Every finding on record at Royal Oaks Nursing and Rehab Center

Based on observation, and interview, the facility failed to provide a homelike environment for all residents who ate their meals in the west wing dining area, by serving the resident's meals on serving trays at the table in an institutional manner.Findings:On 2/22/26 at 12:56 PM, during meal observation on the west wing, 5 residents were observed seated at the tables in the dining area. Each resident was noted to have a serving tray on the table in front of them which contained the lunch meal. The plates, cups, bowls and eating utensils remained on the tray and were not removed from the tray at the table.On 2/23/26 at 1:00 PM, during meal observation on the west wing, 7 residents were observed seated in the dining areas. Staff were observed as they served meals to residents on serving trays. Staff placed the trays on the table in front of each resident but did not remove items from the tray. A family member visiting one of the residents in the room was observed as she removed the items from the serving tray in front of the resident and placed them on the table in front of the resident. Staff continued with meal service and did not remove items from any of the serving trays. On 2/24/26 at 12:49 PM, during meal observation on the west wing, 4 residents were seated in the dining area. Three different staff members were observed as they served the lunch meal on serving trays. The trays were placed on the table in front of each resident but items were not removed from the tray. On 2/24/26 at 1:00 PM, the Administrator was rounding on the west wing and observed the residents and staff in the dining area. He agreed the items on the trays should have been removed and placed on the table in front of the residents. He stated they talked about it a couple of weeks ago but it had obviously not been followed. The Administrator explained it was his expectation that staff provide a home-like environment for residents eating in each dining area. The facility was unable to provide a policy regarding homelike environment in facility dining areas.

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 5 residents reviewed for choices out of a total sample of 34 residents, (#31, #55, #75).Findings 1Resident #31 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia, congestive heart failure and chronic kidney disease.Review of the medical record showed the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 1/16/26 revealed resident # 31 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact. The MDS also revealed that the resident's vision was adequate and she wore corrective lenses.Physician's orders included Refresh Tears Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium (Ophthalmic)) and nurses were directed to instill 2 drops in both eyes two times a day for dry eyes.On 2/22/26 at 12:19 PM, resident #31 was observed in bed, pleasant, alert and oriented. There were three boxes of artificial tears on her bedside table, and she said she applied it by herself twice a day.On 2/22/26 at 12:21 PM, the assigned nurse LPN A was made aware of artificial tears eyedrops found at resident's bedside and she immediately removed the bottles and placed them on the medication cart to review. She acknowledged that there were no orders for self-administration of the eyedrops nor was the self-administration assessment done on resident #31. LPN A said she did not notice the eyedrops on the bedside table and that she worked weekends and was not aware of the resident self-administering the eyedrops.Findings 2Resident #55 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, unspecified asthma, primary open angle glaucoma, left eye severe stage, primary open angle glaucoma right eye moderate stage, dry eye syndrome of bilateral lacrimal glands.Review of the medical record showed the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 12/3/25 revealed resident #55 had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated she was cognitively intact. The MDS also revealed that the resident's vision was impaired and she wore corrective lenses.Resident #55's plan of care revealed that she had impaired vision function related to glaucoma, blind in left eye with appropriate interventions to maintain optimal quality of life within limitation imposed by visual function.Physican's orders for eyedrops included Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) and nurses were directed to instill 1 drop in right eye one time a day; cyclosporine ophthalmic Emulsion 0.05 % (Cyclosporine (Ophthalmic)) and nurses were directed to instill 1 drop in both eyes two times a day; Lumigan Ophthalmic Solution 0.01 % (Bimatoprost) and nurses were directed to instill 1 drop in right eye in the evening and wait 5mins between each eye drop administration. There was also a physician's order for Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 dose in each nostril as needed for allergic rhinitis daily as needed.On 2/22/26 at 12:12 PM, resident #55 was observed in her wheelchair and was alert and oriented. There was a bottle of cyclosporine eye drops, and a bottle of fluticasone nasal spray found on her bedside table. The resident said she administered eye drops twice daily and the nasal spray as needed by herself. The assigned nurse LPN A verified the eye drops, and the nasal spray was from the facility's pharmacy Omnicare by the label. She acknowledged that the medications could not have been brought in by the family. LPN A also acknowledged there were no orders nor assessments for the resident to self-administer medications and she removed them from the bedside table and placed them in the medication cart. Again, she said she had not noticed them before.Findings 3Resident #75 was admitted to the facility on [DATE] with diagnoses that included parkinsonism, chronic pain, Bell's Palsy, cortical age-related cataract bilateral and major depressive disorder.Review of the medical record showed the Minimum Data Set (MDS) Annual assessment with assessment reference date (ARD) of 11/20/25 revealed resident #75 had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated she was cognitively intact. The MDS also revealed that the resident's vision was adequate and she wore corrective lenses.On 2/22/26 at 12:49 PM, resident #75 was up in bed, alert and oriented. There was a bottle of Normal Saline nasal spray on her bedside table. Resident #75 said that she used the nasal spray whenever she felt congested and it helped her. The dates on the bottle showed it was opened on November 2025 with an expiration date of February 2026. The assigned nurse LPN A was made aware, verified the expiration dates and removed it from the resident. LPN A also confirmed there were no physician's orders for the nasal spray and acknowledged there was no assessment for self-administration of medications for resident #75. LPN A said she was not aware of resident #75 using the nasal spray ad did not notice it on her bedside table.On 2/22/26 at 1:00 PM, the East Wing Unit Manager was made aware of the three residents who were self-administering ophthalmic and nasal medications, and he explained that in order for residents to self-administer medications, they needed an assessment and physician orders to do so. He acknowledged that eyedrops and nasal sprays should not have been left at the bedside for residents to self-administer without the proper orders and assessments.On 2/24/26 at 3:20 PM, the director of nursing said that her expectation was not to have medications at the bedside for residents to self-administer unless they have that assessment done.The facility's policy on Self Administration of Medication revised August 2023, states To allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate. The resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered.

Based on observation, interview, and record review, the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for removal of a central venous catheter for 1 of 2 residents reviewed for intravenous lines and for 1 of 2 residents reviewed for limited range of motion, of a total sample of 34 residents, ( #6,#70).Findings: 1.On 2/22/26 at 11:43 AM resident #6 was observed sitting in her wheelchair in her room. Resident was noted to have a single lumen midline to her right upper arm with a date of 2/20/26 on the dressing. Resident #6 was admitted to the facility on [DATE] with diagnoses including dislocation of internal right hip prosthesis, infection following a procedure, and non-pressure chronic ulcer. Review of Infectious Disease note 2/20/26 revealed that on 2/3/26 the resident was assessed and her left buttocks wound was noted to be red and a foul smell. An order was given for culture and sensitivity of left buttock wound which was positive for Proteus mirabilis Extended-Spectrum Beta- Lactamases (ESBL). ESBL are enzymes produced by certain bacteria that make them resistant to a variety of commonly used antibiotics (retrieved on 2/27/26 https://www.cdc.gov/esbl-producing-enterobacterales/about/index.html). She was then started on Meropenem 500 milligrams (mg) every 8 hours for 7 days intravenously. On 2/16/26, the order was given to discontinue the intravenous line. Further review of the note, revealed on 2/19/26 Infectious Disease gave another order to discontinue the intravenous line since the resident was no longer receiving intravenous antibiotics and was instead on oral antibiotics, Review of a progress note on 2/16/26 revealed that the Infectious Disease Nurse Practitioner was at facility and gave an order to discontinue the midline IV as antibiotic therapy was completed. A review of physician orders revealed no order to remove the midline from 2/16/26 Review of physician orders revealed an order on 2/20/26 to remove midline IV with a completed date of 2/21/26 at 3:59 PM. Review of the electronic treatment administration record (ETAR) revealed no documentation for 2/20/26 and 2/21/26. On 2/22/26 at 11:50 AM, Weekend Supervisor A acknowledged that resident #6's midline was still in place and had not been removed. She stated that on 2/20/26 she attempted to remove the resident's midline, but the resident was unavailable as she was in therapy. Weekend Supervisor A assumed the next shift would remove the midline. Review of resident #6's therapy scheduled for the month of February revealed that on 2/20/26 the resident had 45 minutes of Physical Therapy (PT) and 30 minutes of Occupational Therapy (OT). On 2/21/26, the resident received no therapy services On 2/25/26 at 10:27 AM, the Director of Nursing (DON) acknowledged that a resident being in therapy was not an excuse for not removing the midline. If the resident was unavailable during day shift, the expectation would be for the following shift to remove the midline. She also verified that the expectation is that when the physician gives an order it should be followed. The DON did not have an explanation as to why the nurse who received the order to remove the midline on the 16th did not add it to the resident's order sheet. 2.Resident #70 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, aphasia following cerebral infarction and unspecified dementia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #70 was cognitively impaired with a brief interview for mental status score (BIMS) of 3 out of 15 and she also had impairment on one side of her upper extremity. Physician orders included a resting hand splint to right wrist/hand to patient's tolerance to promote skin/joint integrity. Review of resident #70's plan of care showed that the resident had alteration in musculoskeletal status cerebral vascular accident with right sides weakness initiated 9/23/24 and interventions included resting hand splint to right wrist/hand to patient tolerance to promote skin/joint integrity initiated on 11/12/24. On 2/23/24 at 10:30 AM, resident #70 was observed without the splint on her right hand. On 2/22/26 at 1:30 PM, resident #70 was observed sitting up in her wheelchair in the East Wing common area and she was not wearing a splint. Her daughter and son-in-law were visiting at the time and were asked if the resident wore a splint on her right hand. They explained that they rarely saw her with it on. They continued to explain that they had inquired about it as well as the possibility of her starting therapy again but had not heard anything back. On 2/24/26 at 3:38 PM, the Rehab Director said that resident #70 was referred to therapy by nursing yesterday and would now be on services. She said that the evaluation is still in progress. The Rehab Director explained that the last time the resident was on their services was 10/21/25 and had received restorative services but was no longer on it. She verified the order for the right resting hand splint to patient tolerance. She explained that they provided education to the staff regarding the schedule, how to apply the splint, and that it helped to maintain skin/joint integrity. She continued to explain that once the resident is off from services, nursing is responsible for applying the splint/brace and that the Unit Manager (UM) would oversee it. The Rehab Director could not answer why the order was not seen on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). On 2/24/26 4:10 PM, the assigned Certified Nursing Assistant (CNA) C said that resident #70 refused the splint at times, and that she did not like to wear it. On 2/24/26 at 4:25 PM, the East Wing UM verified the order for the splint and stated that the CNAs would apply the splint. He confirmed that the order was not on resident #70's TAR nor was it shown on the CNAs tasks in Point of Care (POC). The only place it was found was on the resident's Kardex (which is used by the CNA). He stated there could have been an error when the order was entered because the order did not specify a time of day or for how long the brace should be applied. When he was asked about resident's refusal to wear the splint and where that would be documented, he confirmed there was no refusal documented. On 2/25/26 at 11:57 AM, the Director of Nursing said that the expectation would be that physician orders were followed and that the order for the splint should have been on the TAR so that nurses could check it off as applied or not. The facility policy titled Physician Orders revised 8/2023 states that orders given by a physician and accepted by a licensed nurse should be documented on the physician order sheet, and physician's orders are obtained to provide a clear direction in the care of the resident.

Based on observation, interview, and record review, the facility failed to supervise a catheter drainage bag per infection control standards, to prevent contamination and the spread of infection for 1 of 1 resident reviewed for a bladder catheter of a sample of 34 residents. Findings:Resident #14 was admitted to the facility 1/30/26 with diagnoses of congestive heart failure, atrial fibrillation, urinary retention, peripheral vascular disease, right femoral embolism, & chronic kidney disease. On 2/22/26 at 10:35 AM, resident #14 was asleep in his chair, his catheter bag on the ground. At 12:12 PM he sat in his chair, and the urine collection bag was on the floor. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed that resident #14 was cognitively intact, used a walker with minimal supervision, and needed moderate assistance for activities of daily living. The resident's care plan from 12/20/25 contained a goal of decreased risk of signs and symptoms of a urinary tract infection (UTI) and other complications related to the catheter. One of the interventions was position or secure tubing to prevent traumatic removal. On 2/22/26 at 12:15 PM, Unit Manager Nurse B commented that the drainage bag should be hooked to the chair. She put on gloves, picked the bag off the ground, and attached it to the resident's wheelchair. The LPN added that the bag should not be on the ground due to infection control. On 2/24/26 at 12:28 PM, CNA F stated that a catheter bag should be hung underneath the bottom of a chair, or a rail. If she saw a drainage bag on the ground, for the sake of infection control, she would pick it up and hang it. On 2/24/26 at 12:42 PM, LPN E remarked she would wear gloves, pick a urine bag up off the ground, hang it up, and make sure it had a privacy bag. She said it does not belong on the ground due to contamination. On 2/24/26 at 1:40 PM, the Director of Nursing (DON) explained that a catheter bag should be placed below bladder level and hung from the bed or wheelchair. She concluded it should not be on the floor, and if there were no place to hang it then it should be moved into a basin. Review of the Catheter Care and Services policy revised 6/2024 read, the intent for the center [is] to ensure that a resident receives the appropriate care. to prevent urinary tract infections. It also stipulated, Do not rest the catheter bag on the floor.

Based on observation and interview, the facility failed to maintain food cooking equipment in a clean and sanitary manner to prevent physical contaminants that may inadvertently enter food eaten by the residents of the facility. Finding: On Sunday, 6/23/24, at 10:58 AM, the facility's kitchen was inspected with the facility cook. The deep fryer was not clean with food debris noted on the metal surfaces of the deep fryer. Inside the fryer itself, food debris particles were observed floating on top of the cooking oil, almost covering the entire surface. The cooking oil was very dark colored and appeared not to have been changed for some time. The cook verified the condition of the deep fryer and stated she had not used the deep fryer this morning and explained it was usually used for cooking chicken and french fries. When asked about the cleaning schedule for the cooking equipment, the cook said she did not know the last time the deep fryer had been cleaned or the cooking oil changed.

Based on observation, interview, and record review, the facility failed to follow a systematic approach to ensure residents were not over hydrated due to health conditions and followed physician ordered fluid restrictions to promote the highest practicable outcome for 1 of 3 residents reviewed for nutrition/hydration issues, of a total sample of 38 residents, (#5). Findings: On 6/24/24 resident #5 was observed in his room on the [NAME] Wing of the facility at approximately 1:34 PM. The resident was awake with some confusion and his wife was in the room with him. She explained her husband was incontinent and it took a long time for staff to change him. The resident's wife indicated her husband had not been in the facility very long and hoped he would return home. She expressed concern he was about to change rooms and be placed in a room on the East Wing where the staff were not familiar with her husband's care. Medical record review revealed resident #5's most recent admission to the facility on [DATE]. The resident's diagnosis included heart Disease, renal Disease, high blood pressure, prostate issues and hyponatremia (low sodium). The Minimum Data Set assessment dated [DATE] noted the resident scored a 10/15 on the Brief Interview for Mental Status which indicated moderately impaired cognition. Review of the physician's orders revealed resident #5 was on a 1000 milliliters (ml) per day fluid restriction for hyponatremia. Hyponatremia occurs when the concentration of sodium in your blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around your cells. In hyponatremia, one or more factors- ranging from an underlying medical condition to drinking too much water -cause sodium in your body to become diluted. When this happens, your body's water level rises, and your cells begin to swell. This swelling can cause many health problems, from mild to life-threatening, (retrieved on 7/15/24 from www.mayoclinic.org). The resident's physician notated how resident #5's fluid restriction would be administered. Dietary was to provide a total of 700 ml of fluid per day in increments of: breakfast 360 ml; lunch 180 ml; and dinner 160 ml. Nursing staff was to provide 300 ml additional fluid per day 120 ml on the 7 AM-3 PM shift; 120 ml on the 3 PM-11 PM shift and 60 ml on the 11 PM-7 AM shift. On 6/25/24 at 2:29 PM, resident #5 was observed in his new room on the East Wing. He was lying in bed with a large cup of water on the bedside table. The cup held approximately 16 ounce of fluid equal to 473 ml, which exceeded the 120 ml nursing was to provide on the 7 AM-3 PM shift and the allotted amount for the entire day. Om 6/26/26 at 1:51 PM, the resident was sitting in a wheelchair in his room with a 16-ounce cup of water on the bedside table. Resident #5 said he was not told he was on a fluid restriction and referred to his water cup. He added the Certified Nursing Assistant (CNA), would refill the water cup, as much as you ask. Approximately 3 minutes later, CNA A, confirmed she was assigned to resident #5, for the 7 AM-3 PM shift and she provided the resident with ice water. CNA A was not aware the resident was on a fluid restriction. She said at one time residents that were on a fluid restriction would have a sticker on their bedroom door/frame but was not sure if that was still being used. She added if the resident was on a fluid restriction it would be, noted in the resident's MAR (Medication Administration Record) in the computer. A few minutes later, at 1:54 PM, CNA A reviewed the resident's Kardex in the electronic medical record and confirmed the resident was on a fluid restriction but said the Kardex did not indicate how much fluid the resident was to receive. On 6/26/24 at 1:58 PM, the East Wing Unit Manager reviewed resident #5's physician orders and confirmed the resident was on a fluid restriction. He said the resident was only to receive 1000 ml of fluid per day and the fluid should have been controlled by dietary and nursing staff.

Based on observation, interview and record review, the facility failed to promote dignity related to missing front teeth affecting the resident's self-esteem for 1 of 2 residents reviewed for dignity, out of a total sample of 52 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE] with diagnosis including polyneuropathy, and major depressive disorder. On 12/12/22 at 11:39 AM, resident #53 stated she lost her upper partial denture back in June, 6 months ago. She recalled she filed a grievance at that time and was told the facility would pay to have it replaced. She stated she had not seen a dentist and explained she had never been without teeth and really wanted to have the partial denture replaced. On 12/14/22 at 3:48 PM, resident #53 clarified it was the West Wing Unit Manager who told her the facility would pay to replace her partial denture. She noted she was unsure why it was taking so long to have the denture replaced. Resident #53 stated she had been a public speaker and appearance was very important to her. She expressed she feels terrible not having upper teeth and as a result lisped when she talked. She said she hated meeting new people because she felt like she had to explain why she did not have front teeth. On 12/14/22 at 2:01 PM, the Social Services Assistant (SSA) confirmed a grievance was filed June 15, 2022 for the missing partial denture. She stated she did not know what happened to resident #53's partial denture but a replacement was in the works. On 12/14/22 at 3:04 PM, the Social Services Director (SSD) stated when a resident reported lost items, the facility would first search for the item and if not found, the facility would replace the missing item. She clarified if a resident lost a denture and it was unable to be located, the resident would be placed on the dental list to be seen on the next visit. On 12/14/22 at 3:34 PM, the SSA provided a form which showed resident #53 was approved for a dental program on December 1, 2022. She explained the application took 54 days to get approved. The SSA was unable to explain why it had been 6 months since the denture went missing and the resident had not received her partial denture.

Based on observation, interview, and record review, the facility failed to provide dental services in a timely manner for 1 of 2 residents reviewed for dental services, out of a total sample of 52 residents, (#53). Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses of polyneuropathy, cardiac pacemaker and major depressive disorder. On 12/12/22 at 11:39 AM, resident #53 stated she lost her upper partial denture 6 months ago, in June. She recalled she filed a grievance at that time and was told the facility would pay to have it replaced. She stated she had not seen a dentist since that time and added she had never been without teeth and wanted to have the partial denture replaced. On 12/14/22 at 2:01 PM, the Social Services Assistant (SSA) confirmed a grievance was filed June 15, 2022. She stated she did not know what happened to resident #53's partial denture but a replacement was in the works. On 12/14/22 at 3:04 PM, the Social Services Director (SSD) stated when a resident reported lost items, the facility would first search for the item and if not located, the facility would replace the missing item. She clarified if a resident lost a denture and it was unable to be located, the resident would be placed on the dental list to be seen on the next visit. On 12/14/22 at 3:34 PM, the SSA provided paperwork which revealed resident #53 was scheduled to be seen by dental services 10/19/22. She stated the resident was out of the facility at the time of the visit and was not seen. The SSA was unable to explain why the dental referral was scheduled in October when the facility became aware of the missing partial denture in June. A review of resident #53's medical record revealed no documentation to indicate why a referral did not occur within 3 days of the facility becoming aware of the missing partial denture as per facility policy. The record also did not contain any documentation of steps taken to ensure resident #53 could eat and drink adequately while awaiting dental services. The facility's policy and procedure for Dental Services revised 8/29/17 read, The facility will refer residents with lost or damaged dentures for dental services within three days of notification. If the referral cannot occur within three days, the facility will provide documentation of measures implemented to ensure the resident's hydration and nutrition status are maintained. The document identified the social services designee was responsible for coordinating dental services in the facility.

Based on observation, interview, and record review, the facility failed to develop a baseline/interim care plans in a timely manner related to intravenous (IV) antibiotics and psychotropic medication use for 1 of 1 newly admitted resident reviewed for IV antibiotic therapy and mood/behavioral services of a total sample of 52 residents, (#311). Findings: Resident #311's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of severe sepsis, alcohol induced pancreatitis, enterocolitis due to clostridium difficile toxin, pneumonia, and alcohol withdrawal delirium. Resident #311 was observed on 12/12/22 at 10:35 AM, lying in bed with his spouse sitting at the bedside. He was noted to have a right upper arm IV line with bag of antibiotics (Vancomycin) currently infusing via IV pump and empty bag IV antibiotics (Zosyn) hanging from pole. The wife said he had been on a lot of drugs to help manage his anxiety and agitation. On 12/13/22 at 3:40 PM, resident #311 was observed in bed, and wife sitting at the bedside. The IV pole was noted with empty bags of IV antibiotics. The resident's wife indicated he was feeling better today, and explained they changed his sedation medication (Ativan) to as needed from scheduled routine. Resident #311 was observed on 12/14/22 at 8:55 AM, asleep in bed with IV antibiotic (Vancomycin) infusing via IV right upper arm and his spouse who was at the bedside said they had to give him medication last night due to being restless and anxious. Review of resident #311's medical record revealed that he or his representative signed consent for Psychoactive Medication Ativan to be given BID (twice per day) for jitters and restlessness. The medication administration record (MAR) revealed the nurse gave Ativan per orders from 12/8/22 to 12/13/22 for symptoms of anxiety and alcohol withdrawal delirium. The IV orders were dated 12/7/22 for STAT (immediate) placement of IV for antibiotics Vancomycin and Zosyn for sepsis for 10 days. On 12/14/22 at 1:09 PM, the Resident Care Specialist (RCS) A said she was one of the nurses who was responsible for completing the Minimum Data Set (MDS) assessments as well as care plans. She explained the interim/baseline care plans were initiated on admission. She noted her supervisor, the MDS Coordinator attended the morning meetings where residents were reviewed and care plans were updated to reflect new orders. The RCS reviewed resident #311's care plans, and acknowledged there were no interim care plans for IV antibiotics or psychotropic medications. On 12/14/22 at 1:18 PM, during a telephone interview, the Lead RCS explained the admission nurse or unit manager were responsible to initiate or update the interim care plans since his comprehensive care plan was not due until 12/19/22. She added the interim care plan was a work in progress and not all updates were done at the morning meetings. She indicated the nurse who received the new orders was responsible for updating the interim care plan. On 12/14/22 at 1:30 PM, the West Unit Manager (UM) reviewed the medical record and acknowledged resident #311 was on psychotropic medication, Ativan since 12/6/22 for alcohol withdrawal and anxiety. She said, it was the UM's responsibility to ensure the interim/baseline care plan was completed. The Assistant Director of Nurses (ADON) joined interview and reviewed the resident's medical record and verified he had psychotropic medications ordered since his admission on 12/6/22 and IV antibiotic ordered on 12/7/22, the day after admission. The ADON explained, nurses were responsible for completing the interim care plan for IV therapy and Social Services (SS) staff were responsible for initiating interim care plan for psychotropic drugs. The ADON explained, they should have initiated the care plan when the resident started IV antibiotic therapy and acknowledged there were no baseline care plans for IV antibiotic therapy or psychotropic medications until it was brought to their attention by the surveyor. On 12/14/22 at 2:09 PM the SS Assistant (SSA) said she usually visited new residents within 72 hours of admission and it was the responsibility of the SS Director (SSD) to initiate the baseline/interim care plan for a resident on psychotropic medications. The SSA reflected and said, she did not know why the baseline care plan was not initiated for resident #311. On 12/14/22 at 2:54 PM the SSD said she was new and learning how to do the care plans. She added that when she worked at a prior facility, MDS staff did all the care plans. She was not aware she was responsible to initiate interim care plans for residents on psychotropic medications. The SSD said it was important that a resident with a history of alcohol abuse to have current plan of care to reflect his history and current interventions, but did not understand why she would need to do them. On 12/15/22 at 11:16 AM, the Director of Nursing (DON) said she thought interim care plans only needed to include falls, activities of daily living, skin, pain, and nutrition needs. She added she was not aware the interim care plans should also reflect IV antibiotic therapy and psychotropic medications. She said she thought those could wait until the comprehensive care plan was completed. The DON stated, I am not good at care plans and don't know when they are supposed to be initiated. The facility's Baseline (Interim/Initial/IPOC) Plan of Care, revised 2/18/19 read, The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care .A comprehensive care plan can be developed in place of the Baseline Care Plan .including, but not limited to .physician orders .The nurse will consider the following areas when developing individualized care plan for each resident .Update the Interim (Initial) Plan of Care on and ongoing basis, as necessary, until the Comprehensive Plan of Care is finalized .

Based on interview and record review, the facility failed to revise discharge plan to reflect additional care needs related to a change in status, and failed to involve the resident's representative, appropriate staff, and the Home Health Agency in education and decision-making to ensure safety, continuity of care and prevent hospital readmission for 1 of 5 residents reviewed for discharge planning, of a total sample of 8 residents, (#1). The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/08/22, the day of her planned discharge home, resident #1 fell in her room and hit the back of her head. An Advanced Practice Registered Nurse (APRN) assessed her and deemed it safe for the facility to continue with current discharge plans and orders, which included blood thinner medications, if the resident scheduled an appointment with her community primary care physician within two days. Resident #1's assigned nurse initiated and conducted neurological checks for four hours rather than 72 hours as noted in the facility's protocol for monitoring residents after unwitnessed falls. The resident was discharged from the facility in the care of her daughter, with no written education or instructions provided regarding monitoring for complications of a head injury. Over the next 48 hours, resident #1 experienced neurological changes and exhibited symptoms of a brain bleed which were unrecognized by the resident and misinterpreted by her daughter as signs of low blood sugar. On 6/10/22, resident #1's speech was slurred and she was transported to the hospital by Emergency Medical Services (EMS), where she was diagnosed with a brain bleed. The resident required emergency brain surgery and had to be transferred to a hospital that offered advanced neurosurgical services. She was subsequently discharged to another skilled nursing facility for rehabilitation. The facility's failure to modify a discharge plan after a fall with head injury contributed to inadequate preparation to meet the resident's post-discharge goals, created an unsafe situation for resident #1, and placed all residents who had a change in status prior to discharge at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 6/08/22 and was removed on 9/22/22. Findings: Cross reference F684. Review of the medical record revealed resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 4/26/22 indicated resident #1 was alert and oriented, followed instructions, and was capable of making healthcare decisions. The form revealed the resident's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Admission assessment with assessment reference date of 4/30/22 revealed resident #1 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The assessment showed she had no behavioral symptoms and did not reject necessary care and services. Section F0400 of the assessment Interview for Daily Preferences indicated resident #1 felt it was very important to have her family involved in discussions about her care. Section Q Participation in Assessment and Goal Setting revealed resident #1 participated in the Admission assessment, expected to be discharged to the community, and had active discharge planning in place. Review of the medical record revealed resident #1 had a care plan for discharge goals initiated on 4/26/22. The document indicated she planned to return home after a short-term rehabilitation stay. The care plan approaches included establishing a pre-discharge plan and revising the plan as indicted, and arranging for required community resources and outside services. The care plan read, Provide diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Admission Record demographic sheet listed her daughter as Emergency Contact #1, Next of Kin, and Care Conference Person. The document revealed on 6/08/22, she was discharged from the facility to Home - with Home Health Services: Home/Live with Family. Review of the facility's incident log revealed on 6/08/22, resident #1 fell and hit her head. An Occurrence Note dated 6/08/22 at 11:57 AM provided details of the incident. Resident #1's assigned nurse, Licensed Practical Nurse (LPN) A, wrote that she heard the resident call out, and upon entrance to the room she observed the resident seated on the floor at end of her roommate's bed. The note revealed resident #1 informed LPN A she fell while trying to unplug her cell phone and read, Also stated she believed she hit her head on other resident's foot of bed. LPN A wrote that she evaluated resident #1, did not observe any injuries, and assisted the resident to walk to her bed with a walker. The note revealed an APRN who was at the facility assessed resident #1 and asked LPN A to communicate with the resident's daughter who was on the way to the facility to pick up her mother for a planned discharge home .to wait a few while she attempted to get resident an appointment with [name of community physician] for tomorrow or Friday for prompt [follow up related to] this incident. Review of a practitioner's note dated 6/08/22 revealed resident #1 was assessed by APRN C after a fall prior to discharge home from the facility. APRN C wrote, .the patient reported that she hit her head.patient remained stable for discharge at this point. The note indicated resident #1 was presented with three options, to stay in rehab for an additional day, get a CT of the head, or present home as scheduled and see her community physician that week. APRN C noted the resident opted to go home as planned and after discussion of the plan with the resident's daughter, she was agreeable. The document read, Of note, patient is on [names of two blood thinning drugs]; also educated the patient and daughter that if she develops any acute symptoms of headache, [nausea/vomiting], etc to present to the ED for further evaluation. The facility's Fall Response Worksheet revealed neurological checks or neurochecks would be conducted for 72 hours after an unwitnessed fall and/or if a resident hit his or her head. The protocol detailed the scheduled frequency of monitoring as every 15 minutes for two hours, then every 30 minutes for two hours, then every 60 minutes for four hours, and then every eight hours for 64 hours. Review of resident #1's medical record revealed a Neurological Assessment Flowsheet was initiated by LPN A on 6/08/22 at 10:40 AM. The document showed neurochecks were completed over the next four hours until the resident was discharged home, and not the 72 hours noted in the facility's protocol. The facility's policy and procedure for Neurological assessment dated [DATE], indicated the purpose of a neurological assessment was to establish a resident's baseline and recognize changes in condition. The procedure detailed the necessary tasks involved in a neurological assessment including assist the resident to a supine position, check blood pressure, temperature, respiratory rate and rhythm, heart rate and rhythm with use of a stethoscope placed on the left side of the chest, and radial pulses located on the inside of both wrists. Next, the resident's level of consciousness, arousability, and orientation to self, time, place, and person, and his or her verbal response should be evaluated. The procedure directed nurses to continue the neurological assessment after slightly darkening the room to evaluate the resident's pupils for size, equality, and reaction to light stimulus, and also assess for eye signs, movement, and appropriate response. The document indicated the resident's strength should be tested in all extremities and sensory response evaluated by the ability to differentiate between dull and sharp objects placed on the skin at locations on both sides of the body. The policy included a section titled Fundamental Information that described dangerous trends to be reported to a physician such as changes in papillary reaction, a decrease in level of consciousness, noticeable change in vital signs and loss of strength or sensation. The document indicated other significant neurological symptoms were nausea, vomiting, [CONDITION(S)] activity, changes in vision and headache. The policy read, Close monitoring of a resident who has signs of increased intracranial pressure is crucial. If early signs of increasing intracranial pressure are not recognized then irreversible brain damage can occur. Increased intracranial pressure is defined as growing pressure inside the skull that can be caused by a head injury and bleeding into the brain. This increase in pressure is an emergency as it can cause further injury to the brain and/or spinal cord. The condition requires immediate medical attention, and the likelihood of recovery is linked to the timeliness of recognition of symptoms and treatment (retrieved on 10/07/22 from www.hopkinsmedicine.org). The Post-Discharge Plan of Care dated 6/08/22 revealed resident #1 was discharged home with Home Health services for her nursing needs, with instructions to keep all pre-scheduled physician appointments and call her primary physician to set up an appointment. The document did not indicate that a detailed description of the steps of a neurological assessment was provided to the resident and her representative. The discharge plan of care did not include instructions regarding the required frequency of post-fall monitoring or list signs and symptoms of dangerous complications of a head injury. On 9/20/22 at 12:10 PM and 3:30 PM, the Director of Nursing (DON) stated neurochecks should be done when a resident hit his or her head. She explained the frequency and duration of neurochecks was specified in the Fall Response Worksheet instructions. She stated it was her understanding that resident #1 chose to leave the facility although the nurse practitioner tried to convince her to stay. The DON explained resident #1 had the right to refuse to remain in the facility. She acknowledged neither the APRN nor any member of the nursing department involved her in post-fall discussions and decision-making, and she was not made aware of any concerns about the resident's discharge home with a possible head injury and no diagnostic tests ordered. On 9/21/22 at 10:18 AM, in a telephone interview, the Clinical Manager of the Home Health Agency (HHA) stated the facility usually sent a referral for services approximately two days prior to a resident's planned discharge home, and the agency would then review the case to verify that they could provide the required services. She checked resident #1's medical record and stated the referral was received from the facility on 6/08/22, the day of discharge. The Clinical Manger explained in most cases, the HHA attempted to do the initial visit within 24 to 48 hours. She was informed resident #1 fell and hit her head in the facility a few hours before she was discharged home. The Clinical Manager stated the referral dated 6/08/22 made no reference to the resident's fall and there was no additional documentation provided to reflect revised orders or interventions for post-fall monitoring for complications of a head injury. The Clinical Manager said, I would absolutely have expected the facility to include that information. When asked if the HHA could provide the frequent monitoring necessary after a head injury, she said, We would not have been able to provide that service. She explained if a patient fell while on their service, they required the person to be seen by a physician that same day. She stated if the patient refused, the HHA involved family to encourage compliance with the protocols. She said, We do this to make sure they understand the ramifications of not getting immediate treatment. On 9/21/22 at 10:51 AM, APRN C confirmed she assessed resident #1 after her fall and she presented the resident with the options of going to the hospital for diagnostic testing, delaying the discharge and staying in the facility overnight, or going home and following up with her physician. She stated she did not consider rescinding the resident's discharge order or discuss the possibility of discharge against medical advice with the resident. APRN C stated the resident chose to go home, and she had a discussion with her regarding self-monitoring for the possible changes she could experience from a head injury. She said, I would typically expect the patient to be able to recognize those signs. like nausea and vomiting. She was asked if the resident who hit her head and suffered a possible head injury with intracranial bleeding would be a reliable assessor of her own neurological changes which could include change in level of consciousness and difficulty in arousing herself. APRN C acknowledged if resident #1 were lethargic or sleeping too much she would not be able to identify the symptoms as signs of a head injury. She reiterated resident #1 was alert and oriented at the time of her assessment, made her own healthcare decisions and voiced understanding of the options and education provided. APRN C stated she never spoke to resident #1's daughter, but to her knowledge, LPN A relayed her recommendations to the daughter. She stated she was aware the resident was being discharged to her home where she lived with her husband who had dementia. She acknowledged she did not discuss the fall or the resident's alleged refusal to comply with the facility's fall protocol with the DON or the Medical Director prior to authorizing the resident's discharge home. On 9/21/22 at approximately 11:00 AM, the facility's Medical Director explained any patient who suffered a fall with a possible or known head injury should be watched. He verified he was easily accessible to all facility providers and administration and would have come to the facility to speak with the resident and her daughter about the risks of not pursuing diagnostic testing. The Medical Director stated he reviewed APRN C's progress note which indicated resident #1 was presented with options related to her care and the resident and her daughter were educated on the symptoms of a head injury that would require emergency department care. The Medical Director was informed despite APRN C's documentation of that education, resident #1 never called Emergency Medical Services (EMS) and her daughter treated her for signs and symptoms of [CONDITION(S)] or low blood sugar. The Medical Director validated the signs of increased intracranial pressure from a head injury could mimic symptoms of low blood sugar. On 9/21/22 at 2:43 PM, a meeting was held with the facility's Medical Director, the Administrator, and resident #1's attending physician. The attending physician stated resident #1 had her own decision-making capability and selected to continue with the planned discharge home after she fell and hit her head. He stated he was informed LPN A educated resident #1's daughter and he said, There was a clear understanding. The attending physician was informed if resident #1 and her daughter were educated, it was not effective as the daughter misinterpreted her mother's symptoms as those related to low blood sugar and the resident never called EMS. He was informed APRN C did not involve the daughter, the DON or the Medical Director in attempts to educate resident #1 on the risks of discharging home without diagnostic testing or appropriate neurological monitoring, and to encourage her to follow the facility's protocols. The attending physician summarized the intervention of encouraging resident #1 to either remain in the facility or go to the hospital as possible coercion since resident #1 was cognitively intact. The Merriam-Webster Dictionary defines coercion as the use of express or implied threats of violence or reprisal.or other intimidating behavior that puts a person in immediate fear of the consequences in order to compel that person to act against his or her will (retrieved on 10/12/22 from www.merriam-webster.com/dictionary/coercion). On 9/21/22 at approximately 2:55 PM, the attending physician was informed that involvement of the residents' representatives and other interdisciplinary team (IDT) members was an acceptable practice, encouraged in the long-term care care care planning process, and was described by the Medical Director as an effective intervention that he used. The attending physician was informed resident #1's discharge plan did not reflect written instructions for required post-fall follow up for the resident including close monitoring for signs and symptoms of complications of a head injury. He was informed no written instructions were provided to the resident or her daughter, and the nursing documentation did not show any related education. The attending physician asked if the entire discharge issue was being narrowed down to a pre-printed piece of paper with boxes to be checked. He was informed that discharge paperwork from any healthcare institution must include information written in plain language that patients and their representatives could understand and use as a reference tool once out of the healthcare setting, with the goal of continuity of care and prevention of rehospitalization . On 9/21/22 at approximately 3:15 PM, the Medical Director was provided with copies of resident #1's discharge paperwork including the Post-Discharge Plan of Care He acknowledged there were no instructions regarding post-fall monitoring and symptoms of a head injury that required immediate medical attention. The Medical Director passed the paperwork to the Administrator and the attending physician for review and they had no additional input. The Medical Director, the Administrator, and the attending physician were informed resident #1's daughter followed the only instruction provided, which was to make an appointment with her primary care physician in the community within two days of discharge. They were informed the Home Health Agency was never made aware of resident #1's fall, and when contacted today, a representative stated the agency would not have accepted the referral for resident #1 under those circumstances. On 9/22/22 at 9:46 AM, in a telephone interview, resident #1's daughter stated she was never informed of any options regarding extending her mother's stay in the facility or transferring her to the hospital for a CT (computerized tomography) scan. She stated she could easily have accommodated those options and picked her mother up later that day or on the following day. The daughter said, I am accustomed to any facility, whether hospital or rehab, going over her [discharge] paperwork with me in case my mother is overwhelmed. The daughter emphasized that she never had any conversations with either the APRN or LPN A regarding symptoms of a head injury related to her mother's fall. She stated she never received any discharge instructions, and only discovered the discharge paperwork in a folder within the past month when she was searching for something else. The daughter stated her parents had companion sitters in their home between 9:30 AM and 7:00 PM every day, but they were not qualified nurses. She said, I never told anyone I was a medical professional. She stated she assessed her mother to the best of her ability, and if she had significant concerns prior to the morning her mother's words were slurred, she would have called EMS as she did on the morning of 6/10/22. The daughter said, I was not thinking about her head.I absolutely would have acted differently that night if I knew the symptoms.I wish I could have known the things I know now. On 9/22/22 at 3:37 PM, in a telephone interview, resident #1 recalled she slipped, fell and hit her head on the footboard of her bed on the day she was discharged from the facility. She stated staff responded immediately and she told them she hit the back of her head. The resident stated she told an unknown nurse she felt strange in her head and wanted to lie down, and she was told that was a good idea. Resident #1 said, I feel they fluffed me off.The next thing I remember was when they woke me up and told me it was time to go home. Resident #1 was informed her medical record and an interview with APRN C indicated she was offered a transfer to the hospital and the option to remain in the facility overnight, but she refused both. Resident #1 said, I don't remember, but if she said so maybe it is so, but I don't think anybody ever discussed all that with me. If it was my facility, I would have done things differently. I thought it was strange that they didn't get an x-ray of my head. The resident stated she remembered the drive home from the facility, but not much after that except the ambulance ride to the hospital. She said, This whole experience, it has taken a lot of things for me. My speech was slurred for a while. It affected my memory, even now I have a hard time remembering details. I have to struggle hard to bring back some things. I have to think hard to find words. I know what I want to say but I can't find the right words. I go blank in my memory bank sometimes. It's awful! The resident was informed APRN C, her attending physician, the DON and other facility staff mentioned they heard she fell at home after she was discharged from the facility. Resident #1 denied any other falls and said, You may not want my opinion, and it's only my opinion, but after all [name of the facility] said happened and how it happened, I feel they will go to any lengths to lie and cover up to protect themselves. Review of the facility's policy and procedure Transfer & Discharge revised on 5/23/17, revealed a purpose .to provide a safe and orderly transfer or discharge from the facility. that supports an effective transition and reduces the risk of preventable readmissions. The document indicated the IDT would discuss the discharge to ensure appropriate procedures were implemented and involve the resident and the representative in discharge planning. The policy revealed a safe and orderly discharge from the facility would include facilitation of follow up care and services determined to be appropriate for the resident and the discharge location. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 6/08/22, resident #1 was evaluated by the APRN after an unwitnessed fall. The APRN determined the resident remained stable for discharge and denied any issues on a 14-point review of systems. *On 9/21/22 during stand-down meeting, the facility conducted an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting on the discharge planning process. In attendance were the Nursing Home Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Infection Preventionist, Social Service Manager, Activity Director, Rehab Program Manager, Admissions Coordinator, Unit Manager, Minimum Data Set Coordinator, Maintenance Director, Certified Dietary Manager, and Medical Director. *On 9/22/22 at 10:00 AM, education was completed by the Corporate Director of Clinical Services with the IDT including Nursing Home Administrator, Director of Nursing, Social Service Manager, Social Service Assistant, Activity Director, Rehab Program Manager, and Admissions Coordinator, on the components of F660 Discharge Planning Process. The education included the system upgrade to hold planned discharges for 72 hours for those residents that have unwitnessed falls to allow for further evaluation. The facility achieved 100% compliance with education of the interdisciplinary team that had completed the education with verbal acknowledgement of the education with in-person education. Retention questions were developed regarding the discharge process for residents. * On 9/22/22 during the morning meeting, the IDT team discussed the Ad Hoc QAPI meeting findings to identify any further opportunities. No other opportunities were identified. *On 9/21/22 and 9/22/22, facility staff reviewed the previous ten discharges to ensure the discharge planning process was completed per protocol to ensure all were safe discharges to the community. There were no concerns with 10 of 10 residents. *On 9/22/22, education was provided to licensed nurses regarding the discharge planning process and to hold planned discharges for 72 hours for those residents who had unwitnessed fall to allow for further evaluation. The facility achieved 90% education of all licensed nurses, and the remaining licensed nurses will be educated prior to their next worked shift. *On 9/22/22, the facility initiated retention questions for licensed nurses regarding rescinding discharge orders when a resident had a fall, and to hold discharge for 72 hours to determine the need for further medical attention. * As of 9/22/22, Social Services will provide written discharge instructions for residents who discharge from the facility. *As of 9/22/22, the Admission/Social Service Manager will initiate Sunshine calls to follow-up with discharged residents to ensure there are no concerns with their discharge process. *As of 9/22/22, newly hired licensed nurses will be educated on the discharge planning process prior to their first worked shift. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On 9/22/22, interviews were conducted with six LPNs and one Registered Nurse, who verbalized understanding of the education provided. The resident sample was expanded to include four additional residents who were discharged home with HHA services. Interviews and record reviews revealed no concerns for residents #5, #6, #7, and #8.

Based on interview and record review, the facility failed to provide and/or arrange post-fall care and services in accordance with facility protocols and professional standards of practice; and failed to adequately inform and educate the resident and her representative regarding the symptoms and risks of a closed head injury to prevent a negative outcome and promote the highest practicable well-being for 1 of 4 residents reviewed for falls, of a total sample of 8 residents, (#1). The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident experienced ongoing residual effects of the brain bleed including memory and language deficits. On 6/08/22, the day of her planned discharge home, resident #1 fell in her room and hit the back of her head. An Advanced Practice Registered Nurse (APRN) assessed her and deemed it safe for the facility to continue with current discharge plans and orders, which included blood thinner medications, if the resident scheduled an appointment with her community primary care physician within two days. Resident #1's assigned nurse initiated and conducted neurological checks for four hours rather than 72 hours as noted in the facility's protocol for monitoring residents after unwitnessed falls. The resident was discharged from the facility in the care of her daughter, with no written education or instructions provided regarding monitoring for complications of a head injury. Over the next 48 hours, resident #1 experienced neurological changes and exhibited symptoms of a brain bleed which were unrecognized by the resident and misinterpreted by her daughter as signs of low blood sugar. On 6/10/22, resident #1's speech was slurred and she was transported to the hospital by Emergency Medical Services (EMS), where she was diagnosed with a brain bleed. The resident required emergency brain surgery and had to be transferred to a hospital that offered advanced neurosurgical services. She was subsequently discharged to another skilled nursing facility for rehabilitation. The facility's failure to provide appropriate post-fall care and services contributed to a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in Immediate Jeopardy which began on 6/08/22 and was removed on 9/22/22. Findings: Cross reference F660. Review of the medical record revealed resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 4/26/22 indicated resident #1 was alert and oriented, followed instructions, and was capable of making healthcare decisions. The form revealed the resident's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's incident log revealed on 6/08/22, resident #1 fell and hit her head. An Occurrence Note dated 6/08/22 at 11:57 AM provided details of the incident. Resident #1's assigned nurse, Licensed Practical Nurse (LPN) A, wrote that she heard the resident call out, and upon entrance to the room she observed the resident seated on the floor at end of roommate's bed. The note revealed resident #1 informed LPN A she fell while trying to unplug her cell phone. The document read, Also stated she believed she hit her head on other resident's foot of bed. LPN A wrote that she evaluated resident #1, did not observe any injuries, and assisted the resident to walk to her bed with a walker. The note revealed an APRN who was at the facility assessed resident #1 and asked LPN A to inform the resident's daughter, who was on the way to the facility to pick up her mother for a planned discharge home, .to wait a few while she attempted to get resident an appointment with [name of community physician] for tomorrow or Friday for prompt [follow up related to] this incident. The Merriam-Webster Dictionary defines prompt as being ready and quick to act as occasion demands [and] performed readily or immediately. Promptness is synonymous with a response without delay or hesitation (retrieved on 10/07/22 from www.merriam-webster.com/dictionary/prompt). Continued review of the Occurrence Note dated 6/08/22 at 11:57 AM, indicated the APRN was unsuccessful in obtaining an appointment with the resident's community physician. LPN A wrote that she contacted the daughter who agreed to schedule a follow up appointment within 24 to 48 hours. The note read, Resident and daughter in agreement to discharge. Review of the facility's Fall Response Worksheet revealed neurological checks or neurochecks would be conducted for 72 hours after an unwitnessed fall and/or if a resident hit his or her head. The protocol detailed the scheduled frequency of monitoring as every 15 minutes for two hours, then every 30 minutes for two hours, then every 60 minutes for four hours, and then every eight hours for 64 hours. Review of resident #1's medical record revealed a Neurological Assessment Flowsheet was initiated by LPN A on 6/08/22 at 10:40 AM. The document showed neurochecks were completed every 15 minutes for only 45 minutes instead of two hours, then every 30 minutes for two hours. The last neurocheck documented on the flowsheet was at 2:25 PM, prior to resident #1's discharge, which indicated her neurological status was monitored for less than four hours rather than the 72 hours noted in the facility's protocol. Review of resident #1's Order Recap Report dated 4/26/22 to 6/08/22 revealed no physician orders regarding the initiation or frequency of neurochecks. The facility's policy and procedure for Neurological assessment dated [DATE], indicated the purpose of a neurological assessment was to establish a resident's baseline and recognize changes in condition. The document indicated a physician's order would dictate the frequency of neurological assessments. The procedure detailed the necessary tasks involved in a neurological assessment including assist the resident to a supine position, check blood pressure, temperature, respiratory rate and rhythm, heart rate and rhythm with use of a stethoscope placed on the left side of the chest, and radial pulses located on the inside of both wrists. Next, the resident's level of consciousness, arousability, and orientation to self, time, place, and person, and his or her verbal response should be evaluated. The procedure directed nurses to continue the neurological assessment after slightly darkening the room to evaluate the resident's pupils for size, equality, and reaction to light stimulus, and also assess for eye signs, movement, and appropriate response. The document indicated the resident's strength should be tested in all extremities and sensory response evaluated by the ability to differentiate between dull and sharp objects placed on the skin at locations on both sides of the body. The policy included a section titled Fundamental Information that described dangerous trends to be reported to a physician such as changes in papillary reaction, a decrease in level of consciousness, noticeable change in vital signs and loss of strength or sensation. The document indicated other significant neurological symptoms were nausea, vomiting, [CONDITION(S)] activity, changes in vision and headache. The policy read, Close monitoring of a resident who has signs of increased intracranial pressure is crucial. If early signs of increasing intracranial pressure are not recognized then irreversible brain damage can occur. Increased intracranial pressure is defined as growing pressure inside the skull that can be caused by a head injury and bleeding into the brain. This increase in pressure is an emergency as it can cause further injury to the brain and/or spinal cord. The condition requires immediate medical attention, and the likelihood of recovery is linked to the timeliness of recognition of symptoms and treatment (retrieved on 10/07/22 from www.hopkinsmedicine.org). The Post-Discharge Plan of Care dated 6/08/22 revealed resident #1 was discharged home with Home Health services for her nursing needs, with instruction to keep all scheduled physician appointments. The document did not indicate a description of the neurological assessment procedures noted above were provided to the resident and her representative. The plan of care did not include instructions regarding the required frequency of post-fall monitoring or list signs and symptoms of increased intracranial pressure. A discharged Resident Medication Transfer Record included with resident #1's discharge paperwork listed insulin [MEDICATION(S)] 25 units in the morning and 20 units at bedtime for diabetes, insulin Aspartame at mealtimes according to a sliding scale for diabetes, and [MEDICATION(S)] 10 milligrams (mg) twice daily for diabetes. In addition, resident #1's discharge medication list included two blood thinners which were antiplatelet drugs, [MEDICATION(S)] coated Aspirin 81 mg once daily and [MEDICATION(S)] 75 mg once daily. Antiplatelet drugs reduce the ability of platelets in the blood to stick together and form clots (retrieved on 10/07/22 from www.drugs.com/drug-class/antiplatelet-agents.html). The Centers for Disease Control and Prevention indicates one of five falls in the elderly population, those age 65 or older, causes serious injuries including fractures or head injuries. Falls are the most common cause of traumatic brain injuries in this age group, and elderly persons who take blood thinners are at higher risk for a brain injury (retrieved on 10/07/22 from www.cdc.gov/falls/facts.html). On 9/20/22 at 8:48 AM, in a telephone interview, resident #1's daughter recalled the events surrounding her mother's fall in the facility. The daughter stated her mother was to be discharged on [DATE] at 11:00 AM. She explained she was running a little late to pick her up, so she called her mother's cell phone and her mother told her she fell and hit her head on the bed. Resident #1's daughter stated her mother did not mention anything about not wanting to go to the hospital. The daughter recalled, She told me she may have to stay longer. The daughter stated she next spoke to LPN A to ask if the discharge would still occur and LPN A told her to wait for a while and she would call her back when she found out. The daughter stated LPN A called back and informed her that her mother could be discharged as long as she saw her community physician in a couple days. The daughter stated when she arrived at the facility, her mother was in bed sleeping in a darkened room. She recalled going to the nurses' station to inform staff she was there and approximately ten minutes later they came to the room, turned the lights on, and awakened her mother. The daughter stated she then left the room and went to wait in the lobby where she saw the Administrator and she mentioned her mother's recent fall to him. The daughter stated nursing staff brought her mother out to the lobby about an hour later and they left the facility. Resident #1's daughter recalled on arrival at her parent's home she noticed her mother spoke in a very low voice. She explained her mother was diabetic and sometimes had episodes of low blood sugar, so she offered her food and a supplement drink before leaving the home. She recalled later that evening, the private sitter who cared for her parents called to say her mother was not acting like herself. The daughter said, I started thinking about it. I called the Administrator, and he told me he heard a little about the incident but had not read the report yet. He said if you are concerned maybe you should take her to the hospital. The daughter stated she drove to her parent's home to check on her mother and found her asleep in bed. She stated her mother was easily arousable and able to walk to the bathroom without assistance. She said, She seemed ok. I spoke to the caregiver [on Thursday] morning, and she said mom is fine. The daughter stated on Friday morning, 6/10/22, her mother had an appointment to see her community physician at 10:45 AM. However, early that morning, her father called to report that her mother was slurring her words. The daughter said, I told him to give her graham crackers and orange juice and I called 911. She stated her mother had a computerized tomography (CT) scan of her head in the hospital that showed a brain bleed, and she was transferred by ambulance to another hospital for brain surgery. Resident #1's daughter said, I am very sad and angry about the whole situation. I feel the facility did not do what they should have done for my mother after the fall. Review of a Fire Rescue Report revealed EMS personnel were dispatched to resident #1's home on 6/10/22 at 9:07 AM. The document indicated she had a fall on 6/08/22 and .husband stated she woke up in the morning and was not acting normal. Husband stated her speech was slurred and not making sense. On arrival, EMS personnel noted resident #1 had slurred speech and was unable to repeat phrases, and during transport to the hospital her speech became incomprehensible. The hospital record History of Present Illness dated 6/10/22 at 10:06 AM, revealed resident #1 was assessed by the Emergency Department (ED) physician who noted she was drowsy, provided the incorrect month and age, and had unintelligible speech. The note indicated she was a poor historian and generally poorly communicative - much which appears to be due to dementia. The ED physician was not aware resident #1's condition was a significant deviation from her baseline cognitive status. The result of a CT Brain Without Contrast done on 6/10/22 was communicated to the ED physician at 10:29 AM. The diagnostic test showed resident #1 had an acute left subdural hematoma with mass effect and midline shift. A subdural hematoma is a collection of blood under the membrane that covers the brain, which exerts increased pressure on the brain. This condition can be life-threatening, and is usually caused by bleeding associated with a severe head injury. Symptoms of a subdural hematoma can depend on the rate of bleeding. A person may appear normal for days after a head injury, but slowly become confused and then pass out several days later. This results from a slower rate of bleeding, causing a slowly enlarging subdural hematoma. (Retrieved on 10/07/22 from www.webmd.com/brain/subdural-hematoma-symptoms-causes-treatments). The hospital record included a Neurology Consult dated 6/10/22. The document revealed resident #1 was alert and keenly responsive but did not answer questions correctly. She had minor facial paralysis, slurred some words and could be understood with some difficulty at the time of the examination. The neurologist indicated resident #1's injury was likely traumatic in etiology and she would be transferred to a facility that could offer neurosurgical care. Review of the hospital record revealed on 6/10/22 at 10:53 AM, the physician at the receiving hospital recommended transferring resident #1 by air ambulance, but due to prohibitive weather conditions air transport was impossible. Resident #1 left the hospital approximately one hour later and was transferred to the receiving facility by ambulance. In interviews on 9/20/22 at 12:10 PM and 3:30 PM, the Director of Nursing (DON) stated neurochecks should be done when a resident hit his or her head. She explained the frequency and duration of neurochecks was specified in the Fall Response Worksheet instructions. The DON stated her expectation was that the physician or APRN would give a verbal or written order for neurocheck frequency if different from the facility protocol. The DON stated it was her understanding that resident #1 chose to leave the facility although the nurse practitioner tried to convince her to stay. The DON explained resident #1 had the right to refuse to remain in the facility. She acknowledged neither the APRN nor any member of the nursing department involved her in post-fall discussions and decision-making, and she was not made aware of any concerns about the resident's discharge home with a possible head injury and no diagnostic tests ordered. On 9/20/22 at 4:00 PM, the Administrator recalled speaking with resident #1's daughter in the lobby on the day of her discharge. He stated she informed him her mother fell and she hoped the fall would not affect her ability to move and walk. The Administrator stated later that evening resident #1's daughter called him to report that her mother did not feel well, was a little lethargic and complained of nausea. He explained he told the daughter he would recommend she took her mother to the hospital ED if she had concerns, and they scheduled a follow up telephone call with himself and the DON the following morning. The Administrator confirmed he was not a clinical professional, and he acknowledged he did not update or involve any clinical staff such as the DON, Medical Director, the resident's attending physician or the APRN regarding the symptoms described by resident #1's daughter during the telephone call. The Administrator said, We spoke to her the next morning at about 10:00 AM and she said mom had a good night and was feeling much better. The DON and the Administrator confirmed the facility did not have any documentation that reflected conversation(s) with the daughter, a description of the resident's symptoms post-discharge, recommendations or instructions given, and any follow up by the facility. The Administrator and DON could not recall how or when they were made aware of the severity of resident #1's head injury. On 9/21/22 at 9:06 AM, the DON confirmed in most cases, the facility sent residents who sustained actual or possible head injuries to the hospital for CT scans. She explained nurses definitely did neurochecks for 72 hours unless another timeframe was specified by the physician. The Regional Nurse Consultant (RNC) verified any unwitnessed fall should be treated as a possible head injury. She explained not all residents who hit their heads were sent out, as it depended on the circumstances, assessment findings and/or the physician's choice. The RNC said, If a resident is on a blood thinner, it's 99.9 % certain they will go out. She stated if a resident did not have a CT, neurochecks should be conducted for 72 hours. When informed resident #1 remained on two antiplatelet drugs and received neurochecks for less than four hours prior to discharge home, the RNC did not comment. The Administrator stated he felt the providers provided firm education and when the resident and daughter demonstrated understanding, the discharge took place. He could not explain why neither the daughter nor the resident recognized the symptoms of a brain bleed if they both received adequate education and showed full understanding of the content. On 9/21/22 at 10:51 AM, APRN C confirmed she was in the facility on 6/08/22 and assessed resident #1 soon after she fell . She stated she conducted a neurological assessment which she described as Not a full neuro, but I did the basics. APRN C stated she presented the resident with the options of going to the hospital for a CT scan, delaying the discharge and staying in the facility overnight, or going home and following up with her physician. She stated she did not consider rescinding the resident's discharge order or discuss the possibility of discharge against medical advice (AMA) with the resident. APRN C stated she had a discussion with the resident regarding self-monitoring for the possible changes she could experience from a head injury. She said, I would typically expect the patient to be able to recognize those signs. like nausea and vomiting. She was asked if the resident who hit her head and suffered a possible head injury with intracranial bleeding would be a reliable assessor of her own neurological changes which could include change in level of consciousness and difficulty in arousing herself. APRN C acknowledged if resident #1 were lethargic or sleeping too much she would not be able to identify the symptoms as signs of a head injury. She reiterated resident #1 was alert and oriented at the time of her assessment, made her own healthcare decisions and voiced understanding of the options and education provided. APRN C validated she never spoke to resident #1's daughter, but to her knowledge, LPN A relayed her recommendations to the daughter. She stated she was aware the resident was being discharged to her home where she lived with her husband who had dementia. APRN C was informed the nursing progress notes and discharge paperwork did not show the resident refused to follow treatment recommendations. She acknowledged she did not discuss the fall or the resident's alleged refusal to comply with the facility's fall protocol with the DON or the Medical Director prior to authorizing the resident's discharge home. APRN C said, There is no specific fall protocol I know of or any neurocheck protocol in the facility. On 9/21/22 at approximately 11:00 AM, the facility's Medical Director described the accepted standard of practice for any patient in any setting who suffered a fall with a possible or known head injury. The Medical Director said, I would advise the patient has to be watched. He stated after a head injury, there could be bleeding inside the skull that affected the brain. He explained someone could fall during the day, hit his or her head and seem normal, but later that night have changes in the pupils or mental status, headache, nausea, or vomiting. The Medical Director stated he would not necessarily hold blood thinner medications, but after an unwitnessed fall an immediate CT scan was required to rule out bleeding in the brain. He acknowledged resident #1 should have remained in the facility and/or had a CT scan of the head. He stated he sometimes had patients who refused treatments, and he made efforts to avoid AMA discharges that would impact the patient's ability to obtain necessary healthcare services after discharge. He said, Instead, I go to the patient, and I explain why it is necessary and beneficial to follow through with treatments. The Medical Director explained this approach was usually effective. He verified he was easily accessible to all facility providers and administration and said, If I had been called I would have come to the facility to talk to the patient and family about the risks of not doing a CT. The Medical Director stated he reviewed APRN C's progress note which indicated resident #1 was presented with options related to her care and the resident and her daughter were educated on the symptoms of a head injury that would require ED care. The Medical Director was informed despite APRN C's documentation of that education, resident #1 never called EMS and her daughter treated her for signs and symptoms of [CONDITION(S)] or low blood sugar. The Medical Director validated the signs of increased intracranial pressure from a head injury could mimic symptoms of low blood sugar. Review of a practitioner's note dated 6/08/22 revealed resident #1 was assessed by APRN C after a fall prior to discharge home from the facility. APRN C wrote, .the patient reported that she hit her head.patient remained stable for discharge at this point. The note indicated resident #1 was presented with three options, to stay in rehab for an additional day, get a CT of the head, or present home as scheduled and see her community physician that week. APRN C noted the resident opted to go home as planned and after discussion of the plan with the resident's daughter, she was agreeable. However, the note did not indicate resident #1 refused to comply with post-fall protocols and recommendations after a thorough explanation of the risks and potential complications of an untreated head injury. The note read, Of note, patient is on [names of two blood thinning drugs]; also educated the patient and daughter that if she develops any acute symptoms of headache, [nausea/vomiting], etc to present to the ED for further evaluation. The document was electronically signed on 6/09/22 at 2:57 PM, approximately 24 hours after resident #1 was discharged from the facility, and after the facility had been notified by the daughter of the resident's symptoms including nausea. Review of nursing Progress Notes dated 6/08/22 revealed no documentation by LPN A or other facility staff to indicate resident #1 was offered different options for care and services, and no evidence she refused APRN C's recommended post-fall interventions. A Post-Discharge Note dated 6/09/22 at 9:34 AM revealed resident #1's daughter called the facility to confirm she made an appointment with the community physician for her mother on 6/10/22 at 10:45 AM, within two days as directed by APRN C. Review of the Minimum Data Set Discharge-return not anticipated assessment, with assessment reference date of 6/08/22 revealed resident #1 had a planned discharge to the community. Her Brief Interview for Mental Status score was 15 which indicated she was cognitively intact. The MDS assessment revealed the resident did not reject evaluation or care .that is necessary to achieve the resident's goals for health and well-being in the seven day lookback period before she was discharged . On 9/22/22 at 9:46 AM, in a telephone interview with resident #1's daughter, she stated she was never informed of any options regarding extending her mother's stay in the facility or transferring her to the hospital for a CT. She stated she could easily have accommodated those options and picked her mother up later that day or on the following day. The daughter emphasized that she never had any conversations with either the APRN or LPN A regarding symptoms of a head injury related to her mother's fall. She said, I never told anyone I was a medical professional. She stated she assessed her mother to the best of her ability, and if she had significant concerns prior to the morning her mother's words were slurred, she would have called EMS as she did on the morning of 6/10/22. The daughter said, I was not thinking about her head.I absolutely would have acted differently that night if I knew the symptoms.I wish I could have known the things I know now. On 9/22/22 at 12:48 PM, the DON stated she would have expected nursing staff to notify her about the resident's fall and any concerns regarding the discharge order. The DON said, I did not know all the pieces at the time she left. She was informed APRN C was not aware the facility had protocols for falls and neurochecks. The DON confirmed she was the facility's clinical nursing leader. but she did not know if or how physicians and other clinical professionals were oriented to facility protocols, policies, and procedures. She did not respond when asked how the facility ensured the wide variety of providers from different specialty areas adhered to and worked within expected facility guidelines and collaborated effectively with nursing staff. On 9/22/22 at 4:40 PM, the Administrator was asked how the facility ensured all independent practitioners were oriented to the facility's culture, specific clinical protocols, and regulatory requirements. He provided a document titled Licensed Independent Practitioner Orientation Information dated 2022. The document indicated practitioners' responsibilities included following facility protocols and procedures. The packet included a Code of Conduct revised on 4/01/22 that read, The Company is committed to providing care in strict compliance with all applicable laws, regulations and standards related to patient care. On 9/22/22 at 3:37 PM, in a telephone interview with resident #1, she recalled she slipped, fell and hit her head on the footboard of her bed on the day she was discharged from the facility. She stated staff responded immediately and she told them she hit the back of her head. The resident stated she told an unknown nurse she felt strange in her head and wanted to lie down, and she was told that was a good idea. Resident #1 said, I feel they fluffed me off.The next thing I remember was when they woke me up and told me it was time to go home. Resident #1 was informed her medical record and an interview with APRN C indicated she was offered a transfer to the hospital and the option to remain in the facility overnight, but she refused both. Resident #1 said, I don't remember, but if she said so maybe it is so, but I don't think anybody ever discussed all that with me. If it was my facility, I would have done things differently. I thought it was strange that they didn't get an x-ray of my head. The resident stated she remembered the drive home from the facility, but not much after that except the ambulance ride to the hospital. She said, This whole experience, it has taken a lot of things for me. My speech was slurred for a while. It affected my memory, even now I have a hard time remembering details. I have to struggle hard to bring back some things. I have to think hard to find words. I know what I want to say but I can't find the right words. I go blank in my memory bank sometimes. It's awful! The resident was informed APRN C, her attending physician, the DON and other facility staff mentioned they heard she fell at home after she was discharged from the facility. Resident #1 denied any other falls and said, You may not want my opinion, and it's only my opinion, but after all [name of the facility] said happened and how it happened, I feel they will go to any lengths to lie and cover up to protect themselves. Review of the job description for the Administrator, revised on 3/15/18, revealed he/she would ensure quality and appropriate resident care that met or exceeded regulatory standards. The job description for the Director of Nursing, revised on 2/20/18, indicated he/she was responsible for the overall direction, coordination and evaluation of nursing care and services. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 6/08/22, resident #1 was evaluated by the APRN after an unwitnessed fall. The APRN determined the resident remained stable for discharge and denied any issues on a 14 point review of systems. *On 9/21/22 during stand-down meeting, the facility conducted an Ad Hoc Quality Assurance and Performance Improvement (QAPI)committee meeting on the discharge planning process. *On 9/22/22, the DON, Assistant DON (ADON), and Staff Development Coordinator (SDC) completed education with the licensed nurses on the discharge planning process. Residents who have fallen prior to discharge will have their discharge placed on hold for 72 hour to determine the need for further medical intervention. *On 9/22/22, the facility achieved 100% compliance with education of licensed nurses with verbal acknowledgement of the education. *On 9/22/22, the facility initiated retention questionnaires for licensed nurses related to rescinding discharge orders when a resident has had a fall within 72 hours of discharge to determine need for further medical attention. *On 9/22/22 during the daily morning meeting, the interdisciplinary team discussed the Ad Hoc QAPI meeting findings to identify any further opportunities. *As of 9/22/22, residents to be discharged will be provided with written discharge instructions by Social Services. *As of 9/22/22, newly hired employees will be educated on the discharge planning process prior to their first worked shift. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on the topics listed above. On 9/22/22, interviews were conducted with seven nurses, six LPNs and one Registered Nurse, who verbalized understanding of the education provided.<[TRUNCATED]

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected fall history for 1 of 4 residents reviewed for falls, of a total sample of 8 residents, (#1). Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Notes from April to June 2022 revealed resident #1 fell twice during her stay in the facility. The first fall was documented in a No Type Specified note dated 5/24/22 at 6:02 PM that read, . observed resident sitting on floor. The second fall was described in an Occurrence Note dated 6/08/22 at 11:57 AM that read, . resident noted to be in sitting position with both legs out in front of her. Review of the MDS Discharge assessment - return not anticipated with assessment reference date of 6/08/22 revealed resident #1 had a planned discharge to the community setting. Section J1800 of the assessment showed resident #1 fell since admission or the prior assessment. Section J1900 was completed on 6/09/22 and indicated resident #1 had one fall with no injury. The document was signed by the Director of Nursing (DON) on 6/16/22 to verify completion of the assessment. On 9/22/22 at 3:56 PM, the Lead MDS Coordinator was informed resident #1's MDS Discharge assessment did not reflect the two falls noted in the medical record. She explained MDS nurses reviewed incident reports and progress notes for information on falls. She stated there was also verbal communication regarding residents' falls in daily clinical meetings. On 9/22/22 at 4:22 PM, MDS Coordinator B confirmed she completed Section J of resident #1's MDS Discharge assessment. She acknowledged the document was inaccurate as it reflected only one fall. She explained she usually reviewed all Occurrence Notes to identify any falls and associated injuries, and then double-checked for accuracy by reviewing incident reports. MDS Coordinator B stated the accuracy of MDS assessments was important to ensure residents received appropriate care and services and benefited from continuity of care. The Lead MDS Coordinator provided the documents used to complete resident #1's assessment. She explained MDS Coordinator B did not capture the fall on 5/24/22 as the nurse who entered the note did not select the Occurrence Note category, therefore the incident did not show on either of the reports reviewed. On 9/22/22 at 4:40 PM, the DON stated her expectation was MDS nurses would identify falls by reading all progress notes instead of pulling selective reports. Review of the facility's policy and procedure for Resident Assessment Instrument (RAI) Process revised on 3/27/18 revealed the RAI process was used to determine residents' needs and to evaluate achievement of goals. The document indicated the facility would utilize different sources of information including communication with staff and review of the medical record. The policy revealed each interdisciplinary team member would review the entire MDS assessment and validate its accuracy before it was finalized.

Based on observation and interview, the facility failed to ensure food and drink items were labeled, dated, and within date of expiration in 2 of 2 nourishment rooms (East Wing and West Wing), failed to ensure the microwave was maintained in clean, sanitary condition and in good repair in 1 of 2 Nourishment Rooms (West Wing), and failed to ensure foods were not expired in the milk cooler in the main kitchen. Findings: 1. On [DATE] at 1:48 PM, the East Wing Nourishment room freezer was noted with an open 1 liter water bottle with no name and no date. On [DATE] at 1:53 PM, Licensed Practical Nurse (LPN) A said she was not sure who was responsible to clean the refrigerator and freezer. She acknowledged the water bottle with no name, no date, and no label should have been discarded. 2. On [DATE] at 1:58 PM, the West Wing Nourishment room refrigerator had a box of powdered donuts was opened with 8 donuts remaining. The box of donuts had an expiration date of [DATE]. There was no name, or date on the box of donuts. The microwave in the West Wing Nourishment room was dirty with caked on food on all interior surfaces including the door. There were patches of rust on the inside left front corner and the door casing of the microwave. On [DATE] at 2:03 PM, LPN B picked up the box of donuts and acknowledged it did not have a name or date. LPN B stated the donuts were expired and should have been discarded. LPN B examined the microwave and noted the rust. He verbalized the microwave was dirty with splattered food. LPN B said he cleaned out the refrigerator on the weekend and dietary staff were responsible for cleaning the refrigerator and microwave during the week. On [DATE] at 2:37 PM, the Director of Nursing (DON) and the Dietary Tech said dietary staff stocked the refrigerators with fluids and milk but nursing staff were responsible to ensure the fluids and food were not expired. On [DATE] at 2:50 PM, the DON said the Unit Managers checked the nourishment rooms daily but did not explain why the microwave was in dirty condition and why refrigerators contained unlabelled and expired foods. Both the Certified Dietary Manager (CDM) and DON said there was no policy and procedure or designation in writing to show who was responsible for cleaning the microwaves or refrigerators. 3. On [DATE] at 9:34 AM, the initial tour of the kitchen was conducted with the CDM. During the initial tour, the milk cooler had two half gallons of lactose free milk with an expiration date of [DATE]. The CDM did not provide an explanation as to why the expired milk was still in the cooler. Review of the facility's Food Storage Principles policy, documents, . Procedure . 3. Label each package, box, can, etc. with date of receipt, and when the item was stored after preparation. a. Discard foods that have exceeded their expiration date. b. Discard leftover foods that have not been used within 72 hours of preparation .

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected injectable anti-diabetic medications prescribed for 2 of 19 residents, of a total sample of 54 residents, (#64 & #4). Findings: 1. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] refers to high levels of sugar or glucose in the blood (retrieved on 3/12/21 from the U.S. National Library of Medicine website at www.medlineplus.gov). Resident #64's MDS quarterly assessment with assessment reference date (ARD) of 2/08/21 revealed she received insulin injections on 7 of 7 days in the look-back period. Review of resident #64's medical record revealed a physician's orders [REDACTED]. This anti-diabetic drug increases the amount of insulin produced by the body, but it is not classified as insulin (retrieved on 3/12/21 from www.drugs.com). 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS admission assessment with ARD of 12/08/20 revealed she received an insulin injection on 1 of the 7 days in the look-back period. Review of resident #4's medical record revealed a physician's orders [REDACTED]. This drug is similar to a naturally occurring hormone in the body. It controls blood sugar, insulin levels and digestion, but is not classified as insulin (retrieved on 3/12/21 from www.drugs.com). On 3/10/21 at 3:35 PM, the MDS Coordinator (Resident Care Specialist) reviewed the MDS assessments, physician's orders [REDACTED].#64 and #4. The MDS Coordinator stated resident #64 had an order for [REDACTED].#64's quarterly assessment with ARD of 2/08/21 and resident #4's admission assessment with ARD of 12/08/20 erroneously indicated they received insulin. The MDS Coordinator stated the Resident Assessment Instrument (RAI) manual provided instructions on coding different types of drugs. She provided page N-3 of the RAI Version 3.0 Manual which included section N0350: Insulin. The document directed MDS staff to review residents' MARs for the 7-day look-back period, and Count the number of days insulin injections were received. She explained the facility had 3 full time MDS nurses and corporate staff who conducted random audits of MDS assessments for accuracy, but the errors had not been identified. The facility's policy and procedure Resident Assessment Instrument (RAI) Process revised on 3/27/18, revealed the MDS assessment was the basis of the comprehensive assessment and guided the development of individualized care plans for all residents. The document read, Before finalizing the completed MDS, each member of the interdisciplinary team reviews the entire MDS assessment for accuracy.

Based on observations, interviews, record review, policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility did not ensure appropriate infection control measures were implemented in regards to proper use of personal protective equipment (PPE) for 2 of 26 residents on enhanced droplet precautions (#99, #106), and failed to contain contaminated resident care supplies, (#99). Findings: 1. Review of resident #106's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the resident's plan of care for isolation precautions, dated 03/10/21, revealed isolation precautions as ordered, monitor for signs/symptoms of infection and to disinfect all equipment used before it leaves the room. Review of the facility's Order Listing Report revealed 26 residents were on enhanced droplet precautions related to monitoring for COVID-19 symptoms. On 03/09/21 at 10:40 AM, resident #106's room door was observed to be closed with a plastic container containing PPE (gowns, gloves, and masks) and a sign that indicated she was on enhanced droplet precautions. The sign noted to perform hand hygiene before entering and leaving the room and the use of a gown, facemask, and gloves while in the room, and to keep door closed. Resident #106 was observed sitting in her wheelchair and Physical Therapy Assistant (PTA) E was standing beside the resident without wearing gown or gloves. PTA E stated he was aware that resident #106 was on enhanced droplet precautions and he was required to wear a gown and gloves while providing resident care. I was in her room hurrying to get her ready for her [MEDICAL TREATMENT] appointment. PTA E stated he had been educated on infection control, isolation and the use of PPE for residents that required isolation precautions. I treat a lot of residents in their rooms and I should have had a gown and gloves on to prevent the spread of infection from resident to resident. On 03/11/21 at 10:45 AM, the Rehabilitation Manager stated the rehabilitation staff had received education/inservice for infection control, COVID-19, hand hygiene, isolation and the proper use of PPE. The Rehabilitation Manager said all therapy staff were expected to follow the facility's policy and procedure for isolation precautions. There is no question that PPE is to be worn at all times while in an enhanced droplet precaution room. PTA E should have been wearing the proper PPE while treating resident #106. On 03/11/21 at 11:15 AM, the Staff Development Coordinator (SDC) stated that 100% of all facility staff had received inservice/education and competencies for infection control, COVID-19, hand hygiene, isolation precautions and proper PPE use. At this point no staff should be in an enhanced droplet precaution room without the proper use of PPE. The SDC said PTA E had attended the facility inservices and completed competencies to ensure compliance with isolation precautions and proper PPE use. Review of the facility's In-Service Report sign in forms revealed PTA E had attended and signed for the following inservices: On 07/08/20 at 7:30 AM, Make sure you are wearing proper isolation PPE when going in a resident's room. On 01/19/21 at 7:30 AM, All new admissions will be on enhanced droplet precautions for 14 days. All staff must wear full PPE including N95 mask when in resident's room, no gowns are to be reused, mask, eyewear, face shields/goggles at all times. On 01/26/21(no time), If patients are on enhanced droplet precautions you must wear gown, gloves, face shield/goggles and mask at all times in resident room even if resident is not present at the time. On 02/21/21 at 8 AM, Enhanced droplet rooms require the use of N95 or higher, gowns, gloves and eyewear upon entering. On 03/09/21 at 7:45 AM, All admissions are on enhanced droplet precautions for the first 14 days, you must wear gown, gloves, mask and eyewear at all times in the resident's room. Review of the PPE Surveillance Competency Audits dated 07/01/20, 11/02/20 and 01/19/21 documented PTA E had met criteria for PPE set up. Donning PPE: 1. Hand hygiene completed prior to donning PPE, 2. Appropriate PPE used for diagnosed isolation, 3. Put on gown then gloves sequence, 4. PPE used correctly, 5. PPE worn only inside isolation room. Doffing PPE. On 03/11/21 at 3:21 PM, the Infection Control Practitioner Officer (ICPO) stated that all staff have received inservice and education for infection control, COVID-19, hand hygiene, isolation precautions and proper use of PPE. Competencies and audits are on-going to ensure compliance with the facility's infection control policy and procedures. All new admissions (14 days) or residents going out of the facility 2-3 times a week for [MEDICAL TREATMENT] are placed on enhanced droplet precautions due to potential exposure in the community and monitoring for COVID-19 signs and symptoms. The ICPO stated, All facility staff are required to adhere to the use of proper PPE which includes mask, gown, gloves, eyewear/goggles when in an enhanced droplet precautions room. PTA E should have had a gown and gloves on while in resident #106's room. Our goal is to contain and prevent the spread of infection to other residents in the facility. Review of the facility's Personal Protective Equipment Policy, revised October 2018, revealed that PPE includes gowns, gloves, masks and eyewear and the type of PPE required is based on the type of transmission-based precaution. Review of the facility's Isolation-Categories of Transmission-Based Precautions Policy, with revised date 03/13/2020, revealed that droplet precautions is implemented when a resident has documented or suspected to be infected with microorganisms that can be transmitted by droplet. Masks are to be worn and gowns, gloves and goggles should be worn if there is a risk of spraying of respiratory secretions. 2. On 03/09/2021 at 10:47 AM, Certified Nursing Assistant (CNA) C was observed pushing the hydration cart on the East Wing A-hallway. The East Wing A-hall began with room [ROOM NUMBER] and ended with room [ROOM NUMBER]. CNA C filled the hydration cups for rooms 109, 110, 111, 112 and then made her way to resident room [ROOM NUMBER], resident #99's room. Resident #99's room was the only room on this hallway that had droplet precaution sign on the door and a hanging rack with personal protective equipment (PPE). CNA C wore mask and goggles. She donned a gown and proceeded to go into resident #99's room without donning gloves. She picked up the small, clear, plastic, five ounce hydration cup that was half full with water and brought it out of the room into the hallway to the hydration cart. CNA C held the cup with her bare hand over the open ice chest. She scooped ice into the cup trying not to spill the water over the sides. The ice chest was half full of ice. At this time, CNA C acknowledged the droplet precaution sign on the door. CNA C said, I only need to wear a gown, I don't need to wear gloves unless I am doing patient care. She added, I'm sure she touched the cup, but I only brought the cup out of the room, I didn't touch the resident. CNA C again stated she did not need to wear gloves since she was not doing direct patient care. CNA C said she had infection control training from the facility. On 03/09/21 at 10:53 AM, the East Wing Unit Manager (UM) stated resident room [ROOM NUMBER] had two residents that received [MEDICAL TREATMENT], and were on droplet precautions. The UM acknowledged that mask, gown, goggles, and gloves were required to be worn when entering the rooms of residents on droplet precautions. The UM noted CNA C had not demonstrated the correct procedure for entering an isolation room and for filling up the cups. He said,no, that procedure was wrong, the whole cart is contaminated now. Reviewed of CNA C's PPE Surveillance Competency Audit dated 06/30/2020, 08/24/2020, 10/31/2020, 11/02/2020, 01/04/2021, 01/28/2021, 02/02/2021, 02/16/2021 documented, that CNA C had met the competency for .PPE set up, Donning PPE and Doffing PPE. Donning PPE included, . 2. Appropriate PPE used for diagnosed isolation. 3. Put on gown, then gloves sequence. 4. PPE correctly used. 5. PPE worn only inside isolation room. Doffing PPE: 1. PPE removed within isolation room. 2. Removed gown, then glove sequence .

Based on observation, interview and record review, the facility failed to maintain patient care equipment in a clean and safe operating condition for 4 of 6 residents reviewed for oxygen therapy out of 23 total sampled residents with oxygen concentrators. (#12, #28, #78, #99). Findings: Resident #99 was a long term care resident who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #99 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS also identified the resident required oxygen (O2) therapy. Review of resident #99's care plan documented she had impaired gas exchange and ineffective airway clearance related to [MEDICAL CONDITION] with a goal to remain free from complications concerning impaired gas exchange. An intervention on the care plan included to administer respiratory therapy as ordered. Review of the physician's orders [REDACTED]. Observations of resident #99's O2 concentrator on 03/08/2021 at 4:54 PM, 03/09/2021 at 10:40 AM, 03/10/2021 at 4:52 PM, revealed both the O2 concentrator's air filters were dirty and filled with dust. On 03/11/21 at 10:17 AM, Licensed Practical Nurse, (LPN) A stated resident #99's O2 tubing was changed every Tuesday on the 11-7 shift. She stated only nurses changed the tubing. She said, Central supply and some company comes in to service the concentrators. On 03/11/21 at 10:25 AM, the East Wing Unit Manager said that the oxygen service company serviced the O2 concentrators before, now, for last couple of weeks the facility cleans the filters. They get checked every Tuesday when we change the O2 tubing. 2. Review of resident #12's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident's plan of care included risk for impaired gas exchange/ineffective airway clearance related to acute [MEDICAL CONDITION] and acute exacerbation of [MEDICAL CONDITION]. Interventions included to provide oxygen as ordered, non-invasive ventilation and to monitor for respiratory distress. Observations conducted on 03/08/21 at 4:13 PM, 03/09/21 at 10:20 AM, 03/09/21 at 4:10 PM, 03/10/21 at 09:50 AM, and on 03/10/21 at 3:30 PM revealed the oxygen concentrator's left external filter was completely covered with gray dust and the right external filter was missing. The opening where the right external filter was missing was covered with gray dust and was pulling room air into the concentrator without being filtered. 3. Review of resident #28's medical record documented she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The admission comprehensive assessment dated [DATE] documented she was cognitively intact and received oxygen therapy. The resident's plan of care dated 01/14/21 included altered cardiovascular status with interventions to provide oxygen as ordered and to monitor for shortness of breath and changes in lung sounds. Observations conducted on 03/08/21 04:36 PM, 03/10/21 at 10:20 AM, 03/10/21 at 2:43 PM, and 03/11/21 at 9:45 AM revealed the oxygen concentrator's left and right external filters were covered with gray dust. 4. Review of resident #78's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The significant change comprehensive assessment dated [DATE] documented she had moderate cognitive impairment and received oxygen therapy. The resident's plan of care included impaired gas exchange/ineffective airway clearance related to obstructed sleep apnea. Interventions included oxygen as ordered and to monitor for respiratory distress. Observations conducted on 03/09/21 at 10:02 AM, 03/10/21 at 10:00 AM, 03/10/21 at 2:25 PM, and on 03/11/21 at 9:30 AM revealed the oxygen concentrator's left and right external filters were covered with gray dust. On 03/10/21 at 12:20 PM, Licensed Practical Nurse (LPN) A stated that all oxygen and nebulizer equipment was changed on Tuesday by the 11 PM- 7 AM nurse. The Central Supply person tracked the oxygen concentrators. LPN A said the the oxygen concentrator company came to the facility and was responsible for cleaning and changing the concentrator filters. On 03/11/21 at 11:55 AM, the Central Supply staff member stated the housekeeping staff were responsible for cleaning the oxygen concentrators. The 11 PM - 7 AM nurses change the oxygen tubing on Tuesday/Wednesday nights on the 11 PM-7 AM shift. Central Supply staff then stated, The filters were being cleaned and changed by the oxygen concentrator company but since COVID-19 they have not been coming to the facility so the nurses are responsible for cleaning the oxygen concentrator filters. On 03/11/21 at 12:00 PM, an interview was conducted with the the Director of Nursing (DON), the Administrator and the Central Supply staff. The DON stated the oxygen concentrator filters removed and prevented dust, particles and bacteria from entering into the resident's lungs. The Central Supply person tracks the oxygen concentrators and housekeeping is responsible for the cleaning the oxygen concentrators. The DON said, The filters should not be dirty to ensure the concentrator is performing properly. The Administrator stated the oxygen concentrator company came to the facility monthly to provide concentrator maintenance and to change and clean the filters. Central Supply stated, They used to come in and clean the filters but since COVID-19 started they have not come into the facility. The nurses are responsible for cleaning the filters. The Administrator stated, I was under the impression the oxygen concentrator company was still coming in to clean the filters. The DON stated, I was not aware of any of these changes. On 03/11/21 at 12:10 PM, an observation of resident #12's oxygen concentration was conducted with the DON. The DON acknowledged the left external concentrator filter was covered with gray dust and the right external concentrator filter was missing. The DON then pulled a thick layer of gray dust out of the right filter opening. At 12:15 PM, the DON acknowledged that the left and right external filters were covered with gray dust. At 12:20 PM, an observation of resident #28's oxygen concentrator filters was conducted with the DON. The DON confirmed the left and right external filters were covered with gray dust. At 12:30 PM, an observation of resident #99 oxygen concentrator filters was conducted with the Administrator. The Administrator noted the the left and right filters were covered with gray dust. Review of the respiratory log provided by the facility revealed 23 residents were receiving oxygen therapy via an oxygen concentrator. Review of the oxygen company's visitation log provided by the Administrator revealed the last visit to the facility was on 05/14/20. Review of the Facility's Oxygen Administration via Concentrator Policy, revised 04/24/2018, revealed the purpose of the concentrator is to deliver oxygen to the resident by a licensed nurse or respiratory care practitioner and to follow the Manufacture's instruction for use. Review of the Facility Assessment Tool, not dated, revealed the facility is competent to provide care and services in a safe manner to residents requiring equipment for oxygen therapy. According to www.drugs.com/cg/using -oxygen-safely, not dated, read, . an oxygen concentrator takes nitrogen gas and other things out of regular air. This leaves only the oxygen from the air. This oxygen is stored in the container and given it back to you through a mask or cannula. Check the air inlet filter to make sure it is in place and clean . Wash it in soap and water if it is dirty. Then rinse it, pat it dry, and put it back on the machine.

Based on observation, interview and record review, the facility failed to ensure that independent activities provided to residents were safe and free of potential choking hazards for 1 of 8 residents sampled for accidents, (#259). Findings: Resident # 259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nursing admission note dated 8/5/19 noted the resident was alert and had moderate confusion. A nursing progress note dated 8/7/19 at 2:53 PM revealed the resident was confused. The resident's diet order was mechanical soft texture. On 08/14/19 at 10:25 AM, resident #259 was observed in her room sitting in her wheelchair. She had an activity blanket in front of her. The blanket was multicolored with zippers, and beads. The resident was observed taking a red bead and putting it into her mouth. The License Practical Nurse (LPN) A was in the room at the time getting ready to administer the resident's medications. The LPN A asked the resident to spit out the bead but the resident continued to chew on the bead. The LPN A attempted to remove the bead from the resident's mouth but was unable to do so. At this time, Certified Nursing Assistant (CNA) D was walking past the resident's door and the LPN A called her to assist with the removal of the bead. Both the LPN A and CNA D managed to get the resident to open her mouth and CNA D removed the bead from the resident's mouth with her gloved hand. The red bead was round and approximately 1 inch in diameter. The LPN A stated that she was thankful the resident did not choke on the bead. On 08/14/19 at 10:45 AM CNA D stated that the resident had pulled off all the 4 beads which were attached onto the activity blanket. The resident had 4 loose red beads on her lap. The CNA D said that she needed to remove the activity blanket from the resident right away. On 08/14/19 at 1:18 PM, the Activity Director stated that based on cognition and family input, she provided the resident with the blanket for independent activity. The blankets were made by volunteers and she inspected them before use. She stated that she did not expect the resident to pull the beads from the blanket and put them in her mouth. She gave the activity blanket to the resident as it was the family's preference as the resident constantly fiddled with her hands. A review of the activity care plan dated 8/06/19 listed the activity blanket as an intervention as per family preference for the resident.

Based on observation, interview and record review, the facility failed to implement proper safety precautions for 1 of 1 resident receiving enteral feedings of a total of 44 residents, (#48). Findings: Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment with reference date of 07/07/19 for significant change in status, revealed that resident #48 was severely impaired cognitively and had a feeding tube. The physician order [REDACTED].#48 had orders for enteral feedings every shift of [MEDICATION NAME] 1.5 @ 45 milliliters per hour continuously, ordered 04/26/19. An order dated 01/25/19 was to elevate the head of bed at least 45 degrees at all times every shift. The care plan initiated on 07/18/18 revealed that resident #48 required tube feedings related to dysphagia. The interventions included, elevate HOB (head of bed) at least 45 degrees at all times. On 08/12/19 at 3:05 PM, resident #48 was observed laying flat in bed while asleep. The head of the bed was not elevated. Her enteral feeding of [MEDICATION NAME] 1.5 was running at 45 milliliters (ml) per hour. The East Wing Unit Manager was called to the resident's room. He acknowledged that the head of bed was not elevated and stated that the head of bed should be elevated when the resident was receiving enteral feedings. On 08/15/19 at 2:27 PM, Licensed Practical Nurse (LPN) C stated that she had started the enteral feedings for resident #48 in the morning of 08/12/19 at 9:00 AM and had elevated the resident's head of bed at 45 degrees. She said that when the certified nursing assistants (CNA) had to provide care to the resident, they would have to lower the head of the bed. They had to first call the nurse to temporarily hold the feedings. She could not remember any CNA notifying her to put the feeding on hold between 11:30 AM to 3:00 PM on 8/12/19. According to the Journal of [MEDICATION NAME] and Enteral Nutrition, Volume 33, No. 2, March/April 2009, elevate the backrest to a minimum of 30 degrees, and preferably to 45 degrees, for all patients receiving enteral nutrition .

Based on interview and record review the facility failed to obtain physician's orders on admission, to ensure the provision of immediate care and services for 1 of 11 sampled residents (#1). Findings: Resident #1 was admitted to the facility on [DATE] for rehabilitation following right knee arthroscopic surgery. His [DIAGNOSES REDACTED]. On 3/20/19 at 8:57 AM, resident #1 stated he was transported from the hospital to the facility via wheelchair van. Resident #1 described the 50 to 60 minute trip as uncomfortable because his right leg was moving all over as he bounced around in the van on the way to the facility. Resident #1 explained he asked licensed practical nurse (LPN) A for pain medication on arrival to the facility at about 6:30 PM. He stated he was told his medication was not available because the hospital did not send any paperwork regarding his orders. He stated the facility nurses told him they were not able to do anything about his pain, and suggested he ask his wife to bring his home medication. Resident #1 explained while he waited for the nurses to get his orders, he attempted to contact the facility's Director of Admissions. He stated she arranged his transfer from the hospital and admission to the facility, and he believed she might have been able to intervene to get the missing paperwork. Resident #1 stated the facility finally obtained the medication orders from the hospital at about 9:00 PM. He described his pain as excruciating, and stated the nurse did not complete the process of getting his medication until almost 1:00 AM. Review of the hospital Home Medication List for resident #1 revealed the document was faxed from the hospital to the facility on [DATE] at 8:51 PM. The list included a physician's order for [MEDICATION NAME] 10 milligrams (mg) every 4 hours as needed for severe pain, levels 7 to 10. The list indicated resident #1 received his last dose of [MEDICATION NAME] 10 mg in the hospital at 1:36 PM. The numeric pain scale is commonly used by patients to rate their pain level on a scale of 0 to 10. A pain level of 0 means no pain, and a pain level of 10 means worst pain ever. (www.medscape.com) On 3/20/19 at 5:07 PM, LPN A recalled resident #1 arrived from the hospital at about 6:30 PM, shortly before the end of his shift. LPN A stated resident #1's admission packet was missing important paperwork such as the 3008 transfer form, prescriptions and discharge orders with a medication list. He explained without orders he was unable to complete the admission process or access any medication for resident #1. LPN A stated before he left the facility, he contacted the Director of Admissions regarding the missing medication list and prescriptions and gave report to RN B, the oncoming night nurse. On 3/20/19 at 5:40 PM, the director of nursing (DON) confirmed resident #1 arrived at the facility without medication orders. The DON acknowledged resident #1 could not receive medications or other services without orders. She said, Unfortunately, the attending physician will not order a narcotic pain medication without orders from the hospital. The DON stated her expectation in that situation was that the nurse would have started the process to obtain orders by immediately contacting the attending physician. The DON reviewed her phone and confirmed she did not have any text message communication from LPN A or RN B regarding the missing orders. She stated if RN B was unable to obtain orders to treat resident #1, a reasonable intervention would have been to send him back to the hospital. On 3/20/19 at 5:59 PM, RN B stated she was resident #1's assigned nurse on the night of his admission. She said, I did not have anything as far as orders. RN B confirmed resident #1 complained of pain and she attempted non-pharmacologic pain management interventions. She said, I think that I offered everything I was able to offer. I followed policy as best as I could. She explained she received the medication list from the hospital at about 9:30 PM but still did not have prescriptions. RN B acknowledged although she had no admission orders [REDACTED]. On 3/20/19 at 6:11 PM, the assistant director of nursing (ADON) stated LPN A called her regarding resident #1's arrival without orders and she advised him to reach out to the Director of Admissions for assistance. The ADON acknowledged that although resident #1 had an ice machine for knee discomfort and swelling, there were no orders for this treatment. She stated the Director of Admissions could probably have been more diligent with assisting to resolve the issue. The ADON acknowledged the Medical Director might have been able to intervene by calling either the attending physician or the hospital. She said, We don't know because she was never contacted. The ADON validated there were several potential dangers related to having a resident in the facility with no orders. She explained there could be a delay or inability to treat emergent issues and meet the resident's immediate needs. On 3/21/19 at 2:33 PM, the Director of Admissions acknowledged she received a telephone call regarding resident #1's arrival at the facility without all the necessary paperwork. She explained the hospital case managers were not available after 5:00 PM, but there was a hospital house supervisor. The Director of Admissions stated she did not call the hospital to intervene when she was made aware of resident #1's arrival without the necessary paperwork. She explained she usually reviewed the orders and got report from the hospital nurse before residents were transferred to the facility. However, the Director of Admissions admitted she did not do this for resident #1. She stated the hospital should have sent the facility a pre-admission packet of information for resident #1, including a 3008 transfer form and final medication list prior to his arrival. On 3/21/19 at 2:48 PM, the Social Services Coordinator (SSC) stated prior to a new admission's arrival she received the pre-admission paperwork described by the Director of Admissions. She stated she was responsible for taking the paperwork to the nurses' station. The SSC confirmed resident #1's transportation was arranged while she was in the facility, but she left before he arrived. She did not recall receiving any pre-admission paperwork for resident#1 before she left the facility for the day. Review of the Order Recap Report and the Medication Administration Record [REDACTED]. The order was entered on 1/04/19 at 11:30 PM, 5 hours after resident #1 arrived at the facility. The MAR indicated [REDACTED]. The facility's policy and procedure Pain Evaluation revised on 8/23/16 revealed nurses were expected to Contact the physician for orders if residents reported or demonstrated signs and symptoms of pain.

Based on interview and record review, the facility failed to adequately treat self-reported, severe pain in a timely manner for 1 of 11 sampled residents (#1). Findings: Resident #1 was admitted to the facility on [DATE] for rehabilitation following total right knee arthroscopic surgery. His [DIAGNOSES REDACTED]. On 3/20/19 at 8:57 AM, resident #1 stated he was transported from the hospital to the facility via wheelchair van. Resident #1 described the 50 to 60 minute trip as uncomfortable because his right leg was moving all over as he bounced around in the van on the way to the facility. Resident #1 explained he asked licensed practical nurse (LPN) A for pain medication on arrival to the facility at about 6:30 PM. He stated he was told his medication was not available because the hospital did not send any paperwork regarding his orders. He stated the facility nurses told him they were not able to do anything about his pain, and suggested he ask his wife to bring his home medication. Resident #1 explained while he waited for the nurses to get his orders he even attempted to contact the facility's Director of Admissions. He stated she arranged his transfer from the hospital and admission to the facility, and he believed she might have been able to intervene to get the missing paperwork. Resident #1 stated the facility finally obtained the medication orders from the hospital at about 9:00 PM. He described his pain as excruciating, and stated although his wife delivered his pain medication from home by 10:00 PM, the nurse did not complete the admission process and administer his medication until almost 1:00 AM. Resident #1 asked, How could anyone treat a post surgical patient of 2 days like this? Review of resident #1's admission Resident Data Set revealed he arrived at the facility on 1/04/19 at 6:30 PM. The document indicated he was alert and oriented and had limited range of motion of his leg. Section M. Pain included 3 pain rating scales. First, resident #1 reported his pain level as 10 on the numeric rating scale. The numeric pain scale is commonly used by patients to rate their pain level on a scale of 0 to 10. A pain level of 0 means no pain, and a pain level of 10 means worst pain ever. (www.medscape.com) The data collection form also used the Wong-Baker Face Scale which interprets a patient's pain level based on his or her facial expression. The facial scale indicated resident #1 Hurts a whole lot. Lastly, the Verbal Descriptor Scale indicated resident #1 described his pain as Very severe, horrible. He reported pain that limited his day-to-day activities and made it hard for him to sleep during the last 5 days. The document revealed resident #1 had incisional, joint and back pain, described as acute, chronic and sharp. Resident #1 reported pain medication provided relief and movement made his pain worse. Section B of the pain data collection form revealed resident #1 displayed non-verbal pain indicators such as groaning, grimacing, bracing and rubbing the affected area with movement. On 3/20/19 at 5:07 PM, licensed practical nurse (LPN) A stated resident #1 arrived in the facility at about 6:30 PM, close to the end of his shift. He confirmed resident #1 arrived in a wheelchair and said, He started complaining right away, as soon as he got to the unit . LPN A validated resident #1 reported pain on admission, but did not arrive with important admission paperwork including a 3008 transfer form, a medication list and prescriptions for narcotic pain medication. LPN A stated the facility had a narcotic emergency kit, but nurses had no access to the medication without a prescription. He stated he notified the Director of Admissions about the missing orders and prescriptions, and she offered to call the hospital. LPN A stated he gave report to the night nurse who relieved him, Registered Nurse (RN) B, before he left the facility. LPN A explained when he arrived at work the following morning, resident #1 was still angry about the delay in obtaining his pain medication. The administrator was present during the interview and acknowledged it would have been reasonable for nurses to reach out to the medical director to address resident #1's pain management needs. On 3/20/19 at 5:40 PM, the director of nursing (DON) stated resident #1 arrived from the hospital without medication orders and prescriptions. She said, Unfortunately, the attending physician will not order a narcotic pain medication without orders from the hospital. The DON explained if nurses could not get an immediate order from a doctor they could reach out to the family. She explained any medication provided by the family still could not be administered without approval from the attending physician. She stated resident #1 had an ice machine to treat the swelling and discomfort related to his right knee surgery. However, she acknowledged there was no physician's order for its use. The DON confirmed untreated pain for any any resident was not acceptable and said, It is an issue. She stated a reasonable intervention would have been to send the resident back to the hospital if the facility could not meet his needs. The DON reviewed text messages on her phone and confirmed staff did not contact her regarding resident #1's missing orders that evening. The DON said, I don't know if he was a level 10. I don't know if he was screaming in pain. However, when asked about the facility's policy regarding pain management, the DON validated a resident's verbalization of pain should be accepted and treated as reported. On 3/20/19 at 5:59 PM, RN B explained she was assigned to resident #1 on the evening of his admission, and said, I did not have anything as far as orders. I got orders at about 9:30 PM after the pharmacy had already left. RN B stated she still did not have access to narcotic medication unless there was a prescription for the pharmacy. She admitted , He was in pain. He was a fresh knee. RN B stated she sat with resident #1 for a while, offered to set up the ice machine and offered him Tylenol which he refused. She said, I followed policy as best as I could. She did not respond when asked about implementing a treatment and offering medication without physician's orders. RN B stated she told resident #1 he could take his pain medication from home with the attending physician's permission, but the wife did not bring it in until almost midnight. RN B acknowledged she did not notify her supervisor or the DON about the delay in administration of resident #1's requested pain medication. She explained she did not call the attending physician until she received the orders from the hospital nor ask the medical director to intervene. RN B validated resident #1 complained of pain. and said, .he did not tell me he was in excruciating pain. He wasn't acting all that uncomfortable. However, when asked about pain assessment standards, RN B acknowledged pain levels should be accepted as reported by residents. On 3/20/19 at 6:11 PM, the assistant director of nursing (ADON) stated staff explained to resident #1 that he could not get pain medication until the facility had physician's orders and a prescription or his pain medication from home. The ADON said, I understand he needed medication, but our hands are tied with the new regulations. The ADON acknowledged the Medical Director might have been able to intervene by calling either the attending physician or the hospital. She said, We don't know because she was never contacted. On 3/21/19 at 4:32 PM, the DON stated the facility had narcotic pain medication on site but the pharmacy would not authorize removal of medication without a prescription, although there was a physician's order for resident #1's [MEDICATION NAME]. The DON stated she was told resident #1's the wife did not arrive at the facility with his pain medication from home until about midnight. She was reminded that resident #1 filed a grievance that indicated his wife arrived with his medication between 9:00 PM and 10:00 PM. The DON could not explain why resident #1 did not receive his pain medication for over 6 hours after reporting pain on admission. Review of the 3008 transfer form dated 1/04/19 revealed resident #1 had [MEDICAL CONDITION] joint disease and was hospitalized for [REDACTED]. He was transferred to the facility for therapy. The New Resident Initial Plan of Care Review dated 1/04/19 revealed resident #1 was identified as at risk for pain on admission. The hospital Home Medication List was date and time stamped as faxed to the facility on [DATE] at 8:51:40 PM. Resident #1's orders included [MEDICATION NAME] 10 milligrams (mg) every 4 hours as needed for severe pain levels of 7 to 10. The medication list revealed resident #1 received his last dose of pain medication in the hospital on [DATE] at 1:36 PM. The pharmacy's Controlled Medication Utilization Record revealed RN B documented 2 tablets [MEDICATION NAME] 5 mg - [MEDICATION NAME] 325 mg were removed from resident #1's medication received from home on 1/05/19 at 12:03 AM. However, review of the Medication Administration Record [REDACTED]. The facility's policy and procedure for Pain Evaluation revised on 8/23/16 revealed The pain experience is very subjective; pain is whatever the resident says it is. The procedure directed staff to ask residents about pain concerns, and If resident states they have pain, take their word for it. The document indicated after a pain assessment was completed, Contact the physician for orders.