Every finding on record at Silverton Health and Rehabilitation of Cascadia

Based on observation, staff and resident interviews, and policy review, it was determined the facility failed to ensure resident's comprehensive care plans were revised to reflect current needs and interventions. This was true for 1 of 12 residents (Resident #3) reviewed for care plans. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's policy titled, Comprehensive Care Plans and Conferences, revised 9/3/25, documented, The facility will ensure that each resident has a timely, person-centered, comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the residents' individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes. The plan will be created, reviewed, and revised by an interdisciplinary team familiar with the residents' status and care needs, with active involvement from the residents and their representative, when applicable. Updates to the care plan will occur as needed based on the residents' response to interventions or changes in condition. Resident #3 was admitted on [DATE], with multiple diagnoses including chronic kidney disease (a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and excess fluid from the blood), muscle weakness, and difficulty walking. A review of Resident #3's care plan, initiated 5/7/26, had a focus which documented, [Resident #3] has impaired mobility with risk for falls related to use of assistive device for ambulation. An intervention for this focus documented, Keep call light and bedside table items within reach. On 7/7/26 at 2:25 PM, Resident #3 was observed sitting in his chair next to the bed. The call light was clipped to the wall, on the opposite side of the bed, out of reach for Resident #3. Resident #3 stated, [The call light] is always over there. On 7/7/26 at 2:51 PM, the RCNA observed the call button was clipped to the wall out of reach of Resident #3, who was seated in the chair. The RCNA confirmed the call button was out of Resident #3's reach. When asked where the call light should be, the RCNA stated, It should be clipped to the bed next to the chair. On 7/10/26 at 10:41 AM, the CNO stated, Resident #3 spent most of his day in his chair, and he had the call light clipped to the wall on the opposite side of the bed as he did not like it clipped on the bed. When asked if his preference to have his call light clipped to the wall out of reach on the opposite side of the bed was care planned, the CNO stated, No.

Based on record review, policy review, and staff interview, it was determined the facility failed to monitor vital signs as ordered by the physician. This was true for 1 of 12 residents (Resident #46) whose records were reviewed for quality of care. This deficient practice created the potential for harm if physician's orders were not followed, and if out-of-parameter vital signs were not monitored for resident safety. Findings include:The facility's policy titled, Vital Signs, revised 8/30/25, documented vital signs will be taken as ordered by the provider, which include oxygen saturation, temperature, blood pressure, and pulse. Vital signs must be documented in the resident's medical record immediately after measurement, abnormal or concerning vital signs, per resident's established baseline, must be reported to the licensed nurse for assessment and appropriate intervention. If a Resident shows signs of distress or a sudden change in condition, vital signs must be taken promptly, even if not scheduled.The National Library of Medicine, accessed 7/15/26, documented individuals with chronic obstructive pulmonary disease (COPD; a progressive and irreversible lung condition that restricts airflow, making it difficult to breathe) and conditions associated with chronic respiratory failure, oxygen should be titrated to achieve a target oxygen saturation range of 88-92%.Resident #46 was admitted to the facility on [DATE], with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia (an ongoing, long-term condition where the lungs cannot properly transfer enough oxygen into the bloodstream), and congestive heart failure (when the heart muscle does not pump blood as effectively as it should).A physician's order dated 5/19/26, documented Resident #46 was to have her vital signs taken once a day during the day shift.Resident #46's June 2026 MAR documented the following:-6/5/26: Oxygen saturation of 87%. There were no follow-up vital signs documented.-6/6/26: No documented vital signs.A review of Resident #46's nursing progress notes did not document any follow-up vital sign monitoring or document that oxygen saturation was below 88%.On 7/9/26 at 3:57 PM, the CNO stated on 6/5/26 there was no documentation in Resident #46's record that any follow-up measures or monitoring were completed related to the low oxygen record, and there should have been documentation. The CNO also stated, on 6/6/26 the night shift did record vitals, they just did not input them into medical record as they should have been, nor did they document why the vitals were not taken during the day shift as ordered by the physician.

Based on record review, policy review, and staff interview, it was determined the facility failed to complete an assessment for a wheelchair alarm prior to implementation. This was true for 1 of 5 residents (Resident #18) whose record was reviewed for comprehensive assessments. This deficient practice created the potential for psychosocial harm if Resident #18 felt restrained and physical harm if Resident #18 was not properly assessed prior to restraint placement. Findings include:The facility's policies, titled, Physical Restraints, revised 9/16/25, and Position Change Alarm Use, dated 9/16/25, defined Position Change Alarms as alerting devices intended to monitor a resident's movement emitting an audible sound when the resident moves in certain ways; the Interdisciplinary team (IDT) will conduct a thorough assessment to determine the appropriateness of restraint use. The decision to use a position change alarm is based on a comprehensive assessment of the resident's needs.Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, difficult walking, repeated falls, and dementia.Resident #18's care plan for impaired mobility with risk for falls, dated 3/8/26, documented a wheelchair alarm was included as an intervention.A Bed Safety and Transfer Device Evaluation dated 4/28/26, documented the bed/chair alarm did not restrict mobility.Resident #18's record did not include an initial Restraint Evaluation dated on or around 3/8/26 identifying the comprehensive evaluation of the chair alarm.On 7/9/26 at 2:14 PM, the CNO stated a Restraint Evaluation had not been completed prior to having the chair alarm placed for Resident #18 on 3/8/26.

Based on observation, staff interview, and the FDA Food Code, it was determined the facility failed to provide a clean and sanitary environment when staff were observed without appropriate beard guard facial covers while in food preparation areas. This deficient practice created the potential for harm by placing residents at risk for potential foodborne illness, physical food contaminants, and adverse health outcomes. Findings include:The FDA Food Code Section 2-402.11 Effectiveness, documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. On 1/5/26 at 11:49 AM, [NAME] #1 was observed plating residents' food wearing a facial beard guard around his neck. When he made eye contact with the surveyor, he moved his beard guard over his chin and mouth with gloved hands and continued plating food. No hand hygiene was observed.On 1/6/26 at 11:58 AM, [NAME] #1 was observed plating residents' food without wearing a facial beard guard. On 1/8/26 at 11:54 AM, the DM stated all staff with facial hair should be wearing a facial beard guard. [NAME] #1 had not been wearing one on 1/5/26 and 1/6/26, and had shaved his facial hair before work on 1/7/26.

Based on observation, record review, and resident and staff interview, it was determined the facility failed to provide food which was palatable and within resident's preferred temperature. This was true for all residents eating meals prepared by the facility. This deficient practice created the potential for decreased quality of life, incomplete meal intake due to dissatisfaction with meals. Findings include:On 1/5/26 at 11:35 AM, Resident #6 stated that her cold salads were served warm as it was placed on the hot food plate under the plate cover. She stated she preferred her salads cold, and she did not know why salads were not served with the cold beverages.On 1/6/26 at 12:31 PM, Resident #22 refused her lunch tray. The surveyor observed the cold salad had been placed on the hot food plate under the plate cover. A cold fruit bowl and juice were located next to the hot food plate.A review of resident council meeting minutes from August 2025 - December 2025 documented residents were not happy with certain meals offering warm food items which should have been served cold. Comments were documented as follows:September 2025: A resident taking meals in their room stated the food was not served hot. Another resident stated that mashed potatoes were watery.October 2025: Residents stated concerns the hot food was not always hot when served to them, and the cold food was not always cold.On 1/8/26 at 11:36 AM, food temperatures were taken on the serving line. Two dishes, the chili macaroni (pureed) and the green peas (regular diet), had to be reheated before plating.On 1/8/26 at 4:12 PM, [NAME] #2 stated the food had been on the serving line for 30 minutes and should not have lost temperature so quickly.On 1/8/26 at 12:10 PM, the Hall Tray meal cart was taken to the facility's [NAME] and East hall for meal delivery, with all meals served to residents by 12:24 PM.On 1/8/26 at 12:35 PM, a test tray was sampled with the following results:Chili Macaroni Casserole - 120 FPeas 119 FToast 94 FCantaloupe 51 FApple Juice 53 FMilk 51 FSalad 56 [NAME] 1/8/26 at 12:41 PM, the RD agreed that smaller cold salads should be kept on the cold side and not on the hot plate. The RD agreed the temperatures measured on the test tray were out of parameters.On 1/8/26 at 3:50 PM, the DM stated he did not know why the food was not keeping appropriate temperature on the steam table and stated the steam table may need to be replaced. The DM agreed the cold food items should not be placed on the hot plates or under the plate covers.

Based on observation and staff interview, the facility failed to ensure Schedule II controlled substances were stored in a permanently affixed, secured compartment. This failure created the potential for drug diversion and misappropriation. Findings include:On 1/7/26 at 4:05 PM, a storage and labeling audit was conducted with LPN #1. Upon entering the medication room, LPN #1 unlocked the medication refrigerator. The Schedule II drug compartment inside the refrigerator was observed to have a black lock attached to the drawer. Upon further inspection, the black lock detached from the drawer, leaving all Schedule II medications accessible.On 1/7/26 at 4:09 PM, LPN #1 confirmed the compartment was not appropriately secured. He stated that to ensure the safety of Schedule II medications, the compartment should remain locked at all times.

Based on record review and staff interview, it was determined the facility failed to ensure the discharge process notified required entities. This was true for 4 of 4 residents (#2, #7, #39, and #50) whose discharges were reviewed. The failure of the facility to notify the Office of the State LTC Ombudsman of each residents' discharge denied the residents added protection and advocacy of their right from being inappropriately transferred or discharged . Findings include: 1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness, dementia, and a history of falls. Resident #2's record documented she required a transfer to the emergency department on 12/9/25 after a fall. The record documented a coordinated discharge with the receiving facility but did not include documentation the Ombudsman was notified of her discharge. 2. Resident #7 was admitted to the facility on [DATE] for care following a surgery and treatment of multiple abscesses (pus-filled, infected pockets of fluid) on various parts of her body. Resident #7's record documented she was discharging home on [DATE] after meeting goals and she no longer required skilled nursing care. The record documented a coordinated discharge but did not include documentation the Ombudsman was notified of her discharge. 3. Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including dementia, diabetes, and neuropathy. On 8/8/25, Resident #39 required transfer to the emergency department for a cellulitis infection on her right lower leg. Her record included documentation her transfer was coordinated with the receiving hospital but did not include documentation the Ombudsman was notified of her transfer. 4. Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including heart failure and COPD. Resident #50 required transfer to the emergency department on 12/14/25 and 12/28/25 for exacerbation of his COPD. His record documented the transfer was coordinated with the receiving hospital but did not include documentation the Ombudsman was notified of his transfer on either date. On 1/8/26 at 12:20 PM, the Administrator stated the facility did not inform the Office of the State LTC Ombudsman of Resident #2, #7, #39, and #50's discharges.

Based on record review and staff interview, the facility failed to ensure resident records were maintained accurately and completely. This was true for 2 of 15 residents (#2 and #3) whose records were reviewed for accuracy. This failure created the potential for miscommunication and delayed treatment when documentation was missing or inaccurate. Findings include:1. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness, dementia, and a history of falls.Review of Resident #2's record documented an unwitnessed fall on 12/9/25 at 5:50 PM.Resident #2's record included an INTERACT Hospital Transfer Form dated 12/9/25, intended to document the resident's most recent condition prior to transfer. The vital signs listed on the form were dated 12/3/25, which was six days prior to the transfer.On 1/7/26, the ADON confirmed the INTERACT Hospital Transfer Form contained inaccurate information, as the vital signs did not reflect Resident #2's condition at the time of transfer.2. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness, visual hallucinations, and dementia.Resident #3's record included a physician order dated 12/1/25 directing staff to document the number of episodes per shift of the following target behaviors:Exit seekingHallucinationsDelusional statementsSexually inappropriate commentsThe order also directed staff to implement and document the following interventions:Provide 1:1 conversationProvide activities of choiceAssist the resident to a quiet and calm location; provide a snack and alternate activitiesReapproach the resident at a different timeReview of Resident #3's behavior monitoring records dated 10/1/25-12/31/25 documented multiple behavior episodes without corresponding interventions on the following dates:10/12/2510/16/2510/17/2510/18/2510/19/2510/20/2512/2/2512/9/2512/10/2512/11/2512/12/2512/16/25On 1/7/26 at 5:03 PM, the surveyor requested documentation of interventions implemented during the above behavior episodes. No additional documentation was provided.On 1/8/26 at 12:53 PM, the DON stated Resident #3's record accurately reflected the behaviors but did not accurately reflect the interventions used at the time the behaviors occurred.

Based on observation, record review, and staff interview it was determined the facility failed to provide sanitary storage of PPE, and to perform appropriate hand hygiene. This was true for 2 of 15 residents (#6 and #33) whose staff infection control interactions were observed. This deficient practice created the potential for harm to residents if staff failed to provide appropriate infection control practices during wound care, medication administration, and PPE storage. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including stage 4 pressure ulcer of the right buttock (the most severe type of pressure damage, characterized by full-thickness skin and tissue loss), and paraplegia (paralysis from the waist down). Resident #6's care plan, dated 7/4/24, directed staff to use EBP to reduce the risk of MDRO transmission related to a suprapubic catheter and chronic wounds when providing direct care. The care plan further documented EBP should be used to prevent infection including the use of gown and gloves when providing high-contact resident care including dressing, changing linens, device, or wound care. On 1/5/26 at 3:02 PM, it was observed in Resident #6's closet, an unwrapped EBP gown stored on top of a pile of linen. On 1/5/26 at 3:12 PM, CNA #1 confirmed Resident #6's EBP gown in her closet was not in a plastic bag and was placed on top of Resident #6's personal linens. On 1/8/26 at 5:05 PM, the IP stated gowns are stored in their original plastic wrapping inside the upper area of the resident's individual closet as there is limited space inside their rooms. The IP stated Resident #6's EBP gown should have been stored within a plastic bag. 2. On 1/8/26 at 10:00 AM, the ADON was observed preparing wound care supplies on top of the wound cart. No sanitation of the cart surface was observed prior to placing the supplies on the cart. The ADON performed hand hygiene and carried the wound care supplies into Resident #33's room. She placed the supplies on the back of the toilet. After attempting to position the resident, the ADON determined she was unable to perform wound care in that location. She assisted Resident #33 back into his wheelchair and positioned him near a rail by the restroom. The ADON obtained sanitizing wipes and sanitized Resident #33's bedside table. After the surface dried, she retrieved the wound care supplies from the restroom and placed them on the bedside table. The ADON performed hand hygiene, applied gloves, and initiated wound care. She removed the old dressing and cleansed the wound site. She then removed her gloves, performed hand hygiene, and applied clean gloves. The ADON applied skin prep and silver collagen to the wound bed, covered the wound with a dressing, removed her gloves, and performed hand hygiene. On 1/8/26 at 10:28 AM, the ADON stated she should have applied a barrier between the wound care items and the surfaces where the supplies were placed. 3. On 1/7/26 at 8:00 AM, MAC #1 was observed sanitizing her hands and preparing medications. After completing preparation, she closed the medication cart drawers and locked the cart. MAC #1 carried a medication cup, a cup of water, and an inhaler to the resident's room. Upon entering, she placed the medication cup, inhaler, and water on the resident's bedside table. MAC #1 obtained a pair of gloves and applied them. No hand hygiene was observed prior to glove application. MAC #1 then assisted the resident with administration of the oral medication and inhaler. On 1/7/26 at 8:08 AM, MAC #1 confirmed she should have performed hand hygiene before applying gloves.

Based on observation and staff interview, the facility failed to ensure residents were supplied with routine medications as ordered. This was true for 1 of 1 resident (Resident #5) reviewed for medication availability. This failure created the potential for harm if Resident #5 experienced worsening anemia requiring timely supplementation. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including a right humerus fracture and iron deficiency anemia.Review of Resident #5's medical record documented a physician order for:Ferrous Gluconate 324 mg, give 1 tablet by mouth once daily for supplementation.On 1/7/26 at 9:08 AM, during a medication administration observation, MAC #1 was observed preparing medications for Resident #5. When reaching the final medication, MAC #1 informed the surveyor that the Ferrous Gluconate was not available in the facility.On 1/7/26 at 9:10 AM, MAC #1 stated the physician's order had been implemented on 12/24/25, but the medication had not been administered. She stated the medication had been ordered but had not been available for administration.On 1/8/26 at 12:38 PM, the DON stated the facility obtained the medication on 1/1/26. She further stated Resident #5 was moved to a different room, and the medication was not transferred to the new medication cart for nursing staff to administer.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided treatment and care in accordance with professional standards of practice, and the residents goals and preferences. This was true for 1 of 15 residents (Resident #35) whose records were reviewed for quality of care. This failure created the potential for harm for Resident #35 when she experienced a change in condition, was not provided a nursing assessment, and diagnostic testing was delayed. Findings include: Resident #35 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure, diabetes, dementia, depression, and muscle weakness.On 12/26/25 at 11:18 AM, a doctor/nursing communication note documented Resident #35 continued to experience dizziness and weakness in her upper body as assessed by nursing. The medical provider documented a follow-up would be scheduled. On 12/30/25 at 12:00 AM, a physician's history and physical note documented a urine analysis collection was pending for Resident #35 related to dysuria (pain when urinating) and altered mental status.On 1/4/26 at 2:21 PM, a nursing progress note documented Resident #35 was experiencing increased weakness and difficulty while transferring. Physical therapy was notified to complete an evaluation at the soonest availability.On 1/6/26 at 6:12 AM, a nursing progress note documented Resident #35 had a tick, dropping arms and head and staff were directed to collect a urine specimen as resident was soiled during the evaluation and was usually continent.On 1/7/26 at 9:35 AM, a nursing progress note documented a urinalysis (UA) and culture was collected and sent to [local laboratory].On 1/7/26 at 6:39 PM, the [local laboratory] faxed results of the urinalysis to the facility with results documenting Resident #35 had a positive UA, indicating infection.On 1/8/26 at 11:44 AM, Resident #35's POA called the facility and requested that Resident #35 be transported to the ER for further evaluation as the POA believed Resident #35 .isn't right. On 1/8/26 at 12:00 PM, the facility transferred Resident #35 to the ER via non-emergent services.A review of Resident #35's vital signs records documented her vitals including blood pressure, heart rate, and oxygen saturation were taken on 1/6/26 and 1/8/26.On 1/8/26 at 2:16 PM, when asked why Resident #35 had not had a urine culture taken prior to 1/7/26, the DON stated facility staff usually complete medical orders within 24-hours if a STAT order is not also placed. When asked why the UA had not been completed on or around 12/30/25, no response was given. The DON also stated unless there is a medical order for vitals to be taken daily, they are only done once every 30-60 days, and Resident #35 had her vitals taken on 1/6/26 and 1/8/26, which was more than usual for a resident to receive without a doctor's order.Resident #35's record did not include documentation of nursing assessment, vital signs, or UA collection related to her change in mental status and weakness between 12/30/25 and 1/6/26.On 1/8/26 at 12:56 PM, hospital records documented Resident #35 was being seen for signs and symptoms of weakness and dizziness lasting 1-2 weeks and was admitted to the hospital for further evaluation. The emergency room physicians assessment and plan for Resident #35 included: Weakness, expressive aphasia (inability to speak), stroke-like symptom, acute kidney injury superimposed on chronic kidney insufficiency, hyperkalemia (elevated potassium levels in the blood), and urinary tract infection.On 1/8/26 at 6:10 PM, the DON stated Resident #35 had been admitted to the hospital and started on antibiotics and fluids.

Based on record review, observation, and staff interview, the facility failed to ensure effective pain management was provided to residents. This was true for 1 of 1 resident (Resident #5) whose record was reviewed for pain management. This failure resulted in ongoing pain when Resident #5 was not evaluated to determine whether the current pain management plan was effective. Findings include:Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including a right humerus (upper arm bone) fracture, head injury, and iron deficiency anemia.Review of the admission Care Conference evaluation dated 12/23/25 documented the following goals:Goal #1: Get pain under controlGoal #2: Work with therapyA Pain Evaluation dated 12/23/25 documented Resident #5's acceptable pain level as 4/10.Review of Resident #5's MAR dated 12/23/25-1/7/26 documented the following pain management orders:Tylenol Extra Strength 500 mg, give 2 tablets by mouth three times daily for painOxycodone 5 mg, give 1 tablet by mouth every 8 hours as needed for severe painThe MAR documented 17 administrations of oxycodone between 12/23/25-1/7/26, with recorded pain levels ranging from 6/10 to 10/10.Review of physical therapy notes dated 12/23/25-1/7/26 documented:12/24/25: Resident #5 had shoulder pain that created barriers to participate and required additional time.12/29/25: Resident #5 was very upset with 10/10 pain and was described as very emotional and wanting to make gains with mobility to return home.12/31/25: Resident #5 was observed with increased pain while lying in bed. Physical therapy requested nursing to administer a pain medication.On 1/5/26 at 3:05 PM, Resident #5 was observed sitting in a chair with her bedside table in front of her, guarding her right shoulder.On 1/5/26 at 3:08 PM, Resident #5 stated she was always in pain and reported she could not recall a time since admission when her pain had been under control.On 1/7/26 at 8:24 AM, during a medication administration observation, Resident #5 stated to MAC #1, I'm pretty much in pain all the time.On 1/8/26 at 11:46 AM, the DON stated she believed Resident #5's pain was well managed because the PRN pain medication results were effective. After reviewing the record, the DON did not identify documentation of reassessment or evaluation of the effectiveness of the pain management plan despite ongoing reports of pain levels above the resident's acceptable pain goal.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 5 of 5 residents (#4, #7, #26, #40, and #41) reviewed for bowel and bladder care. This failed practice created the potential for each of these residents to experience discomfort when their medications were not administered according to the physician's order. Findings include: 1.) Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, and constipation. An Annual MDS assessment dated [DATE], documented Resident #4's decision making was poor, and she needed cues and/or supervision. A physician's order documented Resident #4 was to receive the following medications: -Milk of Magnesia (MOM) suspension 1200 milligram (mg) /15 milliliters (ml), give 30 ml orally as needed for no bowel movement (BM) for two days. Give 1 dose. If no results within 24 hours, see Dulcolax suppository order. -Dulcolax suppository 10 mg, insert 1 suppository rectally as needed for bowel care. Give if no results from MOM. If no results in 24 hours, see Fleets Enema order. -Fleet Enema, insert 1 unit rectally as needed for bowel care. Give if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. Resident #4's Bowel Movement Records, dated 5/15/25 through 6/15/25, documented she did not have a bowel movement from 5/29/25 through 6/1/25 (4 days). Resident #4's Medication administration record (MAR), dated 5/15/25 through 6/15/25, documented she did not receive any bowel care medications when she did not have a bowel movement for 4 days. On 6/26/25 at 1:15 PM, the DON reviewed Resident #4's record and stated Resident #4 should have been offered a bowel medication when she hadn't had a bowel movement on the evening of 5/31/25. 2.) Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain, muscle weakness, and constipation. A Quarterly MDS assessment dated [DATE], documented Resident #7 was cognitively intact. A physician's order documented Resident #7 was to receive the following medications: -Bisacodyl oral tablet delayed release 5mg, give 10 mg by mouth as needed for constipation daily. -Bisacodyl laxative rectal suppository, insert 1 unit rectally every 72 hours as needed for constipation may give every 3 days if no BM. -Milk of Magnesia suspension 400 mg/5 ml, give 30 ml by mouth as needed for constipation. If resident does not have a bowel movement for three days, administer milk of magnesia per physician order on day four. -Miralax Powder, give 0.5 dose by mouth every 24 hours as needed for constipation mix with 4 oz of liquid of choice. Resident #7's Bowel Movement Records, dated 6/1/25 through 6/24/25, documented he did not have a bowel movement from 6/3/25 through 6/8/25 (6 days) and from 6/10/25 through 6/14/25 (5 days). Resident #7's MAR, dated 6/1/25 through 6/24/25, documented he did not receive any bowel care medications when he did not have a bowel movement for 6 days and 5 days respectively. On 6/24/25 at 3:30 PM, Resident #7 stated he frequently gets constipation and has to ask the nurse for a bowel medication when it gets bad. On 6/26/25 at 1:20 PM, the DON reviewed Resident #7's record and stated Resident #7 is cognitively intact and can ask for bowel medications when needed. She further stated the nurse should have been tracking his bowel movements and offered medications when Resident #7 had not had a bowel movement on the evening of 6/6 or the morning of 6/7 and again when he had not had a bowel movement on the evening of 6/12 or the morning of 6/13. 3.) Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including dementia, muscle weakness, and constipation. A Quarterly MDS assessment dated [DATE], documented Resident #27's decision making was poor, and she needed cues and/or supervision. A physician's order documented Resident #27 was to receive the following medications: -Milk of Magnesia suspension 400 mg/5 ml, give 30 ml by mouth as needed for constipation. Give daily as needed. Contact provider if there is three days without significant BM. -Dulcolax suppository 10 mg, insert one suppository rectally as needed for constipation. Contact provider if there is three days without significant BM. -Fleets Enema, insert one dose rectally as needed for constipation. Give if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify provider if no results. Resident #26's Bowel Movement Records, dated 6/1/25 through 6/24/25, documented she did not have a bowel movement from 6/13/25 through 6/16/25 (4 days). Resident #26's MAR, dated 6/1/25 through 6/24/25, documented she did not receive any bowel care medications when she did not have a bowel movement for 4 days. On 6/26/25 at 1:25 PM, the DON reviewed Resident #26's record and stated Resident #26 should have been offered a bowel medication when she did not have a bowel movement on the evening of 6/15 or the morning of 6/16. 4.) Resident #40 was re-admitted to the facility on [DATE], with multiple diagnoses including long term antibiotic use, muscle weakness, and constipation. An admission MDS assessment dated [DATE], documented Resident #40's decision making was moderately impaired. A physician's order documented Resident #40 was to receive the following medications: -Milk of Magnesia suspension 1200 mg/15 ml, give 30 milliliters orally as needed for no BM for 72 hours, give 1 dose. If no results within 24 hours, see Dulcolax suppository order. -Dulcolax suppository 10 mg, insert 1 suppository rectally as needed for bowel care after MOM administration with no results. Give if no results from MOM. If no results in 24 hours, see Fleets Enema order. -Fleet Enema, insert 1 unit rectally as needed for bowel care after 24 hours of suppository with no results, give if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. Resident #40's Bowel Movement Records, dated 6/1/25 through 6/24/25, documented he did not have a bowel movement from 6/17/25 through 6/21/25 (5 days). Resident #40's MAR, dated 6/1/25 through 6/24/25, documented he did not receive any bowel care medications when he did not have a bowel movement for 5 days. On 6/26/25 at 1:30 PM, the DON reviewed Resident #40's record and stated Resident #40 should have been offered a bowel medication when he had not had a bowel movement on the evening of 6/19 or the morning of 6/21. 5.) Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including psychotic disturbance, muscle weakness, and constipation. A Quarterly MDS assessment dated [DATE], documented Resident #41's decision making was poor, and she needed cues and/or supervision. A physician's order documented Resident #41 was to receive the following medications: -Milk of Magnesia suspension 1200 mg/15 ml, give 30 milliliters orally as needed for no BM for two days. Give 1 dose. If no results within 24 hours, see Dulcolax suppository order. -Dulcolax suppository 10 mg, insert 1 suppository rectally as needed for bowel care, give if no results from MOM. If no results in 24 hours, see Fleets Enema order. -Fleet Enema, insert 1 unit rectally as needed for bowel care. Give if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. Resident #41's Bowel Movement Records dated 5/15/25 through 6/15/25, documented she did not have a bowel movement from 5/29/25 through 6/1/25 (4 days). Resident #41's MAR dated 5/15/25 through 6/15/25, documented she did not receive any bowel care medications when she did not have a bowel movement for 4 days. On 6/26/25 at 1:35 PM, the DON reviewed Resident #41's record and stated Resident #41 should have been offered a bowel medication when she did not have a bowel movement on the evening of 5/31 or the morning of 6/1.

Based on observation and staff interview, it was determined the facility failed to ensure (a) food was stored in a safe and sanitary manner and (b) drink wear was maintained in sanitary conditions. This deficient practice created the potential to affect 49 of 49 residents who consumed food and drinks prepared by the facility. This placed residents at risk for adverse outcomes, including food-borne illness. Findings include: a. On 6/23/25 at 10:10 AM, during a initial kitchen inspection a large brown box was observed in the dry goods pantry. The box contained large yellow onions noted with a green fuzzy substance on the surface of multiple onions. On 6/23/25 at 10:11 AM, when asked if the onions were in a safe condition to serve the Dietitian stated obviously we would not serve them to anyone. b. On 6/24/25 at 2:15 PM, during a in-depth kitchen inspection a bread toaster was identified sitting on a counter. The toaster was observed to contained a thick layer of black encrusted particles. Also, during the inspection multiple purple coffee cups were identified in a clean storage cabinet to have a layer of brown substance along the inside of the cup. On 6/24/25 at 2:32 PM, During an interview with the Administrator and Kitchen Aid #1, the Administrator stated the toaster is not in a clean condition and will be replaced. Kitchen Aid #1 stated in his opinion the cups were also not in sanitary condition.

Based on record review, staff interview, review of the State Agency's Long-Term Care Reporting Portal, and review of I&As, it was determined the facility failed to ensure residents are free from abuse. This was true for 3 of 3 residents (Resident #9, #30, #51) whose records were reviewed for abuse. This created the potential for harm when Residents #9, #30, and #51 were struck by Resident #8. Findings include: The facility's Abuse policy revised 10/15/22, documented residents will remain free from abuse, neglect, misappropriation of resident property, and exploitation. Including but not limited to corporal punishment. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dementia with psychotic disturbances and major depressive disorder. 1. Physical abuse directed by Resident #8 to Resident #30. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, pain, and dementia. On review of the State Agency's Long-Term Care Reporting Portal accessed on 6/24/25, a facility report was identified indicating Resident #8 had a physical altercation with Resident #30. On review of the facility's, I&A's a resident-to-resident investigation dated 11/10/24, documented Resident #8 was in the common area when she self-propelled her wheelchair to Resident #30 and began to kick her multiple times. Resident #30 informed a CNA of the incident and both Resident #8 and Resident #30 were separated and assessed for injuries. The I&A documented Resident #8 was the aggressor, and the following interventions were to be implemented for her: - Medication changes - Non-pharmacological interventions - Continue to monitor Resident #8 in line of sight while in the day room. - Divert Resident #8 with activities or with 1 on 1 conversation and provide less stimulation. Resident #8's care plan revised on 11/9/20, directed staff to intervene as necessary to protect the rights and safety of others. A physician order dated 6/28/23, directed staff to document behaviors of verbal and physical aggression as well as refusal of cares. On review of Resident #8's behavior monitor dated 11/1/24 through 11/13/24, Resident #8 displayed physical aggression on the following days with no interventions: - 11/3/24 during day shift - 11/3/24 during night shift - 11/4/24 during day shift - 11/4/24 during night shift - 11/10/24 during night shift - 11/13/24 during day shift - 11/13/24 during night shift On 6/26/25 at 3:45 PM, the DON stated Resident #8 had a medication change to her Risperdal (an antipsychotic medication). However, it is unclear why interventions were not documented. 2. Physical abuse directed by Resident #8 to Resident #51. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including weakness, major depressive disorder and dementia. On review of the State Agency's Long-Term Care Reporting Portal accessed on 6/24/25, a facility report was identified indicating Resident #8 had a physical altercation with Resident #51. On review of the facility's, I&A's a resident-to-resident investigation dated 12/17/24, documented Resident #51 was wheeling herself to the nurse's station when she encountered Resident #8. Resident #8 than slapped Resident #51 and called her a name. Resident #51 than slapped Resident #8 in return. Staff than separated both residents. The report documented both residents were assessed for injuries, but no injuries were identified. Upon conclusion of the investigation Resident #8 was identified as the aggressor and Resident #51 as the victim. The I&A report documented the following interventions for Resident #8: - Review of current medications with increase in dose - Staff educated to implement 1 on 1 when Resident #8 presents with agitation. Resident #8's care plan revised 12/17/24, directed staff if Resident #8 appeared agitated to implement a 1 on 1 supervision and take resident into a quiet place away from environmental triggers. The I&A also documented the facility made the decision to send referrals to 2 behavioral health facilities in the state to best meet the needs of Resident #8. On 6/25/25 at 3:55 PM, the DON stated Resident #8 was given her own room to provide a low stimulation environment when she became overwhelmed. She also stated staff were directed to immediately initiate 1 on 1 care when Resident #8 became agitated. 3. Physical abuse directed by Resident #8 to Resident #9. Resident #9 was readmitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, pain, muscle weakness, and anxiety. On review of the State Agency's Long-Term Care Reporting Portal accessed on 6/24/25, a facility report was identified indicating Resident #8 had a physical altercation with Resident #9. On review of the facility's, I&A's report a resident-to-resident investigation dated 5/19/25, documented Resident #9 was ambulating back to her room with her walker and Resident #8 was self-propelling in her wheelchair. When Resident #9 arrived at the doorway of her room Resident #8 then kicked Resident #9 striking her on her right lateral calf and told her to get in her room. A CNA observed the situation and immediately separated the two residents and notified the nurse. The report documented both residents were assessed for injuries and no injuries were identified. It also documented the facility determined the incident occurred because of Resident #8's agitation. The report directed staff to continue to monitor Resident #8 closely in line of sight when out of her room and around others. Resident #8's care plan revised on 5/19/25, directed staff to keep resident in line of sight at all times due to aggressive behaviors, and to continue to use already care planned interventions with 1 on 1 interventions as needed. On review of Resident #8's behavior monitor dated 5/1/25 through 5/31/25, one episode of physical aggression was documented on 5/5/25 with interventions implemented however, the record was unclear if the interventions were effective. Resident #8's record did not include documentation of the physical aggression that occurred on 5/19/25 during the resident-to-resident incident. On 6/26/25 at 5:00 PM, the DON stated, Resident #8's medications were increased in dose. She also stated when resident #8 became agitated she would make rude verbal comments and would walk around the facility aimlessly. The DON stated, However, that day the staff missed the need for interventions. On 6/26/25 at 5:25 PM, the Administrator stated the incidents that occurred on 11/10/24, 12/17/24, and 5/19/25 were all substantiated for abuse with Resident #8 being the aggressor.

Based on review of incident and accidents (I&A), staff interview, and The State Operation Manual, it was determined the facility failed to ensure adequate supervision was provided to prevent falls. This was true for 1 of 1 resident, (Resident #8) whose record was reviewed for falls. This had the potential to cause more than minimal harm to resident #8. Findings include:The State Operation Manual, Appendix PP, defined Avoidable Accident as an accident occurred because the facility failed to: Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices.Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, difficulty in walking, and history of falls.Resident #8's care plan revised on 8/27/23, directed staff to place personal items and assistive devises within reach.An I&A report dated 4/11/25 at 4:00 PM, documented a CNA assisted Resident #8 to transfer to the couch in the common area. After the transfer the CNA proceeded to place the wheelchair near Resident #8 when the nurse interrupted her and instructed her to remove the wheelchair and place it behind the couch so Resident #8 would not attempt to self-transfer. The report documented Resident #8 attempted to self-transfer and lost her balance causing her to fall on her right side and hit her head. It also documented Resident #8 was 5-7 feet away from a transfer area. The I&A report also documented Resident #8 obtained a goose egg on the right side of her head, the provider was notified and ordered the facility to send Resident #8 to the hospital for further evaluation.The fall investigation included statements from two CNA's documenting the removal of the wheelchair from Resident #8 resulted in the fall.On 6/25/25 at 2:50 PM, during an interview with the DON and Administrator the DON stated education was provided to staff on placement of wheelchairs.

Based on record review, observation,resident and staff interview, it was determined the facility failed to ensure respiratory services were provided. This was true for 1 of 1 resident (Resident #14) whose record was reviewed for respiratory services. This failure created the potential for harm when Resident #14's continuous positive airway pressure (CPAP) machine (a non-invasive ventilation machine) was not applied at bedtime. Findings include: Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including obstructive sleep apnea and muscle weakness. Resident #14's care plan revised 7/4/24, directed staff to see the administration record for the application schedule. A physician order dated 3/30/25, directed staff to apply the CPAP machine at bedtime and remove in the morning. On 6/24/25 at 1:53 PM, Resident #14's CPAP machine was observed on a night stand next to her bed with no water in it. The mask was located directly on the floor near Resident #14's bed. On 6/25/25 at 9:39 AM, Resident #14 stated she had not used her CPAP machine in a month because it doesn't work. She stated, that's why I have been using this during the night and pointed at the oxygen cannula on her nose. On 6/25/25 at 4:58 PM, the DON stated Resident #14's CPAP machine has not worked in two weeks. She also stated she notified the provider on 6/21/25 and he directed her to place Resident #14 on 2 liters of oxygen via nasal cannula while she sleeps. However, neither her nor the provider discussed putting the order for the CPAP machine on hold until it was resolved.

Based on record review, observation, and staff interview, it was determined the facility failed to ensure Residents were monitored adequately to ensure residents were free from chemical restraints. This was true for 1 of 5 residents (Resident #23) whose records were reviewed for unnecessary medication. This failure caused the potential for more than minimal harm when Resident #23 was not able to participate in activities of daily living. Findings include:Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder, dementia, and insomnia.Resident #23's care plan revised 4/28/23, directed staff to monitor, document, and report to the MD changes in cognitive function such as difficulty expressing herself, level of consciousness, and mental status.A physician order dated 3/17/24, directed staff to monitor for the following side effects:1. Over-sedation / Lethargy2. Restless agitation3. Increased confusion/ poor concentration4. Mental status change5. Visual disturbances6. Change in gait/ mobility7. Behavior changes8. Nausea or vomitingOn review of resident #23's records the following physician orders were implemented:- Trazadone (a sleep-aid) 50 mg (milligrams) by mouth at bedtime for insomnia initiated on 11/14/24.- Depakote (an anticonvulsant medication used to treat manic episodes) delayed release 500 mg three times a day for bipolar disorder initiated on 3/26/25.- Risperdal (an antipsychotic medication) 0.25 mg by mouth at bedtime for bipolar disorder initiated on 5/13/24.- Risperdal 0.25 mg by mouth one time a day for bipolar disorder initiated on 5/14/25.On 6/23/25 at 10:50 AM, Resident #23 was observed falling asleep and leaning over a table in the common area during activities.On 6/23/25 at 11:39 AM, Resident #23 was observed in the dining room for lunch. Her lunch was placed in front of her and special eating utensils were provided. Resident #23 was observed taking two bites from her meal before she placed her hands in front of her on the table and began to fall asleep using her hands to support her head. Shortly after she asked staff if she can leave the dining room and was escorted out.On 6/25/25 at 10:55 AM, Resident #23 was observed leaning on the doorway of her room as she closed her eyes. Her hair was noted to be unkempt, and her clothing appeared to be disheveled and slept in. Resident #23 remained leaning on the doorway of her room until staff were able to assist her.On 6/26/25 at 10:53 AM, Resident #23 was noted sleeping in bed.A review of Resident #23's MAR dated 6/1/25 - 6/25/25, the record did not include documentation of Resident #23 experiencing sedation or lethargyOn 6/26/25 at 2:30 PM, on review of Resident #23's record the DON stated staff are not documenting Resident #23's condition and therefore it is unclear if medication adjustments need to be made.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 1 of 3 residents (Resident #39) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident had a serious mental illness and/or intellectual disability, or related condition. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a traumatic event), stimulant abuse and panic disorder. Resident #39's Annual MDS assessment dated [DATE], documented under A1500 in Section A, no for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II observed in his electronic medical record, dated 3/13/25. On 6/26/25 at 2:21 PM, the MDS Coordinator stated Resident #39's MDS assessment was coded that the resident did not receive a PASRR Level II, and it should have been coded yes.

Based on record review and staff interview it was determined the facility failed to ensure residents' care plans were revised according to their needs. This was true for 1 of 13 residents (Resident #8) whose records were reviewed for care plan timing and revisions. This failure created the potential for harm when residents' needs were not identified and or met. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including dementia with psychotic disturbances and major depressive disorder. Resident #8's care plan revised on 11/14/24, directed staff to investigate and identify potential triggers of target behaviors. The care plan also directed staff to use non-pharmacological interventions to reduce target behavior. Resident #8's care plan also directed staff to keep her within line of sight due to aggressive behaviors. The care plan did not include documentation of what triggered Resident #8 to become aggressive with others around her. On 6/26/25 at 3:21 PM, the DON stated Resident #8 becomes agitated when she is over stimulated with loud sounds or too many activities around her. She also stated that Resident #8 will begin to aimlessly ambulate around the facility making rude comments towards others. When asked how staff will know what triggers her behaviors, she stated based on the care plan they wouldn't because the care plan does not include what triggers her aggressive behaviors only interventions.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 7 residents (Resident #8) whose medications were reviewed. This failure created harm to Resident #8 when she received an incorrect administration of medication requiring hospitalization . Findings include: The facility's Medication Errors policy, dated 8/1/23, documented a medication error was the preparation, or administration of drugs or biologicals that were not in accordance with the following: - Prescriber's order - Manufacture's specifications - Accepted professional standards and principles that apply to professionals providing services. This policy was not followed. 48172 Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (result of disrupted blood flow to the brain), and hypertension (high blood pressure). Resident #8's MAR for August 2023, documented a physician's order for Lisinopril (medication used to treat high blood pressure) oral tablet 20 mg to be administered by mouth one time a day for hypertension and to hold (do not administer) if Resident #8's systolic blood pressure (pressure in the arteries when the heart beats) was less than 150 or diastolic blood pressure less than 60 (pressure in the arteries when the heart rests between beats). A nursing note, dated 8/28/23 at 11:10 AM, documented Resident #8's daughter was notified of Resident #8's acute change in condition with hypotension (low blood pressure) and order to transfer her to the hospital emergency department. An Incident and Accident report, dated 8/29/23, investigating Resident #8's hospitalization , documented her Lisinopril was not held when meeting hold parameters prior to her hospitalization . Resident #8's Lisinopril was discontinued on 8/31/23. A document provided by the facility titled, Attention all Nurses, dated 8/29/23, signed by the CNO, documented Resident #8's medications were reviewed and 21 episodes of the medication Lisinopril was given when it should have been held per parameters listed on the physician order. The document stated this was a huge survey/citation risk and carried weight as it could/would cause harm or there would not be parameters. An attendance roster documented the document was reviewed by 7 facility nurses. Resident #8's MAR, dated 8/1/23 through 8/31/23, documented Resident #8 was given Lisinopril 24 times in August 2023 when his blood pressure was outside of the ordered parameters to receive the Lisinopril. After education was provided to facility nurses on 8/29/23, there was 1 episode of Lisinopril given on 8/31/23 with a blood pressure of 139/62, which was outside of the ordered parameters to administer the Lisinopril. Documentation of the education on 8/29/23 included the nurse who administered the Lisinopril on 8/31/23, which was after the provided education. On 10/4/23, at 11:30 AM, the CNO stated Resident #8 had a change of condition related to low blood pressure. She stated a medication review was completed, and the medication errors were identified. The CNO stated she wrote and presented the nursing staff with education on medication errors and following hold parameters for blood pressure medication administration.

Based on observation, resident and staff interview, and review of resident records, facility policies, nursing schedules, and manufacturers' instructions, it was determined the facility failed to ensure infection control measures were consistently implemented when: - There was no designated staff working only with COVID-19 positive residents. - The physical barrier separating the COVID-19 positive unit from other units was not kept closed as required. - A COVID-19 negative resident was placed in the facility's COVID-19 positive unit. - Clinical staff failed to perform hand hygiene between glove changes. - PPE was improperly doffed and donned by clinical staff. - Residents were not offered hand hygiene before meals. - The facility used a cleaning agent that was not EPA-registered. These deficient practices created the potential for the spread of infectious organisms, including COVID-19, from cross contamination (the inadvertent transfer of harmful bacteria, virus, or another microorganism, from one person, object, or place, to another). COVID-19 is a new coronavirus caused by a virus that can spread person to person. This new virus has currently spread throughout the world. Symptoms range from mild to severe illness and even death. The failure of the facility to designate staff to work only with residents who were COVID-19 positive, placed all staff who tested negative for COVID-19 and all residents residing in the facility who tested negative for COVID-19, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: 1. According to a typed document, undated, the facility documented a COVID-19 positive resident was identified on 7/12/21. The facility began testing all staff and residents every 6 days beginning on 7/16/21. Seventeen residents tested positive for COVID-19 between 7/12/21 and 7/27/21, 15 days. The facility did not implement infection prevention and control measures to prevent the spread of infection with COVID-19 as follows: a. The Centers for Disease Control and Prevention (CDC) website, accessed on 8/11/21, included the following guidance in the section Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, states: Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. If possible, HCP should avoid working on both the COVID-19 care unit and other units during the same shift. The facility did not have dedicated nursing staff to work in the COVID-19 positive unit only. On 8/2/21, at 3:40 PM, a plastic barrier was in the facility's 200 hall, which covered floor to ceiling and wall-to-wall. The plastic barrier separated rooms 201 through 206 (the yellow zone) from rooms 207 through 214 (the red zone). Clinical staff were exiting the barrier from the red zone to the yellow zone to care for residents in both areas, creating the potential for the spread of COVID-19. On 8/2/21 at 4:45 PM, CNA #9 was observed exiting the barrier, from the red zone to the yellow zone. She then assisted LPN #1 with delivering a meal to Resident #28 in a third hall, who was negative for COVID-19. On 8/2/21, at 3:45 PM, LPN #1 was observed exiting the barrier from the red zone to the yellow zone. At 4:45 PM, she delivered a meal to Resident #33 in her room in the yellow zone. On 8/3/21, beginning at 3:06 PM, the DNS was interviewed. She confirmed LPN #1 and CNA #9 delivered care to COVID-19 negative residents in the yellow zone and COVID-19 positive residents in the red zone during the same shift. Daily Nursing Staffing schedules for 7/13/21 to 7/31/21 were reviewed. During this time the staffing schedules documented there was 1 licensed nurse scheduled to work at the facility during the following shifts: - On night shift, 10:00 PM to 6:00 AM, there was 1 licensed nurse working from 7/13/21 to 7/31/21. - On night shift, there was 1 CNA working on 7/21/21. - On evening shift, 2:00 PM to 10:00 PM, there was 1 licensed nurse working from 6:00 PM to 10:00 PM from 7/13/21 to 7/31/21. - On evening shift, there was 1 CNA working from 6:00 PM to 10:00 PM on 7/13/21, 7/14/21, 7/19/21, 7/20/21, and 7/28/21. - On evening shift there were no CNAs working from 6:00 PM to 10:00 PM on 7/21/21, 7/26/21, and 7/27/21. The DON and the Administrator were interviewed on 8/4/21, beginning at 9:47 AM. The DON stated she had not immediately designated staff for the COVID-19 positive unit when the outbreak began due to following corporate guidelines. The DON stated that they did not have the staffing resources to dedicate a night nurse for the red zone. The DON stated that mitigation efforts included asking for corporate assistance on 7/16/21, 4 days after the outbreak began, working 3 extra shifts herself, and to ask staff to work extra shifts. The DON stated that a travel nurse was to begin taking shifts on 8/5/21 but that nurse was only scheduled to be at the facility for 6 shifts. Documentation was not provided concerning asking staff to work extra shifts. b. The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated 3/29/21, states, Residents should only be placed in a COVID-19 care unit if they have confirmed SARA-CoV-2 infection. The facility policy Cohorting Plan for SNFs (Skilled Nursing Facilities), updated 4/17/20, documented to place residents who were symptomatic and suspected or tested positive for COVID-19 in the isolation area (red zone). Additionally, asymptomatic residents who had suspected exposure to COVID-19 were to be placed in the quarantine area (yellow zone). This policy and guidance was not followed. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 tested negative for COVID-19 on 8/1/21 and was asymptomatic. On 8/3/21 at 2:45 PM, Resident #28 was no longer in room [ROOM NUMBER], in the yellow zone, and was transferred to room [ROOM NUMBER], in the red zone. In an interview on 8/3/21 at 4:43 PM, the DON confirmed Resident #28 was transferred to the red zone and stated a resident in the red zone, who had completed her isolation period, was having difficulty being away from her previous room, #201. She added there were no available beds in the facility for Resident #28, other than in the red zone, so she was transferred there. The DON also stated rooms #203 and #205, in the yellow zone, were unoccupied due to drywall repairs being performed. c. The following infection control breaches of the barrier separating the red zone from the yellow zone were observed: - On 8/3/21 at 5:05 PM, the plastic barrier separating the red and yellow zones was observed to be unzipped and partially open, allowing airflow from the red zone to the rest of the facility. When asked if the barrier was supposed to be closed, LPN #1, who was assigned to the red and yellow zones, stated, It should stay zipped all the time. On 8/3/21 at 6:10 PM, the plastic barrier was observed unzipped and partially open. CNA #1, who was working in the red zone, was asked about the open barrier and stated, I think it's supposed to be zipped up when we aren't using it. She then zipped the barrier closed. - On 8/4/21 at 4:27 PM Maintenance Staff #1 was standing in front of the barrier. The barrier was unzipped, and a folder was handed to the staff member. It was unknown if that folder had been sanitized. Maintenance Staff #1 stepped away from barrier for approximately 1 minute to place the folder out of sight, leaving the barrier unzipped. Maintenance Staff #1 returned to the plastic barrier and spoke to person behind barrier for approximately 2 minutes without zipping the barrier closed. The IP was interviewed on 8/3/21, beginning at 3:15 PM. She stated the barrier was to remain zipped closed when not in use. On 8/4/21 at 3:06 PM, the Administrator and the DON were informed by written and verbal notification of a determination of Immediate Jeopardy (IJ). On 8/6/21 at 9:36 AM, the facility provided a plan to remove the immediacy which was accepted. The facility alleged compliance of removal of the immediacy on 8/5/21 at 4:30 PM. The facility's removal plan documented the facility would: (a) assign dedicated nursing staff to the COVID-19 positive unit, (b) transfer the COVID-19 negative resident out of the COVID-19 unit to a quarantine room (c) educate staff on CDC guidelines for co-horting residents. Surveyors completed an onsite verification of the implementation of the facility's Immediate Jeopardy removal plan and confirmed the immediacy was removed as of 8/5/21 at 4:30 PM. On 8/5/21 at 4:30 PM, the Administrator was notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at no actual harm with the potential for more than minimal harm which was a pattern. 2. The CDC website, accessed on 8/12/21 and last reviewed on 1/8/21, stated, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - Before moving from work on a soiled body site to a clean body site on the same patient - After touching a patient or the patient's immediate environment - After contact with blood, body fluids, or contaminated surfaces - Immediately after glove removal The CDC Hand Hygiene Recommendations, updated 5/17/20, documented hands should also be washed before eating, and after using the restroom. These guidelines were not followed. Examples include: a. On 8/2/21 at 4:50 PM, LPN #1 delivered and set-up Resident #4 and Resident #32's meals for them in their room. Before exiting the room, LPN #1 removed her gloves without performing hand hygiene afterward. She confirmed she did not perform hand hygiene after removing her gloves. b. On 8/4/21 at 4:00 PM, CNA #3 and CNA #8 performed hand hygiene and put on gloves. CNA #3 unfastened Resident #3's incontinence brief, took a wipe and cleaned Resident #3's suprapubic catheter around the insertion site and assisted her to turn on her left side towards CNA #8. CNA #8 supported Resident #3 by holding her left hip and left shoulder as CNA #3 then wiped the stool from Resident #3's bottom. CNA #3 removed the soiled incontinence brief and applied a new incontinence brief to Resident #3. CNA #3 did not change her gloves prior to putting a new incontinence brief on Resident #3. CNA #8 assisted Resident #3 to lie on her back and CNA #3 fastened the incontinence brief. CNA #3 and #8 removed their gloves, performed hand hygiene and put on new gloves. CNA #3 and CNA #8 then helped Resident #3 to sit at her bedside. CNA #8 took Resident #3's shoes and applied it to Resident #3's feet. CNA #8 then looked for Resident #3's gait belt in her drawer, touched the folded clothes inside the drawer with her gloved hand she used when she applied the shoes to Resident #3. CNA #8 said she did not find Resident #3's gait belt and used the gait belt that was with her. CNA #3 and CNA #8 transferred Resident #3 to her wheelchair with the gait belt. On 8/4/21 beginning at 4:48 PM, CNA #3 and CNA #8 were interviewed regarding the observation of care for Resident #3. CNA #3 said she did not change her gloves before applying a new incontinence brief to Resident #3. CNA #3 said she should have changed her gloves, performed hand hygiene and put on new gloves before applying the new incontinence brief. CNA #8 said she assisted Resident #3 to put on her shoes and did not change her gloves when she looked for Resident #3's gait belt in her drawer. CNA #8 said she should have change her gloves before looking for the gait belt in Resident #3's drawer. c. On 8/2/21 from 11:25 AM to 1:10 PM, lunch trays in the 300 hall were being served to residents. The following was observed: - At 11:35 AM, CNA #5 delivered and set up a lunch tray for Resident #. CNA #5 did not offer Resident #19 hand hygiene prior to eating her lunch. - At 12:07 PM, CNA #3 delivered and set up a lunch tray for Resident #. CNA #3 did not offer Resident #40 hand hygiene prior to eating her lunch. - At 12:13 PM, CNA #5 exited room [ROOM NUMBER] without performing hand hygiene, grabbed 2 cups of coffee from the delivery cart, placed one cup back on the cart and re-entered room [ROOM NUMBER] without performing hand hygiene. - At 12:26 PM, CNA #7 delivered and set up a lunch tray for Resident #35. CNA #3 did not offer Resident #35 hand hygiene prior to eating him eating lunch. - At 12:29 PM, CNA #5 performed hand hygiene prior to entering Resident #15's room, but then exited without performing hand hygiene, touched 2 food delivery carts while selecting Resident #15's meal, then re-entered his room. CNA #5 did not offer hand hygiene to Resident #15 prior to eating his lunch. - At 12:30 PM, CNA #3 entered Resident #7's room to provide a beverage and did not perform hand hygiene prior to entering her room. - At 12:32 PM, CNA #7 entered Resident #15's room and did not perform hand hygiene prior to entering his room. d. On 8/2/21 beginning at 4:50 PM, dinner trays in the 200 hall were being served to residents. The following was observed: - At 4:50 PM, LPN #1 delivered and set-up Resident #4 and Resident #32's meals for them in their room. LPN #1 did not offer hand hygiene to Resident #4 and Resident #32 prior to eating their dinner. -At 4:55 PM, CNA #9 delivered and set-up Resident #28 and Resident #33's meals for them in their room. CNA #9 did not offer hand hygiene to Resident #28 and Resident #33 prior to eating their dinner. On 8/2/21 at 5:00 PM, LPN #1 and CNA #9 said they did not offer hand hygiene to the residents when they delivered their meal trays. e. On 8/3/21 from 12:16 PM to 12:30 PM, lunch trays in the 100 and 300 halls were being served to residents. The following was observed: - At 12:16 PM, CNA #1 delivered and set-up Resident #11 and Resident #36's meal for them in their room. CNA #1 did not offer hand hygiene to Resident #11 and Resident #36 prior to eating their lunch. - At 12:21 PM, CNA #6 delivered and set-up Resident #16's meal for her in her room. CNA #6 did not offer hand hygiene to Resident #16 prior to eating her lunch. - At 12;24 PM, CNA #3 delivered and set-up Resident #31's meal for him in his room. CNA #3 did not offer hand hygiene to Resident #31 prior to eating his meal. - At 12:26 PM, CNA #3 delivered and set-up Resident #9's meal for him in his room. CNA #3 did not offer hand hygiene to Resident #9 prior to eating his meal. -At 12:30 PM, CNA#6 delivered and set-up Resident #21's meal for her in her room. CNA #6 did not offer hand hygiene to Resident #21 prior to eating her meal. On 8/3/21 at 12:33 PM, CNA #3 and CNA #6 said they did not offer hand hygiene to the residents when they delivered their meal trays. f. On 8/3/21 from 11:25 AM to 1:10 PM, lunch trays in the 300 hall were being served to residents. The following was observed: - At 12:18 PM, CNA #1 delivered and set up a lunch tray to Resident #. CNA #1 did not offer Resident #15 hand hygiene prior to eating him eating lunch. - At 12:23 PM, CNA #1 delivered and set up a lunch tray to Resident #. CNA #1 did not offer Resident #26 hand hygiene prior to eating her eating lunch. - At 12:25 PM, CNA #1 delivered and set up a lunch tray to Resident #. CNA #1 did not offer Resident #25 hand hygiene prior to eating her eating lunch. - At 12:28 PM, CNA #3 delivered and set up a lunch tray to Resident #27. CNA #3 did not offer Resident #27 hand hygiene prior to eating her eating lunch. - At 12:29 PM, CNA #1 delivered and set up a lunch tray to Resident #. CNA #1 did not offer Resident #7 hand hygiene to her prior to eating her eating lunch. - At 12:31 PM, CNA #1 delivered and set up a lunch tray to Resident #29. CNA #1 did not offer Resident #29 hand hygiene prior to eating her eating lunch. - At 12:33 PM, CNA #5 delivered and set up a lunch tray to Resident #. CNA #5 did not offer Resident #19 hand hygiene prior to eating her eating lunch. Resident #15 was interviewed on 8/2/21, beginning at 12:36 PM. He stated that staff did not offer him hand hygiene prior to eating meals and sometimes did not wear masks. On 8/2/21 at 1:00 PM, Resident #27 stated that staff had never offered her hand hygiene prior to meals before today. On 8/3/21 at 1:38 PM, Resident #24 stated he was not offered hand hygiene or hand sanitizer prior to eating his lunch. On 8/3/21 at 1:40 PM, Resident #17 stated she was not offered hand hygiene or hand sanitizer prior to eating her lunch. She stated she kept her own bottle of hand sanitizer and performed her own hand hygiene. On 8/3/21 at 1:44 PM, Resident #21 stated she was not offered hand hygiene or hand sanitizer prior to eating her lunch. On 8/3/21 at 1:45 PM, Resident #40 stated she was not offered hand hygiene or hand sanitizer prior to eating her lunch. The DON was interviewed on 8/3/21, beginning at 1:38 PM. She stated the expectation was for staff to perform hand hygiene following CDC guidance. She stated staff should offer hand hygiene to residents prior to eating their meals. 3. The CDC website, accessed on 8/16/21, included a section Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated on 3/29/21, which stated when caring for residents with suspected exposure and under quarantine HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. This guidance was not followed. a. At 12:22 PM, LPN #1 donned a gown to enter Resident #11's room. Resident #11 was in quarantine from potential exposure to COVID-19. LPN #1's gown did not cover most of her back and LPN #1 did not don (put on) protective eyewear. b. At 12:10 PM, CNA #7 delivered and set up a lunch tray to Resident #11 who was in quarantine for potentially being exposed to COVID-19. CNA #7 did not don protective eyewear prior to entering Resident #11's room. c. At 8/4/21 at 4:55 PM, Maintenance Staff #1 was observed entering room [ROOM NUMBER], a quarantine room, wearing a mask. On the front of the door was a PPE kit. Maintenance Staff #1 did not don additional PPE prior to entering room [ROOM NUMBER]. The DON was interviewed on 8/4/21, beginning at 5:00 PM. She confirmed all personnel entering rooms with residents under quarantine should don a gown, gloves, and protective eyewear. 4. The CDC guidance for environmental cleaning procedures for healthcare facilities to prevent the spread of COVID-19, website accessed on 8/12/21, documented all high-touch surfaces and floors should be cleaned and disinfected with an EPA-registered disinfectant from List N of disinfectants for COVID-19. This guideline was not followed. On 8/6/21 at 9:50 AM, the Environmental Services Director was interviewed and stated that the facility floors, including resident rooms, were cleaned daily with a cleaning agent labeled Neutral Floor Cleaner. When asked if the cleaning agent was EPA-registered on List N for COVID-19, she stated, after conferring with the vendor, that it was not.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe and sanitary environment. This was true for 1 of 12 residents (Resident #3) whose environment was observed. Resident #3, who was unable to express herself, experienced psychosocial harm when she was consistently exposed to a strong odor of urine in her room due to her roommate's lack of compliance with personal hygiene. Findings include: * Resident #3 was admitted to the facility on [DATE], with multiple diagnoses which included Alzheimer's disease. A quarterly MDS assessment, dated 7/22/21, documented Resident #3 was severely cognitively impaired. * Resident #16 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus, [CONDITION(S)], and dementia. A quarterly MDS assessment, dated 5/21/21, documented Resident #16 was moderately cognitively impaired. The facility's Tracking Rooms record, documented Resident #3 and Resident #16 were transferred to room 305 on 7/19/21 and were roommates. On 8/2/21 at 12:05 PM, a urine odor was noted outside room 305. On 8/2/21 at 3:46 PM, when a surveyor entered room 305, a strong odor of urine was noted. Resident #3 was in bed, awake. The privacy curtain was drawn between Resident #3 and Resident #16. When asked how Resident #3 was doing, Resident #3 replied Are you [name of her representative]. On 8/3/21 at 5:41 AM and 8/5/21 at 11:28 AM, Resident #3 was observed in the dining room and no urine odor was noted. On 8/5/21 at 111:28 AM, LPN #3 stated the urine odor in room 305 was due to Resident #16. LPN #3 said Resident #16 was non-compliant and would only allow certain staff members to change her incontinence briefs. LPN #3 said Resident #16 refused a lot of peri-care and got angry with staff when they asked to change her incontinence brief. LPN #3 also said Resident #16 was able to go to the bathroom on her own and there were times she urinated on her way to the bathroom. On 8/6/21 at 7:46 AM, when a surveyor entered room 305 there was a strong odor of urine noted. Resident #3 was not in the room. The privacy curtain was drawn and behind the privacy curtain was Resident #16. She was eating her breakfast and looked appropriately groomed. Resident #16 said she was fine and being assisted by the staff as needed. The urine odor was more pronounced closer to Resident #16's area. On 8/6/21 at 7:52 AM, CNA #10 said Resident #16 had been educated and staff offered many times to change her incontinence briefs, as needed. CNA #10 said Resident #16 got angry when staff approached her to change her incontinence brief. CNA #10 said there were times Resident #16 would wear her regular underwear and staff applied a sanitary pad, but Resident #16 removed it. CNA #10 said the room was always cleaned but the smell lingered in the room because of Resident #16 being non-compliant with her peri-care. On 8/6/21 at 7:57 AM, the DON said Resident #3 was moved to room 305 about three weeks ago when the facility had an outbreak with COVID-19 and Resident #16 was also moved to room 305 at the same time. The DON said Resident #16 was incontinent of urine and wore incontinence briefs but was non-compliant with her personal hygiene. The DON said Resident #16 would remove her incontinence brief and urinate on the floor at bedside. The DON said Resident #16 was educated many times by the staff and her representative was also informed of her being non-compliant with personal hygiene. When asked about Resident #3 being in the same room with Resident #16, the DON said Resident #3 did not express any concern being in room 305 with Resident #16. Resident #3 was unable to express herself appropriately and experienced psychosocial harm when she was placed in a room with another resident who was non-complaint with her personal hygiene causing a strong odor of urine.

Based Review of the facility's policy titled, Notification of Change, dated 11/2016, directed the staff as follows: A facility must immediately . consult with the resident's physician . when there is: . 2. A significant change in the resident's physical, mental or psychosocial status . 1. Resident #30 was admitted to the facility on [DATE], and discharged to the hospital on [DATE], and readmitted him on 8/16/18. Resident #30's [DIAGNOSES REDACTED]. Resident #30's Physician order [REDACTED]. [MEDICATION NAME] Patch 72-hour, 12 micrograms (mcg)/hour (a narcotic pain medication in a topical patch form that is applied to the skin and delivered in a time-released manner), apply one patch [MEDICATION NAME], one time a day, every three days for pain. (ordered 08/02/18 and discontinued on 09/19/18). Carvedilol 6.25 mg two times a day for hypertension, ordered 7/31/18. [MEDICATION NAME] 100 mcg one time a day for [MEDICAL CONDITION], ordered 08/01/18. Resident #30's History and Physical Evaluation, dated 8/22/18 at 1:20 PM, documented his attending physician saw the resident at the facility and documented the following findings under Review of Systems: Constitutional Negative (for) . Fatigue, . Malaise and Weight Loss . GI (gastrointestinal) Negative (for) Abdominal pain, . Decreased appetite, . Nausea and Vomiting. A quarterly MDS assessment, dated 8/24/18, documented Resident #30 was cognitively intact with mild depression. The MDS documented Resident #30 required extensive assistance of two or more persons for bed mobility, transfer, dressing, and toileting, did not walk in or out of his room, and required extensive assistance of one to two or more persons for wheelchair mobility, but could eat with setup assistance and supervision. Review of Resident 30's care plan indicated the staff developed the following Focus areas, all initiated on 08/01/18: a. The care plan area addressing Resident #30's altered cardiovascular status, dated 8/1/18, documented he had a history of [REDACTED]. The Interventions documented staff were to monitor, document, and report any signs and symptoms of heart related concerns, included nausea and vomiting to the physician. b. The care plan area addressing Resident #30's [MEDICAL CONDITION], dated 8/1/18, documented the staff were to report signs and symptoms of [MEDICAL CONDITION] such as low blood pressure, decreased breathing, decreased body temp, unresponsiveness; fatigue, impaired memory, and depression. c. The care plan area addressing Resident #30's chronic [MEDICAL CONDITION] pain (nerve-related pain) and acute back pain, dated 8/1/18, documented he had a T12 ([MEDICATION NAME] spine, 12th vertebrae) compression Fx (fracture) with disc retropulsion (herniation) with surgical repair. The interventions documented staff were to observe for signs of nausea or vomiting and report to the physician any occurrences. Resident #30's Progress Notes from 09/01/18 through 09/22/18 documented the following: - On 9/1/18 at 11:02 PM, Resident #30 had post-op back surgery and he was to wear a back brace while up in his wheelchair. The note documented Resident #30 denied pain or discomfort and he was alert and oriented. - On 9/2/18 at 8:17 PM, Resident #30 was administered [MEDICATION NAME] HCl ([MEDICATION NAME]) ([MEDICATION NAME]- an anti-nausea medication) 4 milligrams (mg) due to nausea with vomiting. - On 9/2/18 at 11:48 PM, Resident #30 experienced emesis (vomiting) episode this shift, [MEDICATION NAME] administered and was effective. - On 9/3/18 at 3:08 AM, Resident #30 was administered [MEDICATION NAME] 4 mg due to nausea. - On 9/3/18 at 1:17 PM and at 9:54 PM, and on 09/04/18 at 10:48 PM, the nurses documented Resident #30 was up in his wheelchair with his back brace on, was alert and oriented, participated with PT and OT, and denied pain or discomfort. - On 9/5/18 at 1:09 PM, Resident #30 refused both breakfast and lunch. The Progress Notes did not reflect follow up documentation by the nurse or communication with the physician of the resident's change in status. - On 9/5/18 at 1:33 PM, the LSW met with Resident #30 1:1 and discussed his recent lack of activity and not getting out of bed and his lack of desire to get up and use the restroom. The note documented Resident #30 did not feel up to it. The Progress Notes did not reflect follow up documentation by the LSW or communication with nurses or the physician of the resident's change in status. - On 9/5/18 at 11:02 PM and on 9/6/18 at 11:28 PM, the nurses documented the resident was alert, verbal, oriented x 2, up to his wheelchair with his back brace on, took his medications, and denied pain or discomfort. - Resident #30's MAR indicated [REDACTED]. - On 9/14/18 at 5:44 PM, Resident #30 had a substantial amount of emesis after morning medications. The note documented he did not have much of an appetite for the rest of the day. The note documented his vital signs were obtained and were 88/56 for blood pressure, pulse 59, (and) O2 (oxygen) 94%. The note documented his vital signs were rechecked near dinner time and his (blood) pressure was 102/54, pulse was 70, O2 95%, respirations 16, (and) temp of 96.0. The note documented Resident #30's skin was cold to touch and he was pale. The Progress Notes did not reflect follow up documentation by the nurse or communication with the physician of the resident's change in status. - On 9/15/18 at 4:48 PM, Resident #30's carvedilol (a heart medication) was Held for blood pressure 98/49. - On 9/16/18 at 5:19 PM, Resident #30 experienced episodes of vomited about 5 minutes after evening medications were administered. The note documented he was feeling fine today and his BP was 120/53. - On 9/17/18 at 1:44 PM, Resident #30 remained in bed for most of the day sleeping/resting. The note documented he has not complained of any nausea or had any emesis. - On 9/17/18 at 2:34 PM, Resident #30 was discharged from physical therapy's services. The note documented he did not feel up to participating lately. The Progress Notes from 09/15/18 through 09/17/18 did not reflect follow up documentation with the physician of the resident's change in status. The Progress Notes documented the nursing staff did not document an assessment of Resident #30's medical status from 09/19/18 at 3:34 PM until 09/22/18 at 2:15 AM. - On 09/22/18 at 2:15 AM, Resident #30 experienced an emesis episode at approximately 1:20 AM. The note documented Resident #30 was responsive to verbal and tactile stimuli and continued to vomit while being cleaned up by staff. The note documented his vital signs were taken at this time and his blood pressure was 35/30, pulse 60, temperature 98.3, respirations 10, oxygen saturation 48 percent. The note documented oxygen was applied via nasal cannula while EMR (Emergency Medical Response) were notified. The note documented the responsible party (name) was notified of Resident #30's decline. The note documented his vitals were obtained again and they were BP 58/32, pulse 63, sats (oxygen saturation) 68. The note documented the EMR arrived and Resident #30's breathing had become shallow and his eyes were glazed and fixed. The note documented the EMR was unable to retrieve a pulse. The note documented at 2:00 AM Resident #30 was pronounced dead by EMR staff and the DNS and physician were notified. On 10/12/18 at 1:46 PM, LPN #1 stated that on 9/14/18, he was in facility orientation with and thought he notified the RN (registered nurse) working with him that day of Resident #30's condition but could not recall the name of the RN. LPN #1 stated he did not notify Resident #30's physician of the change in the resident's condition. On 10/12/18 at approximately 2:00 PM, the DNS stated that Resident #30 had exhibited episodes of nausea and vomiting prior to his back surgery, but none of the staff notified the physician when the resident exhibited additional episodes of nausea and vomiting, decreased appetite and intake, refusal of therapy services, and preference to stay in bed. The DNS stated she expected the staff to notify the physician of any change in a resident's condition.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers. This was true for 1 of 2 residents (#25) reviewed for pressure ulcers. Resident #25 was harmed when she developed 2 pressure ulcers. Findings include: The facility's Wound and Pressure Ulcer Management Policy and Procedure, dated 1/17, documented the facility followed protocols and procedures consistent with the Agency for Healthcare Research and Quality (AHRQ), the American Medical Director Association (AMDA), and the Society for Post-Acute and Long-Term Care Medicine. The facility's Positioning Policy and Procedure, dated 10/17, documented staff would reposition residents to reduce their risk of developing pressure ulcers. The 2014 guidelines for staging wounds, from the National Pressure Ulcer Advisory Panel, Prevention and treatment of [REDACTED].) intact redness to skin over a bony area. The guidelines documented a Stage II wound was partially skin thickness loss (A Wound that affects the top two layers of the skin.) with red and or pink in the wound bed without slough (A mass of dead tissue that separates from a wound bed.). The guidelines documented a Stage III wound was full skin thickness loss (A wound that affected the layers of skin and into the subcutaneous tissue of fat.) with possible slough present in the wound bed, however, the base of wound is visible. The guidelines documented a Stage IV wound was a full thickness tissue loss with exposed muscle, bone, or tendon. The guideline documented slough or eschar could be present in parts of the wound bed. The guideline documented an unstageable wound was of unknown depth due to the base of the wound covered by slough or eschar. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The care plan area addressing Resident #25's pressure ulcer, initiated 4/14/17, documented Resident #25 had a stage II pressure injury to her coccyx and a Deep tissue injury (DTI) to her buttock. The care plan documented she was risk related to incontinence, impaired mobility, and a history of [MEDICAL CONDITION]. The care plan documented staff were to encourage Resident #25 to lift her buttock off of her wheelchair seat a minimum of twice per shift. (The facility had two shifts.) The care plan documented Resident #25 was to receive wound care per orders and staff were to encourage her to lay down for pressure relief during the day. Resident #25's clinical record contained Weekly Skin Observation Assessments between the dates of 5/1/18 and 10/10/18. The assessments were completed weekly and PRN. Resident #25's Weekly Skin Observation Assessment, dated 5/8/18, documented her skin was intact. Resident #25 developed and/or re-developed a Stage III pressure ulcer to her coccyx in (MONTH) (YEAR), and the facility did not treat, implement interventions, and assess her pressure ulcer when the skin impairment was first discovered in (MONTH) (YEAR). Examples include: i. Resident #25's Weekly Skin Observation Assessment, dated 5/15/18, documented Resident #25 had a new area to her coccyx which was red with fragile skin noted. The assessment did not document if the skin was blanchable or provided measurements for the area. Resident #25's clinical records did not contain a Wound Data Collection, dated 5/15/18, describing the skin impairment. Resident #25's (MONTH) (YEAR) MAR indicated [REDACTED]. Resident #25's Weekly Skin Observation Assessment, dated 6/9/18 and 6/12/18, documented Resident #25's coccyx had healing buttocks wound and was healing. The assessments did not document if the skin was blanchable or provided measurements for the area. Resident #25's clinical records did not contain a Wound Data Collection or a progress note, dated 6/9/18 and 6/12/18, describing the skin impairment. Resident #25's Positioning Assessment, dated 6/25/18, documented her Braden score was a 16 which placed her at risk for skin breakdown and she had no current skin breakdown. A quarterly MDS assessment, dated 9/7/18, documented Resident #25 was cognitively intact and documented she required extensive assistance of one to two staff members with all cares except eating. The MDS documented Resident #25's skin was intact, and she did not have a pressure ulcer. Resident #25's Positioning Assessment, dated 9/18/18, documented she was incontinent of bowel and bladder and required assistance with bed mobility and transfers. The assessment documented her skin was in good condition. This assessment was not consistetnt with the 9/18/18 weekly skin observtion assessment or progress notes. ii. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25's coccyx had a Stage III pressure injury to her coccyx. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. A Progress Note, dated 9/18/18, documented Resident #25 was found to have a Stage III pressure injury to her coccyx after being assisted in the shower. A Progress Note, dated 9/20/18, documented Resident #25's wound was assessed, and the dressing was changed. The note documented Resident #25's wound bed did not have slough, no evidence of subcutaneous fat, or full thickness tissue loss. The note documented the wound was a Stage II. Resident #25's Wound Data Collection, dated 9/20/18, documented Resident #25 had a previously identified stage II wound to her coccyx, measuring 1.5 cm by 0.5 cm. The assessment documented the wound was pink and intact. Resident #25's Wound Data Collection assessments for her coccyx were completed between the dates of 9/20/18 and 10/11/18 by 11 different nurses. Thedocumentation of the characteristics of the wound was incomplete and inconsistent as follows: *On 9/27/18 Resident #25's wound worsened in size to 2.5 cm by 1 cm and 0.5 cm in depth. *The 9/27/18 assessment documented the wound remained a Stage II wound and the wound bed had 90% slough covering the surface with 5% granulation tissue (pink or beefy red moist tissue). (The national standards documented slough present would not be a Stage II wound, but an unstageable wound.) * On 9/29/18 Resident #25's wound was documented as worsening in size to 3 cm by 2 cm by 1 cm, no staging documented. * The 9/29/18 assessment documented 5% granulation and no other tissue type documented. * The 9/30/18 assessment documented the wound size remained the same, however there was 5% eschar in the wound bed, no staging documented. *On 10/2/18 the assessment documented the wound was 2.5 cm by 1.5 cm by 0.1 with 100% slough in the wound bed, no staging documented. (The depth of a pressure ulcer cannot be determined when the wound bed is covered by slough 100%.) * The 10/2/18 assessment documented the pressure ulcer was worsening. *On 10/3/18 the assessment documented the wound was a Stage III pressure ulcer, measuring 2.5 cm by 1.5 cm by 4 cm deep, with 85% slough covering the wound bed, 10% [MEDICATION NAME] tissue (new skin tissue), and 5% granulation tissue. (The depth of a pressure ulcer cannot be determined when the wound bed is covered by slough or eschar.) A day later on 10/4/18 the Stage III pressure ulcer was documented as measuring 2.5 cm by 1.5 cm by 0.5 cm deep with 80% slough in the wound bed. (The wound healed 3.5 cm in one day according to the assessment.) Five assessments on 10/6/18, 10/7/18, 10/9/18, 10/10/18, and 10/11/18 following 10/4/18 documented the presence of slough in the wound bed. The 9/28/18, 10/5/18, and 10/8/18 assessments did not document an assessment of the wound bed to include the presence of granulation tissue, slough, eschar, or [MEDICATION NAME] tissue. The wound was last measured on 10/10/18 as 2 cm by 1.5 cm by 2 cm deep as a Stage III pressure ulcer. Resident #25's (MONTH) (YEAR) MAR indicated [REDACTED]. This was ordered three days after the wound was discovered. The order was not specific to the location of the pressure ulcer. The dressing was changed as ordered with the exception of 9/21/18. b. Resident #25 developed and/or re-developed a skin impairment in (MONTH) (YEAR) on her left buttocks, and the facility did not treat and implement interventions to her left buttocks when the skin impairment was first discovered in (MONTH) (YEAR). Example includes: i. Resident #25's Weekly Skin Observation Assessment, dated 5/19/18, documented Resident #25 had a recurrent area to her left buttock that was a stage II. The assessment document the wound was an open area approximately 0.5 cm by 1 cm that was previously scabbed over. Resident #25's Wound Data Collection, dated 5/19/18, documented Resident #25 had new wound to her left buttock, measuring 0.5 by 0.5 cm by 0.25 cm deep. The assessment documented the wound was reopened. The assessment did not document an assessment of the wound bed characteristics. Resident #25's Wound Data Collection, dated 5/26/18, documented Resident #25's wound to her left buttock, measured 0.5 by 0.5 cm. The assessment documented the wound bed had 100% [MEDICATION NAME] tissue present in the wound bed. Resident #25's (MONTH) (YEAR) MAR indicated [REDACTED]. ii. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. A Progress Note, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The note documented Resident #25 was being assisted into her wheelchair by two staff members when Resident #25's stated her legs were tired and began to sit down. The note documented Resident #25's legs were tired and gave out on her and she was lowered to the floor. The note documented Resident #25's deep tissue injury may have come from this incident as she hit her buttock on the arm rest of the wheelchair. Resident #25's Wound Data Collection, dated 9/20/18, documented Resident #25 had a previously identified deep tissue injury wound to her left buttock, without measurements. The assessment documented Resident #25's left buttocks had a bruised area. Resident #25's Wound Data Collection assessments for her left buttock were completed between the dates of 9/20/18 and 10/4/18 by 3 different nurses. The documentation of the characteristics of the wound and wound size, were inconsistently documented between nurses as follows: * On the 9/20/18, 9/22/18, 9/23/18, and 9/28/18, Resident #25's wound was not documented as measured. *The 9/23/18 assessment documented the wound bed had 3 small areas open. *The 9/24/18 assessment documented the wound was open and measured 1 cm by 1 cm with 65% granulation and 35% [MEDICATION NAME] tissue. * On 9/27/18 Resident #25's wound was documented as worsening in size to 1.5 cm by 3 cm, with 100% granulation tissue. The 9/27/18 assessment documented the area was no longer bruised, but there were two open areas present. *The 10/4/18 assessment documented the deep tissue injury was 0.5 cm by 0.5 cm with 95% [MEDICATION NAME] tissue present. This was the last assessment of the wound. Resident #25's clinical record did not document when her left buttock wound resolved. Resident #25's (MONTH) (YEAR) MAR indicated [REDACTED]. c. Resident #25 developed new a skin impairment on her left gluteal fold and the facility did not implement interventions or consistently assess the wounds. Example includes: Resident #25's Weekly Skin Observation Assessment, dated 10/2/18, documented Resident #25 had an abrasion to her left gluteal fold. The assessment did not document a size of the wound. Resident #25's Wound Data Collection, dated 10/3/18, documented Resident #25 had previously identified wounds to her left gluteal fold. The assessment documented there were three areas that were connecting with excoriated (rubbed off skin) skin. The assessment documented one area was 1 cm by 0.5 cm by 0.2 cm deep. The assessment documented the biggest wound had slough present in the wound bed and one wound appeared to be a Stage I. The assessment documented there was 85% slough present in the wound bed. A Progress Note, dated 10/3/18, documented Resident #25 had three sores located on her coccyx, right cheak, and crease of buttock and leg on the right hand side. The 3rd sore is a cluster of satellite open areas with one main area measuring 1 cm x (by) 0.5 cm. Resident #25's Wound Data Collection, dated 10/4/18, documented Resident #25 had previously identified wounds to her left gluteal fold. The assessment documented there were three areas, measuring 1 cm by 1.5 cm with 85% slough present in the wound bed. The assessment documented there was a 3 cm by 3 cm excoriated area surrounding the open area. The assessment documented the other two area look like potential problem. The assessment documented there was 85% slough present in the wound bed. Resident #25's clinical record did not contain documentation of the progression of the three areas to the left gluteal folds or documentation of further assessments after 10/4/18. Resident #25's (MONTH) (YEAR) MAR indicated [REDACTED]. d. Resident #25 was not repositioned consistently and every 3 hours as follows: On 10/11/18 at 10:44 AM, the DNS stated the staff were instructed to document repositioning of residents in their chair and beds under the bed mobility section of the charting system. The DNS stated the staff were to document each occurrence of repositioning they provided to residents. The DNS stated the staff were to reposition Resident #25 mininally every 3 hours. The (MONTH) (YEAR) ADL Bed Mobility record documented the following: - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 day shift, except once on 9/7/18 and 9/15/18. - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 evening shift, except once one evening shift on 9/5/18 when she was documented as she was able to do it herself. - There was no documented evidence she was turned/repositioned between 9/1/18 through 9/18/18 night shift, except once per shift on 9/1/18, 9/4/18, 9/5/18, 9/10/18, and 9/18/18 and twice per shift on 9/3/18. The ADL sheet documented Resident #25 was able to provide bed mobility independently once per shift on 9/1/18, 9/6/18, 9/10/18, 9/12/18, 9/13/18-9/15/18 and twice per shift on 9/7/18, 9/8/18, and 9/16/18. * The bed mobility between 9/19/18 through 9/30/18 day shift documented she was repositioned the following hours a day: - 9/19/18- Resident #25 was repositioned at 8:28 AM and again at 3:54 PM (7 1/2 hours). - 9/20/18- Resident #25 was repositioned at 1:10 AM and again at 12:20 PM (9 hours). - 9/22/18- Resident #25 was repositioned at 12:51 AM and again at 6:00 AM (5 hours). Resident #25's ADL documentation documented similar findings for the remainder of (MONTH) (YEAR). The 10/1/18 through 10/11/18 ADL Bed Mobility record documented the following: -10/9/18- Resident #25 was repositioned at 1:33 PM and again at 7:21 PM (6 hours). - 10/10/18- Resident #25 was repositioned at 8:02 AM and again at 1:18 PM (5 hours) and at 2:43 PM and again at 7:34 PM (5 hours). - 10/11/18 Resident #25 was repositioned at 6:15 AM and again at 10:01 AM (4 hours). Resident #25's 10/1/18 through 10/8/18 ADL documentation documented similar findings. On 10/9/18 from 2:15 PM through 4:33 PM, Resident #25 was observed positioned in her wheelchair located in the activity room by the window without staff offering to reposition her or staff providing assistance with repositioning. Resident #25 was observed positioned in her wheelchair on 10/10/18 at 8:38 AM through 12:25 PM, on 10/10/18 at 1:58 PM, and on 10/11/18 from 6:54 AM through 10:01 AM, and 10:15 AM through 11:45 AM, and 12:50 PM through 3:25 PM. On 10/11/18 at 6:10 AM, Resident #25's wound care was observed. RN #1 was observed instructing CNA #1 to assist Resident #25 onto her left side from her back while in bed. CNA #1 rolled Resident #25 onto her left side and Resident #25 began to immediately cry out, Oh, oh! That hurts! CNA #1 reassured Resident #25 that she would not let her fall and adjusted her legs to try and help ease her pain. CNA #1 unfastened the brief on Resident #25's right hip and pulled it down to reveal an intact foam dressing at the midline of her coccyx. RN #1 began to remove the dressing and Resident #25 again cried out in pain and complained of pain. RN #1 continued to dispose of the old dressing and then used her gloved right hand to hold up Resident #25's right buttock to view the pressure ulcer. The pressure ulcer was observed located in the midline of Resident #25's coccyx at the top of the gluteal fold. The pressure ulcer measured approximately the size of a quarter with a depth of approximately 1.5 cm. The wound bed had a pale-yellow appearance with 30% stingy slough present that was moveable after cleansing. The wound was observed with no signs of infection, exudate, eschar, or tunneling of the pressure ulcer, but also no signs of granulation tissue, or re-epithelization. Wound margins were well-defined, with no undermining noted. The peri-wound skin was observed light pink in color with no signs and symptoms of irritation or infection, and no odors were noted. RN #1 disposed of the old dressing and she picked up a can of saline wound cleanser and sprayed the wound bed with a wound cleanser. RN #1 patted the pressure ulcer dry with a sterile 4 x 4 and removed her gloves, sanitized her hands, and re-gloved. While RN #1 was cleansing the wound Resident #25 continued to complain of pain and cry out, That hurts. RN #1 covered Resident #25's pressure ulcer with a cut small piece of oil [MEDICATION NAME] dressing, and with a self-adhering antimicrobial foam dressing. On 10/11/18 at 10:44 AM, the DNS stated the wounds to Resident #25's coccyx and buttock were both found in (MONTH) (YEAR). The DNS stated the (MONTH) (YEAR) assessment documented the wounds being previously identified was a mistake. The DNS stated she was unsure where that information came from. The DNS stated she was unsure what the wounds found in (MONTH) (YEAR) were and she suspected these wounds healed and resolved without facility staff documenting resolution dates and updating the care plan. The DNS stated the staff should be completing a Wound Data Collection assessment when they resolve a wound. The DNS stated staff should notify her when new skin areas were found. The DNS stated she could see there was inconsistency with the documentation of the wounds. The DNS stated the facility did not have a wound certified nurse for wound care and all nurses on the floor completed wound assessments. The DNS stated the staff should be repositioning Resident #25 minimally every 3 hours, and she could see this was not documented as completed.

Based on observation, staff and resident interview, and review of residents' clinical records, it was determined the facility failed to ensure a method for evaluating the effectiveness of residents' pain management plans was in place. This was true for 1 of 5 residents (#25) reviewed for pain. Resident #25 was harmed when she experienced increased pain during cares and a dressing change and the facility did not identify and treat it. Findings include: The facility's Pain Management Policy and Procedure, dated (MONTH) 2012, documented when a resident was identified to be in pain a registered nurse would assess the residents current pain level and offer non-pharmacological interventions and provide medication interventions as needed. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 9/7/18, documented Resident #25 was cognitively intact and documented she required extensive assistance of one to two staff members with all cares except eating. The MDS documented Resident #25's did not have pain. The care plan area addressing Resident #25's chronic pain, revised 6/6/18, documented Resident #25 had generalized pain and could verbalize her pain. The care plan area addressing Resident #25's pressure ulcer, initiated 4/14/17, documented Resident #25 had a Stage II pressure injury to her coccyx and a DTI to her buttock. Resident #25's Physician order [REDACTED]. * Staff were to monitor her pain every shift, ordered 5/16/18. * 650 mg of Tylenol by mouth every 6 hours PRN for pain, ordered 7/27/17. Resident #25 did not have orders for scheduled pain medications. The Wound Data Collection Assessments from 9/20/18, 9/24/18, 9/30/18, 10/3/18, 10/4/18, 10/6/18, 10/7/18, and 10/11/18 documented Resident #25 complained of pain during the dressing changes. Resident #25's Weekly Skin Observation Assessment, dated 9/18/18, documented Resident #25 had a deep tissue injury to her left buttock. The assessment documented the facility changed out the cushion on her wheelchair and planned to reposition her every 3 hours. On 10/11/18 at 6:10 AM, Resident #25's wound care was observed. RN #1 was observed instructing CNA #1 to assist Resident #25 onto her left side from her back while in bed. CNA #1 rolled Resident #25 onto her left side and Resident #25 began to immediately cry out, Oh, oh! That hurts! CNA #1 reassured Resident #25 that she would not let her fall and adjusted her legs to try and help ease her pain. CNA #1 unfastened the brief on Resident #25's right hip and pulled it down to reveal an intact foam dressing at the midline of her coccyx. RN #1 began to remove the dressing and Resident #25 again cried out in pain and complained of pain. RN #1 continued to dispose of the old dressing and then used her gloved right hand to hold up Resident #25's right buttock to view the pressure ulcer. RN #1 disposed of the old dressing and she picked up a can of saline wound cleanser and sprayed the wound bed with a wound cleanser. RN #1 patted the pressure ulcer dry with a sterile 4 x 4 and removed her gloves, sanitized her hands, and re-gloved. While RN #1 was cleansing the wound Resident #25 continued to complain of pain and cry out, That hurts. While the wound care was being provided, Resident #25 stated the pain was located in, My back, and from the wound when they clean it. Resident #25 stated staff had not provided pain medication prior to wound care nor offered. Resident #25 stated, No, but that would probably help. On 10/11/18 at 6:27 AM, RN #1 was observed leaving Resident #25's room. RN #1 stated she had just given Resident #25 Tylenol for pain. On 10/11/18 at 6:28 AM, Resident #25 was observed sitting in her wheelchair with CNA #1 assisting her with her morning cares. While CNA #1 wheeled Resident #25 into the bathroom, Resident #25 was crying out, Ow, ow, ow, ow. CNA #1 proceeded to position Resident #25's wheelchair in the bathroom doorway, and asked Resident #25 stand up and reach for the assist bar on the wall by the toilet. Resident #25 was observed trying to stand up and stated, Nope, I can't stand. Oh, it hurts so bad. It's hurting can you hold my feet. Its hurting so bad. My legs hurt, my whole body hurts, God, that hurts. Resident #25 asked CNA #1 to please use the Hoyer lift. CNA #1 left the room to obtain a mechanical lift. On 10/11/18 at 6:32 AM, CNA #1 returned with a sit-to-stand mechanical lift and placed a body sling around Resident #25's torso, just below her breasts. The CNA asked her to place her feet on the machine's foot plate, and hold onto the lift bars, which she did. Then CNA #1 lifted Resident #25 off her wheelchair and asked her to stand so she could remove her incontinence brief. While Resident #25 was being lifted in the air she said, Hurry, it hurts, ow, hurry it hurts. CNA #1 removed the soiled brief. Resident #25 stated she needed to sit down, and she was going to fall. CNA #1 stated she was almost done and assisted Resident #25 onto the toilet. Then the CNA removed the sling while Resident #25 used the toilet. After Resident #25 used the toilet and CNA #1 provided pericare, the CNA assisted her with applying a clean brief and clean pants. On 10/11/18 at 6:48 AM, CNA #1 was observed as she applied the sit-to-stand sling around Resident #25's torso, just below her breasts, and asked her to place her hands on the lift bars. The sling was slightly loose. As Resident #25 was raised up she cried out, Ow, ow, ow, hurry, I'm going to fall, it hurts, it hurts, it hurts. On 10/11/18 at 6:35 AM, RN #1 stated she had not administered pain medications prior to Resident #25's wound dressing change. RN #1 stated she had not spoken with Resident #25's physician about obtaining a pre-treatment pain medication order. RN #1 stated, Giving her (the resident) pain medication at about 5:00 AM every morning would probably work well. On 10/11/18 at 10:45 AM, the DNS stated she would expect the staff to pre-medicate Resident #25 prior to the dressing change. The DNS stated the nurse told her about the resident's complaint of pain during the dressing change and that Resident #25 had not complained of pain during dressing changes in the past. The DNS stated she would expect staff to wait for pain medications to be effective before providing cares and if a resident verbalized pain during the dressing change or cares the staff should stop and try and address the situation.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to: a) Ensure residents diagnosed with [REDACTED]. This was true for 2 of 5 (#2 and #5) residents reviewed for diabetic management. As a result: * Residents' blood glucose (BG) levels were not monitored as ordered * Hyperglycemic BG levels were not reported to physicians * A policy for [MEDICAL CONDITION] was not developed * The facility's [DIAGNOSES REDACTED] policy was not followed * Insulin was administered without physician orders These systemic practices placed the health and safety of sampled residents #2 and #5, and 10 other residents in the facility with a [DIAGNOSES REDACTED]. b) Ensure 1 of 13 (#11) sampled residents received timely assessments of injury and effective pain control. Resident #11 was harmed when the facility failed to promptly assess her complaint of rib injury in a timely manner and control the resulting pain after she experienced a fall. Findings include: 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, dated 4/25/17, documented Resident #2 was cognitively intact. a. The [MEDICAL CONDITION] Care Plan, revised 5/4/17, directed staff to monitor, document, and report to the physician, as needed, when Resident #2 experienced signs and symptoms (s/s) of [MEDICAL CONDITION]. The care plan did not document how often staff was to monitor Resident #2's BG levels, when staff was to notify the physician if BG levels were outside of physician-established parameters, when to administer insulin, or when to follow hyper/hypo glycemic protocols. Resident #2's May 2017 Physician's Orders included: * HumaLOG (Insulin [MEDICATION NAME]) solution before meals and at bedtime (HS) per sliding scale for BGs (all measurements in milligrams/deciliters) of: 70 - 130 = 0 units; 131 - 180 = 4 units; 181 - 240 = 8 units; 241 - 300 = 10 units; 301 - 350 = 12 units; 351 - 400 = 16 units; 401 - 499 = 20 units, and call physician for BG levels greater than 400 mg/dl, ordered 4/20/17. * 28 units of Tresiba (Insulin Degludec) solution in the morning for DM, ordered 5/1/17. * Resident #2 was to have BG levels checked before meals and at bedtime related to Type II DM for BG > (greater than) 400 call physician for BG < (less than) 70 and resident is able to swallow give a rapidly absorbing carbohydrate such as: 4 oz (ounces) juice. Repeat BG in 15 min (minutes) and repeat if carbohydrate (is) necessary, beginning 4/19/17. The physician's orders did not document at what BG level staff were to notify the MD when hypoglycemic BG levels were less than 70 mg/dl. A Nurse's Note, dated 4/18/17 at 5:00 am, documented Resident #2 experienced a BG level of 68 mg/dl. Resident #2 received apple juice, but the clinical record did not contain documentation the facility rechecked her BG level after 15 minutes, as stated in her care plan. The 68 mg/dl BG level was not documented on Resident #2's April Medication Administration Record (MAR). A Nurse's Note, dated 4/18/17 at 6:01 pm, documented Resident #2 experienced a BG level of 514 mg/dl. Resident #2's MAR from 4/19/17 through 4/30/17 documented: * BG levels ranging 209 - 509 mg/dl. * 13 BG levels greater than 400 mg/dl, including 1 BG greater than 500 mg/dl. Resident #2's record did not contain documentation of staff interventions for this time period. Resident #2's physician was notified of 3 of the 13 hyperglycemic BG levels above 400 mg/dl, on 4/20/17, 4/21/17, and 4/27/17. Resident #2's MAR from 5/1/17 to 5/16/17 documented: * BG levels ranging from 119 - 586 mg/dl. * 13 BG levels greater than 400 mg/dl, 6 of which were greater than 500 mg/dl. * BG of 586 mg/dl on 5/1/17 at 4:00 pm. Resident #2's record did not contain documentation of staff interventions for this time period. Resident #2's physician was notified of 1 of the 13 hyperglycemic BG levels above 400 mg/dl, on 5/14/17. A Nurse's Note, dated 5/1/17 at 4:21 pm, documented Resident #2 received 25 units of insulin for the 586 BG level, however, the clinical record did not contain orders for the 25 units of insulin that were administered. A Nurse's Note, dated 5/2/17 at 10:09 pm, documented Resident #2's BG levels ranged over 600 . used sliding scale. The 600 BG level was not documented on the 5/2/17 MAR and the Nurse's Note did not document the resident's physician was notified. The May 2017 MAR documented Resident #2's BG was 512 mg/dl on 5/7/17 MAR at 11:00 am and 4:00 pm. Resident #2's record did not document whether insulin was administered. A Nurse's Note, dated 5/7/17 at 8:38 pm, documented Resident #2's BG level was 591 mg/dl and 20 units of insulin were administered. The 591 mg/dl BG levels was not documented on the 5/7/17 MAR. Resident #2's MAR on 5/7/17 at 9:00 pm, conversely, documented a BG of 291 mg/dl for which 10 units of insulin were administered; it was not clear whether the resident received a total of 30 units of insulin - 20 units at 8:38 pm and 10 units at 9:00 pm. A Nurse's Note, dated 5/9/17 at 11:44 am, documented Resident #2's BG level was 500 mg/dl and 25 units of insulin was administered. Resident #2's clinical record did not contain physician orders for the 25 units of insulin that were administered. Resident #2's MAR documented she was administered insulin on 5/8/17 at 11:00 am and on 5/12/17 at 7:00 am. The dosages of insulin administered was not documented on the MAR and there were no corresponding Nurses' Notes documenting the insulin dosages. Resident #2's clinical record did not document: * Rechecks of her BG levels after she experienced hyperglycemic and hypoglycemic episodes. This was true for all episodes. * Physician notification, as ordered, for 25 of 30 hyperglycemic episodes * Evidence the facility followed its hypoglycemic protocol for low BG levels * The reason for the excess doses of insulin administered on 5/1/17 and 5/9/17. On 5/18/17 at 8:42 am, the Interim Director of Nursing Services (IDNS) stated facility staff were to notify the physician, as soon as possible, when BG levels exceeded parameters specified by the physician and re-check the resident's BG levels in 15-30 minutes to assess whether insulin administrations were effective. For a resident experiencing a hypoglycemic episode, the IDNS said staff was to recheck the BG 15 minutes after administering 15 grams (g) of carbohydrates and that this process would be repeated until the BG level reached 70 mg/dl or greater. On 5/18/17 at 11:15 am, Licensed Practical Nurse (LPN) #1 stated she would notify a physician when BG levels were outside established parameters and document that she called the physician in a Nurse's Note. She stated she would recheck BG levels depending on physician orders and document the rechecks in a Nurse's Note. On 5/18/17 at 3:15 pm, Resident #2's physician stated he was aware of Resident #2's elevated BG levels and he was not all that upset that he was not notified on every occasion, but that he expected nurses to follow his orders all the time. He stated the facility would usually send a fax notifying him of elevated BG levels and that sometimes he received a phone call from nursing staff informing him Resident #2's BG levels were over 500 mg/dl, for which the nurse had administered 20 units of insulin. b. Physician's Order, dated 4/14/17, documented Resident #2 was to receive [MEDICATION NAME] 0.5 milligrams (mg) every 4 hours as needed for anxiety related to her disease process. Resident #2's Antianxiety Care Plan, revised 5/4/17, documented staff was to monitor and document side effects and effectiveness of the [MEDICATION NAME]. The Care Plan did not state the specific behaviors staff were to monitor and for which Resident #2 was to receive [MEDICATION NAME]. Resident #2's [MEDICATION NAME] Controlled Drug Record documented: * 0.5 mg of [MEDICATION NAME] administered on 5/3/17 at 1:20 am. * 0.5 mg of [MEDICATION NAME] administered on 5/3/17 at 2:00 am. 2. Resident #5 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #5's 5/8/17 admitting physician orders directed staff to administer Actos 30 mg daily and [MEDICATION NAME] (for treatment of [REDACTED]. a. Resident #5's recapitulated May 2017 orders directed staff to obtain a FSBS (Fingerstick Blood Sugar) once daily beginning 5/12/17. Resident #5's May 2017 MAR documented the FSBS was completed daily from 5/12/17 to 5/16/17, however BG levels were not documented. On 5/17/17 at 3:30 pm, the MDS Coordinator said Resident #5's daily FSBS results should be documented on the MAR or on vital signs (VS) documents. At 5:00 pm the same day, the MDS Coordinator provided a Blood Sugar Summary for 2015 and said she did not find any results for 2017. On 5/17/17 at 6:00 pm, the IDNS said Resident #5's FSBS result was documented only once, on 5/12/17, in progress notes. The results and any need of intervention to address hypo- or [MEDICAL CONDITION] for Resident #5 were unknown 4 of 5 times (80%) the FSBS was performed. On 5/17/17 at 6:00 pm, the facility provided a copy of its diabetic management policy and procedure. The Facility's Hypoglycemic Policy, revised December 2015, documented For residents with diabetes, the practitioner should be called 'immediately' when the blood glucose value is less than 70 mg/dl .give 15 grams of carbohydrates .Repeat blood glucose test after 15 minutes. The Diabetic Management procedure did not address how staff was to manage residents with hyperglycemic episodes. The lack of a protocol for [MEDICAL CONDITION] created the potential for residents not to receive interventions for hyperglycemic episodes or to receive interventions that were incorrect. The combined effect of the facility's deficient diabetic management practices placed all 12 residents in the facility with diabetes at risk of imminent serious harm, impairment, or death due to diabetic ketoacidosis or severe [DIAGNOSES REDACTED]. Notification and Removal of Immediate Jeopardy: On 5/18/17 at 1:35 pm, the facility was informed Resident #2 and Resident #5, as well as all 12 residents in the facility diagnosed with [REDACTED]. The facility was informed it needed to develop and implement an acceptable plan to remove the Immediate Jeopardy. On 5/19/17 at 2:24 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * BG levels and diabetic medication orders for Resident #2 and Resident #5 were reviewed with their physicians on 5/18/17. * Resident #2 and #5's vital signs were assessed by nursing staff. * Notifications to responsible parties were completed for Resident #2 and #5 on 5/18/17. * Physician orders, including those for insulin, and MARs were audited for those residents diagnosed with [REDACTED]. * Guidelines for managing hyper- and hypoglycemic incidents were approved by the MD on 5/18/17. * The IDNS will provide education to nursing staff prior to their next shift on BG level parameters for hypo and [MEDICAL CONDITION]; treatment guidelines for hypo and [MEDICAL CONDITION]; notification to the physician and responsible party; and appropriate documentation of notification and interventions for hyper/hypo glycemic episodes. * The MARs and physicians' orders of residents who are diabetic will be monitored daily for 2 weeks, weekly for 2 weeks and then every two weeks for two months. The facility's Quality Assessment and Assurance Committee will evaluate the potential need for monthly audits. 4. Resident #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 2/22/17, documented Resident #11 was cognitively intact; required supervision with transfers and ambulation; had 1 non-injury fall prior the assessment; rejected cares 1-3 days during the look back period; and was administered PRN, rather than scheduled, pain medications. a. Resident #11's April 2017 Physician's Orders documented: * 650 mg [MEDICATION NAME] every 4 hours as needed for pain, ordered 2/23/17. * 5 mg [MEDICATION NAME] Tablet 5-325 mg ([MEDICATION NAME] - [MEDICATION NAME]) every 6 hours as needed for pain, ordered 2/23/17. * 50 mg [MEDICATION NAME] every 6 hours as needed for pain, ordered 2/23/17. The Pain Care Plan, revised 12/12/16, documented Resident #11 had acute and chronic pain related to [MEDICAL CONDITION] as evidenced by non-verbal indicators such as grimacing, resistive to cares, and complaints of (c/o) itching or burning. She was able to call for assistance and able to ask for pain medication. Care Plan interventions included: * Staff was to monitor Resident #11 for signs and symptom (s/s) of non-verbal pain, initiated 2/1/16. * Staff was to evaluate the resident using the Pain Assessment in Advanced Dementia (PAINAD) scale, revised 12/12/16. On 5/19/17 at 2:25 pm, the IDNS stated the facility evaluated residents' pain levels at least once per shift and immediately prior to the administration of PRN pain medications. Staff also assessed residents who received PRN pain medication to determine whether it was effective. Resident #11's MARs for January 2017 through 4/24/17, did not contain documentation that her pain was consistently assessed prior to- or following the administration of pain medication. The April 2017 MAR documented Resident #11 received 9 doses of the PRN [MEDICATION NAME] from 4/3/17 through 4/24/17. The Controlled Drug Record for PRN [MEDICATION NAME] documented Resident #11 received 21 doses between 4/3/17 through 4/24/17. Resident #11's pain was not assessed prior to- or following 12 of the 21 PRN [MEDICATION NAME] administrations during this time period. The April 2017 MAR documented Resident #11 was administered 34 doses of PRN [MEDICATION NAME] between 4/3/17 and 4/24/17. Resident #11's Controlled Drug Record for [MEDICATION NAME] documented she was administered 61 doses of [MEDICATION NAME] from 4/3/17 through 4/24/17. Resident #11's pain and was not assessed prior to- or following 27 of the 61 PRN [MEDICATION NAME] administrations. The conflicting records also created the potential for harm related to excessive dosage and this was not addressed in the resident's clinical record. b. Incident & Accident reports documented Resident #11 experienced a fall on 4/1/17 and 2 falls on 4/3/17. Progress Notes, for 4/3/17 through 4/7/17, included 24 entries that Resident #11 complained of left sided pain, requested pain medications, or that she suspected her ribs were broken. A Nurse's Note, dated 4/3/17, documented Resident #11 had fallen twice that day, and told the LPN she thought she had broken a rib. The note did not document physician notification of Resident #11's complaint of a broken rib. A Nurse's Note, dated 4/4/17 at 5:00 am, documented Resident #11 had a marked dark purple bruise on the left thorax from the 4/3/17 fall and (complains of) pain in rib area .and reports that she feels the rib was broken. The note did not document physician notification of Resident #11's pain and complaint of a broken rib. A Nurse's Note, dated 4/5/17 at 6:53 am, documented Resident #11 complained of pain on left flank rib area from (the) falls (she) sustained on 4/3/17 .(and) stated 'it feels like my rib is cutting me on the inside.' A Nursing Communication, dated 4/7/17 at 4:03 pm, documented two progress notes regarding Resident #11's complaint of left sided rib pain were sent to the physician. The first Progress Note, dated three days after the fall on 4/7/17 at 10:19 am, documented, Resident fell last Monday, she has a 10 x 10 discoloration on her upper waist. She has 8/10 pain at times. May we send her for a left rib x-ray at (hospital) today? The second Progress Note, dated 4/7/17 at 11:49 am, documented, Asking for an order to send (Resident #11) down for a x-ray for her left side . The physician responded to the facility on [DATE], ordering an x-ray of Resident #11's left ribs and changing the resident's [MEDICATION NAME] schedule from three times daily (TID) to four times daily (QID). On 4/8/17, an RN noted the orders and documented [MEDICATION NAME] was already ordered for every 6 hours PRN, and the clinical record did not document Resident #11's [MEDICATION NAME] order was changed from PRN administrations every six hours to scheduled dosages four times daily. Progress Notes 4/8/17- 4/24/17 documented Resident #11 complained of pain to the left rib area, was holding her left side in pain, and/or received PRN pain medications 37 more times. A Nurse's Note, dated 4/24/17 at 10:13 pm, documented Resident #11 was being transferred to hospice services for pain management. The note documented Resident #11 said she wanted hospice services because her pain definitely was not being controlled at this time. She also mentioned that she was relieved to finally get some help with her pain, rolled her eyes, and said, 'Finally!' On 5/19/17 at 8:25 am, the IDNS stated nursing staff were to administer medications per physicians' orders. On 5/19/17 at 2:25 pm, the IDNS stated if a resident requested more frequent administration of PRN pain medications the facility was to notify the physician, who then evaluated whether scheduled pain medications would be more appropriate for that resident. The IDNS stated she did not see changes to Resident #11's ordered pain medications. When asked about the 7-day delay between Resident #11's 4/3/17 fall with complaints of rib pain and the request for an x-ray, the IDNS stated Resident #11 declined an offer to go to the hospital on the day of the fall, but the nurse still should have notified the physician of the incident and complaints of pain. The IDNS stated a second x-ray on 4/24/17 documented Resident #11 had sustained acute fractures of the ribs. On 5/22/17 at 11:10 am, Resident #11's Physician stated he would expect nursing staff to notify him of a resident's complaints of increased pain after a fall and/or suspected injury.

Based on observations, staff interview, and review of clinical records and incident/accident reports, it was determined the facility failed to ensure residents received sufficient supervision, toileting assistance, every 15 minute checks as care planned, and care plan updates to prevent falls and injuries for 2 of 7 sample residents (#3 & #11) reviewed for falls. As a result: a) Resident #3, was harmed when she fell 4 times in 24 days and sustained fractures to the right femur that required surgical intervention. b) Resident #11 experienced 3 falls in 2 days that resulted in extensive bruising and severe pain to her left chest and rib area and required increased use of 2 pain medications and an antianxiety medication. Resident #11 was harmed when she fell twice more and was diagnosed with [REDACTED]. c) Resident #3, who wandered into other residents' rooms, rummaged through other residents' things, layed on other residents' beds, and hit, kicked, and spit when redirected, was placed at risk of harm, as were other residents who may encounter Resident #3, if an altercation developed between them and one or both residents were injured. Findings include: 1. Resident #3 was admitted to the facility in May 2016 with multiple diagnoses, including dementia with behavioral disturbance, restlessness, and agitation. She was readmitted on [DATE] for orthopedic aftercare following surgical intervention of a right hip fracture related to a fall in the facility. Resident #3's most recent quarterly and significant change MDS assessments, dated 1/19/17 and 2/27/17 respectively, documented short- and long-term memory impairment; severely impaired cognition; delusions, and frequent urinary and bowel incontinence. The 1/19/17 quarterly MDS assessment also documented physical behavioral symptoms such as hitting, kicking, pushing, scratching, and grabbing directed toward others; verbal behavioral symptoms, such as threatening and/or screaming at others; and behavioral symptoms not directed at others, such as pacing, rummaging, and disrobing in public, all of which occurred 4-6 days during the look back period; rejection of care 1-3 days and wandered daily; supervised assistance with bed mobility, transfers and eating; limited 1 person assistance with ambulation in room/corridors and locomotion on/off the unit; extensive 1 person assistance with dressing, personal hygiene and bathing; and use of antipsychotic medication for 7 days. The 2/27/17 significant change MDS assessment documented the physical behavioral symptoms, rejection of care and wandering occurred 1-3 days in the look back period; extensive 2 person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; extensive 1 person assistance with eating, total 1 person assistance with bathing; ambulation in room/corridors did not occur; and total 2 person assistance with locomotion on/off unit, and no antipsychotic medication use. On 5/17/17 at 3:10 pm, the MDS Coordinator said 2 non-injury falls and 1 fall with major injury were documented in Resident #3's 2/15/17 discharge MDS assessment. Resident #3 was observed in a wheelchair in the common areas of the facility, including the main dining room and hallways, with a staff member next to her on 5/15/17 at 5:20 pm; on 5/16/17 from 7:55 am to 8:05 am, 8:30 am to 8:45 am, 9:55 am, 10:55 am, 11:15 am, 11:55 am, 12:10 pm, and 3:15 pm; and on 5/17/17 at 9:05 am to 9:15 am, and 11:00 am. She was also observed in her room, either in bed with staff present or while being toileted by staff, on 5/16/17 at 11:20 am to 11:25 am and on 5/17/17 at 3:00 pm. a. On 5/19/17 at 12:30 pm, the care plan in place in January and February prior to Resident #3's falls was provided by the facility's medical records department. The care plan in place prior to 3 falls in February 2017 included focus areas and associated interventions related to falls, Activities of Daily Living (ADL), and bladder incontinence as follows: * ADL self care performance deficit - independent ambulation with four wheeled walker (FWW), needs cues, supervision to locations such as the dining room and her own room, revised 8/18/16; 1 staff assistance with toilet use, revised 1/25/17. * Bladder incontinence - prefers to use the bathroom for toileting and take to the bathroom before and after meals, at bedtime and when she indicates the need to void, revised 1/25/17. * Risk for falls - monitor every 15 minutes, initiated 5/24/16 and revised 1/25/17. On 5/18/17 at 5:30 pm, the MDS Coordinator and Staff Development Nurse (SDC) said that in addition to every 15 minute checks, the facility also began 1:1 monitoring (1 staff to 1 resident) and audio/visual monitoring when Resident #3 was alone in her room, was recently added. They agreed to provide documentation of every 15 minutes checks and 1:1 monitoring. On 5/19/17 at 9:30 am, the MDS Coordinator provided Progress Notes, dated 2/17/17 through 4/3/17, which she said documented 1:1 monitoring. She said that 1:1 monitoring started after Resident #3 returned to the facility on [DATE] and ended when Medicare ended. Resident #3's Fall Scene Huddle Worksheets (FSHW) and Investigations documented the following: * 1/22/17 at 5:25 pm - unwitnessed fall, no injury, last toileted at 5:00 pm, roommate notified staff the resident fell in the bathroom while sitting on trashcan trying to go to the bathroom. Resident #3 said she was going potty. Factors that may have contributed to the incident: Had been restless during the day (up arrow and down arrow). Highly demented; does not understand instructions or safety needs. Corrective actions: Continue 15 minute checks and assistive device near door. Every 15 minute checks on 1/22/17 contained documentation that Resident #3 was checked at 3:19 pm and 6:09 pm, 2 hours and 50 minutes between checks. * 2/13/17 at 9:30 am - unwitnessed fall, no injury, incontinent when last toileted at 8:30 am, dry at time of incident, 15 minutes between last staff member contact and fall, Resident #3 said she was trying to go to the bathroom, Lost balance one foot in pants leg all the way through, the other not. Factors that may have contributed to the incident: Attempting to toilet self. Highly confused, poor safety awareness. Corrective actions: Motion light added and toilet before breakfast. A 2/13/17 unsigned typed note attached to the FSHW documented Resident #3 was at high risk for falls, and exhibited poor safety awareness and decline in cognition. Breakfast started at 7:00 am in the facility, which was 2 1/2 hours before Resident #3's fall at 9:30 am. The FSHW documented Resident #3 was toileted at 8:30 am, an hour before the fall. Every 15 minute checks on 2/13/17 contained documentation that Resident #3 was checked at 8:58 am and 9:58 am, an hour between checks. * 2/13/17 at 11:10 pm - unwitnessed fall, no injury, time last toileted was blank, time between last staff contact and fall unknown. Factors that may have contributed to the incident: unsteady gait, shuffling gait, poor balance, anxious (and) restless. Comments included, Unaware of dangerous situations. Disregard for safety (no) longer has antianxiety med(ication) & very anxious/restless . Corrective actions: Toilet before all meals. Resident #3's 2nd fall on 2/13/17 occurred more than 3 hours after the last meal service of the day at 5:00 pm, and her care plan prior to the fall included toileting assistance before and after meals. The corrective action, toilet before all meals, did not address the factors that contributed to the fall or add interventions to further protect Resident #3 from falls. A 2/14/17 unsigned typed note attached to the FSHW documented Resident #3 was at high risk for falls and, 2/13/17 .found sitting on the floor .at 11:10 PM .unknown when or who last checked in on (Resident #3) .(Resident #3) had a fall at 10:00 am and has been on 15 minute checks .poor safety awareness, does not always remember to use her walker .continues to be restless and agitated .will not wait for staff and does not have the cognitive ability to use her call light when she has the urgency to urinate .anxious this morning and had been redirected back to her room. Continue with all current interventions per care plan. Every 15 minute checks on 2/13/17 contained documentation that Resident #3 was checked at 10:41 pm and 11:23 pm, 42 minutes between checks. * 2/15/17 at 12:30 pm - No injury fall witnessed by roommate, time last toileted 12:25 pm. The time between last staff contact and the fall was blank. Factors that may have contributed to the incident: Confusion, did not use walker for ambulation. Corrective actions: Do not leave seated on toilet by self. A 2/15/17 unsigned, typed note attached to the FSHW documented Resident #3 was at high risk for falls and that the roommate said Resident #3 had exited the bathroom and fell while attempting to open the door to the main hallway. It documented Resident #3 complained of pain with right leg movement and Emergency Medical Services was called to transport her to a local hospital. A facility Suggestion or Concern form, dated 2/15/16, and signed as reviewed by the LSW (Licensed Social Worker) on 2/16/17 and by the Administrator on 2/17/17, documented Resident #3 had an injury fall and was transported to a local hospital then to a regional hospital for surgery for [REDACTED]. The Concern form investigation documented a CNA assisted Resident #3 to the bathroom and placed the walker at the bathroom door. It documented that when Resident #3 exited the bathroom, the bathroom door swung into the door to the hallway causing it to close and Resident #3 fell when she attempted to open the door to the hallway. It also documented that the care plan for toileting was in compliance but indicated the CNA left Resident #3's room while she was in the bathroom. Therefore, the care plan for 1 staff assistance with toileting was not implemented. Every 15 minute checks on 2/15/17 were out of sequence chronologically. For example, 7:30 am was followed by 12:16 pm, which was followed by 9:30 am, then 12:16 pm again, then 10:30 am. In addition, every 15 minute checks were documented as done on 2/15/17, 2/16/17, 2/17/16, 2/18/17, 2/19/17, and 2/20/17, when the resident was hospitalized and not in the facility. On 5/19/17 at 3:30 pm, the Interim Director of Nursing Services (IDNS) said that out of sequence documentation of every 15 minute checks may have been due to more than one staff documenting the checks. She said multiple entries with the same time may have occurred because the staff documented multiple checks at the same time. The IDNS said documentation of every 15 minute checks after Resident #3 left the faciity on [DATE] was not accurate and it called into question the accuracy of all the documentation. Falls Tools documented Resident #3 was at medium risk for falls on 1/22/17 at 5:21 pm (4 minutes before a fall), high risk for falls on 2/13/17 at 9:20 am (10 minutes before the 1st fall on this day), medium risk for falls on 2/13/17 at 11:10 pm (the time of the 2nd fall on this day), and at high risk for falls on 2/15/17 at 12:30 pm (the time of the fall that day). Resident #3 was harmed when she fell and sustained fractures to the right femur which required surgical intervention. The facility did not provide staff assistance with toileting on 2/15/17 as care planned and failed to ensure every 15 minutes checks were consistently implemented as care planned. b. Resident #3's care plan focus areas and associated interventions related to wandering, resistance to cares, and physically aggressive behavior included: * Psychosocial well-being problem, interventions included: - Assistance/supervision/support to reduce/eliminate causative and contributing factors: may be redirected when she needs assistance, cued she is in the wrong room or bed . revised 11/3/16. - Wandering: ask if you can assist her back to her home, revised 1/25/17. * Mood/behavior problem, revised 1/25/17, interventions included: - Walking without assistance, forgets walker, unsafe: calmly approach and engage in conversation, cue her for walker/wheelchair assistance. - Sitting/sleeping in roommates' bed: in calm manner inform her where her bed is. - Rummaging through others' belongings: redirect in calm manner and in quiet tone of voice. Inform her the things belong to her roommate, assist her to find her own things. - Physical abuse towards staff: if resident becomes agitated put enough space in between yourself and resident and speak calmly in a soft tone of voice. * Behavior symptom, physical abuse directed at others, interventions included: - Intervene as necessary to protect the rights and safety of others. Divert attention. Remove from situation and take to alternate quiet location, revised 7/26/16. Minimize potential for disruptive behaviors, such as hitting, offer distractions which may divert her attention after meals, revised 1/25/17. - Hitting/spitting: attempt non-pharmacological interventions, assess for possible needs, fear or disorientation, revised 1/25/17. - Physically abusive to others, hits, kicks, spits: remove from over stimulating situations which could cause increased agitation and escalate behaviors. If resident refuses to leave and becomes more agitated, give her space to walk where she can be monitored. Change of care provider may help, revised 1/25/17. Resident #3's Medication Review Report of current orders on or after 12/30/16 documented: * Aricept (to treat dementia) 10 mg one time a day for dementia started 12/28/16; * Namenda (to treat dementia) 10 mg two times a day started 5/23/16; * Zyprexa (antipsychotic) 2.5 mg in the morning started 11/13/16; * Zyprexa 5 mg one time a day started 11/14/16; and * Zyprexa 5 mg every 8 hours as needed for aggressive behavior, spitting, hitting, scratching, biting, started 12/30/16. All of these medications were ordered for dementia with behavioral disturbance. The Medication Review Report of current orders on or after 1/31/17 documented the same order for Aricept and Zyprexa 5 mg two times a day started 1/24/17. The other noted medications were not ordered. The Medication Review Report of current orders on or after 2/20/17, 2/28/17, and 3/31/17 documented Zyprexa 5 mg two times a day. The other noted medications were not ordered. The Medication Review Report of current orders on or after 5/16/17, documented Zyprexa was decreased to 5 mg in the evening on 4/18/17. Resident #3's Progress Notes, dated 6/29/16 to 2/15/17, documented the following: * 9/11/16 at 3:48 am - Awake and eager to enter other residents rooms, unable to redirect. When brought to her room, sat on her roommate's legs. Roommate was kind and understanding of situation. Brought out to day room where she tried to go outside. Hit staff 3 times when guided away. * 11/8/16 at 9:53 am - Hit her daughter. Leaving messes in the bathroom. * 11/13/16 at 3:33 pm - Out of room wandering around several times this morning. Difficult to redirect and at one point tried to smack, punch, hit and scratch this nurse. * 12/17/16 at 12:38 pm - Slapped caregiver redirecting her away from another resident's room. * 12/27/16 at 3:22 pm - Very agitated, gets verbally abusive and physically abusive with staff when redirected. Took resident for a long walk offered warm blanket and her recliner. This worked for about 5 minutes and she was back up wandering into other rooms. When redirected, she slapped at and grabbed staffs' arms and led us to the door of another residents (sic) room and pushed us out and she turned around and went back in. A staff offered to walk resident to her room and she was willing to go. (H)as been this way all weekend. * 12:30/16 at 12:33 pm - Resident smacked, tried to bite, scratched and spit in nurse's face. * 1/16/17 at 10:28 am - Continues to exhibit significant behavioral problems. She will hit, scratch, kick and spit at staff. Recent addition of PRN sublingual Zyprexa has been effective when used. * 1/17/17 at 8:56 am - Wandering this morning. Tried to go into another resident's room, removed he pull up. Redirected to her room. * Date illegible (hole punch over month and day) 2017 at 3:43 pm - At breakfast time, resident wandered into a resident's room and was redirected to her room. Resident did not stay in her room and wandered down hall into another resident's room. Unable to redirect and she laid on the resident's bed. Resident informed her she was in the wrong room and bed. She tried to kick the staff member repeatedly and said to leave her alone. The resident was eventually redirected to her room. * 2/7/17 at 10:21 am - Combative with cares, got angry with CNA trying to change her. Shoved CNA into closet doors and tried to slap CNA. A second CNA came to help and while assisting the resident with soiled clothing the resident punched and kicked at the staff. They stepped back and tried to calm the resident. The resident then kicked one CNA in the stomach. * 2/8/17 at 10:21 am - Continues to be combative with cares. Out of room walking and very upset when redirected to her room. Punched and tried to bite nurse. Eventually went to her room and laid down. * 2/10/17 at 4:35 pm - Got into bed with her roommate. Redirected back to her bed without incident. * 2/15/17 at 1:46 pm - 1:1 with resident while waiting for ambulance. CNA records included Monitor (Resident #3) every 15 minute for safety. 1:1 with staff as directed by nurse, PRN and contained documentation that every 15 minute checks were not consistently implemented January through March 2017 and ended on 4/14/17 at 5:46 pm. In addition, there was no documentation of when 1:1 was provided. On 5/19/17 at 9:30 am, the MDS Coordinator said that 1:1 care started when Resident #3 returned to the facility on [DATE] and ended when Medicare ended. On 5/19/17 at 11:45 am, the LSW said Resident #3's physical aggression was not predictable and it had everything to do with approach. The LSW said Resident #3 was able to self toilet, was independent, and that she wandered when she first came to the facility. The LSW said, Yes, when asked if another resident could be harmed if Resident #3 directed physical or verbal behaviors toward them. She said, Yes, that Resident #3 could be harmed if another resident did not tolerate her intrusion into their room, onto their bed or rummaging through their things. The LSW said Resident #3's physical and verbal behaviors had only occurred with staff. 2. Resident #11 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #11's quarterly Minimum Data Set (MDS) assessment, dated 2/22/17, documented no cognitive impairment, staff supervision required with transfers and ambulation, 1 non-injury fall prior to the assessment, and rejection of cares 1-3 days during the look back period. Resident #11's April 2017 physician's orders [REDACTED].>* 5 mg Norco Tablet 5-325 mg every 6 hours as needed (PRN) for pain, ordered 2/23/17. * 50 mg Tramadol Tablet every 6 hours PRN for pain, ordered 2/23/17. * 0.5 mg Ativan Tablet every 12 hours PRN for anxiety, ordered 8/23/16. Resident #11's Limited Physical Mobility Care Plan, revised 7/7/16, documented she was at risk for falls. Interventions included: * Resident #11 required non-weight bearing staff support with mobility and required staff distant supervision of stand by assist and contact guard assist PRN with use of her All Terrain Walker (ATW). Resident #11 usually ambulated independently, revised 12/12/16. * Resident #11 used a wheelchair for locomotion and her ATW for ambulation, revised 2/18/16. Resident #11's Fall Care Plan, revised 9/22/16, documented she had an actual fall with minor injury related to weakness as evidenced by her history of falls, poor balance, unsteady gait, and poor safety awareness. Interventions included: * Staff was to encourage Resident #11 to do activities and exercise whenever possible and support Restorative Nursing Aide (RNA) walking program, initiated 3/22/16. * Staff was to ensure Resident #11 was wearing appropriate footwear, revised 9/22/16. * Resident #11's bed was to be unplugged to keep the bed in one position due to Resident #11's inability to understand she cannot adjust the bed height for safety reasons, revised 7/7/16. * Staff was to ensure Resident #11's bed height was correct to the marking on the wall, to the headboard, or the mattress, initiated 3/22/16. * Resident #11 was to be reviewed for significant changes in cognition, safety awareness, and decision-making capacity, initiated 3/28/16. * Staff was to monitor Resident #11 every 15 minutes for whereabouts and keep her door ajar when cares were not being provided for ease in observation, revised 3/22/16. Resident #11's Activities of Daily Living (ADL) Care Plan documented an intervention that she required assistance of 1 staff member, as needed, and self-toileted often, initiated 2/1/16. a. Resident #11 experienced 5 falls between 4/1/17 and 4/25/17. * Fall on 4/1/17 at 3:15 am: Resident #11's 4/1/17 at 3:15 am, Fall Scene Huddle Worksheet (FSHW) documented she was found on her hands and knees crawling out of the bathroom. The worksheet documented she seemed forgetful, confused and had just been out to (the) nurses station looking for her husband stating she had seen him outside her window. Resident #11's FSHW documented she had no injuries from this fall. The Incident Report had a Social Service Note attached, dated 4/1/17, which documented (Resident #11) had a large bruise to her left thorax. (Resident #11) stated she fell and her ribs hurt .SSD (Social Service Director) asked (Resident #11) if she hurt herself, had any bruising, (Resident #11) stated she did not think so but her ribs hurt. SSD asked (Resident #11) to lift her shirt and show SSD and SSD did not see any bruising at this time. The note documented Resident #11's Interested Party was contacted in regards to what appears to be a non-injury incident from a fall. Resident #11's clinical record did not contain the Social Services Note attached to the 4/1/17 Incident Report. Resident #11's clinical record did not contain documentation that her physician was informed of her 4/1/17 fall and her complaint of her ribs hurting. On 5/22/17 at 10:05 am, the SSD stated the Social Service Note attached to the 4/1/17 Incident Report was not in Resident #11's clinical record. The SSD stated she wrote the note to herself, to remind her of the incident and what she needed to do. A 4/1/17 Fall Tool documented Resident #11 had experienced a recent fall. The Fall Tool documented she was taking more than two psychoactive medications and had a moderate cognitive impairment. The Action Plan portion of the document was blank. Additional preventative measures to protect Resident #11 from falls were not initiated. Resident #11's Care Plan was not updated following the 4/1/17 fall. * Fall on 4/3/17 at 9:00 am: Resident #11's FSHW, dated 4/3/17 at 10:15 am, documented she was found on the floor in the hallway. The worksheet documented she seemed agitated, and the documented root cause was, consider disease processes progressing. Resident #11's FSHW documented she had no injuries from this fall. A Fall Tool, dated 4/3/17 at 10:16 am, documented Resident #11 had experienced a recent fall. The Fall Tool documented she was taking more than two psychoactive medications and had a moderate cognitive impairment. The Action Plan documented she was referred to the RNA program and her physician, and her care plan was updated. The following interventions were added to Resident #11's Fall Care Plan on 4/3/17: - Staff was to encourage Resident #11 to ambulate with staff. - Staff was to modify her environment for maximum safety. Staff was to ambulate with Resident #11 all the way. - When Resident #11 was out of her room staff was to ambulate with her when she went back to her room. Resident #11's 4/3/17 Fall Care Plan, continued to include interventions found on her 9/22/16 Fall Care Plan. These included: - Staff was to encourage Resident #11 to do the RNA walking program. - Resident #11's bed was to be unplugged to keep the bed in one position due to Resident #11's inability to understand she cannot adjust the bed height for safety reasons. - Staff was to monitor Resident #11 every 15 minutes for whereabouts. - Staff was to keep her door ajar when cares were not being provided. As resident allows, was added at the end of this intervention on 4/3/17. * Fall on 4/3/17 at 4:00 pm: Resident #11's FSHW, dated 4/3/17 at 4:00 pm, documented she was found on the floor in her room attempting to ambulate. The worksheet documented she seemed agitated, and the documented root cause was, agitated; refusing to move away from the med-cart. Resident #11's FSHW documented she had no injuries from this fall. Resident #11's clinical record did not contain a Fall Tool for the second fall on 4/3/17 at 4:00 pm or care plan updates. Resident #11's clinical record did not contain documentation that the facility reported the fall Resident #11 experienced on 4/3/17 at 4:00 pm, to her physician. Progress Notes between 4/3/17 and 4/23/17 (21 days) documented 55 entries that Resident #11 complained of (c/o) left sided/left rib pain, requested pain medications, was holding her left side in pain, and/or that she suspected her ribs were broken. Progress Notes and x-ray reports included: - A Nurse's Note, dated 4/3/17, documented Resident #11 had fallen twice that day, once in the morning and once in the afternoon. The note documented she was given all the medication available to her. The note documented Resident #11 told the Licensed Practical Nurse (LPN) she thought she had broken a rib. - A Nurse's Note, dated 4/4/17 at 5:00 am, documented Resident #11 had a marked dark purple bruise on the left thorax from the fall last shift. She c/o pain in (her) rib area under (her) left breast and reports that she feels the rib was broken. I medicated her for pain and advised her to drink plenty of fluids, rest, and intentionally take slow deep breaths for lung expansion to avoid complications. - A Nurse's Note, dated 4/5/17 at 5:14 am, documented Resident #11 stated, It feels like my rib is cutting me on the inside. - A Nurse's Note, dated 4/5/17 at 9:35 am, documented Resident #11 was given Ativan, her anti-anxiety medication, because she was anxious about falling. - A Nurse's Note, dated 4/6/17 at 7:24 pm, documented Resident #11 did not want to take a bath and was finally talked into taking one. The note documented Resident #11's reason for not wanting a bath was due to her hurting too bad. - A Mood and Behavior Note, dated 4/7/17 at 8:36 am, documented Resident #11 complained of pain in her rib area. - A Medication Review Note, dated 4/7/17 at 10:42 am, documented Resident #11 had increased behaviors and the writer was unsure if the behaviors were due to an increase in pain from an injury to her left rib from a fall or changes in her lung cancer. - A Nurse's Note, dated 4/17/17 at 10:11 am, documented Resident #11 had increased pain, was sleeping more, and experienced a decrease in mobility. - A Nurse's Note, dated 4/18/17 at 3:55 am, documented Resident #11 had a nose bleed and did not know how it happened. The note documented, She stayed up all night and remained confused. - A Nurse's Note, dated 4/23/17 at 1:11 pm, documented Ativan was given due to Resident #11's complaint of anxiety due to severe pain level 9. - A 4/23/17 at 1:03 pm, Nurse's Note documented Resident #11 had severe pain under her left breast and left side, giving her pain medication .she wakes up in severe pain. - A Nurse's Note, dated 4/24/17 at 11:41 am, documented Resident #11 slept in and did not want to wake up. The note documented Resident #11 was tired. * Fall on 4/24/17 at 1:00 pm: Resident #11's FSHW, dated 4/24/17 at 1:00 pm documented staff found her on her hands and knees crawling out of the bathroom. The worksheet documented she seemed forgetful and was not sure what she was doing .then stated that she was coming out of the bathroom. Resident #11's FSHW documented she complained of left chest pain and left hip pain from this fall. A Fall Tool, dated 4/24/17 at 1:00 pm, documented Resident #11 had experienced a recent fall. The Fall Tool documented she was taking more than two psychoactive medications and had a moderate cognitive impairment. The Action Plan documented she was referred to her physician. A Nurse's Note, dated 4/24/17 at 1:43 pm, documented Resident #11 was transferred to a hospital, after a fall, for evaluation of her complaint of severe pain under (her) left breast near ribs. A Rib X-Ray Report, dated 4/24/17 at 3:04 pm, documented Resident #11 had a Posteroanterior (PA) x-ray and 2 additional rib detail view x-rays of her left side. The obliques rib detail view showed nondisplaced acute appearing fractures of the lateral portions of her left 6th, 7th, and 8th ribs. * Fall on 4/24/17 at 5:40 pm: Resident #11's FSHW, dated 4/24/17 at 5:40 pm, documented she was found on her right hip sitting on the floor trying to go to the bathroom. The worksheet documented she seemed forgetful, confused and agitated. Resident #11's FSHW documented she complained of left chest pain and right hip pain from this fall. Resident #11's clinical record did not contain a Fall Tool for the second fall on 4/24/17 at 5:40 pm. A Nurse's Note, dated 4/24/17 at 5:45 pm, documented Resident #11 fell on her way to the bathroom unassisted. The note documented she had increased intermittent confusion. Resident #11's Limited Physical Mobility Care Plan interventions were revised as follows: - Resident #11 required (specify: PT (Physical Therapy)/OT (Occupational Therapy) recommended adaptations, horn, adjusted speed, use of protective gear, rearview mirror, safety flag, reflective tape on device and/or clothing, etc,) initiated 4/24/17. - Resident #11 required the use of a gait belt during transfers and ambulation, initiated 4/24/17. Resident #11's Limited Physical Mobility Care Plan interventions were revised on 4/25/17, to require non-weight bearing staff support with mobility and staff distant supervision of stand-by assistance and contact guard assistance, as needed, with use of her ATW. Resident #11's ADL Care Plan was revised on 4/25/17, to include that she required assistance of 1 staff member, and staff was not to leave her unassisted in the bathroom. On 5/19/17 at 2:25 pm, the IDNS stated she was not working at the facility during the time of Resident #11's first falls in April 2017. The IDNS stated when Resident #11 complained of her rib cutting her on the inside the facility should have called the physician for orders and directions. The IDNS stated the x-ray on 4/24/17 documented acute fractures of the ribs. The IDNS stated Resident #11 was known to wander and walk without assistance. She stated she could not speak to what happened when she was not in the facility. The IDNS stated from experience staff should have reinforced/educated Resident #11 on the risks of not following care planned interventions and documented the refusals. On 5/22/17 at 11:10 am, Resident #11's Physician stated he would expect nursing staff to notify him when residents' complaints of pain increased after a fall and/or there was a suspected injury. The facility failed to ensure Resident #11 was provided sufficient supervision and care plan updates to prevent repeated falls. The facility fai

Based on family, staff, Ombudsman, hospice staff interview, review of Suggestion and Concern forms, and record review, it was determined the facility failed to recognize the importance of a resident's right to meet privately with a hospice agency for an informational visit, and the choice to utilize hospice services at the end of her life. This was true for 1 of 2 residents (# 11) sampled for hospice services. Resident #11 experienced psychosocial harm when a) she and her family experienced an interrupted grief process while attempting to enroll in hospice services; b) when hospice services were ordered to be discontinued without her input or consent, two days prior to her death; and c) when the hospice agency was not contacted to provide support to Resident #11's family so as to allow them to be with Resident #11 in the moments after she passed away. Findings include: Resident #11 was re-admitted to the facility on [DATE], following a [MEDICAL CONDITION]. Her [DIAGNOSES REDACTED]. Resident #11's readmission orders [REDACTED]. On [DATE] at 12:43 pm, a SSPN documented Resident #11 and her family met with a hospice agency. The SSPN documented, .Hospice Team excluded all facility staff who have taken care of (Resident #11) since admission from care planning. (Hospice MSW) was (misinformed) in regards to Medicare billing. (Resident #11) was admitted on [DATE] and was competent in understanding the paperwork she was signing upon admit. (Resident #11) signed all of her paperwork including Medicare authorization . On [DATE] at 3:47 pm, Resident #11's SSPN's documented the facility placed a call to hospice to inform them that the LSW and DNS had met with Resident #11's family and they were ready to proceed with enrollment in hospice. On [DATE], a facility Suggestion or Concern form, filled out by the facility LSW, documented Resident #11's family was upset because the facility LSW went over hospice with (Resident #11). (Family) feels SSD was trying to talk (Resident #11) out of services. The resolution area of the form documented review with the Ombudsman regarding Resident #11's right to make her own decision regarding hospice, and documented that Resident #11's family did not feel she should make her own decision. The form did not document whether Resident #11 and her family were satisfied with the resolution of their concern. A hospice MSW note, dated [DATE], documented Resident #11 was counseled as to grief and anticipatory grief, as the facility had indicated an intent to cancel their contract with the hospice agency. The note documented Resident #11's family was considering moving her to another facility should the contract be canceled. A hospice MSW note, dated [DATE], documented the MSW was working with facility staff to ensure services and assistance for Resident #11 after the current contract between the facility and hospice expired in [DATE]. A hospice MSW note, dated [DATE], documented the MSW had spoken with the facility Administrator and received permission for the hospice provider to continue to work with Resident #11, as long as she would need service. A physician's orders [REDACTED]. A SSPN, dated [DATE] at 4:26 pm, documented the hospice agency was informed of the discontinuation of services, and a message was left Resident #11's family to that effect. A NN, dated [DATE] at 10:00 am, documented Resident #11 was notified of the discontinuation of hospice services. The note documented she did not want hospice services discontinued, and was provided with information as to how to change physicians. There was no documentation Resident #11's current physician was made aware of her preference to continue hospice, or of measures that were taken to re-institute hospice services. A NN, dated [DATE] at 11:46 am, documented the Administrator, DNS, and LSW had a conference call with Resident #11's family. The family requested a care conference with the facility, hospice agency, and the physician, due to wanting hospice services to continue. The note documented that the physician would not likely be willing to have such a meeting, and information was provided to the family as to how to change physicians that for Resident #11. The note documented if the family were to contact the physician, and the physician was willing to attend, and then the facility would attend the meeting. The note documented the family called back later and had arranged for the meeting to take place on [DATE]. On [DATE] at 1:13 pm, a SSPN documented Resident #11's family was distrustful of facility staff, and was questioning the process by which Resident #11 was assessed to no longer need hospice services. A NN, documented Resident #11 passed away, and the physician and family were notified. The NN documented, .daughter came here but (left) unable to get self under control over mother passing . There was no documentation in the Resident #11's record that the hospice agency was notified of Resident #11's passing, or asked to provide support to Resident #11's daughter. A SSPN, dated [DATE], documented, Resident's daughter had set up a meeting with IDT, (Physician) and Hospice for 1:00 pm on [DATE]. (Physician) informed DNS he would not be in attendance. Hospice did not show up, (LSW) saw (Daughter) out front however she did not come into the building to talk about/cancel meeting with (LSW). On [DATE] at 4:15 pm, a representative for Resident #11 reported that on [DATE], the family made arrangements to meet with a hospice agency to discuss the possibility of enrolling in hospice. The representative stated the meeting was arranged at the facility, so as to allow Resident #11 to participate in the discussion. The representative stated Resident #11 and her family wanted to meet privately with the hospice agency, as they had some concerns with the care in the facility. During the process of Resident #11 and her family meeting with hospice staff to make the final enrollment decision, the facility Administrator became angry, stated the paperwork completed thus far with hospice was not valid, and tore up the documents. The representative stated Resident #11 had participated in the discussion to the best of her ability, but was fatigued due to a recent [MEDICAL CONDITION] and breathing problems. The representative stated Resident #11 wanted to be excused once hospice had been explained, for family to finish the discussion and complete the admission paperwork. The representative stated that after Resident #11 was finally admitted to hospice services, the facility made multiple efforts to have hospice stopped, including threats to cancel the hospice contract as a whole, so as to force Resident #11 to discontinue hospice services or selecting a different hospice provider, and asking the physician to discontinue hospice services. The representative stated the facility requested hospice services be discontinued less than a week before Resident #11 passed away. The representative stated it was very difficult for Resident #11 and her family, as they felt, they had to spend the last three months of her life fighting for her to get her hospice benefit. On [DATE] at 9:05 am, the Ombudsman stated she was aware of a conflict between Resident #11, her POA, and the facility regarding hospice services. The Ombudsman stated she was aware Resident #11's family had concerns that the facility had not wanted Resident #11 on hospice, and there was a time the order was discontinued, perhaps at the facility's request. The Ombudsman stated she believed Resident #11 was never officially taken off of hospice, despite the conflict. On [DATE] at 3:00 pm, the hospice admissions person who attempted the first meeting with Resident #11 and her family to discuss hospice services on [DATE], reported when she arrived at the facility to meet with Resident #11 and her family, no one was in either the facility business office or the social services office. The Admissions person stated she stepped into the Administrator's office to let her know hospice staff would be meeting with Resident #11 and her family, and there would be a service agreement for hospice and the facility to sign should Resident #11 decide to enroll in hospice. The Admissions person said the Administrator did not seem too concerned, so hospice proceeded to meet with Resident #11 and her family as planned. The Admissions person stated Resident #11 was initially part of the meeting, and wanted to enroll in hospice, but became fatigued and asked to be excused. The Admissions person stated while Resident #11 was being assisted to lay down, she went again to the business office to have the service agreement signed. The Admissions person stated the BOM appeared confused by the document, but signed it anyway. Shortly thereafter, the Admissions person reported she was summoned into the Administrator's office, where the Administrator was visibly upset and tore up the service agreement. The Admissions person then left the facility, and requested not to return. On [DATE] at 3:25 pm, the hospice LCSW stated that on [DATE], when she was informed the Administrator had torn up the original service agreement, she reached out to both the facility Administrator and the physician who had provided the initial referral to hospice as part of the resident's discharge from the hospital. The LCSW stated she was able to address the Administrator's concerns with the initial hospice visit and confirm with the physician that Resident #11 qualified medically for hospice services, and she and her family wanted hospice services. The LCSW stated Resident #11 enrolled with hospice on [DATE], but at the time the agency was told the contract would only be good until [DATE]. On [DATE] at 3:50 pm, the hospice MSW reported she was aware the facility had concerns with hospice involvement for Resident #11, which she understood to be a concern that hospice would be billing fraudulently as the facility believed Resident #11 did not really need hospice services. The MSW stated there was a slight delay in Resident #11's enrollment in hospice, as the facility Administrator had become angry with the first hospice team who met with Resident #11 and her family, and that the team felt the most prudent action would be to leave the facility to research the situation before proceeding. The hospice MSW stated when she initially came to the facility, she met with both Resident #11 and her family, and that Resident #11 was aware of her diagnosis, prognosis, and the purpose of hospice services. The MSW stated Resident #11 wanted hospice services, and over time benefited from the services as her physical and emotional comfort needs were met. The MSW stated the facility communicated to the hospice agency frequently their intent to discontinue the hospice contract with them as a whole, which would mean Resident #11 would not be able to continue with services through their agency. The MSW stated this topic came up every month, and so each month she talked with Resident #11 to prepare her to either change hospice agencies or discontinue services. The MSW stated as they approached each contract termination date, the facility Administrator extended the contract. During this same interview, the hospice MSW stated the hospice agency received a faxed physician's orders [REDACTED].#11's death which read simply, D/C hospice. The MSW stated the fax did not include an assessment or rationale to explain why hospice had been discontinued. The MSW stated the facility was in the process of clarifying this order through communication with the hospice Medical Director and contact with Resident #11 and her family if, in fact, hospice services were no longer wanted or warranted for Resident #11, when she was notified via email that Resident #11 had died . The MSW stated the hospice agency was not notified at the time of Resident #11's death, so they could not be present with her and her family. The MSW stated, I still don't know if we were officially involved at the time (Resident #11) died , but I have kept in contact with her family. The MSW stated, Unfortunately, the politics of this whole situation have really complicated their grief. On [DATE] at 4:40 pm, the facility LSW confirmed the facility was aware Resident #11 returned to the facility with a referral for hospice. The LSW stated Resident #11 returned to the facility late in the day, so she was not able to act on the order until the following day. The LSW stated she had not yet had a chance to visit with Resident #11 about her desire for hospice when the hospice agency referred by the hospital, arrived at the facility. The LSW stated the facility felt the hospice agency should have met with herself and the Administrator before meeting with either Resident #11 or her family. The LSW was aware some words were exchanged between the facility and the hospice agency. The LSW stated ultimately, Resident #11 enrolled with and remained on hospice, but the length of the contract with the agency she had chosen was always under review. The LSW stated Resident #11 did well with hospice. The LSW stated hospice came to see Resident #11 often, and over time she was able to resume her normal socialization patterns, the quality of her interactions with peers improved, and her family seemed to visit more frequently than prior to hospice involvement. The LSW stated late one afternoon shortly before Resident #11 passed away the physician was in to see Resident #11, and had written an order to discontinue hospice. The LSW stated no explanation was offered for the sudden discontinuation, and that she struggled with the fact this step had been taken as she knew Resident #11 enjoyed interacting with her hospice providers, and the LSW felt she benefited from that service. The LSW stated when she was informed of the order, she only had a few minutes left in her work day, so she called and left messages for Resident #11's family and hospice, and faxed the discontinuation order to hospice. The LSW stated that since it was so close to the end of her workday, she did not have time to talk with Resident #11 about whether she was aware hospice services was being discontinued, or agreed with that decision. The LSW stated when Resident #11 was informed of this development the following day, she was unhappy. The LSW reported Resident #11 stated she liked hospice and wanted them back, and was angry the physician had discontinued the service. The LSW stated she believed the DNS had hospice reinstated. The LSW stated Resident #11 passed away a day or two later. The LSW stated the Administrator chose the course of action with Resident #11 and hospice, and as Resident #11's advocate she disagreed with the course, but did not say or do anything to alter or influence the action. On [DATE] at 8:35, the facility Administrator stated when the hospice Admissions person first arrived at the facility, she did not identify herself properly as being a representative of hospice. The Administrator stated when the BOM came to show her the service agreement which the BOM had signed, she considered it invalid and wadded it up. The Administrator stated, I feel I did the right thing. The resident has the right to be informed, and I would do it again. The Administrator stated after Resident #11 was enrolled in hospice, she remained on hospice without further incident, and had no concern that the contract could or would be canceled until after Resident #11 no longer needed them. The Administrator stated there was some confusion a few days before Resident #11 died , but she was, never taken off of hospice. The Administrator stated the confusion ensued when Resident #11's physician came to the facility to see another resident, who was also on hospice. The Administrator stated she asked the physician if he would review the other resident to see if that resident was appropriate to remain on hospice services, and as long as he was doing that suggested he review Resident #11's appropriateness for hospice as well. The Administrator stated she did not have any specific reason to ask the physician to review Resident #11's hospice, e.g.,. improvement in medical status, resident desire to discontinue hospice, etc. The Administrator stated, It just seemed like a good idea. The Administrator stated the physician may have interpreted her request as a directive to discontinue hospice services for Resident #11, although that was not the intent of her request. The Administrator stated that same day, as soon as she saw the order to discontinue hospice, she went and talked to Resident #11, confirmed she wanted to continue hospice, and called the physician to make sure Resident #11 could continue with hospice services. The Administrator stated she did not document these conversations, and when asked by the surveyor, could not find an order in Resident #11's record to continue hospice services. The Administrator stated it was a mistake not to communicate that information with the LSW, as she did not realize the LSW had already communicated the order with both Resident #11's family and the hospice agency. Resident #11 was experienced psychosocial harm when: *She experienced interference from the facility when she had arranged for an informational visit from, and was attempting to enroll in hospice services following a [MEDICAL CONDITION]; *The facility requested the physician review the appropriateness of hospice and an order to discontinue hospice was received without first consulting with Resident #11 or her representative, causing distress for both parties, in the days leading up to Resident #11's death, and; *Hospice agency was not notified when Resident #11 passed away, and support was not obtained to aide the family in their immediate grief following the event.

Based on staff interview and record review, it was determined the facility failed to ensure a resident was allowed to make decisions about how to meet her physical and emotional needs at the end of life. This was true for 1 of 7 residents (Resident #11) sampled for social services. Resident #11 was harmed when an order was sent to a hospice agency discontinuing services without her knowledge or consent, three days before she passed away. Findings included: Resident #11 was re-admitted to the facility on [DATE] following a hospitalization for a heart attack and pulmonary edema. Resident #11's readmission orders [REDACTED]. Resident #11 enrolled with hospice on [DATE]. Resident #11's hospice MSW notes documented on [DATE], [DATE], and [DATE], that Resident #11 was receptive to hospice services, wanted to continue the services, and benefited from the emotional support from the hospice team. The MSW notes for these dates documented Resident #11 was experiencing increased distress and anxiousness as the facility was planning to cancel the contract with her hospice provider in [DATE], and she would either have to select a different hospice agency, or discontinue hospice services. There were no SSPNs in Resident #11's record between [DATE] and [DATE]. On [DATE] at 2:00 pm, Resident #11's hospice MSW notes documented the MSW had spoken with the facility Administrator, and the Administrator had agreed to, allow (hospice) services to stay in place .as long as (Resident #11) would need service. On [DATE] at 4:08 pm, the facility LSW documented the Resident #11 had engaged in a social activity before a hospice visit that day, and participated in a painting class afterwards. The next SSPN was documented on [DATE]. On [DATE], a physician's orders [REDACTED]. On [DATE] at 4:26 PM, Resident #11's SSPNs documented the LSW informed the hospice agency that their services had been discontinued, and left a message for Resident #11's family. On [DATE] at 10:00 am, Resident #11's NNs documented she was asked how she felt about the hospice discharge. Resident #11 stated she did not want them discharged and liked having them come. Resident #11 stated her physician was a quack for discharging her from hospice. On [DATE] at 11:46 am, Resident #11's NNs documented her family was upset with the discontinuation of hospice services. The NN documented Resident #11's family wanted a meeting with the physician, hospice, and facility staff to discuss this further. The NN documented the facility would not arrange such a meeting, but would attend if Resident #11's family made the arrangements. The note documented Resident #11's family was able to arrange the care conference for [DATE]. On [DATE] at 3:13 pm, Resident #11's SSPNs documented Resident #11's family was upset with the discontinuation of hospice services without documented rationale, and had lost trust with facility staff. Documentation that the LSW spoke with Resident #11 regarding the discontinuation of hospice, or how the discontinuation of those services impacted her, was not found in Resident #11's record. On [DATE] at 12:07 am, Resident #11's NN documented she had passed away. The note documented, .daughter came here but (left) unable to get self under control over mother passing . There was no documentation of the hospice agency's involvement at the time of Resident #11's death. On [DATE] at 1:17 pm, Resident #11's SSPNs documented, .daughter had set up a meeting with IDT, (Physician), and Hospice .Hospice did not show up .saw (Daughter) out in front however she did not come into the building to talk about/cancel meeting with (LSW). On [DATE] at 4:40 pm, the LSW stated: *There was a barrier to Resident #11 enrolling in hospice when she initially met with hospice staff on [DATE], as the facility felt hospice should have first met with the Administrator and LSW before meeting with Resident #11. The LSW stated this should have been the case because the facility was concerned Resident #11's choice to involve hospice would impact the facility's reimbursement from Medicare. *The Administrator eventually made the decision to allow Resident #11 to enroll in hospice with the provider of her choice, after which Resident #11 enrolled with hospice. *After Resident #11 enrolled in hospice, the Administrator initially made the decision for the facility to stop working with the agency Resident #11 chose. As the termination date for the contract approached, the Administrator agreed to let Resident #11 continue services with that agency. *Once Resident #11 enrolled with hospice, she was able to resume her socialization patterns, the quality of those interactions improved, and her family visited more often. *When the LSW was informed of the physician's orders [REDACTED]. She did not talk to Resident #11 about the impact of discontinuing hospice until after she had faxed the order to hospice and called Resident #11's family to inform them hospice had been discontinued. The LSW stated this was because the order came in at the end of her work day, and she needed to decide whether to talk to Resident #11 or get the order to hospice before she went home. The LSW stated at the time, she made the decision not to talk to Resident #11, but chose to fax the discontinuation order to hospice. *Resident #11 was very unhappy when she found out the next day that hospice services were discontinued, and insisted something be done to reinstate the service. *The LSW had many concerns about how the facility handled Resident #11's course with hospice, but did not advocate for Resident #11 when concerned because, The Administrator chose the actions and course of action. I would not have done it that way. It was incorrect. Resident #11 was harmed when the facility failed to recognize the importance of hospice services to her as she neared the end of her life. The facility failed to advocate for Resident #11 to assure her hospice services would continue without interruption, causing her ongoing distress. Resident #11 was further distressed when her physician discontinued hospice services with no rationale three days before she died , and the hospice was notified of the discontinuation prior to Resident #11 being assessed for the psychosocial impact of the discontinuation. There was no evidence Resident #11's physician or the hospice agency were notified of Resident #11's wishes to continue services. The hospice agency was not notified at the time of Resident #11's death, or that her family was overcome with grief at her passing.

Based on observation, interview, review of Incident Reports and Suggestion Concern forms, and record review, it was determined the facility failed to ensure care and services necessary for residents to achieve their highest practicable physical, emotional, and psychosocial wellbeing. This was true for 6 of 11 sampled residents (#1,#2, #3, #6, #10, and #11). a) Resident #11 was harmed when the facility failed to inform the physician for four hours after an acute onset of symptoms, requiring hospitalization and resulting in her being placed on palliative care. Resident #11 was at further risk of harm from a lack of communication and coordination with hospice. b) Resident #3 was harmed when his narcotic pain patch was discontinued and he experienced debilitating prolonged pain and he was not included in decisions made about his pain management needs and goals. c) Resident #1 had the potential for harm when her narcotic pain medication was discontinued and she experienced increased pain. d) Resident #2 had the potential for harm when the facility did not coordinate care with the [MEDICAL TREATMENT] unit. e) Resident #10 was placed at risk of harm when he was administered antipsychotic medication without clear indication for use and without effective behavioral monitoring systems in place. f) Resident #6 had the potential for harm when the facility failed to develop a dementia care plan consistent with recognized standards of practice. Findings include: 1. Resident #11 was initially admitted to the facility on [DATE] following a stroke, with additional [DIAGNOSES REDACTED]. On [DATE], Resident #11's care plan documented a focus area of altered thought process related to her stroke, involving forgetfulness, impulsivity, impaired safety awareness, and poor judgement. a. Resident #11's Annual MDS assessment, dated [DATE], documented she was able to answer orientation questions correctly. On [DATE] at 4:00 am, her facility incident report documented Resident #11 had a fall from bed following an acute change in her medical status, due to leaning forward and to the right to cough. On [DATE] at 7:15 am, Resident #11's NN documented she had difficulty breathing in the night, with decreased oxygen saturations in the nighttime which continued in the morning. The NN documented her oxygen saturations at 83%, on 5 liters of oxygen. The note documented the physician was notified at that time, and a new order for a chest x-ray was obtained. On [DATE] at 7:25 am, Resident #11's NN documented the facility called her family with information that she had fallen from bed in the night, and was being sent out for a chest x-ray. On [DATE] at 9:53 am, Resident #11's SSPNs documented she had returned from the hospital and did not feel well. The note documented she had refused returning to the hospital twice before the facility reviewed the results of the chest x-ray with her. After Resident #11 was made aware of the results of the x-ray taken that morning, she agreed to go to the hospital for evaluation if her physician felt it was necessary. On [DATE], a facility Suggestion or Concern form documented Resident #11's family was concerned she was not taken to the hospital, soon enough when she was having heart, chest pains. The Investigation into the family's concern was documented on [DATE], the Resolution on [DATE], and the Follow-up on [DATE]. The form documented Resident #11 was not incompetent and had refused to go to the hospital, and that she had a DNR in place. On [DATE], the hospital H&P stated Resident #11 had previously been hospitalized from [DATE] through ,[DATE] for similar symptoms, and was noted with suggestive EKG changes for the potential for a [MEDICAL CONDITION] at that time. The H&P documented Resident #11 was sent to the ER at 4:00 pm on [DATE], due to continued reports of chest pain and shortness of breath. Upon arrival at the ER, Resident #11's blood pressure was ,[DATE] and oxygen saturations were documented at 85%. The H&P documented Resident #11 was found to have had a [MEDICAL CONDITION] with the complication of [MEDICAL CONDITIONS], with the onset of symptoms at 7:00 am or earlier. The H&P documented discussions were held with Resident #11's family at that time, and due to the additional time delay, the decision was made to keep her in the hospital on comfort measures. On [DATE] at 4:40 pm, the LSW stated that on [DATE], she was informed when she arrived at work at approximately 8:00 am that Resident #11 was not feeling well and had refused to go to the hospital. The LSW stated she and the DNS reapproached her to discuss risks and benefits of her decision, and she agreed to go to the hospital. She could not be certain of the timeframe. On [DATE] at 8:35 am, the DNS stated that on [DATE] at approximately 3:00 am, Resident #11 awoke with shortness of breath, decreased oxygen saturations, and was coughing up orange and yellow sputum. The DNS stated the nurse on duty offered several times to send her to the ER, but she refused to go. The DNS stated Resident #11 fell from bed at 4:00 am. The DNS stated that though the onset of symptoms was 3:00 am, the physician was notified at 7:00 am. The DNS stated the facility considered Resident #11 to be able to speak for herself, so did not feel the need to notify the physician when Resident #11 was refusing to go to the hospital. The DNS did not know if there were other assessments or treatment options the physician would have ordered, aside from evaluation at the ER, if such notification had been made. The DNS was unable to explain how Resident #11 was assessed for decision making capacity at the time of her refusals. Resident #11 had impaired judgement at baseline, low oxygen saturations, and illness at the time of the discussions. Resident #11 was harmed when the facility did not notify the physician for four hours after the onset of acute symptoms, including shortness of breath with decreased oxygen saturation levels and a fall. When the physician was notified, Resident #11 agreed to have a chest x-ray. When the chest x-ray results were known, Resident #11 agreed to go to the hospital for evaluation. She was found to have suffered a [MEDICAL CONDITION] several hours earlier, which had worsened over the course of the day. Resident #11 and her family opted for palliative care, in part due to the time delay in [DIAGNOSES REDACTED]. b. Resident #11 was re-admitted to the facility on [DATE] following her [MEDICAL CONDITION], with an order for [REDACTED]. Resident #11's care plan at the time of her death on [DATE], documented a focus area of a terminal [DIAGNOSES REDACTED]. The care plan did not include how cares and services would be coordinated between the facility and the hospice agency, which hospice agency was working with her, or when or how the hospice agency was to be contacted. On [DATE], a facility Suggestion or Concern form documented Resident #11 was sent to the hospital for evaluation of a stomach ache, but her family was not notified. The Resolution area of the form documented the facility nurse notified the hospice agency, but did not notify Resident #11's family as it was assumed the hospice agency would make that notification. On [DATE] at 12:07 am, Resident #11's NN documented Resident #11 passed away. The note documented her family came here but (left) unable to get self under control over (Resident #11) passing . The NN did not include documentation the hospice agency was contacted regarding Resident #11's passing or her family's response to her death. On [DATE] at 8:35 am, the DNS and Administrator stated they had no further documentation to offer to show the coordination between the facility and the hospice agency for Resident #11. 2. Resident #3 was admitted to the facility with multiple [DIAGNOSES REDACTED]. The Annual MDS assessment, dated [DATE], indicated Resident #3 was cognitively intact; received scheduled pain medications and non-medication interventions for pain; and denied the presence of pain during a pain assessment interview. Resident #3's pain care plan, revised on [DATE], documented Resident #3 had chronic pain/discomfort related to [MEDICAL CONDITION] disk disease, [MEDICATION NAME] and lumbar compression fractures, [MEDICAL CONDITION], and (chronic) low back pain. A list of Resident #3's strengths were identified under interventions and included Resident #3 was able to call for assistance when in pain; could reposition himself; ask for medication; and verbalize what increased and/or alleviated the pain. Interventions included warm blankets, repositioning, 1:1 visits, reading, watching television, reminiscing about hunting and fishing, and listening to music. The interventions also included assessing Resident #3's pain using the numeric pain scale. The numeric pain scale identified pain on a scale of 1 to 10, with 10 being the worst pain. A physician progress notes [REDACTED].#3 verbalized complaints related to his diffuse chronic arthritic pain in his hands, shoulders, hip, knees, [MEDICATION NAME]/lumbar spine. Resident #3 required opioid therapy for chronic pain and the [MEDICATION NAME] appeared to work well at reducing the chronic pain to a bearable level without adverse side effects. Physician Orders, dated [DATE], included: * [MEDICATION NAME] 100 mg tablet by mouth two times a day for severe pain * Tylenol 650 mg tablet by mouth three times a day for severe pain * Give [MEDICATION NAME] and Tylenol together * Evaluate the resident's pain level A physician progress notes [REDACTED].#3 continued to complain of chronic pain; however, the pain was reduced to a level of 3 on the pain scale. Additionally, the physician documented, Specifically, the [MEDICATION NAME] ([MEDICATION NAME]) appeared to be controlling his pain adequately without side effects. A physician progress notes [REDACTED].#3 was completely focused on his arthritic pain, and stated he was in pain on a daily basis; however, the pain medication was helping to reduce it to a 3 to 4. The note stated, I informed him that he is on a narcotic pain medication and that I will not increase it due to safety issues .I believe the risks outweigh any benefits. The note did identify the specific safety concerns and risks identified by the physician. Documentation that Resident #3 was given the opportunity to participate in the decision making process related to his individual pain management plan, needs, and goals, was not included in the note. A physician progress notes [REDACTED].#3) chronic pain in his back, hip, and knees. He is on the lowest dose of [MEDICATION NAME] currently and I clearly discussed with him my reasoning of not increasing it due to increasing his risk for falls and other side effects. I feel he is on the lowest dose of narcotic pain medication possible to control his severe arthritic pain. Nursing reports no untoward side effects to the medication and it does offer him pain relief. The note did not include how it was determined Resident #3 would be at increased risk for falls or describe the other potential side effects. Documentation that Resident #3 was given the opportunity to participate in the decision making process related to his individual pain management plan, needs, and goals, was not included in the note. Fall Incident and Accident reports reviewed from [DATE] to [DATE], did not include documentation that Resident #3 had fallen. Resident #3's Fall Risk Assessments documented: * [DATE] - low risk for falls; * [DATE] - medium risk for falls; and * [DATE] - low risk for falls. Resident #3's Pain Medication Administration Record [REDACTED]. Physician order [REDACTED]. * [MEDICATION NAME] 12 mcg apply [MEDICATION NAME] every 72 hours related to collapsed vertebra and fatigue [MEDICAL CONDITION] region * [MEDICATION NAME] 100 mg tablet by mouth two times a day for severe pain * Tylenol 650 mg tablet by mouth three times a day for severe pain * Give Tylenol with [MEDICATION NAME]. * Evaluate pain level using PAINAD due to cognitive deficits. An MD/Nursing Communications form, dated [DATE], documented Resident #3 had routinely asked for pain medication in the middle of the afternoon and at 11:30 PM. Nursing staff requested an, as needed, order for Tylenol 650 mg to be given at the identified times, in addition to the scheduled Tylenol Resident #3 was already receiving. On [DATE], the form included a handwritten Yes, signed by the physician. A Nursing note, dated [DATE], documented Resident #3 was kicked in the back ,[DATE] times by another resident and was not injured. A Nursing note, dated [DATE], documented Resident #3 complained of back pain after being kicked by another resident on [DATE] and stated, Resident #3 thought the other resident injured his spine and back and asked, 'What if I have a bad disc? The note stated, The resident was able to move his feet but did not feel he should propel his wheelchair any more so he does not injure anything. He wants an x-ray of his back on Monday to ensure there are no fractures. He has been very anxious about the incident and will talk to whoever will listen. Resident #3 received as needed pain medication and accepted ice and heat to the area with positive results. A Nurse note, dated [DATE], documented Resident #3 was sent to a local medical center for x-rays of his [MEDICATION NAME] and lumbar spine. Diagnostic x-ray reports, dated [DATE], documented Resident #3 had an old compression fractures at T12 and L3. The compression fracture at T12 is unchanged from previous x-ray. The compression fracture at L3 had interval progression when compared to prior study. Multi-level [MEDICAL CONDITION] changes were identified through out the [MEDICATION NAME] spine, with disc space narrowing and marginal osteophytes at multiple levels. No acute compression fractures were identified. A physician progress notes [REDACTED].#3 continued to have primary complaint of chronic musculoskeletal pain. The note stated, I informed him of the new CDC guidelines and the fact we will wean him off narcotics. We will begin weaning (the [MEDICATION NAME]) off with the new CDC guidelines. We will rely on NSAID's, Tylenol, topical [MEDICATION NAME], and [MEDICATION NAME]. Documentation that Resident #3 participated in the pain management plan to discontinue use of [MEDICATION NAME] was not included in the note. Consideration of the potential negative impact discontinuation of the [MEDICATION NAME] could have on Resident #3's quality of life, was not documented. Resident #3 had used [MEDICATION NAME]es at the lowest dose to manage his pain since [DATE]. The potential risks and benefits of Resident #3's continued use the [MEDICATION NAME] were not documented, nor discussed with Resident #3. Resident #3's Pain Medication Administration Record [REDACTED]. A Physician Order, dated [DATE], documented: * [MEDICATION NAME] 12 mcg apply patch every four days times eight days and then discontinue. * [MEDICATION NAME] 50 mg tablet give one tablet twice a day as needed for pain. The Medication Administration Record, [REDACTED]. A Nurse progress note, dated [DATE], documented, The resident ate two meals in his room yesterday related to increased pain in his back. He says it is getting more difficult to self-propel in his wheelchair. His shoulders, back, and knees are getting more stiff and painful. Will continue to assess. An MD/Nursing communication form, dated [DATE], documented nursing staff notified the physician of Resident #3's increased pain. A new order was received to apply cold spot/Biofreeze to painful joints and back twice a day for increased pain. A Nurses note, dated [DATE], documented, Resident #3 is in so much pain he 'can't do it no more.' Stated he could not even use his wheelchair anymore due to increasing pain. The note stated Resident #3 appeared to be stiff and unable to move due to pain. A physician progress notes [REDACTED]. I had a lengthy discussion with him regarding the CDC guidelines regarding pain medication. The physician documented Resident #3 would continue with current pain medications, [MEDICATION NAME] and tylenol, and [MEDICATION NAME] would be added for pain management. Documentation that Resident #3's increased pain was evaluated by the physician after the [MEDICATION NAME] was discontinued on [DATE], was not included in the note. Resident #3's record did not include documentation that the risks and benefits of receiving [MEDICATION NAME] were discussed with Resident #3 and he had participated in the decision to add the medication to his pain management regimen. A Physician Order, dated [DATE], documented: * [MEDICATION NAME] 50 mg give one capsule by mouth two times a day for pain. * [MEDICATION NAME] 50 mg give one to two tablets three times a day as needed for pain. Nurses notes, dated [DATE] and [DATE], documented Resident #3 indicated the [MEDICATION NAME] and Cold Spot had help to decrease his pain. Nurse notes dated [DATE], documented: * 4:05 PM - Resident #3 was bent over in his wheelchair and said his lower back was very painful. A hot pack was applied to Resident #3's lower back. * 4:20 PM - Resident #3's family member was notified and asked the nurse if Resident #3 could be transferred to the emergency room if the pain worsened. The family member was informed that if Resident #3 wanted to go to the emergency room the facility would take him. The note did not state facility staff had discussed this option with Resident #3. * 4:50 PM - Resident #3 was observed sitting more upright in his wheelchair and reported the pain was still present and rated it ,[DATE]. Resident #3's pain level was not assessed prior to the application of the hot pack; therefore, the effectiveness of the intervention could not be determined. Nurses' notes reviewed from [DATE] through [DATE] did not include: * Continued evaluation(s) related to signs or symptoms of pain exhibited by Resident #3 * Whether, and how, the changes in Resident #3's pain management interventions impacted Resident #3's ability to function and participate in routine care and activities * The effectiveness of the interventions for controlling Resident #3's pain Resident #3's Pain Medication Administration Record, [REDACTED]. In addition to scheduled pain medication, Resident #3 also received 13 doses of PRN medication related to increased pain. Assessments of Resident #3's pain level were not documented prior to administration of the PRN medication or after administration. On [DATE], from 1:50 PM to 2:15 PM, Resident #3 attempted to propel himself in his wheelchair several times without success. Staff offered him assistance and each time he politely declined. At 2:15 PM, RN #4 observed Resident #3 struggling with his wheelchair and when she asked him if he was hurting and needed something for pain, he responded, Yes. Resident #3 was taken back to his room and verbalized the pain was ,[DATE] and was in his lower back. When RN #4 asked him if he had pain in his knees, Resident #3 responded, Yes, and rated the pain ,[DATE]. RN #4 applied topical [MEDICATION NAME] gel to Resident #3's spine/back and bilateral knees. Resident #3 requested the gel be applied to his right elbow. After RN #4 applied the gel to his right elbow he asked if there was any of it left for his left elbow. RN #4 informed him she had used the last of it on his right elbow. RN# 4 was not observed to obtain more [MEDICATION NAME] gel for Resident #3's right elbow. A Nurse note, dated [DATE] at 9:10 am, documented, Resident #3 had uncontrolled pain for the last two days. We are using ALL prescribed medications, plus [MEDICATION NAME] gels. He continues to verbally say he is in ,[DATE] pain. May I schedule him to see a pain specialist? On [DATE], at 10:55 am, Resident #3 was laying in bed and CNA #2 stated he had a rough night and did not sleep well related to terrible pain in his legs. CNA #2 stated Resident #3 was very stiff in his joints and he had struggled with routine activity that morning. CNA #2 stated it was not routine for Resident #3 to lay back down once he got up in the morning. On [DATE], at 11:00 AM, when RN #1 was asked what had been done to address Resident #3's increased pain. The RN shook her head and stated The resident started having increased pain when his physician decided to discontinue the resident's [MEDICATION NAME]. When asked if Resident #3 was part of the decision making process, RN #1 stated she did not think so. RN #1 stated she and the Unit Manager had expressed their concerns to the physician several times after the patch was discontinued. RN #1 stated Resident #3 had verbalized increased pain in his joints, knees, shoulder, and legs; the CNAs reported he struggled with routine activities; and he was observed to have increased stiffness in his joints. RN #1 stated she and the Unit Manager had informed the physician Resident #3's pain was not controlled and requested the [MEDICATION NAME] be restarted. RN #1 stated the physician was unwilling to discuss the use of the [MEDICATION NAME] and would not restart it. On [DATE], at 11:15 AM, when asked about the reason Resident #3's physician had discontinued the [MEDICATION NAME], the DNS stated Resident #3's physician informed the facility at the last QA meeting he would be discontinuing narcotic pain medications for all of his patients. The DNS was asked if Resident #3 was involved in the decision to discontinue the [MEDICATION NAME]. The DNS stated he was not, nor were the other residents. The DNS stated the IDT was not involved in the decisions. The DNS stated the physician made the decisions independently based on his interpretation of the new CDC guidelines. On [DATE], at 4:40 PM, Resident #3 was laying in bed and CNA #3 stated he was having a lot of pain and would not be getting up for dinner. CNA #3 stated Resident #3 attempted to assist staff with routine activities, but due to increased pain he was unable to provide much assistance. On [DATE], at 12:25 PM, when Resident #3 was asked if he had recently experience increased pain, he stated he was having more pain in his back, knees, joints, shoulders, and wrists. When asked if he felt better today than yesterday, he stated, I was in so much pain yesterday that if I could have killed myself I would have. When asked if he felt the [MEDICATION NAME] provided him with more sustained and continuous pain control, he stated it did and you have to use what works. On [DATE], at 11:00 AM, the physican was asked about who participated in decision making process to discontinue Resident #3's [MEDICATION NAME]. The physician stated, I made the decision solely on my own and did not feel I needed to discuss it with the resident and/or nursing staff. When asked if a dialogue had occurred with Resident #3 and/or hisfamily, the physician stated, No, Resident #3 was not given a choice. I informed the resident I would be weaning him off and discontinuing the pain patch. When asked if the nursing staff had been in communication with him related to Resident #3's increased pain after the patch was discontinued, the physician stated,Nursing staff notified me and challenged my decision to discontinuing the patch. I told the nursing staff I would absolutely not consider restarting the patch as it was not recommended for treating chronic MSK pain. When asked how it was determined the risks were greater than the benefits for Resident #3, who was on the lowest dose of [MEDICATION NAME] and had been receiving the medication since ,[DATE], the physician stated, He is on the lowest dose of the [MEDICATION NAME]? I guess I did not realize that. The CDC guidelines, BEERS criteria, and the fact the resident had not had a trial on non-narcotic pain medication had a major influence on my decision to discontinue the patch. When asked if he would consider restarting the [MEDICATION NAME] for Resident #3, initially the physician stated, Of course I would if I felt the resident was not experiencing adequate pain control with the current medications. The physician then stated, I would not consider restarting the patch; however, there is always a plan B. The physician stated he had considered giving Resident #3 injections in his shoulder and knees and/or referring him to a Pain Management Physician in the community. The physician stated the waiting list for the Pain Management physicians was approximately ,[DATE] months and they did not take Medicare. Resident #3 was harmed when: * He experienced debilitating pain after the [MEDICATION NAME] was discontinued, which diminished his w/c mobility, ability to eat and sleep, complete functions of everyday life, and enjoy leisure activities, to point he felt he would rather end his existence than live with the pain. * He was not provided with the risks and benefits of continuing the use of Fentanly patches to manage his pain, and was not allowed to participate in decisions regarding his pain management regimen. 3. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1's Admit MDS assessment, dated [DATE], documented Resident #1 had a moderate cognitive impairment. The MDS assessment further documented Resident #1 used medications as needed, and had no scheduled pain medications. Resident #1 reported occasional pain during a pain assessment interview. The MDS documented Resident #1 was occasionally incontinent of bowel and frequently incontinent of bladder. Resident #1 had no upper or lower extremity impairments. Resident #1's Quarterly MDS assessment, dated [DATE], documented Resident #1 was cognitively intact. The MDS documented the same findings in regards to pain as in the [DATE]. The MDS documented that Resident #1 was always incontinent of bowel and bladder. The assessment stated Resident #1 had one sided upper extremity impairment and both sided lower extremity impairment. Resident #1's pain plan of care, dated [DATE], documented Resident #1 had pain medication therapy related to unilateral primary [MEDICAL CONDITION] of the hip and bilateral primary [MEDICAL CONDITION] of the knees. Interventions included: * Staff were to report any changes in usual activity related to c/o pain. * Staff were to observe and record changes in Resident #1's usual routine, changes in sleeping patterns, decreased functional abilities, decreased ROM ability, and withdrawal or resistance to care. * Staff were to attempt non-pharmacological intervention of offering a warm blanket or repositioning for comfort. * Staff were to use PAINAD to rate pain. Resident #1's current Physician Orders, dated [DATE], included: * Tylenol 650 mg every 4 hours PRN for pain beginning on [DATE] * [MEDICATION NAME] 50 mg every 6 hours PRN for pain beginning on [DATE] Resident #1's discontinued physician's orders [REDACTED]. The order was gradually decreased to every 8 hours for pain. The [MEDICATION NAME] dose was changed [DATE] to ,[DATE] mg every 12 hours and then the [MEDICATION NAME] was discontinued completely [DATE]. Resident #1's [DATE] MAR indicated [REDACTED]. Resident #1's [DATE] MAR indicated [REDACTED]. After [DATE] [MEDICATION NAME] was given 23 times and Tylenol was given 8 times. Resident #1's [DATE] MAR (from [DATE] through [DATE]) documented that Resident #1 was given [MEDICATION NAME] 35 times and Tylenol 6 times. On [DATE] a NN documented Resident #1 had pain for which she received PRN medications. On [DATE] Resident #1's NN documented she complained of pain, could hardly move and did not want to get out of bed. On [DATE] Resident #1's NN documented Resident #1 was unable to lift her legs due to pain. On [DATE] Resident #1's NN documented she complained of pain in her shoulder and back. On [DATE] Resident #1's MD note documented Resident #1 continued to experience arthritis pain of the upper extremity and lower extremities. The note stated Resident #1 had been receiving [MEDICATION NAME] but with the new CDC guidelines the MD recommended discontinuing the medication and changed Resident #1's pain medications to [MEDICATION NAME] and Tylenol. On [DATE] Resident #1's social service note documented Resident #1's pain to her shoulders and knees were her biggest hindrance. On [DATE] Resident #1's Care Plan Note documented that Resident #1 stated that she did not want to use a sit-to-stand device for toileting as it jarred her too much. The note stated staff offered her a bed pan and she had declined and stated she would like to use her attends to avoid the jarring. On [DATE] Resident #1's NN documented she did not want to get out of bed. On [DATE] Resident #1's NN documented she did not want to get out of bed for meals. On [DATE] Resident #1's NN documented she had complained of pain in her left wrist. On [DATE] at 10:25 am, Resident #1 stated she experienced pain the majority of time and she said the nursing staff were aware of it. She stated she liked to stay in bed as much as possible because it hurt less. Resident #1 stated she did not like to do activities, in part, due to the pain. On [DATE] at 3:15 pm the DNS, stated Resident #1 had bone on bone areas due to her [MEDICAL CONDITION] and she complained of pain often. 4. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's recapitulated [DATE] physician's orders [REDACTED]. * Bruit at the [MEDICAL TREATMENT] site * Bleeding at the [MEDICAL TREATMENT] site * Monitor for s/s of infection at the [MEDICAL TREATMENT] site * Report as indicated every morning and at bedtime to the MD and [MEDICAL TREATMENT] unit. Resident #2's [DATE] Physician Orders, and MAR for [DATE] through [DATE] did not include: * Resident #2's [MEDICAL TREATMENT] schedule * Location of the [MEDICAL TREATMENT] port * When to remove bandage after [MEDICAL TREATMENT] * A pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] check list * Clear indication of where and when Resident #2 was to be given morning medications on days he received [MEDICAL TREATMENT] Resident #2's [MEDICAL TREATMENT] Care Plan, dated [DATE], identified the access site as an AV fistula in the left forearm. Interventions included: * Monitor and document for signs of [MEDICAL CONDITION] * Monitor for s/s of [MEDICAL CONDITION] * Monitor for s/s of infection to the access site * Do not use the left arm for blood draws or blood pressure * Nursing staff were to obtain vital signs daily in the PM, and Resident #2 was to be weighed at the [MEDICAL TREATMENT] unit M, W, & F, and weighed on bath days 2 times a week in the facility. The staff were to report significant changes to the nurse immediately. On [DATE], the CP was updated to include: the staffs was to monitor and document on the M