 9 stated it was not uncommon for staff to do one-person transfers when a two-person transfers was indicated due to staffing shortages and not being able to wait for someone else to assist with the transfers. Staff 9 stated when asked, she would come in early or stay late to help out. Staff 9 stated Sundays were a struggle with the medication pass because the CNA's needed so much assistance with resident care. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA and acknowledged there was no current program in place to ensure the residents received RA. On 7/29/22 at 7:28 AM Staff 24 (LPN) stated the facility was often short staffed. Nursing staff often had to care for up to six residents in addition to completing her nursing duties. On 7/29/22 at 9:19 AM Staff 15 (Staffing Coordinator/CNA) stated he attempted to staff to the daily requirements, but it had been a challenge with regular staff and agency staff calling off. Staff 15 stated he will cover CNA shifts when the requirements cannot be met and there are days the RCM's and the DNS have had to cover the floor to help out. On 7/29/22 at 1:36 PM Staff 2 (DNS) stated staffing had been a struggle with Sundays being the toughest day to cover. Staff 2 stated regular staff and agency staff call off and it was a struggle to find coverage. She stated the staffing coordinator, CMA's, RCM's and sometimes herself would cover as needed. Staff 2 stated the CMA's are not given sections but rather two to three resident's during their shift. Staff 2 stated staffing continued to be an ongoing struggle and they are actively trying to hire staff for several positions. Refer to F688.

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 4 of 6 sampled residents (#s 20, 23, 33 and 48) reviewed for advanced directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 20, 23, 33 and 48 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 7/27/22 at 12:45 PM Staff 11 (Admissions Director) stated a POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 11 stated if there is a POLST there is not typically an advance directive and if an advance directive were filled out it would be done by the charge nurse the day of admission. On 7/27/22 at 1:13 PM Staff 13 (RN) stated she does not offer the advance directives with new admissions, the Resident Care Managers would do the paperwork with the residents on the day of admission. On 7/27/22 at 1:14 PM Staff 8 (RNCM) stated the advanced directives are in the resident admission packet and she had not filled out an advanced directive with a resident since the pandemic. Staff 8 stated she put please see POLST on the top of the advance directive and she had not offered an advanced directive with residents or their representatives in over a year. On 7/27/22 at 1:32 PM Staff 2 (DNS) stated there was not a process for discussing advance directives with residents upon admission to the facility. Staff 2 stated the facility had not provided documentation or verify residents were notified of their right to formulate an advance directive. On 7/27/22 at 2:30 PM Staff 1 (Administrator) provided an undated advanced directive policy and procedure which stated it was the Resident Care Managers responsibility to discuss filling out an advanced directive with a new resident or their representative. Staff 1 stated it was his expectation that residents were presented with an advanced directive and informed upon admission.

Based on interview and record review it was determined the facility failed to ensure residents received restorative aid (RA) therapy to prevent ADL decline for 2 of 3 sampled residents (#s 22 and 52) reviewed for RA and falls. This placed residents at risk for physical decline and a decrease in well-being. Findings include: 1. Resident 52 admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident's 5/2/20 care plan, with revisions on 6/21/22, indicated she/he was on a restorative nursing program to maintain/improve functional status related to strengthening and ambulation skills. The 6/21/22 Assistive Devices Assessment indicated Resident 52 worked with Restorative Nursing with a goal to maintain current strength and ambulation ability. The Restorative program was currently on hold. On 7/29/22 at 1:00 PM Resident 52 stated she/he was not working with RA but it would be good for someone to work with her/him so she/he can walk. On 7/28/22 at 12:04 PM and 8/1/22 at 10:45 AM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including resident 52 and acknowledged there was no current program in place to ensure the residents received RA. 2. Resident 22 was admitted to the facility in 3/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 3/3/20 Care Plan indicated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/3/22 Annual MDS Functional Rehabilitation Potential indicated the resident required assistance to maintain functional status. The 6/2/22 Quarterly MDS indicated Resident 22 was cognitively intact. On 7/26/22 at 10:37 AM Resident 22 stated she/he would like to receive restorative therapy but the RAs were not available to assist her/him due to them being pulled to the floor to work as CNAs. Resident 22 further stated she/he was unable to open her/his left hand independently or move her/his left leg and foot independently. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including Resident 22 and acknowledged there was no current program in place to ensure the residents received RA.

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 7 of 58 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 6/1/22 through 7/28/22 revealed on 6/3/22, 6/17/22, 6/24/22, 7/1/22, 7/8/22, 7/15/22 and 7/22/22 there was no RN coverage for eight consecutive hours. On 8/1/22 at 9:55 AM Staff 2 (DNS) acknowledged the lack of RN coverage on the indicated dates.

Based on interview and record review it was determined the facility failed to ensure resident fall interventions were followed to prevent falls for 1 of 3 sampled residents (#5) reviewed for falls. Resident 5 sustained a fall with a left [MEDICAL CONDITION]. Findings include: Resident 5 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. An observation on 10/15/19 at 11:25 AM with Staff 3 revealed Resident 5's flip flops were no longer in the facility. The 9/5/19 Admission MDS Assessment revealed Resident 5 had a history of [REDACTED]. The 9/11/19 Comprehensive Fall Care Plan revealed Resident 5 was at risk for falls and interventions included to wear non-skid shoes or slippers. The 9/16/19 Post Fall Assessment revealed Resident 5 sustained a fall on 9/16/19 at 3:30 PM. Resident 5 was found on the floor on her/his left side and face down. Resident 5 stated she/he bumped into the wall and tripped on the flip flops she wore. The investigation concluded Resident 5 tripped on her/his flip flops. The 9/16/19 progress note indicated Resident 5 hit the wall and tripped on her/his flip flops. The 9/30/19 physician progress notes [REDACTED]. On 10/14/19 at 9:39 AM Staff 2 (DNS) and Staff 3 (Resident Care Manager) verified Resident 5 wore flip flops at the time of the fall which resulted in a left [MEDICAL CONDITION]. When asked if flip flops were considered non-skid shoes or slippers Staff 2 stated it depended on the surface of the shoe. On 10/11/19 at 2:10 PM Staff 4 (Physical Therapist) stated flip flops were not non-skid shoes or slippers.

1. Based on interview and record review it was determined the facility failed to timely ensure a resident was thoroughly assessed and treated timely to rule out a fractured arm for 1 of 5 sampled residents (#39) reviewed for accidents. This resulted in Resident 39 experiencing a delay in hospital treatment of [REDACTED]. Resident 39 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Progress Note dated 4/3/18 by Staff 12 (LPN) revealed Resident 39 was found on the floor next to her/his bed. The resident was yelling to get help. The resident was assisted by staff up off the floor and walked to the bathroom. When asked what happened the resident stated I fell and broke my arm. The resident was holding her/his left hand and refused to allow a range of motion (ROM) assessment. No other injuries were found and the resident was administered Tylenol for comfort. The physician was notified and the resident was placed on alert. Progress Notes dated 4/4/18 revealed the resident was administered Tylenol for left hand pain. The resident was assisted with a shower and complained of left arm pain. The resident told staff not to touch her/him when they attempted to check her/his wrist. The resident continued to complain of left shoulder/arm/wrist pain and refused to allow staff to touch her/his arm. The resident stated I have a broken arm. The physician was called and an order was received for an immediate x-ray. The physician was notified the resident had a broken arm and the resident was sent out to the hospital. On 10/15/18 at 1:49 PM, Staff 12 stated after the resident fell on [DATE] the resident did not appear to be in severe pain and was just concerned about getting up off the floor. The resident refused to allow him to assess her/his ROM. He did not remember if he checked the resident's vital signs, if the resident stated she/he had a broken arm or complained of pain. Staff 12 stated he notified the physician who responded for staff to monitor the resident. He stated he didn't think the resident was injured because she/he was able to use the walker and ambulate to the bathroom. A fax to the physician dated 4/3/18 revealed Resident 39 was Found on the floor. Initial assessment no injury. The notification did not indicate the resident's statement about having a broken arm, refusal to allow ROM assessment or complaint of pain. The notification did not include any instructions or new orders from the physician. A Radiology Interpretation dated 4/4/18 revealed Resident 39 had a new displaced (the ends of the broken bone are separated from each other) [MEDICAL CONDITION] upper arm. A hospital After Visit Summary dated 4/4/18 revealed the resident was provided [MEDICATION NAME] (pain medication) and a shoulder immobilizer. On 10/15/18 at 12:17 PM Staff 2 (DNS) acknowledged that based on the resident's statement of having a broken arm, pain and refusal to allow a ROM assessment Staff 12 should have called for an x-ray right away. 2. Based on interview and record review, it was determined the facility failed to follow physician orders [REDACTED].#23) whose medications were reviewed. This placed residents at risk for unmet medication needs. Findings include: Resident 23 was readmitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On 9/27/18, after reviewing Resident 23's PT/INR ([MEDICATION NAME]/International normalized ratio - a blood test measurement of the blood's ability to coagulate) labs, the resident's physician increased the dosage for [MEDICATION NAME] to 2.5 mg and ordered to recheck the resident's PT/INR in one week. Review of the medical record revealed Resident 23's [MEDICATION NAME] was not increased to 2.5 mg and the PT/INR was not rechecked as ordered by the resident's physician. On 10/15/18 at 1:39 PM, Staff 2 (DNS) acknowledged the facility failed to follow the 9/27/18 physician order [REDACTED].

1. Based on interview and record review it was determined the facility failed to ensure a resident maintained acceptable parameters of nutritional status for 2 of 4 sampled residents (#s 4 and 44) reviewed for weight loss. This resulted in Residents 4 and 44 experiencing severe unplanned weight loss. Findings include: a. Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 4's current care plan included a goal of no unplanned weight changes initiated on 7/3/18. The listed interventions were: allow the resident to eat independently with cueing and oversight, diet per physician's orders [REDACTED]. These interventions were all initiated on 7/3/18. The only new intervention was to offer a morning snack because the resident was often not up for breakfast which was initiated on 9/4/18. A Dietitian assessment dated [DATE] revealed Resident 4 ate an average of 75% of most meals and lab values were within normal limits. The resident ate independently without reported behavior issues. Meal intake was good and the resident ate 76-100% of meals. The resident's weight was stable with no known weight changes. No new interventions were implemented. A review of Resident 4's Weight Summary revealed the following: - On 6/25/18 the resident weighed 179.4 pounds. - On 8/4/18 the resident weighed 171.4 pounds. - On 9/3/18 the resident weighed 166.2 pounds. - On 10/7/18 the resident weighed 153 pounds. This was a 26.4 pound, or 14.7% body weight, loss over 104 days. A Progress Note dated 8/26/18 at 11:44 AM revealed Resident 4 was involved in incident this morning which resulted in the resident being admitted to the hospital. Progress Notes dated 8/28/18 revealed the resident returned to the facility from the hospital. A Dietitian assessment dated [DATE] indicated Resident 4 lost five pounds while she/he was in the hospital and had no significant weight loss. The resident consumed 50% of most meals. The assessment then indicated the resident had inadequate intake related to only eating 26-50% of meals. Interventions included small portions, liberalized diet, nutritionally enhanced meals and snacks. A review of Resident 4's Weight Summary revealed no weights recorded immediately prior to the resident's hospitalization on [DATE] or on the resident's return to the facility on [DATE] to reflect a five pound weight loss while the resident was in the hospital. A review of Resident 4's clinical record revealed no indication the resident's weight loss was planned, expected or unavoidable based on the resident's clinical condition or preferences. On 10/11/18 at 1:30 PM Staff 2 (DNS) verified Resident 4's weigh record, acknowledged the resident's weight loss was not planned and could not verify the five pound weight loss was attributed to the resident's hospital admission on 8/26/18. b. Resident 44 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Resident 44's current care plan included a goal of no further significant weight loss initiated on 8/17/18. Interventions included: assisting the resident with eating when she/he was fatigued, provide constant encouragement, cueing and observation during meals, and provide a house supplement twice daily. The care plan did not identify the resident's [DIAGNOSES REDACTED]. Resident 44's Nursing Admission assessment dated [DATE] indicated the resident had [MEDICAL CONDITION] but the assessment failed to indicate the location or severity of the [MEDICAL CONDITION]. A Nursing Note dated 7/7/18 indicated Resident 44's physician was notified regarding [MEDICAL CONDITION] in hand of affected arm with humerus fracture. The note did not provide a measurable assessment of the [MEDICAL CONDITION]. A Dietitian assessment dated [DATE] indicated Resident 44 ate 75% of most meals. The assessment identified the resident's [DIAGNOSES REDACTED]. Resident 44's Weight Summary revealed the resident weighed 162 pounds on 7/17/18 and weighed 120.6 pounds on 10/14/18. This was a 41.4 pound or 25.6% body weight loss over 89 days. A Nursing Note dated 7/23/18 indicated Resident 44's [MEDICAL CONDITION] in the lower extremities appears to be slowly resolving. The note did not provide a measurable assessment of the [MEDICAL CONDITION], when the [MEDICAL CONDITION] in the lower extremities was first identified or a resolution to the resident's hand and arm [MEDICAL CONDITION]. A Weight Change Note dated 7/24/18 indicated Resident 44 lost 7.2% in three weeks with no change in meal intake and decreased [MEDICAL CONDITION]. The note did not provide a measurable assessment of the [MEDICAL CONDITION] or location. Resident 44's Weight Summary revealed the resident weighed 146 pounds on 7/30/18. This was a 9.2 pound or 9.9% body weight loss since the resident's weight of 162 pounds on 7/17/18. A Weight Change Note dated 7/31/18 indicated Resident 44's weight fluctuated but not significantly, the resident's 7/23/18 weight of 144 pounds was inaccurate and nutritionally enhanced meals would be discontinued due to the weight error. The note did not explain why the 7/23/18 weight was inaccurate, identify the 7/30/18 weight of 146 pounds or explain how this did not constitute a significant weight fluctuation. A physician's Progress Notes dated 8/7/18 at 11:00 AM indicated Resident 44's [MEDICAL CONDITION] was resolved and part of her/his weight loss was fluid related and the resident's diuretic medication dosage would be reduced. A Weight Change Note dated 8/7/18 at 12:42 PM indicated Resident 44 had a significant weight loss over 30 days related to decreased [MEDICAL CONDITION], diuretic use and fair meal intakes. Weight Change Notes dated 8/14/18, 8/21/18, 8/28/18 and 9/4/18 indicated Resident 44's initial weight loss was related to [MEDICAL CONDITION] and diuretic use on admission to the facility. A physician's orders [REDACTED]. A Dietitian assessment dated [DATE] indicated Resident 44 lost 14.6% body weight over 30 days, the resident ate 50% of most meals and the resident's intake was less than her/his estimated needs as evidenced by 26 to 50 percent meal intakes. The assessment indicated the resident had significant weight loss related to [MEDICAL CONDITION]/fluid loss and decreased meal intakes. A physician's orders [REDACTED]. The order did not indicate how much health shake to administer to the resident. Resident 44's 8/2018 MAR indicated [REDACTED]. Supershake 120 ml BID with medication pass was started on 8/29/18. A review of Resident 44's clinical record did not reveal a physician's orders [REDACTED]. Resident 44's Weight Summary revealed the resident weighed 136.4 pounds on 9/2/18 and weighed 127.8 pounds on 9/10/18. This was an 8.6 pound weight loss in 8 days. A Weight Change Note dated 9/11/18 indicated Resident 44's weight loss of nine pounds in about one week may be attributed to hip aspiration (the removal of fluid around the joint using a needle and syringe). A physician's orders [REDACTED]. Resident 44's 9/2018 MAR indicated [REDACTED]. A review of Resident 44's Progress Notes from 9/4/18 through 9/11/18 revealed no assessments or documentation regarding hip swelling (for reference one gallon of water weighs about 8.3 pounds). A Weight Change Note dated 9/25/18 indicated Resident 44's health shake was increased to three times a day. Resident 44's health shake was ordered by the physician to be increased to three times a day on 8/29/18 and again on 9/11/18 however a review of the resident's clinical record revealed those orders were not implemented. Resident 44's Weight Summary revealed the resident weighed 136.4 pounds on 9/2/18 and weighed 120.6 on 10/14/18. This was an additional 15.8 pound weight loss after the resident's health shakes were ordered increased to TID on 8/29/18. A Weight Change Note dated 10/2/18 indicated Resident 44 lost about six pounds in two days. The resident's intake continued to be fair or poor. New interventions included adding ice cream to the resident's lunch. A Weight Change Note dated 10/9/18 indicated Resident 44 had slight left leg [MEDICAL CONDITION], the health shakes were no longer in orders and was discontinued. A review of Resident 44's 10/2018 MAR indicated [REDACTED]. Resident 44's lunch tray menu slip dated 10/15/18 revealed no ice cream was included with the resident's lunch. A review of Resident 44's Diet Order & Communication slips from 7/3/18 through 10/9/18 revealed no order for ice cream with lunch. On 10/15/18 at 11:32 AM Resident 44 was observed in the dining room and the resident initially started eating lunch independently with no oversight or cueing from staff. At 10:42 AM Staff 15 (LPN) sat next to the resident and at 11:55 AM began feeding the resident. There was no ice cream provided to the resident. On 10/15/18 at 12:02 PM Staff 15 verified Resident 44 did not receive ice cream with lunch and her/his lunch tray ticket did not include ice cream. Resident 44's Weight Summary revealed from 10/1/18 through 10/14/18 the resident lost an additional 2.6 pounds. A review of Resident 4's clinical record revealed no measurable assessment or monitoring of significant [MEDICAL CONDITION] and subsequent fluid loss which would have been attributable to the resident's severe weight loss and no indication the resident's weight loss was planned, expected or unavoidable based on the resident's clinical condition or preferences. On 10/16/18 at 8:55 AM Staff 2 (DNS) verified Resident 44's clinical record did not include measurable assessments of the resident's [MEDICAL CONDITION], the resident's weight loss was significant, the orders to increase health shakes to TID and add ice cream to her/his lunch were not implemented. 2. Based on observation, interview and record review it was determined the facility failed to implement an individualized fluid enhancement program as recommended by the registered dietitian, to complete an assessment of hydration when fluid intake remained suboptimal and to initiate an individualized plan of care for addressing dehydration risk factors for 1 of 3 sampled residents (#17) reviewed for hydration. This resulted in Resident 17 requiring IV fluids for rehydration during hospitalization . Findings include: Resident 17 was admitted to the facility in 4/2018 with [DIAGNOSES REDACTED]. Transfer information received dated 4/9/18 and received by facility prior to admission included a hospital history and physical dated 3/29/18. It indicated the resident was sent to the hospital emergency room (ER) due to concerns she/he may have another UTI or dehydration that was prompting aggressive behaviors. The resident was noted to be dehydrated and to have a UTI, thought to play a role in the behaviors. During the subsequent ER visit the resident was identified as having a slightly elevated creatinine level (a potential symptom of dehydration) above her/his baseline and was administered one liter of IV (intravenous) normal saline. The resident's care plan dated 4/12/18 identified the resident was at risk for UTIs. Interventions included: encouraging fluid intake, labs MD order, monitor for signs and symptoms of dehydration including: sunken eyes, dry mucous membranes, lethargy, mental changes, decreased urine output, dark concentrated urine or tenting of the skin. No problem related to insufficient fluid intake and risk for dehydration was care planned and no individualized interventions for promoting fluid acceptance were found. A Registered Dietitian (RD) assessment dated [DATE] (after initial care plan entry) reflected the resident averaged 400-999 ccs of fluid intake with meals. The resident's baseline fluid need was identified as 1485-1610 ccs daily, and oral intake was described as suboptimal averaging 51-75%. The dietician recommended a fluid enhancement program (FEP) of 240 cc bid. There was no evidence found that an individualized FEP was initiated. A 4/26/18 RNCM Summary, in response to the RD recommendation, reflected the FEP was not implemented. There was no explanation as to why the recommendation was declined. The resident's care manager was unavailable for interview at the time of the survey. According to the resident's 4/2018 and 5/2018 fluid monitoring records, the resident's average fluid intake remained at less than the RD identified baseline fluid need, averaging 1165 ccs daily from 4/19/18 through 4/29/18 and 886 ccs daily from 5/5/18 through 5/12/18. The 5/2018 fluid monitoring record indicated that Resident 17 either refused fluids or had no fluid intake documented during 17 of 46 (37%) meals and/or routine fluid passes. A progress note dated 5/3/18 at 10:30 AM indicated the primary care physician was contacted regarding the resident's meal refusal and hitting and yelling out behaviors. On 5/9/18 a behavior monitoring record was initiated by the facility. Resident 17 was documented as exhibiting physically aggressive, verbally abusive behaviors toward staff, and resisting care during the four-day period prior to 5/12/18. Progress notes reflected the only previously documented behaviors occurred on 4/23/18 and included exit seeking and confusion regarding her/his shared room and believing the roommate's belongings were her/his. A progress note dated 5/12/18 at 6:50 PM indicated the resident's family called the facility and reported Resident 17 had an episode of unresponsiveness while out of the facility and was sent to the hospital ER. Hospital records dated 5/12/18 indicated the resident was admitted through the ER, following a sudden [MEDICAL CONDITION] episode. The initial ER physical assessment described the resident as having dry mucous membranes (a potential symptom of dehydration). As part of a 5/13/18 physician assessment, the resident was diagnosed with [REDACTED]. A [DIAGNOSES REDACTED]. Following readmission to the facility an individualized FEP for 240 ccs to be given TID was initiated on 5/23/18. Observation of the resident on 10/12/18 11:46 AM during the lunch meal, the resident drank independently, had consumed 30% of her/his meal and appeared well hydrated. During an interview on 10/15/18 at 9:52 PM, Staff 2 (DNS) stated she believed a FEP was initiated prior to Resident 17's hospitalization on [DATE]. When asked why the RNCM had written the FEP recommendation were declined and no offered fluid amounts were documented, she was unable to provide additional information. On 10/15/18 at 9:52 AM a copy of the facility's fluid enhancement policy and procedure was requested of Staff 1 (Administrator) and Staff 2 (DNS). On 10/15/18 at 2:56 PM, Staff 2 shared a generic protocol used for all residents which included an offering of fluids and snacks between meals twice daily. The protocol made no reference to the amount of fluids to be offered or individual fluid preferences. She acknowledged that a FEP which tracked specific amounts of fluid offered, in addition to the amount of fluids accepted was not initiated before the residents 5/12/18 hospital stay. No FEP policy was provided. During an interview on 10/16/18 at 11:54 AM, Staff 9 (Food Services Manager) stated all residents were offered snacks and fluids twice daily between meals regardless of need. The facility's generalized fluid enhancement program ensured that 1440 ccs of fluid was offered daily during meal times. FEPs calling for prescribed fluid amounts at specific frequency were physician prescribed and would be documented by nursing staff.

Based on interview and record review, it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled resident (#4) reviewed for change in condition. This resulted in Resident 4 being admitted to the hospital for treatment and observation. Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Progress Note dated 8/26/18 at 11:44 AM revealed Resident 4 was involved in incident this morning which caused the resident increased lethargy, sweating, low blood pressure, low pulse and a change in her/his level of consciousness. The on-call physician was called at 10:00 AM and orders were given to send the resident to the emergency department. 911 was called and the resident was sent to the hospital at 10:30 AM. The resident was responsive to painful stimuli only when the resident left the facility. The note did not indicate what kind of incident the resident was involved in or any details about the incident. A Progress Note dated 8/26/18 at 1:40 PM revealed the resident was in the hospital and still sleepy and an IV started and will continue to flush (her/his) system. The note did not indicate why the resident was sleepy or needed her/his system flushed. Progress Notes dated 8/28/18 revealed the resident returned to the facility from the hospital and was placed on alert. The notes did not indicate why the resident was sent to the hospital or what staff should be monitoring for as a result of being on alert. Progress Notes dated 8/30/18 revealed the resident was readmitted to the facility from the hospital related to a medication error. A review of Resident 4's clinical record revealed no documentation to indicate how the medication error occurred or what medications the resident was administered in error. On 10/10/18 at 3:00 PM, Staff 2 (DNS) provided a Medication Error Report dated 8/26/18 which revealed the following: - Staff 14 (former facility CMA) prepared medications for Resident 22 and asked Staff 15 (LPN) can you give these to (Staff 14 used Resident 22's first name). Staff 15 administered Resident 22's medications to Resident 4 (both Resident 4 and Resident 22 had the same first name). - The medication error occurred at 8:00 AM on 8/26/18 and was reported to Staff 3 (LPN). - Resident 4 was administered Resident 22's medications including: [MEDICATION NAME] (treats high blood pressure), [MEDICATION NAME] (antidepressant), vitamin D, [MEDICATION NAME] (treats high blood pressure), Tums (antacid), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (antipsychotic) and Tylenol. - Resident 4 was also administered her/his own medications including: vitamin B12, iron supplement, [MEDICATION NAME] (treats heartburn), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (treats [MEDICAL CONDITION] and nerve pain), [MEDICATION NAME] (treats dementia), [MEDICATION NAME] (treats asthma and congestive obstructive [MEDICAL CONDITION] disease) and Tylenol. - At 10:00 AM on 8/26/18 Resident 4 was sweaty, lethargic and responsive only to painful stimuli. The resident's blood pressure was 98/58 and heart rate was 50. - The physician was notified at 10:00 AM on 8/6/18. A review of Resident 4's clinical record revealed no documented assessment of the resident, including vital signs, related to the medication error or notification to the physician prior to 10:00 AM on 8/26/18 when the resident was unresponsive except to painful stimuli. A witness statement by Staff 14 dated 8/26/18, revealed Staff 14 prepared Resident 22's medications and took them into the dining room sometime after 8:00 AM (on 8/26/18). The resident was not in the dining room and Staff 14 was told (by an unnamed staff) the resident was still in bed because she (the unnamed staff) was not able to get the resident up by herself. Staff 14 spoke to Staff 3 (LPN) about the aides getting their residents up. Staff 15 was standing nearby and Staff 14 thought he heard her conversation with Staff 3. Staff 14 started to go down the hall with Resident 22's medications at the same time as Staff 15. Staff 14 asked Staff 15 where he was going and he replied to get (he used the first name for Resident 4 and Resident 22) up. Staff 14 asked him if he would give the resident the medications since he was going there. Staff 15 agreed. Staff 14 continued to administer medications to other residents. A few minutes later Staff 15 told Staff 14 he may have administered the medications to the wrong resident with the same first name who also was left in bed. Staff 14 reported the error to Staff 3. Later Staff 14 went to Resident 4's room to check on the resident and the aide was having difficulty waking the resident up. This was closer to 9:00 (AM on 8/26/18. Staff 14 went and told Staff 3 and checked Resident 4's vital signs. Staff 3 took over the assessment. A witness statement by Staff 15 dated 8/27/18, revealed Staff 15 was working on 8/26/18 as a CNA when he went to the dining room to get a tray for a resident. While in the dining room he was informed Resident 4 was in bed and he said he would get the resident up. He started down the hall with a resident's tray when he was asked by Staff 14 to give medications to (he used the first name for Resident 4 and Resident 22). He administered the medications to Resident 4. After leaving Resident 4's room an aide asked him to help with another resident with the same first name as Resident 4. Staff 15 then realized he administered the medications to the wrong resident and notified Staff 14 who notified Staff 3. Staff 15 indicated he assumed the medications were for Resident 4. An Investigation of Incident by Staff 2 (DNS) dated 8/28/18, indicated on 8/26/18 Staff 14 prepared medications for Resident 22 and asked Staff 15, an LPN working as a CNA on 8/26/18, who was on his way to Resident 4's room to administer the medications. Staff 14 thought Staff 15 was on his way to Resident 22's room which resulted in the medication administration error. Staff 3 indicated assessment and monitoring of Resident 4 started immediately which resulted in sending the resident to the hospital due to low blood pressure for further monitoring. Staff 14 and Staff 15 were at fault for not following protocol to pass medications and scope of practice was ignored. Staff 14 should not have given the medications to Staff 15 nor asked him to administer the medications. Staff 15 should not have accepted the medications from Staff 14 nor administered medications to any resident he had not prepared himself. On 10/10/18 at 9:46 AM and 10/11/18 at 12:57 PM, Staff 2 (DNS) confirmed Staff 14 gave Resident 22's medications to Staff 15 who administered them to Resident 4 in error. She verified Staff 15 was working as a CNA at the time of the error. Staff 2 acknowledged staff should have notified the physician immediately. On 10/10/18 at 2:31 PM and 10/11/18 at 1:14 PM, Staff 3 (LPN) stated on 8/26/18 she was notified Resident 4 was administered the wrong medications by Staff 15 and they were monitoring the resident. She stated the resident was erroneously administered medications including [MEDICATION NAME] and [MEDICATION NAME]. She stated she assessed the resident right away and the resident was at her/his baseline with normal vital signs. Staff 3 stated Resident 4's blood pressure was low, respirations were fine, the resident was sweaty, pale and would only arouse to a sternal rub (the application of painful stimuli by rubbing of knuckles to the center of the chest). Staff 3 verified no vitals were charted in the resident's clinical record for the incident. Staff 3 verified she called the physician at 10:00 AM on 8/26/18 and did not know why she did not call the physician right away. Staff 4 stated she assumed it was all of Resident 22's morning medications which were administered to Resident 4. On 10/11/18 at 12:29 PM, Staff 15 stated he overheard a conversation with Staff 14 and thought it was about Resident 4 and he was going to go assist the resident. Staff 14 asked him to administer medications to (she used the first name for Resident 4 and Resident 22) as he was walking down the hall. He administered the medications to Resident 4. When he came out of Resident 4's room an aide asked him for assistance with a resident who had the same first name as Resident 4. Staff 15 stated that is when he realized he administered the medications to the wrong resident and he notified Staff 14 then continued to assist other residents with breakfast. He did not know if the nurse assessed the resident. Staff 15 acknowledged he was working as a CNA on 8/26/18 and should not have administered medications. Staff 15 did not know what medications he administered to Resident 4 or how many medications there were. He said he administered the medications sometime between 7:30 AM and 8:30 AM. A Hospital Course dated 8/26/18 indicated Resident 4 was diagnosed with [REDACTED]. A hospital History and Physical dated 8/26/18 revealed the resident was in the hospital for a medication error. The treatment plan included IV (intravenous) fluids for the [MEDICAL CONDITION] which should resolve as the medications wore off. The resident was noted to have received [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] and the resident typically did not receive any of these medications. The resident was asleep likely due to the [MEDICATION NAME] and mildly bradycardic (low heart rate) and hypotensive likely due to the [MEDICATION NAME] and [MEDICATION NAME].

Based on interview and record review it was determined the facility failed to ensure Staff 3 (LPN), Staff 12 (LPN), Staff 14 (former facility CMA) and Staff 15 (LPN) adhered to standards of practice regarding medication administration and change of condition for 2 of 7 sampled residents (#s 4 and 39) reviewed for change in condition and accidents. This resulted in Resident 4 experiencing adverse medication consequences and being admitted to the hospital for treatment and observation, and Resident 39 experiencing a delay in obtaining an x-ray and being sent to the hospital for treatment of [REDACTED]. 1. Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 10/10/18 at 3:00 PM Staff 2 (DNS) provided a Medication Error Report dated 8/26/18 which revealed the following: - Staff 14 (former facility CMA) prepared medications for Resident 22 and asked Staff 15 (LPN) can you give these to (Staff 14 used Resident 22's first name). Staff 15 administered Resident 22's medications to Resident 4 (both Resident 4 and Resident 22 had the same first name). - The medication error occurred at 8:00 AM on 8/26/18 and was reported to Staff 3 (LPN). - Resident 4 was administered Resident 22's medications including: [MEDICATION NAME] (treats high blood pressure), [MEDICATION NAME] (antidepressant), vitamin D, [MEDICATION NAME] (treats high blood pressure), Tums (antacid), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (antipsychotic) and Tylenol. - Resident 4 was also administered her/his own medications including: vitamin B12, iron supplement, [MEDICATION NAME] (treats heartburn), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (treats [MEDICAL CONDITION] and nerve pain), [MEDICATION NAME] (treats dementia), [MEDICATION NAME] (treats asthma and congestive obstructive [MEDICAL CONDITION] disease) and Tylenol. - At 10:00 AM on 8/26/18 Resident 4 was sweaty, lethargic and responsive only to painful stimuli. The resident's blood pressure was 98/58 and heart rate was 50. - The physician was notified at 10:00 AM on 8/6/18. A review of Resident 4's clinical record revealed no documented assessment of the resident, including vital signs, related to the medication error or notification to the physician prior to 10:00 AM on 8/26/18 when the resident was unresponsive except to painful stimuli. A witness statement by Staff 14 dated 8/26/18 revealed Staff 14 prepared Resident 22's medications and took them into the dining room sometime after 8:00 AM (on 8/26/18). The resident was not in the dining room and Staff 14 was told (by an unnamed staff) the resident was still in bed because she (the unnamed staff) was not able to get the resident up by herself. Staff 14 spoke to Staff 3 about the aides getting their residents up. Staff 15 was standing nearby and Staff 14 thought he heard her conversation with Staff 3. Staff 14 started to go down the hall with Resident 22's medications at the same time as Staff 15. Staff 14 asked Staff 15 where he was going and he replied to get (he used the first name for Resident 4 and Resident 22) up. Staff 14 asked him if he would give the resident the medications since he was going there. Staff 15 agreed. Staff 14 continued to administer medications to other residents. A few minutes later Staff 15 told her he may have administered the medications to the wrong resident with the same first name who also was left in bed. Staff 14 reported the error to Staff 3. Later Staff 14 went to Resident 4's room to check on her/him and the aide was having difficulty waking the resident up. This was closer to 9:00 (AM on 8/26/18. Staff 14 went and told Staff 3 and checked Resident 4's vital signs. Staff 3 took over the assessment. A witness statement by Staff 15 dated 8/27/18 revealed Staff 15 was working on 8/26/18 as a CNA when he went to the dining room to get a tray for a resident. While in the dining room he was informed Resident 4 was in bed and he said he would get the resident up. He started down the hall with a resident's tray and he was asked by Staff 14 to give medications to (he used the first name for Resident 4 and Resident 22). He administered the medications to Resident 4. After leaving Resident 4's room an aide asked him to help with another resident with the same first name as Resident 4. Staff 15 then realized he administered the medications to the wrong resident and notified Staff 14 who notified Staff 3. Staff 15 indicated he assumed the medications were for Resident 4. An Investigation of Incident by Staff 2 (DNS) dated 8/28/18 indicated on 8/26/18 Staff 14 prepared medications for Resident 22 and asked Staff 15, an LPN working as a CNA on 8/26/18, who was on his way to Resident 4's room to administer the medications. Staff 14 thought Staff 15 was on his way to Resident 22's room which resulted in the medication administration error. Staff 3 indicated assessment and monitoring of Resident 4 started immediately which resulted in sending the resident to the hospital due to low blood pressure for further monitoring. Staff 14 and Staff 15 were at fault for not following protocol to pass medications and scope of practice was ignored. Staff 14 should not have given the medications to Staff 15 nor asked him to administer the medications. Staff 15 should not have accepted the medications from Staff 14 nor administered medications he had not prepared himself to any resident . On 10/10/18 at 9:46 AM and 10/11/18 at 12:57 PM Staff 2 (DNS) confirmed Staff 14 gave Resident 22's medications to Staff 15 who administered them to Resident 4 in error. She verified Staff 15 was working as a CNA at the time of the error. Staff 2 acknowledged the physician should have been notified immediately. On 10/10/18 at 2:31 PM and 10/11/18 at 1:14 PM Staff 3 stated on 8/26/18 she was notified Resident 4 was administered the wrong medications by Staff 15 and they were monitoring the resident. She stated the resident was erroneously administered medications including [MEDICATION NAME] and [MEDICATION NAME]. She stated she assessed the resident right away and the resident was at her/his baseline with normal vital signs. Staff 3 stated Resident 4's blood pressure was low, respirations were fine, the resident was sweaty, pale and would only arouse to a sternal rub (the application of painful stimuli by rubbing of knuckles to the center of the chest). Staff 3 verified no vitals were charted in the resident's clinical record for the incident. Staff 3 verified she called the physician at 10:00 AM on 8/26/18 and did not know why she did not call the physician right away. Staff 4 stated she assumed it was all of Resident 22's morning medications which were administered to Resident 4. On 10/11/18 at 12:29 PM Staff 15 stated he overheard a conversation with Staff 14 and thought it was about Resident 4 and he was going to go assist the resident. Staff 14 asked him to administer medications to (she used the first name for Resident 4 and Resident 22) as he walked down the hall. He administered the medications to Resident 4. When he came out of Resident 4's room an aide asked him for assistance with a resident who had the same first name as Resident 4. Staff 15 stated that was when he realized he administered the medications to the wrong resident and he notified Staff 14 then continued to assist other residents with breakfast. He did not know if the nurse assessed the resident. Staff 15 acknowledged he worked as a CNA on 8/26/18 and should not have administered medications. Staff 15 did not know what medications he administered to Resident 4 or how many medications there were. He said he administered the medications sometime between 7:30 AM and 8:30 AM. A Hospital Course dated 8/26/18 indicated Resident 4 was diagnosed with [REDACTED]. A hospital History and Physical dated 8/26/18 revealed the resident was in the hospital for a medication error. The treatment plan included IV (intravenous) fluids for the [MEDICAL CONDITION] which should resolve as the medications wore off. The resident was noted to have received [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] and the resident typically did not receive any of these medications. The resident was asleep likely due to the [MEDICATION NAME] and mildly bradycardic (low heart rate) and hypotensive likely due to the [MEDICATION NAME] and [MEDICATION NAME]. Refer to F760 2. Resident 39 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Progress Note dated 4/3/18 by Staff 12 (LPN) revealed Resident 39 was found on the floor next to her/his bed. The resident was yelling to get help. The resident was assisted by staff to get up off the floor and walk to the bathroom. When asked what happened, the resident stated I fell and broke my arm. The resident was holding her/his left hand and refused to allow a range of motion (ROM) assessment. No other injuries were found and the resident was administered Tylenol for comfort. The physician was notified and the resident was placed on alert. Progress Notes dated 4/4/18 revealed the resident was administered Tylenol for left hand pain. The resident was assisted with a shower and complained of left arm pain. The resident told staff not to touch her/him when they attempted to check her/his wrist. The resident continued to complain of left shoulder/arm/wrist pain and refused to allow staff to touch her/his arm. The resident stated I have a broken arm. The physician was called and an order was received for an immediate x-ray. The physician was notified the resident had a broken arm and was sent to the hospital. On 10/15/18 at 1:49 PM Staff 12 stated after the resident fell on [DATE] she/he did not appear to be in severe pain and was just concerned about getting up off the floor. The resident refused to allow him to assess her/his ROM. He did not remember if he checked the resident's vital signs, if the resident stated she/he had a broken arm or complained of pain. Staff 12 stated he notified the physician who responded for staff to monitor the resident. He stated he didn't think the resident was injured because she/he was able to use the walker and ambulate to the bathroom. A fax to the physician dated 4/3/18 revealed Resident 39 was Found on the floor. Initial assessment no injury. The notification did not indicate the resident's statement about having a broken arm, refusal to allow ROM assessment or complaint of pain. The notification did not include any instructions or new orders from the physician. A Radiology Interpretation dated 4/4/18 revealed Resident 39 had a new displaced (the ends of the broken bone are separated from each other) [MEDICAL CONDITION] upper arm. A hospital After Visit Summary dated 4/4/18 revealed the resident was provided [MEDICATION NAME] (pain medication) and a shoulder immobilizer. On 10/15/18 at 12:17 PM Staff 2 (DNS) acknowledged that based on the resident's statement of having a broken arm, pain and refusal to allow a ROM assessment Staff 12 should have called for an x-ray right away. Refer to F684

Based on interview and record review it was determined the facility failed to immediately notify the physician of a significant medication error for 1 of 1 sampled resident (#4) reviewed for change in condition. This resulted in Resident 4 experiencing a significant, unaddressed change in condition which resulted in hospitalization . Findings include: Resident 4 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. A Progress Note dated 8/26/18 at 11:44 AM revealed Resident 4 was involved in incident this morning which caused the resident increased lethargy, sweating, low blood pressure, low pulse and a change in her/his level of consciousness. The on-call physician was called at 10:00 AM and orders were given to send the resident to the emergency department. 911 was called and the resident was sent to the hospital at 10:30 AM. The resident was responsive to painful stimuli only when the resident left the facility. The note did not indicate what kind of incident the resident was involved in or any details about the incident. On 10/10/18 at 3:00 PM Staff 2 (DNS) provided a Medication Error Report dated 8/26/18 which revealed the following: - Staff 14 (former facility CMA) prepared medications for Resident 22 and asked Staff 15 (LPN) can you give these to (Staff 14 used Resident 22's first name). Staff 15 administered Resident 22's medications to Resident 4 (both Resident 4 and Resident 22 had the same first name). - The medication error occurred at 8:00 AM on 8/26/18 and was reported to Staff 3 (LPN). - Resident 4 was administered Resident 22's medications including: [MEDICATION NAME] (treats high blood pressure), [MEDICATION NAME] (antidepressant), vitamin D, [MEDICATION NAME] (treats high blood pressure), Tums (antacid), [MEDICATION NAME] (anticonvulsant), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (antipsychotic) and Tylenol. - Resident 4 was also administered her/his own medications including: vitamin B12, iron supplement, [MEDICATION NAME] (treats heartburn), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (treats [MEDICAL CONDITION] and nerve pain), [MEDICATION NAME] (treats dementia), [MEDICATION NAME] (treats asthma and congestive obstructive [MEDICAL CONDITION] disease) and Tylenol. - At 10:00 AM on 8/26/18 Resident 4 was sweaty, lethargic and responsive only to painful stimuli. The resident's blood pressure was 98/58 and heart rate was 50. - The physician was notified at 10:00 AM on 8/6/18. A review of Resident 4's clinical record revealed no documented assessment of the resident, including vital signs, related to the medication error or notification to the physician prior to 10:00 AM on 8/26/18 when the resident was unresponsive except to painful stimuli. On 10/10/18 at 9:46 AM and 10/11/18 at 12:57 PM Staff 2 (DNS) acknowledge the facility should have notified the physician immediately. On 10/10/18 at 2:31 PM and 10/11/18 at 1:14 PM Staff 3 (LPN) stated on 8/26/18 she was notified Resident 4 was administered the wrong medications by Staff 15 (LPN) and they were monitoring the resident. Staff 3 stated the resident was erroneously administered medications including [MEDICATION NAME] and [MEDICATION NAME]. She stated she assessed the resident right away and the resident was at her/his baseline with normal vital signs. Staff 3 stated Resident 4's blood pressure was low, respirations were fine, the resident was sweaty, pale and would only arouse to a sternal rub (the application of painful stimuli by rubbing of knuckles to the center of the chest). Staff 3 verified no vitals were charted in the resident's clinical record for the incident. Staff 3 verified she called the physician at 10:00 AM on 8/26/18 and did not know why she did not call the physician right away. Staff 4 stated she assumed it was all of Resident 22's morning medications which were administered to Resident 4. A hospital History and Physical dated 8/26/18 revealed the resident was in the hospital for a medication error. The treatment plan included IV (intravenous) fluids for the [MEDICAL CONDITION] which should resolve as the medications wore off. The resident was noted to have received [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] and the resident typically did not receive any of these medications. The resident was asleep likely due to the [MEDICATION NAME] and mildly bradycardic (low heart rate) and hypotensive likely due to the [MEDICATION NAME] and [MEDICATION NAME]. Refer to F760

Based on observation, interview and record review it was determined the facility failed to assess [MEDICAL CONDITION], notify the physician of a change in condition in a timely manner, arrange appropriate transportation to the hospital and follow physician orders [REDACTED].#s 1, 2 and 5) reviewed for changes in condition. Resident 2 was inappropriately transported to the hospital, was hospitalized and placed on Hospice. Resident 5 was at risk of complications from [MEDICAL CONDITION] and Resident 1 was at risk of complications from a fracture due to not using a brace as ordered. Findings include: The facility's 10/2008 Change Of Condition/Alert Charting Procedural Guidelines noted the following: "A change of condition is any change good or bad in a resident's physical, mental or psychosocial status. Alert charting monitors this change...You observe or a CNA reports a change of condition. Examples include and are not limited to:...skin problem of any type...Depending on the type of condition change, perform an evaluation of the resident condition....Determine what is needed. Can you provide it....No....Notify physician for orders...Yes...Provide TX (treatment)/Care & notify physician. Document in the resident record. This begins alert charting. All initial charting will be performed in nurses notes. Charting should include what was reported and/or observed and what you did....Skin problems have documentation at least weekly on the skin sheet. Alert charting for conditions other than skin will occur on each shift...." 1. Resident 2 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The 6/25/14 11:54 am Progress Note disclosed the physician evaluated Resident 2 due to increased [MEDICAL CONDITION] in both of Resident 2's legs. New orders were written for increasing [MEDICATION NAME] (a diuretic medication) and obtaining a venous Doppler (a test to estimate blood flow) of both legs and an EKG. The 6/25/14 physician progress notes [REDACTED]." 6/25/14, 6/27/14 and 6/28/14 Progress Notes documented the status of the [MEDICAL CONDITION]. The 6/28/14 4:08 am Progress Note disclosed Resident 2 continued to have 2+ [MEDICAL CONDITION] to the legs and feet. The 7/9/14 10:43 am Progress Note indicated the physician evaluated Resident 2's [MEDICAL CONDITION] to the bilateral lower extremities. New orders included increasing [MEDICATION NAME], adding HCTZ (a diuretic medication) for three days and wrapping the bilateral lower extremities with ace wraps and kerlix. The 7/9/14 physician progress notes [REDACTED]. The 7/9/14 7:00 pm Progress Note described Resident 2's lower legs as "still swollen with scattered open, weeping areas to both legs." The 7/15/14 11:46 am Progress Note indicated Staff 16, RN observed the kerlix and ace wraps on lower extremities were soiled, possibly with urine since it smelled bad. No drainage was noted on the lower extremities. The 7/21/14 1:21 pm Progress Note disclosed drainage was noted on the ace wraps and kerlix. The right heel and right lower extremities were cleansed with wound cleanser and treatment cream was applied. The 7/21/14 4:36 pm eMar Medication Administration Note revealed "Resident still grimacing and moaning in pain. Routine [MEDICATION NAME] (a narcotic pain medication) given. PRN Administration was: Ineffective." The 7/21/14 11:31 pm eMar Medication Administration Note indicated the resident was treated for [REDACTED]. At 1:59 am pain medication was noted as ineffective. The 7/22/14 10:19 am Progress Note disclosed staff contacted the nurse practitioner for PRN pain medication orders "since resident is really grimacing, crying...." an order for [REDACTED]. The 7/22/14 10:56 am Progress Note indicated the resident's right leg and foot was "very red and draining foul drainage. Cleanse with wound cleanser, but resident tries to jump out form (sic) the recliner. PRN Tylenol given just before doing this tx. PRN not helpful at this time. Will give another PRN [MEDICATION NAME] (a narcotic pain medication) at this point. Resident seems in severe pain..." as the resident could barely tolerate the leg treatment. The resident had a temperature of 99.2 and seemed seemed very anxious and distressed. The 7/22/14 12:06 pm Progress Note revealed Staff 3, RNCM spoke with the nurse practitioner. There was concern the resident had severe [MEDICAL CONDITION] due to running a low grade fever. The resident vomited at lunch and was in "excruciating pain." Orders were given to send the resident to the hospital. Staff 16, RN requested non-urgent medical transportation to the hospital for the bilateral lower extremities, especially the right leg which was draining "very badly" with foul odor. The 7/22/14 Weights and Vitals Summary noted Resident 2 had a blood pressure of 92/52 at 12:22 pm. The 7/22/14 1:22 pm Progress Note documented the resident left at 1:20 pm with medical transportation. The 7/22/14 3:39 pm Progress Note revealed a hospital physician reported to the facility the resident was non responsive by the time the resident arrived at the hospital. The 7/22/14 Emergency Department Note indicated Resident 2 was sent to the hospital via taxi. Per the facility the resident was alert and mentating at her/his baseline when transported. The resident had [DIAGNOSES REDACTED] (skin redness), induration, warmth and weeping from several open [MEDICAL CONDITION] on the right leg. The resident was hypotensive and her/his oxygen saturations were at 88% on oxygen. "Apparently pt (patient) has had progressive swelling, redness and skin breakdown over bilateral lower legs, being treated with gauze wraps only. Had foul smelling discharge from the right leg today. Pt. appears likely to be in septic shock with [MEDICAL CONDITION]." [MEDICAL CONDITION] protocol was initiated and IV antibiotics were ordered. The resident was diagnosed with [REDACTED]. The resident was admitted to the hospital then placed on Hospice. In interview on 8/26/14 at 9:02 am Witness 3, Complainant reported on 7/22/14 she was walking through the ER waiting room and observed Resident 2 sitting in a wheelchair. The resident was transported to the hospital in a taxi, which was why Resident 2 was sitting in the waiting room rather than immediately brought into the emergency room itself. The resident was brought back to the emergency room at 2:39 pm when oxygen was placed, which was five minutes or less from when Witness 3 initially observed the resident in the ER. Witness 3 described Resident 2 as "in bad shape" and met [MEDICAL CONDITION] protocol. Witness 3 stated she questioned the facility's assessment that the resident was "taxi appropriate" based on the resident's condition at the time. In interview on 8/13/14 at 11:47 am, Staff 15, LPN stated the resident always had [MEDICAL CONDITION], but drainage started a couple of days before the resident was sent out to the hospital. Initially there was a little bit of drainage, however, there was a lot the day the resident was hospitalized . Staff 15 stated "it has never been our protocol to document or track the [MEDICAL CONDITION]." In interview on 8/15/14 at 10:41 am, Staff 7, LPN stated Resident 2's legs were always swollen and the resident was treated with a diuretic due to gaining "water weight." Staff 7 stated he did not document the status of Resident 2's [MEDICAL CONDITION]. In interviews on 8/13/14 at 10:15 am, 8/14/14 at 9:06 am and 8/15/14 at 11:10 am Staff 16, RN stated she never measured [MEDICAL CONDITION] other than noting if it was 1+ or 2+ [MEDICAL CONDITION]. Staff 16 stated she did not see that type of documentation in the facility. "It would be nice if there was a measurable report for accuracy." Staff 16 stated she did not recall if there were any open areas on the resident's leg or weeping on 7/15/14, however after that date there was some weeping. On 7/20/14, Staff 5, RN reported to her at the end of shift there was an open area on the right heel. Staff 16 did not know if there was drainage at that time. On 7/21/14 she informed Staff 3, RNCM regarding the drainage on the resident's leg and Staff 3 asked her to complete an incident report on the open area. Staff 16 informed Staff 3 it was Staff 5, RN who observed the open area and Staff 3 stated she would follow up with Staff 5. Staff 16 stated she did not call the physician and was not sure if the physician was notified of the changes on 7/21/14 as notifying the physician was the responsibility of the person who completed the incident report. On 7/22/14 at 7:00 am, Staff 16 noted changes from the previous day. There was more drainage, the resident complained of a lot of pain which was new for the resident and the lower extremities looked "very bad." Staff 16 reported the changes to Staff 2, DNS and Staff 3, RNCM. The nurse practitioner was contacted and the resident was sent to the hospital. Staff 16 called the medical transport for non-emergent transport and was told there was a wait of two to three hours. Staff 16 stated the resident needed to be seen as soon as possible as she/he was complaining of pain and the drainage was bad, so the transport company arranged for a cab. Staff 16 stated she discussed the resident being sent by cab with Staff 3, RNCM and other staff, "everybody said okay." The resident was alert, talking, had an oxygen saturation of 91% before leaving the facility. In interview on 8/15/14 at 12:07 pm, Staff 5, RN stated any documentation on the status of Resident 2's [MEDICAL CONDITION] was in the Progress Notes. Staff 5 stated on 7/20/14 she did not recall any open areas on the resident's lower extremities, however, the legs were really wet and the heels were somewhat mascerated, which was reported to Staff 3, RNCM. Staff 5 stated she did not think the physician needed to be notified based on the resident's vital signs and the resident was alert and oriented. In interviews on 8/14/14 at 2:18 pm and 8/15/14 at 9:41 am Staff 3, RNCM stated nursing staff documented the status of the [MEDICAL CONDITION] if it worsened. On 7/21/14 the [MEDICAL CONDITION] was definitely weeping, which was new for the resident. Both legs were reddened and there was the start of an open area on the right heel. Staff 3 initially stated she recalled telling Staff 16 to notify the physician if the area worsened, then later stated she had advised Staff 16 to call the physician with the status of the resident's legs and drainage for advisement. On 7/22/14 the right heel area was considerably worse and the nurse practitioner was contacted for treatment orders. When Resident 2 was sent to the hospital on [DATE] she/he did not meet the medical transport company's parameters for being sent to the hospital via 911 as the resident was responsive and talking. Staff 3 stated Staff 16, RN did not tell her the resident was going out by cab and had she known the medical transport was a two to three hour wait, based on her nursing judgement she would have called 911. Staff 2, DNS was interviewed on 8/12/14 at 12:30 pm and again on 8/14/14 at 3:18 pm and 8/15/14 at 11:36 am with Staff 1, Administrator. Staff 2 stated she expected staff to document the resident was either negative or positive for [MEDICAL CONDITION] on the TAR and measurements of the [MEDICAL CONDITION] should have been documented on a skin sheet. Staff 2 acknowledged the lack of documentation on the status of the resident's [MEDICAL CONDITION]. Regarding the resident's changes in condition on 7/20/14 and 7/21/14, Staff 2 stated if there was a new condition staff needed to notify the physician for orders. Staff 1 & 2 stated they were not aware the resident was sent to the hospital by cab. Staff 2 acknowledged the transportation by cab was not appropriate based on the resident's condition. There was no documentation in the clinical record of when Resident 2's [MEDICAL CONDITION] began, no documented alert charting related to [MEDICAL CONDITION] and no consistent assessment of the [MEDICAL CONDITION], including measurements, drainage and skin status. There was no documented evidence the physician was notified in a timely manner of the changes including the open areas on the leg and continued drainage. The resident was transported to the hospital via taxi rather than with medical personnel when she/he experienced a change in condition requiring hospital evaluation and treatment. 2. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/9/14 11:03 am Progress Note indicated the physician visited the resident due to increasing [MEDICAL CONDITION] to bilateral lower extremities. The physician ordered [MEDICATION NAME] for one month and TED hose as needed. The 7/9/14 physician progress notes [REDACTED]. Progress Notes from 7/10/14 to 7/12/14 documented the [MEDICAL CONDITION] at either 2+ or 3+. There was no further documented assessment/status of the [MEDICAL CONDITION] until 8/8/14. The 8/8/14 3:48 am and 8/9/14 3:50 am Progress Notes documented Resident 5 had 3+ [MEDICAL CONDITION]. However, the 8/9/14 11:51 am Progress Note indicated "[MEDICAL CONDITION] is slightly noted in lower extremities." There was no further documentation regarding the status of Resident 5's [MEDICAL CONDITION] until 8/12/14 when the resident was noted to have 2+ [MEDICAL CONDITION]. In interview on 8/12/14 at 12:30 pm Staff 2, DNS stated she expected staff to document the resident was either negative or positive for [MEDICAL CONDITION] on the TAR and measurements of the [MEDICAL CONDITION] should have been documented on a skin sheet. In interview on 8/13/14 at 11:47 am, Staff 15, LPN stated "it has never been our protocol to document or track the [MEDICAL CONDITION]." On 8/14/14 at 8:50 am, Resident 5 was observed sitting in a recliner chair. The resident was cognitively impaired and her/his lower extremities were [MEDICAL CONDITION]. In interview on 8/14/14 at 9:06 am Staff 16, RN stated the resident currently had 2+ [MEDICAL CONDITION], which was an increase from the previous week. Staff 16 stated she did not measure residents' [MEDICAL CONDITION] in the facility. "It would be nice if there was a measurable report for accuracy." In interview on 8/14/14 at 12:18 pm Staff 3, RNCM stated Resident 5's [MEDICAL CONDITION] exhibited in July and continued to occur. The lack of documentation and the discrepancy in documentation on 8/9/14 was discussed with no further information provided. In interview on 8/15/14 at 12:07 pm, Staff 5, RN stated any documentation regarding the status of Resident 5's [MEDICAL CONDITION] was in Progress Notes. 3. Resident 1 was admitted to the facility in 2013 with [DIAGNOSES REDACTED]. A 4/20/14 Progress Note disclosed Resident 1 was sent to the hospital for a right femur fracture. The 4/24/14 Hospital Discharge Orders noted "Brace on right leg at all times." A 4/24/14 Progress Note revealed Resident 1 was readmitted to the facility. A 4/25/14 Progress Note disclosed Staff 18, LPN contacted the hospital regarding the resident's brace. Staff did not know of any brace and a message was left for the resident's nurse while she/he was in the hospital. There was no further documentation regarding the brace in the clinical record, including notifying the physician there was no brace available, until 5/2/14 when a brace was ordered from a medical supply company, eight days after the resident's re-admission. The 5/8/14 Orthopedic Surgeon Progress Note documented the resident was not using the knee immobilizer brace "despite strict instructions to never be out of the immobilizer." A family member reported she had never seen the resident use the immobilizer since discharge from the hospital. The physician placed a knee immobilizer on the resident and gave an order to the facility noting "Knee immobilizer to be on at all times." On 8/11/14 at 8:50 am Resident 1 was observed to be cognitively impaired and was confused regarding the details of the fracture. In interview on 8/12/14 at 11:41 am, Staff 18, LPN stated she called the hospital several times about the status of the brace but nothing was ever followed through at the hospital. Staff 18 stated she did not inform the physician there was no brace available for use. The resident returned from a visit with the orthopedic surgeon with a brace in place. The lack of follow up for the brace with discussed with Staff 3, RNCM on 8/14/14 at 2:18 pm and Staff 1, Administrator and Staff 2, DNS on 8/14/14 at 2:18 pm. Staff 1 stated a brace had been ordered for the resident and no further information was provided.