Every finding on record at Sky View Nursing Center

Based on interview and record review, the facility did not ensure 3 of 3 residents (R3, R18, and R21) or the residents' legal representatives were notified of the reason for a transfer/discharge and did not ensure they were provided a bed hold policy in writing including the rate to reserve the residents' beds.The facility did not include the daily rate for bed hold to R18 and R21 prior to transfer to hospital.R3's, R18, and R21 transfer form did not contain appeal rights or ombudsman contact information. Findings include: Example 1 R18 was admitted to the facility on [DATE]. On 03/17/2026 and 04/04/2026, R18 was transferred to the hospital. R18's medical record did not include documentation that R18 or R18's legal representative was provided with written or verbal communication of bed-hold daily rate charges. The facility's written transfer/discharge notice did not include ombudsman contact or the resident's right to appeal discharge for R18. Example 2 R21 was admitted to the facility on [DATE] On 01/01/2026 and 02/11/2026, R21 was transferred to the hospital. R21's medical record did not include documentation that R21 or R21's legal representative was provided with written or verbal communication of bed-hold daily rate charges. On 04/29/2026 at 8:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A if R18 and R21 were provided bed-hold daily rates. NHA A could not provide this information for R18 and R21. The facility's written transfer/discharge notice did not include ombudsman contact or the resident's right to appeal discharge for R21. Example 3 R3 was admitted to the facility on [DATE]. On 11/20/25, R3 was transferred to the hospital. R3's notice of transfer notice did not include appeal rights or Ombudsman contact information.

Based on interviews and record reviews, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 (R25) of 12 residents reviewed.R25 was diabetic and had as-needed (PRN) insulin for blood sugars > (greater than) 400 mg (milligrams)/dL (deciliter). The facility did not follow the provider's orders to administer PRN (as needed) insulin and did not notify the provider of blood sugars outside of parameters.This is evidenced by:R25 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia.R25's physician orders include:On 05/09/25, Facility standing orders ok.On 03/05/26, Novolin R (regular insulin) give 10 units subcutaneously for blood sugars >/= (equal to) 400 as needed every 2 hours until blood sugar < (less than) 300.Surveyor reviewed R25's medication administration record (MAR):On 03/21/2026 at 6:09 PM, blood sugar documented as 413 mg/dL; 10 units of Novolin administered; at 9:28 PM, follow-up blood sugar was 323 mg/dL. Of note: No additional Novolin was administered to reduce R25's blood sugar to less than 300 as ordered. There is no documentation that the provider was notified of R25's blood sugar of 413 mg/dL. On 03/22/2026 at 4:59 PM, blood sugar documented as 416 mg/dL; 10 units of Novolin administered; at 8:54 PM, follow-up blood sugar was 349 mg/dL. Of note: No additional Novolin was administered to reduce R25's blood sugar to less than 300 mg/dL as ordered. There is no documentation that the provider was notified of R25's blood sugar of 416 mg/dL. On 04/03/2026 at 4:21 PM, blood sugar documented as 446 mg/dL; 10 units of Novolin administered. Of note: No follow-up blood sugar documented. There is no documentation that the provider was notified of R25's blood sugar of 446 mg/dL. On 04/19/2026 at 3:52 PM, blood sugar documented as 415 mg/dL; 10 units of Novolin administered. Of note: No follow-up blood sugar documented. There is no documentation that the provider was notified of R25's blood sugar of 415 mg/dL. On 04/21/2026 at 3:21 PM, blood sugar documented as 436 mg/dL; 10 units of Novolin administered; at 6:33 PM, follow-up blood sugar was 400 mg/dL. Of note: No additional Novolin was administered to reduce R25's blood sugar to less than 300 as ordered. There is no documentation that the provider was notified of R25's blood sugar of 436 mg/dL. On 04/28/26 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding blood sugars. LPN C stated that she believed the facility's standing orders were to notify the provider if a resident's blood sugar is <60 and >400 but wasn't sure. Surveyor asked LPN C if this gets documented anywhere. LPN C stated that a communication form is filled out, faxed to the provider and put in the resident's paper chart and a progress note is entered into the MAR (medication administration record). Surveyor asked LPN C about R25's Novolin insulin order. LPN C stated that if additional doses of Novolin had to be given it would be entered in the MAR and in a progress note.On 04/28/26 at 11:33 AM, Surveyor interviewed Director of Nursing (DON) B regarding R25's insulin orders and blood sugars. DON B stated that the facility's standing orders are for the nurse to notify the provider if blood sugars are >400 and to document the communication in a progress note, unless the provider enters a specific parameter for notification. Surveyor asked DON B to review R25's Novolin order and MAR entries for the month of April 2026. DON B was unaware the provider's order was not being followed and stated the nurse should have administered additional Novolin and notified the provider of the >400 blood sugar.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 2 (R9, R7) out of 13 residents observed. The facility did not have Enhanced Barrier Precaution (EBP) signage displayed near the door or in room for a resident on Enhanced Barrier Precautions (EBP) and staff did not consistently use Personal Protective Equipment (PPE) when in direct contact with R7 who is on EBP.Staff inserted eye drops for R9 with contaminated gloves and did not practice hand hygiene when gloves were changed.Findings include:Example 1On 4/27/2026 at approximately 10 AM, Surveyor observed R7 has a urinary catheter. R7 does not have Enhanced Barrier Precaution (EBP) signage near the entry of his room or anywhere in his room. Surveyor also observed there was no Personal Protective Equipment (PPE) in the entry way or room of R7.On 4/28/2026 at 1:04 PM, Surveyor observed Certified Nurse Assistant (CNA) D wheel R7 into the shared bathroom and empty R7's catheter after putting on a gown, face shield, and gloves. Surveyor interviewed CNA D, who stated staff only needed to wear the PPE when providing catheter care for R7. On 4/28/2026 at 1:25 PM, Surveyor interviewed CNA D and Director of Nursing (DON) B. Both stated a gown only needs to be worn when providing catheter care or coming in contact with the catheter. DON B showed Surveyor that R7 has a drawer near his bed with PPE and inside the drawer contained an EBP sign. Surveyor asked DON B how staff know R7 is on EBP and when to wear PPE. DON B reported staff are told who is on EBP. On 4/28/2026 at 1:50 PM, Surveyor interviewed CNA E, who reported she has cared for R7 before. CNA E stated R7 is on droplet precautions, just for his catheter though. CNA E reported she would wear a gown and gloves only when working with R7's catheter in case urine was splashed. On 4/29/2026 at 8:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and DON B, who agreed that EBP was not understood by staff. NHA A and DON B indicate staff did not understand the need to wear PPE when providing any direct care to R7 who has a catheter and is on EBP.Example 2On 4/28/2026 at 10:45 AM, Surveyor observed Licensed Practical Nurse (LPN) C apply gloves then pick up R9's used drinking cup by the rim and throw it away. LPN C then proceeded to administer R9's eye drops with contaminated gloves. Surveyor observed LPN C remove her contaminated gloves and apply clean gloves without practicing any hand hygiene. On 4/28/2026 at 10:50 AM, Surveyor interviewed LPN C who agreed she should not have touched the rim of R9's used cup and then with the same contaminated gloves to apply R9's eyedrops. LPN C also agreed she should have sanitized her hands when she changed her gloves.

Based on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 29 residents. -Chemical dishwasher temperature did not reach the required 120 degrees. -Perishable item was only good for 24 hours after thawing. Item was not labeled to ensure it was discarded timely to prevent foodborne illnesses to the residents. Evidenced by: Example 1 According to federal regulation S483.60(i)(1)-(2), Low Temperature Dishwasher (chemical sanitization): Wash - 120 degrees F; and Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. On 03/03/25 at 8:50 AM, Surveyor observed Dietary Staff (DS) C wash dishes in the dishwasher. DS C stated that it is a chemical sanitizing dishwasher. Surveyor asked where the thermometer is that they record the dishwasher temperatures. DS C showed Surveyor the thermometer on the lower unit of the dishwasher and began a washing cycle. Surveyor observed and confirmed with DS C that the temperatures reached a high of only 106 degrees. DS C ran the dishwasher a second time and it read 104 degrees. DS C reached out to Nursing Home Administrator (NHA) A who contacted Maintenance Director (MD) D. At 9:49 AM, MD D stated he adjusted the mixing valve and to try it again. At that time the temperature read 110 degrees. DS C then ran the dishwasher and took the temperature in the standing water immediately after a cycle and it read 104 degrees. DS C was asked if this was concerning, and DS C stated it was and it needs to be fixed. On 03/03/25 at 10:26 AM, Surveyor requested dishwasher manufacturer instructions. Instructions state: Operator Procedures .5. Fill machine with water using Fill Switch. If water temperature gauge has not reached 120 degrees F (49 degrees C) when the water level is just below the overflow, drain water from the machine and continue to fill until proper temperatures is attained. Dishwasher water did not reach the required temperatures to ensure dishes are properly sanitized. Example 2 According to federal regulation S483.60(i)(2), facilities must store, prepare, distribute and serve food in accordance with professional standards for food service safety. 2017 Recommendations of the United States Food and Drug Administration Food Code states. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. On 03/03/25 at 9:43 AM, Surveyor was inspecting the resident refrigerator in the dry storage room located next to the kitchen. Surveyor discovered an open bag that had printing on it that read, Mini cream puffs, good for 24 hours after thawing. There was no open or discard dates on the item. Surveyor brought DS C to the storage room refrigerator to look at the concern. Surveyor asked DS C what was in the bag. DS C replied, Cream puffs, with no dates on them. The activity staff probably forgot to date them. DS C then discarded the cream puffs. NHA A was made aware and asked Surveyor which refrigerator the item was found in. Surveyor informed NHA A it was in the resident refrigerator in the dry storage area by the kitchen.

Based on observation and interview, the facility did not always serve food to 4 out of 13 residents (R11, R13, R23, and R29) that was palatable and served at the proper temperature. R11, R13, R23, and R29 all had food complaints that food was not palatable. This is evidenced by: Example 1 Federal regulation S483.60(d)(2) states, each resident receives and the facility provides food and drink that is palatable, attractive, and at a safe and appetizing temperature. On 03/03/25 at 11:10 AM, Surveyor observed lunch food arrived in steam table containers that were transported from a sister facility. Surveyor requested a test tray to be sent on the last cart to be delivered to the wing. Surveyor observed Dietary Staff (DS) C place food on steam table. Ground chicken and chopped carrots did not fit and were placed against the wall on the outer edge of the steam table. Food temperatures were checked and revealed the following: Chicken 166 degrees. Mashed potatoes 142 degrees. Carrots 182 degrees. Gravy 177 degrees. Minced and moist carrots 126 degrees. DS C microwaved the carrots and rechecked the temperature which then read 170 degrees. Ground chicken that did not fit on steam table was 167 degrees. Chopped carrots that did not fit on steam table were 166 degrees. At 11:24 AM, DS C started dishing food onto plates. At 11:42 AM, Surveyor observed DS C retrieve a plastic divider plate with a sealed lid. Surveyor asked DS C who receives it and why. DS C stated, [R23] requests it to keep the food warmer. Surveyor followed the last meal cart with the test tray on it. At 12:01 PM, Surveyor tested the food immediately after all trays were passed. Test tray temperatures were as follows: Milk 55 degrees. Mashed potatoes 113. Chicken 118. Carrots 104. Surveyor sampled the food and found it to be lukewarm and milk was warmer than desired. On 03/04/25 at 8:36 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who was informed that multiple residents complained about receiving cold food and that a test tray confirmed it. NHA A stated they were not aware, it is not acceptable and will look into it. 44863 Example 2 R13 was admitted to the facility on [DATE]. Diagnoses included mild protein-calorie malnutrition. R13's Minimum Data Set (MDS) assessment, completed on 12/17/24, confirmed R13 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating mild cognitive impairment. R13 eats independently after set-up. R13's care plan included areas of concern related to nutrition and dehydration due to potential for weight loss. On 03/03/25 at 11:23 AM, Surveyor interviewed R13. R13 resides on the third floor of the facility. R13 stated the facility's meals are 'lousy.' Surveyor asked R13 to describe the lousy food, and R13 responded, It's just lousy, that's all I can say about it. Example 3 R29 was admitted to the facility on [DATE]. Diagnoses included heart failure, atrial fibrillation, and history of chronic non-pressure ulcer of lower leg. R29's MDS assessment, completed on 12/04/24, confirmed R29 scored 13/15 during BIMS, indicating intact cognition. R29 eats independently after set-up. R29's nutritional assessment indicated her body mass index is slightly below healthful range for geriatric population. R29's goal for weight stabilization is gradual weight gain within a healthful range. On 03/03/25 at 10:59 AM, Surveyor interviewed R29. R29 resides on the third floor of the facility. R29 stated she eats meals in her room. R29 reported the facility's meals are not 'that good,' and often meals are cold or lukewarm. R29 stated food is covered, but the plates are cold, so all hot food items are cooled when placed on a cold plate. On 03/03/25 at 11:38 AM, Surveyor observed dietary staff prepare food carts to be served on the second and third floors. Surveyor noted the facility's kitchen is located on the first floor. Surveyor observed the second-floor food cart was a covered and insulated cart. Surveyor observed the third-floor food cart was uncovered and not insulated. On 03/03/25 at 11:55 AM, Surveyor observed staff passing meal trays to residents residing on the third floor, including R13 and R29. On 03/03/25 at 12:06 PM, Surveyor received last tray on the third-floor meal cart. Meal served was fried chicken with gravy, mashed potatoes, sliced carrots, and a dinner roll. Surveyor taste tested all food items and noted each item to be lukewarm. 51095 Example 4 R23 was admitted to the facility on [DATE]. Diagnoses include type 2 insulin dependent diabetes mellitus. R23's Minimum Data Assessment (MDS), dated [DATE], stated R23's Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating intact cognition. On 3/03/25 at 10:28 AM, Surveyor interviewed R23. R23 complained the food is terrible and not nutritious. R23 reported the food is not good. R23 provided Surveyor with several notes taken on the daily menus. Surveyor reviewed her notes and noted several of complaints of food dislikes, cold food that should have been served warm, and meats that were dry and hard to chew. On 3/3/25 at 11:55 AM, Surveyor observed lunch trays being served to residents on third floor in their rooms due to COVID outbreak. R23 reported the food was not very warm and the meat was dry. Example 5 R11 was admitted to the facility on [DATE]. Diagnoses include morbid (severe) obesity, weakness, and vitamin D deficiency. Minimum Data Set (MDS) assessment, dated 1/14/25, states R23's Brief Interview for Mental Status (BIMS) score is 15 out 15, indicating intact cognition. On 3/03/25 at 10:06 AM, Surveyor interviewed R11. R11 reported the facility food is their weak point. R11 stated the food is not always hot or very good. R11 reported the food comes from the other place so by the time it gets here, it is cold.

Based on record review and interview, the facility did not ensure that 1 of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. This has the potential to affect all 31 residents. Certified Nursing Assistant (CNA) C was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery. Findings include: On 1/31/24, Surveyor reviewed CNA certifications for a sample of 5 CNAs. CNA C was hired on 6/19/23. Nursing Home Administrator (NHA) A provided a state of Michigan CNA registry for CNA C. No Wisconsin CNA registry information was provided. On 1/31/24 at 12:22 PM, Surveyor interviewed NHA A about the missing Wisconsin CNA Registry for CNA C. NHA A stated CNA C had lost her social security card and had been unable to obtain CNA registry in Wisconsin. NHA A stated that they have been working on this for a while now. On 1/31/24 at 1:57 PM, NHA A provided Surveyor with a Wisconsin CNA registration for CNA C with a valid date of 1/31/24. This was completed today after Surveyor asked for the registry. Surveyor asked NHA A for a policy regarding employment requirements for a position requiring licensure or certification. NHA A provided Surveyor with the new employee checklist. NHA A stated this was all they had. According to the Wisconsin Nurse Aide Training and Registry team, nurse aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed in any federally eligible health care setting in Wisconsin. Surveyor reviewed the staffing schedule and identified CNA C was scheduled and worked since hire date 6/19/23, prior to obtaining Wisconsin CNA registry, and NHA A confirmed this.

Based on interviews and record review, the facility failed to submit Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for the third quarter of 2023 (April 1-June 30). This has the potential to affect all 31 residents. This is evidenced by: Surveyor noted the facility failed to submit PBJ data for Fiscal Year Quarter 3. On 1/31/24 at 2:41 PM, Surveyor completed an interview with Nursing Home Administrator (NHA) A and Payroll Specialist (PS) D about the PBJ submissions. PS D stated the facility attempted to submit PBJ on the deadline date but was unable to do so. PS D stated that PS D was unaware that this needed to be submitted prior to the deadline date. PS D stated that he made sure Quarter 4 was submitted on-time and stated the next quarter submission, due 2/14/24, would also be submitted on time. Surveyor then reviewed the staff schedules for that time period (April 1 -June 30, 2023) and compared the data with time punches. There were no concerns uncovered related to licensed staff coverage or Certified Nursing Assistant coverage. The facility had failed to submit PBJ data for third quarter. Surveyor reviewed the PBJ submission for Fiscal Year 2023 Quarter 4 (July 1 - September 30). The facility was noted to have submitted the 4th quarter's data on 11/8/23, accurately. The facility is in compliance as of 09/30/23. This was cited past noncompliance.

Based on observation, interview and record review, the facility did not provide the services needed to maintain mobility for 1 of 3 residents reviewed (R20). R20's plan of care includes an ambulation program twice daily. The program was not implemented as directed in the care plan. This is evidenced by: Surveyor reviewed the facility policy titled Restorative Nursing Services dated as revised on July 2017. The policy in part states: ~Residents will receive restorative nursing care as needed to help promote optimal safety and Independence. ~Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. ~Residents may be started on restorative nursing upon admission, during course of stay or when discharged from rehabilitative care. ~Restorative goals and objectives are individualized and resident-centered, and are outlined in the residents plan of care . On 01/24/23 at 12:38 PM, Surveyor spoke with R20 in his room. Surveyor observed R20 in a wheelchair. R20 informed the Surveyor he had a stroke which affected his ability to walk. He has a restorative walking program in place. R20 further expressed the program is supposed to occur daily but it occurs 1 to 3 times a week, depending on the restorative aide's schedule. R20 expressed he is scheduled for re-evaluation from therapies at the sister facility some time this month, which has not yet occurred. Resident stated he would like to improve his ambulation to be able to discharge home. Surveyor reviewed R20's record and noted R20's diagnosis includes: Hemiparesis and hemiplegia affecting his left non-dominant side following cerebral infarction (stroke), difficulty walking and weakness. R20's Minimum Data Set (MDS) most recently completed on 12/20/22 (Annual) notes R20 understands, is understood and is cognitively intact. He walks in room and corridor with extensive assistance of 1 staff. He has a range of motion impairment affecting one side, upper and lower. Previous comprehensive MDS (admission) completed 12/27/21 notes R20 walks in room and corridor with extensive assistance of 1 staff and has range of motion impairment on one side upper and lower. R20's care plan notes: Problem start date: 12/21/2021 Walking: health maintenance related to restorative/maintenance program: walking Goal target date: 3/05/2023: In next 3 months will ambulate 100 feet twice per day or as tolerated with walker and assist of one staff with w/c (wheel chair) follow. Approach: start date: 12/21/2021: walks with assist of one, gait belt, wheeled walker and wheel chair following behind two times a day with a goal of 125 feet. On 01/24/23 at 1:37 PM, Surveyor observed Restorative Aide (RA) C place a gait belt on R20's waist. RA C assisted R20 to stand. Using a 2 wheeled walker RA C assisted R20 to ambulate up hallway holding gait belt and pulling his wheelchair behind. RA C and R20 walked to end of hall and back to his room. Surveyor reviewed Restorative Nursing Data from 11/01/23 to 1/24/23. The data shows R20's walking program occurred as follows: November 2022: One time a day: 4 occasions Unanswered: 15 occasions Not performed: (refusal, unavailable): 11 occasions There is not a second opportunity noted any of the 30 days. December 2022: Twice a day as outlined in R20's care plan: 3 occasions One time a day: 7 occasions Unanswered: 13 occasions Not performed: 15 occasions There is not a second opportunity noted on 4 days. January 2023: 1/01/23-01/25/23: Twice a day as outlined in R20's care plan: 3 occasions One time a day: 7 occasions Unanswered: 17 occasions Not performed: 20 occasions On 1/25/22 at 1:40 PM, Surveyor spoke with Director of Nursing (DON) B about R20's restorative walking program. DON B indicated the goal of R20's program is to maintain his mobility walking status to walk twice a day with staff assistance of 1 for up to 125 feet. DON B explained the facility noted a few months ago certified nursing assistants (CNAs) were having problems completing the restorative programs. The facility designated one of their CNAs to conduct restorative programs initially one day a week and as of January 9th, 3 days a week. The expectation is for CNAs to conduct the programs the days the restorative aide is not scheduled. On 1/26/23 at 9:00 AM, Surveyor spoke with RA C about R20's walking program. RA C expressed she has worked at the facility several years and is familiar with R20. RA C expressed she works at the facility full time, part time as a restorative aide and part time as a certified nursing assistant. RA C explained she started the restorative aide position one day a week 3 weeks ago and went to 2-3 days a week 2 weeks ago. RA C expressed the days she is designated to restorative R20 ambulates with her down the hall as observed by the surveyor. The days she works as a Certified Nursing Assistant she does not have time to do R20's walking program or other residents' restorative programs. RA C further explained the data collection does not have an option to note not offered so she will not answer the question, thus the system reads unanswered or not performed. On 1/26/23 at 9:10 AM, Surveyor spoke with CNA D about R20's walking program. CNA D indicated she has worked at the facility many years and is familiar with R20. CNA D indicated there are times R20 does not want to walk at the time the CNAs are available to walk him so she will chart refused or unavailable. CNA C further expressed sometimes the CNAs do not have enough time in a day to offer R20 his walking program thus they will not answer the question for walking program and it shows as unanswered. The facility has added a restorative aide to help with resident programs but the restorative aide only works 1-3 days a week. Certified Nursing Assistants are supposed to do the programs when the restorative aide is not scheduled but they do not have the time to do them.

Based on observation, record review, policy review and interview, the facility did not ensure a medication error rate of 5% or less. There were 5 errors out of 38 opportunities which calculates to 13.16% medication error rate. R13 was given Novolog insulin 56 minutes before eating a meal. In addition, the pen was not primed which would alter the dose ordered. Novolog is a rapid acting insulin and should be given 5-10 minutes within a meal. R8 was given Novolog insulin 26 minutes before eating a meal. In addition, the pen was not primed which would alter the dose ordered. R18 was given [MEDICATION(S)], an inhaled medication, and was not instructed to rinse her mouth. [MEDICATION(S)] is a steroid that may cause a mouth and throat infection if the resident does not rinse the mouth after use. R20 was given Calcitonin nasal spray following incorrect technique thus altering the dose. R11 was given [MEDICATION(S)] nasal spray following incorrect technique thus altering the dose. This is evidenced by: Surveyor requested and reviewed facility policies and manufacturer recommendations on insulin injection using a pen, nasal sprays, and administration of an inhaled medication. Surveyor reviewed facility policy titled Insulin Pen Delivery Device for Diabetes Care. Noted in the policy was the insulin pen must be primed prior to each injection to ensure proper dosing. In addition the policy stated a meal tray should be at the resident's bedside prior to administering rapid acting insulin. The policy also stated insulin given before a meal should not exceed 15 minutes before the meal. Review of the manufacturer's recommendations for Novolog also instructed user when using an insulin pen, it should be primed with 2 units of insulin prior to each injection to ensure proper dosing. In addition the manufacturer recommended Novolog should be given within 5-10 minutes of a meal because it is a rapid acting insulin and may cause [CONDITION(S)] (low blood sugar). Example #1: R13 was admitted to the facility for long term care on 08/08/19. R13 was diagnosed with diabetes and treated with insulin. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/12/21 at 3:31 p.m., Surveyor observed Registered Nurse (RN)-C check R13's blood sugar which was 223. On 12/12/21 at 3:38 p.m., RN-C administered 2 units of Novolog insulin into R13's abdomen. RN-C did not prime the insulin pen thus not providing the prescribed dose. At 4:05 p.m., Surveyor observed the evening meal carts arrived on R13's unit. At 4:18 p.m., Certified Nursing Assistant (CNA)-E served R13 the evening meal. R13 was sleeping on her right side and would not accept the meal. At 4:21 p.m., RN-C arrived onto R13's unit. At 4:28 p.m., RN-C attempted to arouse R13. R13 remained seated at the edge of the bed but was not eating or drinking. R13 was not encouraged to eat and RN-C did not recheck R13's blood sugar. At 4:34 p.m., R13 drank the strawberry supplement. Fifty six minutes elapsed from the time of Novolog injection to R13's meal. Example #2: R8 was admitted to the facility for long term care on 10/26/18. R8 was diagnosed with diabetes and was treated with insulin. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/12/21 at 3:49 p.m., Surveyor observed RN-C administer 11 units of Novolog insulin via a pen into R8's abdomen. RN-C did not prime the insulin pen thus not providing the prescribed dose. R8 was served the evening meal at 4:15 p.m. by CNA-F. Twenty six minutes elapsed from the time of Novolog injection to R8's meal. On 12/12/21 at 4:11 a.m., Surveyor interviewed RN-C regarding insulin administration. RN-C stated she was not aware of the need to prime the insulin pen with 2 units. RN-C confirmed she did not prime the Novolog pen when administering insulin to R13 and R8. RN-C stated Novolog insulin should be given within 15 minutes of a meal. Example #3: R18 was admitted to the facility for long term care on 01/29/2020. R18 was diagnosed with Alzheimer's dementia and asthma and treated with inhalers. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 8:06 a.m., R18 was seated at the edge of the bed when RN-D entered room. RN-D handed R18 the [MEDICATION(S)] inhaler and provided no instructions. R18 exhaled then placed inhaler on her mouth and deeply inhaled once. RN-D placed a glass of water at the bedside, but did not instruct R18 to rinse her mouth. On 12/14/21 at 8:44 a.m., Surveyor interviewed RN-D regarding above observation. RN-D stated she did not have R18 rinse her mouth and should have done so to prevent an oral infection. Example #4: R20 was admitted to the facility for long term care on 6/20/19. R20 was diagnosed with [CONDITION(S)] and treated with calcium supplements. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The instructions read to instill one spray daily in alternating nostrils. Surveyor reviewed the manufacturer recommendations for proper administration of Calcitonin. The instructions read: ~Do not shake bottle. ~Blow your nose before use. ~Change nostrils every day On 12/13/21 at 7:35 a.m., Surveyor observed RN-D administer morning medications to R20. RN-D shook the bottle of Calcitonin nasal spray, handed the bottle to R20 who instilled 1 spray of Calcitonin into the right nares. RN-D did not instruct R20 to blow nose or block the left nostril. These techniques help ensure proper dosing of the medication. Review of the MAR (medication administration record) noted R20 had received Calcitonin nasal spray daily; however, the documentation did not include what nostrils was used to administer the Calcitonin. The manufacturer recommendations instructions included to alternate nostrils to prevent irritation. Example #5: R11 was admitted to the facility for long term care on 10/22/21. R11 was diagnosed with allergic rhinitis (inflammation of the nose) and treated with [MEDICATION(S)] nasal spray. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/13/21 at 8:19 a.m., Surveyor observed RN-D administer [MEDICATION(S)] nasal spray in R11's right nostril then left nostril. RN-D did not instruct R11 to blow nose or block opposite nostril. These techniques help ensure proper dosing of the medication. On 12/14/21 at 8:44 a.m., Surveyor interviewed RN-D regarding proper nasal spray administration. RN-D stated she was unfamiliar with asking the resident to blow nose and unfamiliar with blocking the opposite nostril with the nasal spray administration. RN-D also stated she should have first sprayed the medication into the air to ensure proper dosing of each medication. On 12/14/21 at 7:59 a.m., Surveyor interviewed Director of Nurses (DON)-B regarding the medication observations. DON-B stated the facility had policies on administering medications via different routes but also used the manufacturer's recommendations. DON-B stated when injecting insulin using a pen, the pen must be primed with at least 2 units to ensure proper dosing. DON-B stated giving Novolog insulin must be within 15 minutes of a meal to prevent [CONDITION(S)]. DON-B also stated prior to administering medications via a nasal spray, the nurse should instruct the resident to blow nose to clear nasal passage for better absorption of the medication. DON-B also stated if giving nasal sprays in both nostrils, the nurse should block one nostril, insert the applicator into the opposite nostril, administer the medication, and instruct the resident to inhale. DON-B stated that process should be repeated for the opposite side. DON-B stated this technique improves absorption and proper dosing for each nostril.

Based on observations, interviews, and record reviews, the facility did not consistently assess 1 of 2 resident's nutritional status (R10) following admission when they noticed poor food intakes and meal acceptance. The facility did not implement, monitor or modify interventions that were consistent with her needs, choices and historical habits to maintain acceptable parameters of nutritional status. As a result, R10 sustained a 3.92 % loss in one month and a 8.26 % loss in 3 months. This is evidenced by: R10 has medical [DIAGNOSES REDACTED]. According to staff, R10 was recently a tavern owner and tends to be awake during the very early morning hours of 2:00-3:00 AM. According to documentation by the Dietary Manager dated 10/17/19, R10's family indicated that R10 weighed around 150 pounds a year or two ago but her normal weights during the look back period was around 132-136 pounds. The facility completed the admission Minimum Data Set Assessment with an Assessment Reference Date of 10/22/19. According to this assessment, R10 was identified as having a non-prescribed, unplanned weight loss. She eats independently after tray set-up. Her Basic Interview of Mental Status (BIMS) score was 5/15, indicating severe cognitive decline. On 10/24/19, the facility completed a Nutritional Risk Assessment. According to this assessment, R10 has a regular diet with regular consistency fluids, has no chewing or swallowing disorders and only eats 25-50% meals. Her admission weight (10/15/19) was recorded as being 136 lb (pounds). However, DM-E (Dietary Manager) indicated on her assessment that the admission weight may be inaccurate, as the 10/17/19 weight was measured as being 128.4 lb., and the 10/24/19 weight was measured as being 126.4 lb. There is no direct evidence of the inaccuracy, however this change still indicates a 2 lb loss in one week. The facility completed another Nutritional Assessment on 10/27/19. The form has a section titled Risk Criteria. The question asks if there is a Change in eating habits- significant noted decrease in usual food or fluid intake OR meal intake of <50% (less than 50 percent) The facility marked Yes on the form. The form then asks the evaluator if Resident determined to be at nutritional risk. The facility marked Yes. Further review of R10's Medical Record revealed the following included in the Physician Orders: - 10/15/19: Dietary supplements per Dietician Recommendations - 10/15/19: Regular Diet, Regular Fluids - 10/25/19: Vitamin B 12 one time each Month - 10/25/19: Vitamin D, U (units) each Monday - 10/25/19: 2 Cal, 60 CC (Centimeters) twice daily (Given at 8: 00 AM and 4:00 PM) Note that these orders were before both Nutritional Assessments were completed. There were no further interventions the physician ordered for prevention of weight loss. The surveyor then reviewed R10's recorded weights and noted the continued decline (R10 is 63 inches tall): - 10/15/19: 136 - 10/17/19: 128.4 - 10/18/19: 127.4 - 10/24: 126.4 - 10/25: 124.4 - 10/31: 122.4 - 11/7: 121.8 - 11/14: 120 - 11/22: 120.6 - 11/28: 120.5 - 12/2: 122.6 - 1/2/20: 117.8 (Last recorded weight with high risk resident) 1 Month: On 12/02/2019, the resident weighed 122.6 lbs. On 01/02/20, the resident weighed 117.8 pounds which is a 3.92 % Loss. 3 month: On 10/15/2019, the resident weighed 136 lbs. On 01/02/2020, the resident weighed 117.8 pounds which is a 13.38 % Loss. If one follows the assumption that the admission weight of 136 was inaccurate and uses the 10/17/19 weight of 128.4, then R10 still had a 8.26 % weight loss over 3 months time. This is considered significant. The surveyor then reviewed R10's daily meal intakes. [NAME]TOBER 2019: R10 had 46 meals with the following intakes recorded: - 0%- 2 meals - 25% - 23 meals - 50% - 13 meals - 75%- 4 meals - 100% - 4 meals The average intake was 41.8% of the meals (calculated by adding the total percentage accepted and diving by the number of meals offered). Of concern is there are many entries for intakes of 25%, yet there is no indication that a snack was given to R10 to compensate for her low intakes. R10 was also given snacks, however it is not clear what type of snack was given and accepted as the documentation does not clarify whether the snack was substantial (sandwich versus a bag of potato chips or a cookie). R10 accepted the following percentage of the snacks: - 75-100% - 16 times - 26- 50%- 1 time Note: all snacks were recorded on the Evening Shift. There were no entries in the nursing progress notes of a substantial snack given. NOVEMBER 2019: R10 had 90 meals in the facility. - 0% -1 time - 25% - 18 meals - 50% - 44 meals - 75% - 14 meals - 100% - 12 meals - one meal not recorded The average intake for R10 during the month of (MONTH) was 54.4%. Of concern is there are many entries for intakes of 25%, yet there is no indication that a snack was given to R10 to compensate for her low intakes. R10 was also given snacks, again, it is not clear what type of snack was given and accepted as the documentation does not clarify whether the snack was substantial. R10 accepted the following percentage of the snacks: - 75-100% - 30 times R10 refused one offer. Note: All snacks were recorded on the Evening Shift with the exception of 11/25, in which one was given on the Day Shift as well as one on the Evening Shift. There was no snack recorded on 11/1 or 11/28. The last recorded weight for R10 was 11/28, which was 120.5. There were no nursing progress notes for the month of (MONTH) that indicate a substantial snack was given on the night shift. DECEMBER 2019: R10 had 93 meals in December - 0% - 2 meals - 25% - 26 meals - 50% - 39 meals - 75% - 17 meals - 100% - 8 meals One meal was not recorded. The average intake for R10 during the month of (MONTH) was 50.2%. R10 also accepted 32 snacks during the month of December. All snacks were given on the Evening Shift with the following exception: - 12/3, 12/4, 12/6, 12/9, 12/16, 12/18, 12/19, 12/24 and 12/28, R10 received one snack on day shift as well as the evening shift Of concern is there are many entries for intakes of 25%, yet there is no indication that a snack was given to R10 to compensate for her low intakes. The only recorded weight for R10 in (MONTH) was 12/2, which was 122.6 Nursing progress notes for 12/6/19 indicate that on the night shift, staff provided R10 with a sandwich, fruit cup and string cheese. However, there is no entry on whether R10 accepted this snack. Also of importance, is that on 12/5/19, staff sent a facsimile to the physician stating that R10 was more tearful, making frequent calls to home, wanting to go home, less talkative with increased pacing and withdrawn. On 12/6/19, the physician ordered [MEDICATION NAME], 10 MG (milligrams) daily to treat her depression. [MEDICATION NAME] can have both a negative or positive impact on appetite. However, there was no mention in the note that R10 had poor intakes or that her weight was declining. On 12/7, 12/12, 12/15 and 12/18 the night shift documented R10's acceptance of substantial snacks. JANUARY 2020: R10 had 63 meals from 1/1/20 - 1/21/20: - 0% - 4 meals - 25% - 26 meals - 50% - 19 meals - 75% - 10 meals - 100% - 4 meals The average intake of meals for R10 from (MONTH) 1st through (MONTH) 21st was 43.6%. There was no indication that when R10 refused the 3 noon meals, a snack was offered. Snacks again were offered on the Evening Shift with the exception of 1/17, in which one was offered on both the day shift and another on the evening shift. R10 accepted 22 snacks. Note: There were no snacks documented on the night shift, when R10 was awake and wandering around the facility. This would have been a prime time to offer her a full meal or substantial snack, such as a sandwich. Also of concern, there are many entries for the breakfast and lunch meals of 25%, yet there is no indication that a snack was given to R10 to compensate for her low intakes. The last recorded weight for R10 was on 1/2/20 and was 117.8. Again, this is an 8.26% weight loss from 10/17/19 Nursing progress notes for (MONTH) do not make mention of snack offers on the night shift. The Surveyor then reviewed R10's care plans. The facility recently initiated new Electronic Medical Records from American HealthTech (AHT) to Matrix Care (1/28/2020) Reviewed Comprehensive Care Plan from AHT: - Baseline E-Care Routine CP: (undated): includes the following related to meal/snack intakes 1. prefers to eat in her room 2. regular diet 3. bedtime snack 4. record in between meals fluid intake 5. weight daily or weekly 6. weight report results to nurse These approaches are not individualized to R10's needs and historical practices. Matrix Comprehensive Care Plan: 1. Self Care deficit related to Dementia: implemented 1/2/20 - record fluid intake every shift 1/18/20 - weights monthly 1/18/20 - regular diet. Regular fluids. Monitor and accurately record all food and fluid intake every shift 1/2/20 - Eating: independent. Prefers to eat in room [ROOM NUMBER]/2/20 2. Potential for impaired skin integrity: Implemented 1/2/20 and following interventions implemented the same date - Dietary supplements as per Provider order and/or Registered Dietician - Provide encourage and assist with fluids to ensure adequate hydration NOTE: There was no care plan implemented to address R10's poor intakes, best times to approach with snacks and what snacks she would most likely accept. The care plans also do not address R10's history of being up in the very early hours, which would be a prime time frame to offer R10 a full meal. OBSERVATIONS: 1. On 01/27/20 at 11:43 AM, R10 was gently awakened by staff and given her meal tray, which consisted of baked chicken breast, pea pods and cheesy mashed potatoes. She sat on the side of the bed and began to eat on her own without any problems. At 11:51 AM she pushed the table away and laid back down on the bed. She took approximately 1/2 of the chicken and 1/2 of the potatoes but did not eat any of the pea pods. No staff entered her room to encourage her to eat. 2. On 01/28/20 at 10:02 AM, R10 was given a snack of a 4 ounce cup of vanilla ice cream with fudge ripples. She ate all of it. At 10:22 AM, she drank a supplement supplied to her by the nurse. According to documentation, this was 2 ounces of 2 Cal. 3. On 1/28/20 at 11:56 PM, R10 had the noon meal on the over the bed table. Meatballs in Marinara sauce over penne pasta, mixed vegetables and garlic toast. R10 appeared to only have eaten a very small portion of the entrée. No staff entered to encourage to eat. Staff did offer something different. Resident refused. Staff then removed the tray from her room. On 1/28/20 at 3:04 PM the Surveyor interviewed RN-D (Registered Nurse) regarding R10's meal intakes. RN-D stated that R10 often does not eat supper meal but is a night owl and will get up late, late night into early, early morning and will eat sandwiches. She stated that she gives R10 2 Cal supplements on the Evening Shift but that R10 sometimes refuses these. On 1/29/20 At 8:56 AM, the Surveyor interviewed DM-E (Dietary Manager) regarding R10. DM-E stated that R10 eats between 25 to 75% meals. When she was first admitted , acceptance was only 35%, but felt that R10 has improved. She stated that R10 had weight loss on admission and the facility initiated a 2 cal supplement, 60 cc (cubic centimeter) twice daily, and according to charting, DM-E stated that R10 accepts the majority of the time. She stated that if R10's meal intakes are below 50%, staff should offer an alternative. Note: 60 cc's is the equivalent of 2 ounces. RD-E went on to state that R10's next MDS assessment is in process. She stated the RD (Registered Dietician) will review and will most likely increase the 2 cal based on time of acceptance or start another supplement between meals. She stated that currently, R10 receives the following: - 2 cal twice daily - a sandwich at snack pass - and staff are to offer fluid and foods based on her meal acceptance. DM-E further stated that staff have not reported to her of R10 not accepting the sandwiches, and . No staff here informed me of a poor intake. If they would, I would try to meet with resident if able, reach out to family, kitchen and nursing staff. They would be able to give me details of best time and best supplements of acceptance. No staff informed me she was not eating. Had I known prior to this, I would have initiated fortified foods, extra toast with peanut butter, whatever she would be willing to take. DM-E stated that it is nursing's responsibility to keep her updated, but that she also should monitor meal acceptance. The surveyor then reviewed the supplement intakes recorded for R10. - (MONTH) 2019: accepted all 13 offers - (MONTH) 2019: refused 13/60 times, again most often the 4:00 PM offer - December: refused 23/62 times, most often the 4:00 PM offers - (MONTH) 2020: refused 14 /42 times, most often the 4:00 PM offers On 1/29/20 at 9:20 AM, Surveyor interviewed CNA-G (Certified Nursing Assistant) regarding R10's meal intakes. CNA-G stated R10 prefers to eat in her room and intakes are poor. She stated that breakfast is normally 50%, lunch about 25%. She stated the staff are to offer alternatives when her intake is only 25- 50%. CNA-G stated that historically, R10 is up late at night. She thinks the night shift gives her a lot of snacks, ice cream, fruit or sandwiches on their shift. When asked what snacks were available throughout the day and night for staff to offer, CNA-G stated, cookies, ice cream, string cheese, muffins, sandwiches, potato chips, that sort of thing. She likes potato chips. At 9:24 AM, Surveyor interviewed RN-H regarding her knowledge of R10's intakes. RN-H stated CNA staff inform her if R10 does not eat. She stated she gives R10 60cc's of 2 cal supplements on her shift. When asked the process she is to follow should a resident have poor intakes, RN-H stated she is to notify the Dietary Manager, monitor weights more closely and update the physician. At 10:39 AM, the Surveyor interviewed the Director of Nursing regarding the expectation of staff when a resident has poor intakes. The DON was recently hired approximately 1 1/2 months ago. The DON stated that due to R10's weight loss and poor intakes, weights should be done at least weekly. She did not know that they were changed to one per month. She stated that she would change this on her care plan. When informed of the R10's care plan had no individualized approaches to maintain or improve her intakes or of R10's historical practice regarding awake hours, the DON stated that she has a plan review care plans and make them more detailed and individualized to each resident. My expectations of the care plan is that they are to be detailed and specific for that resident. Care Plans should be individual to each resident. Her (R10) care plan should include the information that she is up in the early morning direct staff to offer substantial food items during those times.

Based on record review and interview the facility did not ensure 1 out of 5 residents (R4) reviewed for unnecessary medications, received these medications with comprehensive assessment for need of medication and adequate monitoring of the medication. R4 receives Trazadone 50 mg (milligrams) at bedtime for [MEDICAL CONDITION]. The facility has not comprehensively assessed her need for medication to promote sleep. The facility does not have a system in place to monitor R4's sleep to determine if the Trazadone is effective. This is evidenced by: Surveyor reviewed R4's medical record. R4 was admitted [DATE] with a physician order [REDACTED]. Surveyor reviewed R4's Medication Administration Record [REDACTED]. The surveyor reviewed R4's care plan and noted the following: Problem Start Date: 08/27/2019: Potential for sleep disturbance Goal Target Date: 02/06/20: In the next 3 months will sleep 6-8 hours each night Approach Start Date: 08/27/19: Allow time to vent feelings and frustrations, discourage caffeine rich beverages/foods prior to bedtime, if awakens in night provide conversation, reassurance, snack and comfort measures, medication per order, monitor sleep patterns and notify charge nurse of changes, provide quiet and dark environment, sleep study as needed. Surveyor reviewed R4's medical chart. A comprehensive sleep assessment, evaluating R4's sleep habits, quality of sleep and quantity of sleep, could not be located. Surveyor requested a comprehensive sleep assessment from the Director of Nursing, (DON). The DON indicated a sleep assessment could not be located and R4 was not comprehensively assessed for sleep disturbance. Surveyor reviewed R4's medical chart for sleep monitoring. Surveyor was unable to locate any documentation showing R4's sleep, sleep pattern, quality or quantity of sleep. Surveyor requested sleep monitoring from the DON. The DON indicated R4 does not have a sleep log or sleep monitoring in place to monitor her sleep. The surveyor asked the DON how the facility knows whether R4's Trazadone that is used for [MEDICAL CONDITION] is effective. The DON indicated the facility would not be able to determine if the medication is effective without some type of monitoring. Although the facility has a care plan to address R4's [MEDICAL CONDITION] there is no monitoring system in place to determine the effectiveness of the approaches. On 01/28/20 at 02:44 PM Surveyor spoke with Registered Nurse (RN)-C and the DON regarding the facility's process related to assessing resident sleep and monitoring resident sleep when medication is used to promote sleep. RN-C indicated she is familiar with R4. RN-C explained the facility conducts a 3 day log of resident sleep when a resident has complaint of sleep difficulty or is noted to be awake for extended periods of time. RN-C further indicated she is unsure if R4 had a sleep log completed. The DON indicated the facility does not complete a comprehensive sleep assessment. A sleep log is done for 3 days and placed in the resident chart. No sleep diary was conducted for R4. The DON further indicated there is no monitoring in place to evaluate effectiveness of R4's medication and care planned approaches used for sleep.

Based on interview and record review the facility did not ensure it maintained staff certified in cardiopulmonary resuscitation to immediately initiate emergency care for 3 of the 27 residents (R4, R24, R25) requiring such care. The facility employed 18 staff in the nursing department, 6 of which were licensed staff. Only two licensed staff - the DON (Director of Nursing) and 1 casual RN (Registered Nurse) - held current CPR (Cardiopulmonary Resuscitation) certification. The facility did not have licensed staff available on a 24 hour basis who could immediately initiate CPR should any of the 3 residents who desired CPR have a cardiopulmonary arrest. Failure to have staff available on a 24 hours basis to initiate CPR led to the finding of immediate jeopardy that began on [DATE]. The facility was informed of the immediate jeopardy on [DATE] at 3:03 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity level of D (potential for harm/isolated) as the facility continues to implement its action plan. This is evidenced by: On [DATE] Surveyor received and reviewed the facility's CPR policy. The policy indicated, .If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR .shall initiate CPR . The facility is located in a small rural town with the closest hospital 11 miles away. While there was local emergency medical services (EMS) available it was manned by volunteers who were dispatched by the local Sheriff's office. EMS staff would not be able to respond to perform CPR within the critical window of time to 4 to 6 minutes to prevent brain death or death. Surveyor completed a review of R4's advanced directives. The advanced directives indicated R4 was a full code indicating in the event of a cardiopulmonary arrest R4 desired CPR. Surveyor completed a review of R24's advanced directives. The advanced directives indicated R24 was a full code indicating in the event of a cardiopulmonary arrest R24 desired CPR. Surveyor completed a review of R25's advanced directives. The advanced directives indicated R25 was a full code indicating in the event of a cardiopulmonary arrest R25 desired CPR. On [DATE] at 4:42 PM Surveyor spoke with the NHA regarding staff who held current CPR certification. The NHA indicated historically they certified all nursing staff. The NHA stated those staffs' certifications expired [DATE]. The NHA indicated while he knew CPR certification was something he needed to follow up on, he was not aware who or how many staff held current certification. Surveyor completed a review of licensed staff who held current certification. Two licensed staff were noted, the DON and one casual RN who was hired in (MONTH) (YEAR). On [DATE] at 12:15 PM Surveyor spoke with LPN-E (Licensed Practical Nurse). Surveyor asked LPN-E if she held a current CPR certification. LPN-E indicated she did not know. LPN-E gathered her purse and viewed her CPR certification card. It had expired. Surveyor asked LPN-E what she would do in the event of a cardiopulmonary arrest. LPN-E stated she would call 911 and initiate CPR. Although LPN-E had been certified at one time, she would not count as currently qualified staff for two reasons. First, it is difficult to remember, in an emergency, training one had over two years ago and has not used. Secondly, the steps and process for completing CPR change over time as a result of new research. For example, the original ABC's of CPR (airway, breath, compressions) was recently reordered and is now taught as CAB (compressions, airway, breath). Also the number of breaths and compressions was changed to better reflect what research had shown to be most effective. On [DATE] Surveyor requested the nursing schedule back to [DATE]. Surveyor completed a review and noted the following: ~From [DATE] through [DATE] the facility scheduled CPR certified staff on the day shift 24 of the 31 days. There were no CPR certified staff scheduled for the evening or night shifts. ~From [DATE] through [DATE] the facility scheduled CPR certified staff on the day shift 22 of the 31 days. There were no CPR certified staff scheduled for the evening or night shifts. ~From [DATE] through [DATE] the facility scheduled CPR certified staff on the day shift 23 of the 31 day shifts and 2 of the 31 evening shifts. There were no CPR certified staff scheduled for the night shifts. ~From [DATE] through [DATE] the facility scheduled CPR certified staff on 20 of the 31 day shifts, and 1 of 31 the evening shifts. There were no CPR certified staff scheduled for the night shifts. ~ From [DATE] through [DATE] the facility scheduled CPR certified staff 16 of 19 day shifts, 1 of 19 days evening shifts, and 1 of 19 night shifts. Of the 420 shifts since [DATE], 310 shifts were not covered by a CPR certified staff. Should a resident experience a cardiopulmonary arrest who desired CPR, there would have been no certified staff to initiate CPR. On [DATE] 7:55 AM Surveyor spoke with the NHA again regarding lack of CPR certified staff. The NHA indicated he knew it was something he needed to look at but the information got shuffled back and he hadn't had the time to address it timely. The failure to ensure that staff who were currently certified to perform CPR worked each shift created a finding of immediate jeopardy. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility: 1. Verified the CPR status of all staff; 2. Offered CPR training for all licensed staff on [DATE] 3. Amended schedule to ensure CPR Certified staff on all shifts, everyday; 4. Arranged training for remaining staff to obtain CPR certification; and 5. Developed a system to track CPR certifications and expirations.

Based on observation, interview, and record review the facility did not ensure that Schedule II medications in the facility's contignecy medication supplu were secured in a separately locked permanently affixed compartment in the medication room. This was discovered in the facility's only medication storage room. This is evidenced by: On 2/21/19 at 8:38 a.m. Surveyor reviewed the storage in the medication room with RN-C (Registered Nurse). Surveyor observed a small tackle box on an open shelf with a blue breakable plastic tag. In it were the facility's contingency scheduled medications. The list on the box included several doses of Schedule II classified narcotics: ~3 [MEDICATION NAME]es of various strengths ~5 doses of [MEDICATION NAME] 10 mg/ml (milligram/milliliter) ~10 tablets of [MEDICATION NAME] 15 mg ~10 doses of [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg ~8 doses of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg ~8 doses of [MEDICATION NAME]/[MEDICATION NAME] 10/325 mg ~10 tablets of Tylenol #3 At 8:40 a.m. Surveyor interviewed the DON (Director of Nursing) about the narcotics not being locked and permanently affixed. The DON stated she understood the need to do so but was not aware that the facility had stored these medications in such a manner. The DON stated she does not have a key to the medication room or the medication cart.

Based on observation, interview, and record review the facility did not ensure a medication pass review error rate of less that or equal to 5%. The review found a 6.25% error rate. There were 2 error found out of a total of 32 opportunities for error. RN-C (Registered Nurse) was observed administrating the wrong topical cream onto R5's skin. She put a vaginal cream on the resident's lower back. RN-C was also observed to give R7 his rapid acting insulin too far in advance of his meal creating a greater chance of his blood sugars dropping to a dangerous level. This is evidenced by: Error 1: On 2/21/19 at 7:44 a.m., Surveyor observed RN-C give R5 her oral medications, a nasal spray and eye drops. RN-C then put a cream on R5's left lower back. RN-C applied it after asking R5 where she wanted it applied. RN-C had earlier stated, R5 gets [MEDICATION NAME] for her pain as she retrieved from the cart the vaginal cream in a box and showed it to Surveyor prior to giving it. [MEDICATION NAME] is prescribed for postmenopausal changes to her vagina. R5 has in her orders for a Lodocaine-[MEDICATION NAME] cream to be applied topically twice a day to her left knee, hip, and lower back. There were 2 tubes of the [MEDICATION NAME] cream in the plastic bag. On 2/25/19 at 2:00 p.m. the DON was informed of the error and she indicated to Surveyor she would be following up with a medication error investigation. Error 2: On 2/19/19 at 11:20 a.m. Surveyor observed RN-C administer 4 units of R7's rapid acting insulin, [MEDICATION NAME]. into his right bicep. Prior to the administration, R7 had told Surveyor that he was concerned as he felt there was no system for his insulin administration with the nurses giving it at any time without regard for his blood sugar levels and diet. Surveyor observed R7's meal to be served to him at 11:50 a.m. which was 30 minutes prior to his meal. This brand and type of insulin is designed to work very quickly and is to be given 5 to 10 minutes prior to a persons meal in order to reduce the risk of very low blood sugars. At 1:21 p.m. Surveyor interviewed RN-C about the facility's guidelines for administration of insulins and the recommended administration times. RN-C stated the facility follows the AMDA (American Medical Directors Association) guidelines, Diabetes Management in the Long Term Care Setting published in 2008. The guidelines state, Must be given just before eating and the onset of action is less than 15 minutes.

Based on observation, interview, and record review the facility did not ensure 1 of 1 sampled residents (R3) on an antipsychotic medication had clinical indications for continued use. R3 was on [MEDICATION NAME]. There was no indication the facility, developed a care plan including non-pharmacological approaches for facility defined target behaviors; or attempted a GRD (Gradual Dose Reduction) in order to determine if the medication was still necessary. This is evidenced by: [MEDICATION NAME] is an antipsychotic medication. It is used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. It carries a black box warning which indicates it is not approved for treatment for [REDACTED]. Surveyor completed a review of R3's clinical record and noted the following. R3 had current [DIAGNOSES REDACTED]. R3's most current MDS (Minimum Data Set) was dated 12/25/18. The MDS indicated, ~ R3's BIMS (Brief Interview for Mental Status) score was 3 indicating a severe cognitive impairment; ~ R3's mood score was 0 indicating no signs or symptoms of depression; ~ Had no behaviors; ~ Did not wander; and ~ Did not reject care. Surveyor completed a review of R3's behavior care plan was dated 10/22/13. The care plan had the following approaches. ~ 7/24/17, .Monitor frequently when in day room .Ensure resident preferences are being met .prefers to be in room after meals .Assess for any unmet needs .Monitor targeted behaviors Q (every) shift .provide reassurance .redirection .calm and consistent environment . According to R3's record, targeted behaviors included refusing care, aggression towards staff, swearing, yelling, hitting. Of notation, refusing care is not a behavior. None of the approaches on R3's plan of care directed staff on individualized non-pharmacological resident specific approaches of how to manage R3's behaviors. Surveyor completed a review of R3's physician orders [REDACTED]. ~ On 1/30/18, [MEDICATION NAME] 2.5 mg (milligrams) was ordered twice a day. ~ On 4/25/18 the facility initiated a GDR, reducing R3's [MEDICATION NAME] to 2.5 mg every morning and 2.5 mg every evening on Monday, Wednesday, and Friday. ~ On 7/2/18 [MEDICATION NAME] was increased back to the original dose of 2.5 mg twice a day. Surveyor completed a review of the facility's quarterly review of [MEDICAL CONDITION] medication for R3 and noted the following. ~ On 4/25/18 a quarterly review indicated the R3 was on [MEDICATION NAME] 2.5 mg (milligrams) twice a day. The facility requested a GDR. The physician reduced R3's [MEDICATION NAME] form 2.5 mg twice a day to 2.5 mg every morning and 12.5 mg in the evening 3 times a week. On 7/2/18 the facility obtained a physician's orders [REDACTED]. There was no indication the facility quantified R3's behaviors in order to determine if there was an actual increase in behaviors. There was no indication the facility completed quarterly review in order to quantify R3's behaviors. ~ On 10/10 18 a quarterly review indicated R3's behaviors had improved since the dose was increased on 7/2/18. There was no indication the facility discussed a GDR. There were no further quarterly reviews. Surveyor completed a review of the facility's behavior tracking from 7/1/18 to 2/21/19 and noted the following. ~ R3 had a decrease in episodes of refusing care from 13 episodes to 2 episodes. ~ R3 had a decrease in episodes of aggression, swearing, yelling, and hitting from 10 episodes to 2 episodes. Despite a reduction of R3's behaviors there was no indication the facility discussed a GDR of R3's [MEDICATION NAME]. Surveyor observed R3 multiple times during the course of the survey, both in her room and during mealtime. Surveyor witnessed no aggressive behaviors or verbal outbursts. On 2/19/19 at 10:46 AM Surveyor spoke with FM-D (Family Member). FM-D described R3 as being fiercely independent. FM-D also described R3 as having a life long history of being irritable. As FM-D was exiting R3's room FM-D leaned over and kissed R3 on the forehead. This startled R3 as R3 had been sleeping. R3 responded in an irritable fashion asking FM-D what FM-D was doing and requested in no uncertain terms FM-D leave. FM-D turned to Surveyor and indicated, see what I mean. On 2/21/19 Surveyor requested further information regarding a discussion of a GDR for R3 including rationale for not attempting a GDR. No further information was received. On 2/25/19 at 3:46 PM Surveyor spoke with the NHA (Nursing Home Administrator). The NHA indicated resident behaviors were discussed quarterly during the time frame a residents MDS was due. Surveyor requested the quarterly reviews missing for R3. The NHA indicated the quarterly reviews Surveyor received were the only 2 he could find. The NHA indicated some of the facility's processes had fallen by the way side as they have struggled to attract and maintain staff.

Based on interview and record review the facility did not ensure 1 of 5 sampled residents (R3) medication regimen was reviewed monthly for irregularities by a licensed pharmacist. R3 was on [MEDICATION NAME]. There was no indication the pharmacist had addressed the need for a GDR (Gradual Dose Reduction) of R3's [MEDICATION NAME]. This is evidenced by: R3 had current [DIAGNOSES REDACTED]. R3's most current MDS (Minimum Data Set) was dated 12/25/18. The MDS indicated, ~ R3's mood score was 0 indicating no signs or symptoms of depression; ~ Had no behaviors; ~ Did not wander; and ~ Did not reject care. Surveyor completed a review of R3's physician orders [REDACTED]. ~ On 1/30/18, [MEDICATION NAME] 2.5 mg (milligrams) was ordered twice a day. ~ On 4/25/18 the facility initiated a GDR, reducing R3's [MEDICATION NAME] to 2.5 mg every morning and 2.5 mg every evening on Monday, Wednesday, and Friday. ~ On 7/2/18 the facility requested [MEDICATION NAME] be increased to the original dose of 2.5 mg twice a day. [MEDICATION NAME] is an antipsychotic medication. It is used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. It carries a black box warning which indicates it is not approved for treatment for [REDACTED]. Surveyor completed a review of form titled Long Term Care Pharmacy Services. The form was utilized by the pharmacist to review, make recommendations, and note irregularities of residents medication regimens. Surveyor completed a review of R3's Long Term Care Pharmacy Services log since 5/22/18. There were no recommendations on the part of the pharmacist except on 1/28/19 when the pharmacist recommended blood work. According to current standards of practice regarding antipsychotic medication, a dose reduction needs to be attempted on 2 separate occasions during the first year of therapy. There was no indication the pharmacist addressed R3's [MEDICATION NAME] and need for consideration of a GDR. On 2/25/19 at 3:46 PM Surveyor spoke with the NHA. The NHA indicated the pharmacist was not making recommendations for GDR's. The NHA stated the pharmacist generally made recommendations for blood work only.

Based on observation and interview the facility did not ensure 1 of 6 residents (R7) at risk for falls received the necessary care and services to prevent falls. R7 experienced 8 falls. The facility did not conduct a root cause analysis or put measures in place, based on root cause analysis in attempt to prevent falls. Subsequently R7 fell and fractured her right foot. This is evidenced by: Surveyor reviewed R7's medical record and noted R7 is responsible for her own decisions. R7's most recent Minimum Data Set (MDS) was a quarterly review conducted 2/13/18 and indicates R7: ~Is able to understand others ~Is able to make self understood ~Requires extensive assist of one staff for bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene ~Falls: 2 with no injury, 2 with injury, 1 major injury. Surveyor reviewed R7's Fall Risk Assessments dated 8/16/17, 11/14/17 and 2/13/18 all of which indicated R7 is at high risk for falls. R7's Fall Care Plan include interventions of: Ensure proper foot wear. Assure well lighted clutter free environment Signs in place in room in attempt to remind her to stop when attempting to self-transfer to call for assistance, given bell to have on bedside table for additional intervention she can use to alert staff for assistance 15 minute checks (Discontinued). Resident in agreement to use stationary alarm (Discontinued) Continue to provide education on call light, provide education on risks of injury. Assure bell is over bed table when she is in recliner, call light in front of her. R7's Certified Nursing Assistant Care Plan (E-Tasks) and noted: Reacher stick, low/locked bed, four wheel walker with transfer and ambulation, continue to encourage use of call light, assist of one for transfers, toileting every 2 hours. Surveyor reviewed R7's fall investigations and noted the following: ~7/01/17: Skin tears to left forearm and abrasion to left back. Ask the resident and staff what happened: left blank Root cause analysis: Walker not in reach as resident lost balance causing her to use sink and wall for stability to lower self to the floor. What new Interventions do we need to put in place to prevent another fall: 30 minute checks, assist with all ambulation and transfers with use of a gait belt. Educate and encourage use of call light for all needs and wants. Although the facility identified R7's walker was not in reach at time of the fall, it was not addressed as a potential root cause. ~7/08/17: No injury. Ask the resident and staff what happened: Resident lost her balance cleaning her table. Root cause analysis: resident cleaning off her table lost balance and fell back. Hit head, skin tear to left arm. What new interventions do we need to put in place to prevent another fall: Resident continues to be non-complaint with allowing assist despite continuous encouragement for same. Education given to resident to allow staff assist for all tasks involving transfer and ambulation. Also added stationary alarm. *Of note the resident reported losing her balance while cleaning off her table. This was not addressed as a potential root cause of the fall. ~8/31/17: No injury. Ask the resident and staff what happened: Resident heard knocking on her window she went to see who it was. Went back to recliner to sit down and missed recliner and ended up on buttocks, on the floor. Root cause analysis: Resident with history of non-compliance with use of call light for needs and wants despite education. Resident misjudged distance to recliner falling on buttocks. Not utilizing walker. Alarms d/c (discontinued) 8/28/18. What new interventions do we need to put in place to prevent another fall: 30 minute safety checks, education/reminders to utilize call light. *The resident missing her recliner when she sat was not addressed as a potential root cause of her fall. ~12/10/17: Skin tear on elbow. Ask the resident and staff what happened: left blank. Root cause analysis: Resident self-transferring out of bed, fell on to garbage can-leaning on recliner. What new interventions do we need to put in place to prevent another fall: 30 minute checks, reminders to use call light, education to risks of injury with falls. *Although R7 is her own person and is cognitively intact, the facility did not ask R7 what happened. The facility did not conduct a root cause analysis and the interventions were previously noted. ~12/11/17: Skin tear left elbow. Ask the resident and staff what happened: left blank Root Cause Analysis: Resident trying to self-transfer without her walker. What new interventions do we need to put in place to prevent another fall: 15 minute checks, cues to use call light, make sure walker in reach. ~1/19/18: Right ankle increased pain, bruising and swelling. Ask the resident and staff what happened: Resident stated I heard (ex-husband) cough in the hallway so I got up to see where he was and I fell . Root Cause Analysis: Resident with unsteady gait and confusion. What new interventions do we need to put in place to prevent another fall: 15 minute checks, continued education to ring call light and wait for assistance, signs next to chair. Nurses Notes: 1/19/18: Sent to ER. Right ankle sprain. 1/22/18: x-ray results possible incomplete fracture at base of 5th metatarsal ./Walking boot. *The facility identified R7 experienced some confusion. The facility did not address the confusion or unsteady gait. R7 was previously on frequent checks and education to use call light has been provided and was ineffective. ~2/03/18: No injury. Ask the resident and staff what happened: Resident tried to transfer from recliner to bed, lost balance falling to left side. Root Cause Analysis: Not utilizing call light, unsteady gait. What new interventions do we need to put in place to prevent another fall: Education and encouragement to allow assist of transfers and ambulation. *The facility did not identify a root cause of the fall or put measures in place that have not already proven ineffective in the past. ~4/23/18: No injury. Ask the resident and staff what happened: Resident stated she lost her balance, falling to her buttocks. Root Cause Analysis: Resident ambulating without using her call light for assistance, lost her balance and fell to her buttocks. What new interventions do we need to put in place to prevent another fall: Frequent reminders to resident to use call light for ambulation and transfer. Maid bell placed in sight for extra reminder. *Again the facility did not identify a root cause of the fall or put measures in place that were based on root cause. On 4/30/18 at 10:00 a.m., Surveyor spoke with R7 about her falls. R7 explained she often falls in her room and had broke something in her foot. R7 stated she is not sure how or why she falls. Surveyor asked R7 what the facility has done to address her falls. R7 responded they want her to call for help. On 5/02/18 at 11:45 a.m., Surveyor spoke with the Director of Nurses (DON) and Nursing Home Administrator (NHA) regarding the facility's fall process and R7's falls. The DON indicated the floor nurse notifies the DON or NHA if a resident falls. The DON/NHA will work with the nurse to put an immediate intervention in place until the special needs committee reviews the fall information and is able to put an intervention in place. The surveyor asked about the root cause of R7's fall and interventions put in place to prevent future falls. The NHA indicated the facility did not dig deep enough into the root cause of R7's falls or put measure in place based on the root cause.

Based on interview and record review the facility did not ensure 1 of 4 sampled residents (R4) nutritional status was maintained within acceptable parameters. R4 had a weight loss of 13.4 pounds equivalent to 10.76% loss of body weight over a period of 6 months. The facility did not recognize the weight loss nor place interventions in place in order to maintain weight and prevent further weight loss. This is evidenced by: R4 was admitted [DATE]. R4's [DIAGNOSES REDACTED]. R4 did not have a hospital stay and was admitted directly from home. R4's current MDS (Minimum Data Set) was dated 4/23/18 with an ARD (Assessment Reference Date) of 4/17/18. The MDS indicated R4 had ~A BIMS (Brief Interview for Mental Status) score of 9 indicating a moderate cognitive impairment; ~Had no mood indicators; ~Required supervision to limited assistance of 1 staff person for all aspects of activities of daily living; ~Ate independently with supervision; ~Weighed 113 pounds; ~Was 5 feet 8 inches tall; and ~Did not have a weight loss. R4's nutrition care plan was dated 10/26/17. The care plan indicated R4 had a potential for weight loss. The care plan had the following approaches. ~10/26/17, .Weight monthly, if on nutritional risk, weight weekly. Report significant weight losses/gains to RD (Registered Dietician) and MD (Medical Doctor) .Nutritional supplement per MD order/RD recommendation .Encourage adequate food and fluid acceptance. Offer snacks . The care plan did not identify R4 had a weight loss. There were no approaches added to R4's plan of care when R4 began to loose weight. Surveyor completed a review of R4's weights and noted the following. All weights were noted in pounds. ~10/9/17 - 126.4 ~10/23/17 - 120.6 The was a 4.59% loss of body weight in 14 days. Surveyor requested R4's admission dietary comprehensive assessment. None was received. R4's weight loss after admission was not identified. There was no comprehensive dietary assessment completed. R4's weight loss should have heightened the facility's awareness of R4's nutritional status. There were no measures put into place in order to maintain or improve R4's nutritional status. ~1/1/18 - 118.8 R4 now had a 6.01% loss of body weight a total of 7.6 pounds in 3 months, since admission. This was not identified by the facility. There were no new approaches added to R4's plan of care to improve R4's nutritional status. ~3/19/18 - 118.2 ~4/1/18 - 115.8 ~4/16/18 - 112.8 R4's weight loss continued. R4 lost 13.6 pounds, a 10.76% loss of body weight since admission and within a time frame of 6 months. There were no new interventions added to R4's plan of care to improve R4's nutritional status. Surveyor requested all dietary assessments including comprehensive assessments. Surveyor received 2 dietary assessments one dated 1/21/18 and the other dated 4/21/18. The assessment dated [DATE] indicated R4's current weight was 118 pounds. The assessment indicated R4 had not had a significant weight loss. There were no new approaches recommended. R4's weight on admission on 10/9/17 was 126.4. R4's weight on 1/1/18 was 118.8. This was a significant weight loss of 7.6 pounds or 6.01% weight loss in 3 months. Surveyor completed a review of the dietary assessment dated [DATE]. The assessment noted R4's weight as 113 pounds. The assessment indicated, .Weight is down slightly - non significant at this time . R4's had now lost a total of 13.4 pounds or 10.76% weight loss since admission. Surveyor completed a review of a dietary note dated 4/21/18. The dietary entry in R4's progress notes. The dietary note indicated, .resident weight is down slightly at 112.8 .Will ask to add 2.0 hical (high calorie) supplement 60 cc's (cubic centimeters) bid (twice a day) . The dietary assessment dated [DATE] and dietary note dated 4/21/18 were both completed by the RD. The recommendation of the RD to add a nutritional supplement was never added to R4's plan of care. The supplement was never implemented. On 5/2/18 at 9:40 a.m. Surveyor spoke with RN-C (Registered Nurse) regarding the facility's practice for monitoring weights. RN-C indicated the DON monitored weights. RN-C indicated nursing enters weights but does not monitor for weight loss/gain. 05/02/18 at 10:08 a.m., Surveyor spoke with the DON (Director of Nursing). The DON indicated she did not monitor weights. The DON stated the facility's RD was the person who monitored weights. The DON indicated the RD worked off-site and has access to their computerized charting system. Surveyor asked the DON about R4's admission comprehensive dietary assessment. The DON indicated R4 did not have an admission comprehensive dietary assessment. The DON indicated she did not know why it was missed. Surveyor asked the DON about the dietary note dated 4/21/18 which identified weight loss and recommended a nutritional supplement. The DON indicated the dietary note itself was not reviewed by nursing. The DON indicated the RD typically faxes her recommendations. The DON stated R4's recommendations were never faxed to her. The DON stated she therefore did not know the RD recommended a supplement.

Based on observations, record review and interview, the facility did not ensure that 2 out of 4 sampled residents reviewed for pain had individualized nonpharmacological interventions to address pain. Resident #4 has a physician's orders [REDACTED]. Staff only utilized this intervention 1 time. The care plan does not include any other individualized, nonpharmacological interventions to address daily pain. Resident #3 has a physician's orders [REDACTED]. There is no evidence that staff used this intervention. The care plan does not inlcude any other individualized nonpharmacological interventions to address daily pain. This is evidenced by: Example #1: Resident #4 has a [DIAGNOSES REDACTED]. Resident #4's care Plan for potential for alteration in comfort included an approach of .Assess for what relieves pain most quickly & utilize (ie: med, diversion, positioning, rest, etc) . Pain assessment dated [DATE] indicates likely cause of pain is [DIAGNOSES REDACTED]. Can verbalize pain and had pain within the last 5 days. Descriptors of pain are upon movement and soreness. Pain Details are lower back, intermittent, intensity #6 and time is mostly morning and intermittent. Other indications of source of pain is [MEDICAL CONDITION] changes spine; scoliosis. Pain affects quality of life for mobility. What improves the pain is medications and rest. What makes the pain worse is movement. Resident does not usually voice pain unless asked. Notes; faxed out to MD for possible medication change. The MDS (Minimum Data Set) assessment, dated 4/14/16 indicates Resident #4 had frequent pain rated at a 5 (moderate pain). Physician orders [REDACTED]. ~4/5/16: [MEDICATION NAME] 400 mg three times a day, [MEDICATION NAME] 25 mg three times a day as needed and WMC (Warm Moist Cloth) 1/2 hr three times a day as needed. ~6/15/16: [MEDICATION NAME] 25 mg three times a day. Discontinued on 6/20/15; and ~6/20/16: [MEDICATION NAME] 12 meq 1 patch every 72 hrs. ([MEDICATION NAME]). Review of April, May and June Medication record indicates that the facility only used the WMC one time on 4/5/16. There is no evidence that the facility utilized any individualized nonpharmacological approaches prior to implementing as needed medications or before starting Narcotics. ~April 2016, Resident #4 received 10 doses of [MEDICATION NAME] 25 mg as needed. Tylenol 650 mg 3 doses, and Ben Gay 9 times. ~May 2016, Resident #4 received 19 doses of [MEDICATION NAME] 25 mg as needed. Tylenol 650 mg from 5/7/16 through 5/18/16. Ben Gay 5 times. The only nonpharmacological intervention was a WMC on 5/1/16. ~June 2016, Resident #4 received 13 doses [MEDICATION NAME] 25 mg as needed from 6/10/16 through 6/14/16. There is no evidence nonpharmacological interventions were offered or tried prior to administering pain medications. On 6/21/16 at 8:23 a.m., Surveyor # observed CNA-C and CNA-E transfer Resident #4 from wheelchair to bed. Resident #4 yelled out in pain with movement. On 6/22/16 at 10:20 a.m., Surveyor # interviewed Family-F who stated that her mother never could tolerate medications. Family-F stated that at home she would put ice on her shoulder but before March/April she never took any pain medications. Family-F stated that she is declining since she got pneumonia in April. Example #2 Resident #3 has a [DIAGNOSES REDACTED]. Received 2 units of RBC's (red blood cells) in January and May 2016. The MDS assessment dated [DATE] indicates Resident #3 has a history of falls with rib fracture and no pain. TPain assessment dated [DATE] indicates the following: Receiving as needed pain medication for back problem and Dementia. Resident #4 can verbalize pain and experienced no pain within the last 5 days. Form indicates that if no pain, Do not complete remainder of assessment. Pain assessment dated [DATE] indicates the following: ~Back problem, constipation, Dementia and Other; age related changes. Can verbalize pain and had pain within the last 5 days. ~Description of pain is upon movement. Per staff occasional discomfort when transferring. ~Calls out/Screaming. Lower back, intermittent. Pain scale of 5 (moderate pain). Time of pain is intermittent. No change in quality of life. What improves the pain is medications and rest. What makes the pain worse; movement. Resident is satisfied with pain control. It's fine! Review of Care Plan dated 1/6/16, Potential for alteration in comfort related to age-related changes .1/30/16: Hx.(history) of Left Rib Fracture. Goal: Comfort will be attained through use of medication or comfort measures as evidenced by (Resident #3) voicing relief of pain 90 days. 4/6/16, 7/6/16. Approaches: .Assess for what relieves pain most quickly & utilize (ie: med, diversion, positioning, rest, etc) . These are canned phrases not individualized nonpharmocological approaches. Physician orders [REDACTED]. [MEDICATION NAME] 5/325 mg every 6 hours as needed for pain. 2/25/16 apply ice for 20 minutes three times a day as needed for pain. Review of April, May and June Medication record indicates the following: ~April 2016: Tylenol one dose, [MEDICATION NAME] 5/325 mg, 7 doses. ~May 2016: Tylenol one dose, [MEDICATION NAME] 5/325 mg, 17 doses given. ~June 2016: Tylenol two doses. [MEDICATION NAME] 5/325 mg, 13 doses given through 6/22/16. For the above listed months. there was no evidence that ice or any other nonpharmacological interventions were offered or used prior to administering medications. On 6/22/16 at 10:38 a.m., Surveyor # spoke with LPN-D (Licensed Practical Nurse) on the facility policy and procedure for administering pain medications. LPN-D stated that nursing does a pain assessment on where the pain is, severity of the pain and how long it has been going on. We check the MAR (medication record) to see what is ordered and give a prn (as needed) medication. We document in the MAR indicated [REDACTED]. We document the effectiveness in the MAR. We do not document in the nurses notes unless the pain is persistent or ineffective. We discussed the nonpharmacologicals. LPN-D stated that staff would document nonphamacologicals in the communication book and give in report. Some residents have nonpharmacological interventions in the care plan. We do position changes, lay down but write in our report book. If we note an approach helps we give it to the IDT (Interdisciplinary Team). We only give ice or heat if ordered by the physician. When asked why Resident #3 hasn't gotten any ice per physician order, LPN-D stated, I don't know.

Based on observation. record review and interview, the facility did not ensure that 1 out of 4 sampled residents reviewed for pressure injury received proper care and services to promote the healing of a Stage II pressure injury. Resident #3 developed a Stage II pressure injury. Surveyor # observed no dressing covering the wound per physician order [REDACTED]. This is evidenced by: Resident #3 has a [DIAGNOSES REDACTED]. Received 2 units of RBC's (red blood cells) in January and May 2016. According to the nurses notes dated 6/6/16, Resident #3 developed a Stage 2 Pressure Injury; Area on the right glute (buttock) measuring 0.5 cm (centimeters) x 0.8 cm, continue with current cue/reposition program every 2 hours and toileting. Resident with history and ongoing intermittent refusals to ambulate and participate in AROM (active range of motion). Resident is declining, poor appetite, weight loss. Change in Condition Assessment is scheduled. Review of Physician orders [REDACTED]. A DuoDerm dressing is a [MEDICATION NAME], moisture-retentive wound dressing used for partial and full-thickness wounds. On 6/21/16 at 6:15 a.m., Surveyor # observed Resident #3 sitting in the wheelchair asleep in the day room. At 7:13 a.m., she went down for breakfast. At 8:23 a.m., Surveyor # observed CNA-B (Certified Nurse Aide) and CNA-C going to lay down Resident #3. Surveyor requested to see Resident #3's buttocks. Surveyor # observed the Stage 2 pressure injury with no dressing. Resident #3 yelled out, Oh my ass hurts so! when being transferred from wheelchair to bed. CNA-B stated Resident #3 got up around 6:00 a.m. and the duoderm was not on that time. The duoderm was stuck in her underwear. On 6/21/16 at 8:48 a.m., Surveyor # spoke to CNA-C who stated that she told LPN-D right away this morning, in fact the night nurse was also there and was made aware CNA-C stated that LPN-D replied OK. CNA-C stated, I just reminded her again. On 6/21/16 at 9:00 a.m., Surveyor # spoke to LPN-D who stated that CNA-C reported it before breakfast. The night nurse did not report the dressing was off. Surveyor # and LPN-D reviewed the nurses notes. No documentation on the night shift. On 6/21/16 at 3:05 p.m., Surveyor # interviewed the DON (Director of Nurses) who stated the facility is now in the process on getting a Wound Care Certified Nurse in the building. The DON stated that starting today, nursing will be monitoring dressing placement every shift and documenting in the Medication/Treatment record.

Based on observation, interview and record review, the facility did not ensure that 1 of 1 resident sampled with a Foley catheter, had a Foley catheter inserted and left in place based on medical necessity. Resident #3 was admitted to the facility without a Foley catheter. 2 days after admission, the facility determined Resident #3 had low urine output and a Foley catheter was subsequently placed. According to facility records, when the Foley catheter was inserted, the amount of urine in Resident #3's bladder was 100 cc's. Despite the low volume of urine in Resident #3's bladder, the Foley catheter was left in place without a comprehensive assessment. Since the Foley catheter was placed, Resident #3 has been sent to the emergency room 3 times with hematuria (blood in the urine) causing a significant amount of blood loss with subsequent low hemoglobin, pain and UTIs (Urinary Tract Infections). Additionally, after the Foley catheter was placed, Resident #3 was seen by a urologist at the request of Resident #3's POA-A (Power of Attorney Activated). During the clinic visit, the urologist noted Resident #3 had significant pain related to paraphimosis (the inability to reduce a swollen foreskin over the glans penis). This is evidenced by: According to the EAUN (European Association of Urology Nurse) "Evidenced-based Guidelines for Best Practice in Urology Health Care Catheterisation Indwelling catheters in adults" February 2012, there needs to be clear indication for the placement of a Foley catheter and Foley catheters were not to be left in longer than necessary. According to Medscape, "...Paraphimosis is most often...occurring when medical personnel forget to reduce the foreskin after instrumentation or catheterization of the urethra...Patients present with a red, painful, and swollen glans penis associated with an [MEDICAL CONDITION], proximally retracted foreskin that forms a circumferential constricting band..." Resident #3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Resident #3 was admitted to the facility after being hospitalized and diagnosed with [REDACTED]. Resident #3's admitting [DIAGNOSES REDACTED]. Surveyor # completed a review of Resident #3's nursing notes. Nursing notes from 5/13/14 through 5/15/14 indicated Resident #3 had no issues with paraphimosis or [MEDICAL CONDITION]. Surveyor # completed a review of a facility form titled "Intake and Output Roster" for Resident #3 for the time frame of admission to 5/15/14, when the Foley catheter was placed. According to the "Intake and Output Roster," Resident #3 was continent of urine. Surveyor # also completed a review of Resident #3's voiding diary from admission until the facility placed a Foley catheter. The voiding diary indicated Resident #3 was continent and was assisted to the bathroom every 2 to 3 hours. Nursing notes continue: ~ 5/15/14, "...Resident with multiple attempts to empty bladder this shift. Resident voided between 10-50 cc (10 cc's to 50 cc's) multiple times. Palpation of bladder with slight distention. No verbalization of pain. Review if (sic) intake and output shows intake much > (greater) than output...order received to place indwelling catheter..." The nursing note did not contain information indicating the amount of urine output when the Foley catheter was placed nor if the Foley catheter was inserted post void. On 5/15/14, the facility faxed Resident #3's primary physician information regarding the occurrence as noted in the nursing note of 5/15/14. The physician returned the fax questioning what the urine output was when the Foley catheter was inserted. The facility's response was, "...approx (approximately) 100cc..." The assessment by the facility of slight distention of Resident #3's bladder, no pain, and only 100 cc's of urine output when the Foley catheter was inserted, should have prompted the facility to remove the Foley catheter. The assessment and findings were not indicative of [MEDICAL CONDITION]. The findings by the facility should have prompted a thorough assessment of Resident #3's bladder status to determine why Resident #3 was voiding in only small amounts. There was no indication a comprehensive bladder assessment was completed. Nursing notes continue: ~ 5/24/14, "...Res (Resident) noted with dark red blood with a few blood clots in Foley bag...T (temperature) 99.8...BP (blood pressure) 90/50...received order to send res to...ER (emergency room )..." On 5/24/14, Resident #3 was transported to the ER. Surveyor # completed a review of hospital records dated 5/24/14. Hospital records indicated Resident #3 had gross hematuria and a Hgb (Hemoglobin) of 10.4 g/dl (grams per deciliter). Resident #3 was diagnosed with [REDACTED]. Nursing notes continue: ~ 5/26/14, "...Continues with gross hematuria...No drop in hemoglobin noted..." ~ 5/27/14, "...No hematuria observed today..." ~ 5/31/14, "...Resident with an increase in agitation this shift. Hematuria noted...B/P 82/40...T 98.4...C/O (complained of) pain in groin area...orders to send resident to...ER..." On 5/31/14, Resident #3 was transported to the ER. Surveyor # completed a review of hospital records dated 5/31/14. Hospital records indicated Resident #3 had hematuria and complaints of needing to go to the bathroom. Hospital records indicated Resident #3 pulled out the Foley catheter while at the hospital causing urethral trauma and significant bleeding. A Foley catheter was reinserted "...which did cause pt (patient) considerable amount of discomfort..." The hospital records also questioned the management of the Foley catheter due to the continued hematuria. Resident #3 returned to the facility. Nursing notes continue: ~ 6/1/14, "...11:17 AM...Urine continues with hematuria with large clots around catheter tubing passing through urethral opening...expresses lower abdominal pain with standing and movement...order received for [MEDICATION NAME] (pain medication)...and to flush catheter with...saline PRN (as needed) for excess clotting or blocking of catheter...11:08 PM...increase in pain as evidenced by resident moaning with movement...extremely restless...Temp (temperature) 101.1...yells out with palpation of abdomen...order obtained to transfer to ER..." On 6/1/14, Resident #3 was again transported to the ER. Surveyor # completed a review of hospital records dated 6/1/14. Resident #3 was diagnosed with [REDACTED]. Nursing notes continue: ~6/2/14, "...Hgb low at 9.5..." Since 5/24/14, Resident #3's Hgb had dropped almost one gram. Despite the significant change in Resident #3 since the Foley catheter was placed, there was no indication a comprehensive assessment was completed related to the use of the Foley catheter, continued hematuria, and complaints of pain. There were no changes made to Resident #3's plan of care. Nursing notes continue: ~ 6/3/14, "...No hematuria...showing signs of discomfort with cares..." On 6/4/14, Resident #3 was seen by a urologist. The appointment was made at the request of Resident #3's POA-A. Surveyor # completed a review of the physician's progress note. The progress note indicated, "...is here presumably because of an elevated PSA (Prostate-Specific [MEDICATION NAME], a test for [MEDICAL CONDITION]) but its at 13 (13.0 nanograms per milliliter), his urine is infected...continue to complain to me that he's having pain and that in some way feels like he needs to void...On examination however, he has a paraphimosis, which took about 15-20 minutes to reduce...which gave him instant relief from his pain...the biggest issue for me is to know why he has an indwelling catheter and for how long...The other issue is whether or not it would be worthwhile at some point to do a trial of voiding..." There was no evidence that staff completed a bladder assessment for Resident #3. Nursing notes continue: ~ 6/6/14, "...Resident with complaints of pain this shift and [MEDICATION NAME] given X3 (three times)[MEDICATION NAME] is effective for pain for approximately two hours then resident becomes restless and agitated and states 'Wow that hurts so bad' then when asked about pain resident states, 'I'm OK really...'" On 6/6/14, the facility received an order from the physician for a [MEDICATION NAME] (pain patch). On 7/14/14 at 8:40 a.m., during the initial tour of the facility, RN-B (Registered Nurse) indicated to Surveyor # that Resident #3 had a Foley catheter related to [MEDICAL CONDITION]. On 7/14/14 at 11:10 a.m., Surveyor # noted Resident #3 in the dining room. Surveyor # noted Resident #3 had a Foley catheter in place. On 7/15/14 at 10:03 a.m. Surveyor # observed RN-C check Resident #3's Foley catheter bag to ensure there was urine in the bag and there were no kinks in the tubing. Surveyor # noted Resident #3's Foley catheter had no kinks and was secured. On 7/16/14 at 11:00 a.m., Surveyor # observed RN-B assess Resident #3's abdomen and Foley catheter. Surveyor # again observed the Foley catheter was secured. Surveyor # also noted no indication of paraphimosis. Surveyor # noted Resident #3's urine to be dark amber. A moderate amount of milky white sediment was noted in the Foley catheter tubing. Surveyor # asked RN-B about Resident #3's paraphimosis. RN-B stated Resident #3 had a swollen and painful penis and indicated she thought he had this since admission. RN-B stated the swelling had gone down since the urologist reduced the foreskin. On 7/15/14 at 3:55 p.m., Surveyor # spoke with RN-B. RN-B indicated she works full time and was the nurse on duty when Resident #3 initially had the Foley catheter placed. RN-B stated Resident #3 was voiding in small amounts, fluid intake was greater than urinary output, and Resident #3's abdomen was distended. RN-B stated she got an order to put in a Foley catheter. RN-B stated she could not remember for sure what Resident #3's urinary output was when the Foley catheter was placed, but thought it was around 300 cc's. RN-B stated she was surprised at the low amount of volume in Resident #3's bladder as she had expected a larger volume. Surveyor # asked RN-B if the facility had attempted to remove Resident #3's Foley catheter. RN-B stated they had not. Surveyor # asked RN-B why a voiding trial had not been tried. RN-B stated Resident #3 had a "huge prostate" which was probably causing the [MEDICAL CONDITION]. RN-B stated those things "won't change." On 7/16/14 at 11:30 a.m., Surveyor # spoke with the DON (Director of Nursing) and RN-B about Resident #3. RN-B stated she thought the [DIAGNOSES REDACTED].#3's ER visits. There was no evidence of a [DIAGNOSES REDACTED]. On 7/16/14 at 10:50 a.m., Surveyor # spoke with CNA-D. CNA-D stated she worked full time. Surveyor # asked CNA-D about Resident #3's paraphimosis. CNA-D indicated she remembered Resident #3 had a lot of swelling around his penis and it was painful. CNA-D stated she didn't recall if Resident #3 had this on admission or after the Foley catheter was placed.

Based upon observations and record reviews the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of all 28 residents living at the facility. This is evidenced by the number and seriousness of the citations issued at this survey, which included 6 deficiencies at the level of immediate jeopardy, 3 deficiencies at the level of actual harm, and 5 deficiencies that found substandard quality of care. The immediate jeopardy began on 7/29/13. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy at 1:15 p.m. on 8/22/13. The immediate jeopardy was not removed by the exit date of the survey. Findings include: A facility's administrative staff (which includes the administrator, department managers, and nurse managers) are responsible for ensuring that facility policies and procedures are being operationalized and implemented and that all systems are in place to safeguard residents and to ensure each resident is attaining or maintaining his or her highest practicable physical, mental and psychosocial well being. That this was not being done is evidenced by the following: 1. 5 deficiencies F157, F223, F250, F309, and F333 identified immediate jeopardy at this survey. * The facility administration failed to ensure that systems were in place such that facility nursing staff promptly consulted with the physician regarding significant condition changes and the need to significantly alter treatment. * The facility administration failed to ensure that systems were in place to protect residents from physical and verbal abuse. Staff did not separate residents after an incident of verbal abuse and allowed the aggressor to stay in the same room as the victim without supervision. * The facility administration failed to ensure systems were in place to assist residents with verbalizing the desire to end their lives. Three residents made statements of wanting to end their lives. Staff did not take steps to keep these residents safe or to assist them with their feelings leading them to want to end their lives. * The facility administration failed to ensure that residents received appropriate care including medications and assessments by a Registered Nurse when a change in condition was evident. * The facility administration failed to ensure that systems were in place whereby contingency medications were available to all residents of the facility no matter which pharmacy provider was chosen by the resident. 2. Substandard Quality of Care was identified at F223, F250, F226, F309, and F333. 3. Deficient practices resulting in actual harm were identified at F314, F323, and F327. 4. In addition, 4 deficiencies were identified as having the potential to cause more than minimal harm to nearly all residents of the facility. F226, F441, F496, and F520. 5. This deficiency, at F490, has the potential to affect all 28 residents residing at the facility at a level of immediate jeopardy. 6. In total 25 federal deficiencies were issued as a result of this survey. Administrative staff did not ensure that systems were in place to make certain that residents received appropriate care and services as demonstrated by the following additional deficiencies: *F157 - s/s J removed to an E. The facility did not ensure that staff consulted with a residents' physician when a change in condition was evident and/or when there was a potential need to alter a resident's treatment. *F223 - s/s J not removed at the time of survey exit. The facility did not protect a resident from physical and verbal abuse of another resident. *F225 - s/s E. The facility administration did not thoroughly investigate or report allegations of abuse, neglect, and injuries of unknown origin. *F226 - s/s F. The facility administration did not operationalize their policies and procedures to prohibit mistreatment, neglect, and abuse as they pertain to investigating and reporting allegations, completing criminal background checks and pre-employment reference checks. *F250 - s/s K not removed at the time of survey exit. The facility administration did not provide medically related social services and/or notify their social worker of 2 residents' [MEDICAL CONDITION]. *F272 - s/s D. The facility administration did not ensure that staff completed comprehensive assessments prior to the application of a medical device. *F278 - s/s E. The facility administration did not ensure that Minimum Data Set assessments were accurately coded. *F279 - s/s E. The facility administration did not ensure that care plans included individualized approaches, implementation dates, and measurable goals and timeframes. *F309 - s/s J removed to an E. The facility administration did not ensure that residents received necessary and appropriate care following deterioration in health status within the limits of licensure status. *F314 - s/s G. The facility administration did not implement up-to-date policies and procedures related to pressure ulcer prevention and treatment. *F323 - s/s G. The facility administration did not ensure that staff identified causes or reasons for falls and/or elopements and implemented interventions to prevent re-occurrence of the incident. *F325 - s/s D. The facility administration did not consult with the Registered Dietitian to assess residents' nutritional status when significant weight loss was identified. *F327 - s/s G. The facility administration did not consult with the Registered Dietitian to assess a resident's hydration status following hospitalization for dehydration. *F329 - s/s D. The facility administration did not advocate for a gradual dose reduction in psychoactive medications when monitoring no longer demonstrated adequate indications for use. *F333 - s/s J removed to an E. The facility administration did not provide a contingency supply of medications to ensure that residents were free from significant medication omissions. *F354 - s/s E. The facility administration did not provide Registered Nurse coverage for 8 consecutive hours a day, 7 days a week. Deficiencies were identified when a Registered Nurse did not provide an assessment of a resident during a significant change of condition. *F428 - s/s D. The facility administration did not ensure that the pharmacist identified and reported irregularities in residents' drug regimens. * F441 - s/s F. The facility administration did not ensure that complete and accurate surveillance was completed in real time. Administration did not ensure that staff took appropriate steps to prevent the transmission of blood borne pathogens during insulin administration and blood sugar testing. *F496 - s/s F. Facility administration did not ensure that CNAs (Certified Nursing Assistants) were on the Wisconsin CNA registry. Without registry inclusion, these staff are them ineligible to work in Wisconsin nursing homes as CNAs. *F497 - s/s E. Facility administration did not ensure that all CNAs had a performance review every 12 months. *F514 - s/s D. Facility administration did not ensure that incidents were thoroughly and accurately documented in residents' records. *F519 - s/s C. Facility administration did not ensure that the facility had a signed transfer agreement with a hospital. *F520 - s/s F. Facility administration did not ensure that the Quality Assessment and Assurance committee was effective in identifying quality of care issues in the facility and developing action plans to address those issues. The immediate jeopardy that began on 7/29/13 was not removed at the time of the exit from the survey. The facility failed to implement systemic changes needed to ensure efficient and effective administration of the facility which can affect all residents of the facility.

Based upon observations and record reviews the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of all 28 residents living at the facility. This is evidenced by the number and seriousness of the citations issued at this survey, which included 6 deficiencies at the level of immediate jeopardy, 3 deficiencies at the level of actual harm, and 5 deficiencies that found substandard quality of care. The failure to ensure the facility was administered effectively and efficiently increased the likelihood that residents would not attain or maintain their highest level of physical, mental, and psychosocial well-being. The facility was notified of this finding on 8/22/13. The Immediate Jeopardy was removed on 8/23/13 at which time a licensed corporate administrator was assigned to mentor the facility administrator and monitor the administrative actions in the facility. The deficient practice continues at a scope/severity level of an F (potential for harm that is not immediate jeopardy/widespread). The actions of the administrative staff have the potential to affect all residents of the facility. The facility still needs to fully operationalize their plan to ensure efficient and effective administration.

Based on record reviews and interviews, the facility failed to provide medically related social services, resulting in risk of serious injury, impairment or death to 3 of 3 residents who made statements related to ending their lives. Resident #5 made suicidal statements to family regarding taking her life. Family reported these statements to the facility. The facility did not aggressively act on these statements, nor did they report these to the Social Worker. Seven months later, Resident #5 was found with her call light cord wrapped around her neck. The facility did not immediately report the full and complete details to the Social Worker, only reporting that she was making negative statements. The facility did not inform the Social Worker of the cord light incident so that a thorough assessment and evaluation could be conducted, in order to seek the assistance Resident #5 needed. Resident #14 experienced a significant loss when her daughter died in [DATE]. In [DATE], Resident #14 began to refuse medications and stated, "I don't want those and I don't care if I die." The facility did not inform the Social Worker so that an assessment could be completed and assistance with grief/depression could be provided. Resident #1 was admitted to the facility on [DATE]. On [DATE], Resident #1 stood at the top of the stairs on the 3rd floor and stated, "I should jump off and kill myself." The Social Worker was notified and 15 minute checks were initiated as well as behavior monitoring. There were no interventions implemented to address Resident #1's suicidal statements and to address the root cause of Resident #1's wanting to end his life. Additionally, Resident #1 repeatedly took off his wanderguard bracelet and wanted to leave the facility. There is no evidence that medically related social services were provided to help the resident with adjustment difficulty. The immediate jeopardy began on [DATE] when Resident #14 expressed her desire to end her life without any interventions and was identified on [DATE]. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy at 1:15 p.m. on [DATE]. The immediate jeopardy was not removed by the exit date of the survey. This is evidenced by: Example #1: Resident #5 has medical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments for Resident #5, included assessments of the resident's mood status (Section DO200): ~ [DATE]: Admission- no mood indicators coded, Brief Interview of Mental Status (BIMS) score ,[DATE] (cognitively intact); ~ [DATE]: Quarterly- no mood indicators coded, BIMS of 13; ~ [DATE]: Quarterly-no mood indicators coded, BIMS of 13; and ~ [DATE]: Quarterly-no mood indicators coded, BIMS of 13. Resident #5's Nurse's notes included the following: On [DATE], the family notified nursing that Resident #5 was making negative remarks of wanting the family to bring in a belt or rope so that she could hang herself or that she could just slit her wrists. There was no evidence in the medical record that the resident had made comments like these in the past, since admission on [DATE]. The documentation indicated the facility initiated behavior monitoring and every 15 minute checks for 24 hours. There is also no documentation on what types of behavior staff were to monitor for or how to respond. Checking on an individual every 15 minutes is not a sufficient approach, as an individual with the will to self-harm can be successful in between the 15-minute checks by staff. There was no evidence that the facility contacted the Social Worker regarding the comments so that the underlying causes to the resident's feelings could be addressed or that facility staff initiated more aggressive suicidal prevention approaches, such as 1:1 supervision, removal of harmful objects in room, removal of the call light, etc. There was no additional care plan approaches or even a care plan initiated for these behavioral threats made by Resident #5. On [DATE] at 9:35 a.m., Surveyor # spoke with SW-E (Social Worker) regarding the statements the family indicated Resident #5 made on [DATE]. SW-E stated that the following day ([DATE]), she was informed of Resident #5 making negative statements. Surveyor # pointed out in the documentation of the family informing staff of the resident's desire for a belt or rope, or slitting her wrists. SW-E was very shocked and not aware of the charting. SW-E stated that if she would have been informed of the details of wanting a rope or belt, she would have completed interventions such as discussing with the resident suicidal ideation screening and plans for self-harm. SW-E stated she would have updated Resident #5's physician and consulted with him regarding additional outside services, possibly seeking emergency detention or a short-stay in a facility equipped to handle individuals with suicidal ideation. SW-E stated she would have immediately initiated 1:1 supervision by staff, to not leave Resident #5 unattended and all objects that have the potential to be used for self-harm would have been removed from her room, including the call-light cord. Documentation dated [DATE] and [DATE] indicated Resident #5 made no negative statements. There was no documentation from [DATE] to [DATE] regarding any negative comments made by Resident #5 or her verbalizations of self-harm. MDS dated [DATE]: indicated no mood indicators coded, BIMS of 11 (moderately impaired). On [DATE], Resident #5 was started on Lexapro 5 milligrams (mg) daily for depression. However, there was no documentation in the resident's medical record of what the symptoms of her depression were or what had led to this order. The nursing notes dated [DATE] state ."..occasional negative statements..." but do not give details. Behavior monitoring was also initiated [DATE] by staff. However, the behavior monitoring did not give target statements in which staff were to monitor for. It simply states "negative statements." There also were no care plans formulated or interventions regarding target statements or behaviors. On [DATE], the facility changed Resident #5's room, but documentation does not indicate the reason for the room change. The [DATE] MDS indicated no mood indicators coded, BIMS of 11. Throughout this time, Resident #5 had several unwitnessed falls. On [DATE], Resident #5 was admitted to the hospital for evaluation of an elevated body temperature, diminished lung sounds, and a cough. She was discharged from the hospital to a Skilled Nursing Facility on [DATE] (a sister facility), and readmitted to this facility on [DATE]. On [DATE] nursing documentation states, :...No negative statements...Continue Q15 min. (every 15 minute) checks...TCP (Temporary Care Plan) initiated for negative comments. Continue target behaviors. SS (Social Service) interview conducted...." The documentation did not indicate why the facility initiated 15-minute checks or why a temporary care plan was started, however, an interview with CNA-I on [DATE] at 8:30 a.m revealed that CNA-I had found Resident #5 with the call light cord wrapped around her neck on [DATE]. CNA-I said that Resident #5 was in bed at the time. CNA-I said that Resident #5 had told her "I failed to do it." CNA-I said that she reported this to the Administrator and the Director of Nursing because of Resident #5's comments. Documentation dated [DATE] by SW-E (Social Worker) stated that at 10:00 a.m. on [DATE] the NHA (Nursing Home Administrator) had contacted the SW to inform her that Resident #5 was verbalizing a desire to die. On [DATE] at 11:58 a.m., SW-E stated in interview that she immediately came to the facility on [DATE] and initiated suicidal screening and learned Resident #5 did want to die and that the resident felt she didn't have anything to live for. The SW documented that she initiated a depression screen, behavior monitoring for negative comments and 15-minute checks for "...support, socialization, and re-orientation..." On [DATE] at 9:35 a.m., SW-E stated that Resident #5 scored a 7 on the depression screen, which indicated to her the resident had depression. SW-E also contacted Resident #5's son and clergy to visit. During this interview, SW-E stated that while she was informed of Resident #5 making negative statements on [DATE], she was not told that Resident #5 actually had been found with the call light cord wrapped around her neck on [DATE]. SW-E stated she learned of the actual event going through staff written statements of the proceeding events. (In the investigation was a copy of a handwritten note dated [DATE], written by CNA-Q. The note is as follows: "I entered residents room with the other day shift aide already in the room, resident was laying on her back with her eyes closed, the call light was wrapped around her neck twice, and clipped shut. The other day aide proceeded to take call lite from her neck and woke her up.") SW-E stated on [DATE] at 11:58 a.m., that she should have been informed of all the details and felt the unwitnessed falls Resident #5 experienced could be indicators of self-harm by Resident #5. SW-E stated, "This just makes me sick. Had I known back in [DATE] of her desires for self-harm, all of my interventions would have been in place and we may have been able to prevent this incident" referring to the [DATE] incident. Resident #5 continued to have 5 more falls following this event ([DATE], [DATE], [DATE], [DATE], and [DATE]). All of these falls were unwitnessed by staff. On [DATE], Resident #5's physician increased the Lexapro dose to 15 mg daily. The facility behavior monitoring is vague and does not indicate what behaviors or negative statements the staff are to be monitoring Resident #5 for or what to do should they witness these behaviors or acts. The care plan dated [DATE], still only mentions staff to monitor for negative statements but does not indicate what details to monitor for and what staff response should be. On [DATE] at 1:30 p.m., Surveyor # asked CNA-T (Certified Nursing Assistant) about her knowledge of Resident #5. CNA-T stated prior to the incident of [DATE], she had been ambulating Resident #5 and noticed Resident #5 to just let go of the walker and push herself back, "...like she was doing the Nestea plunge..." She stated she reported it verbally to the nurse, but could not recall which nurse it was. She felt it may just have been an opinion that Resident #5 purposefully "threw" herself backwards, but wanted it monitored. CNA-T then stated Resident #5 purposefully threw herself backwards a second time after the call light cord incident and she reported this to the nurse as well. CNA-T stated that she was able to catch Resident #5 and prevent the fall. CNA-T stated with both incidents, a fall monitoring was put into place. The facility did not assess whether these falls, the suicide statements, and the potential for falls were somehow connected to an attempt at self-harm. Example #2: Resident #14 was admitted to the facility on [DATE]. The facility developed a care plan for "Potential for adjustment problems and depression related to placement in nursing home, loss of prior independence..." On [DATE], The SW (Social Worker) completed a Geriatric Depression Scale due to "Recent loss of daughter." The scale showed no evidence of depression. There were no updates to Resident #14's care plan to address the grief and loss following her daughter's death. On [DATE], Resident #14 was admitted to the hospital for lethargy. History of present illness stated, "...has been increasingly depressed since the death of her daughter recently and had stopped eating and drinking for several days..." Resident #14 was readmitted to the facility on [DATE] with an order for [REDACTED]. Remeron is an antidepressant that also has appetite-stimulating effects. During [DATE], Resident #14 stopped eating and began to refuse medications. On [DATE] at 7:58 p.m., RN-J documented, "..Resident has been refusing medication off and on for the last few weeks. Resident stated, 'I don't want these and I don't care if I die'..." On [DATE] (Thursday) at 8:14 p.m., RN-J faxed a note to the physician indicating Resident #14 is refusing medications and stated, "I am not taking my pills and I don't care if I die." The physician responded on [DATE] (Monday), "Continue to be supportive and offer meds...Meds reviewed. No changes." Surveyor # reviewed Resident #14's medical record. There were no other nursing or social services notes related to Resident #14's statement that she didn't care if she died until [DATE] (20 days after the statement was made). On [DATE], the DON (Director of Nursing) made an entry, "SW...Made a phone call to MD regarding residents decrease in appetite, s/sx (signs/symptoms) depression, flat affect. Questioned possible medication adjustment. MD with telephone order to increase current Remeron order to 15 mg po (by mouth) q (every) d (day)..." On [DATE], Resident #14 was transferred to the hospital after a fall. The hospital Admission History and Physical dated [DATE] stated, "...history of diabetes and depression who was admitted here in May after she stopped eating and drinking, became weak and dehydrated. This apparently has happened again. The patient has had two daughters die..." On [DATE], Surveyors # and # interviewed RN-J. RN-J confirmed that she documented Resident #14's statement of not caring if she died . RN-J stated she sent a fax to the primary physician. RN-J was asked if she put any other interventions in place. RN-J stated she could not recall. RN-J was asked if the SW was alerted to Resident #14's statement. RN-J stated she could not recall. When asked if she thought Resident #14's statement was related to the loss of her daughter. RN-J stated Resident #14 learned of her daughter's death in May, and thought it was possible she was still grieving in July. On [DATE], Surveyor # spoke with CNA-T (Certified Nursing Assistant) about Resident #14. CNA-T stated after learning of her daughter's death, Resident #14 would carry a picture of her. Resident #14 would show it to everyone and say "This is my daughter who passed away." CNA-T stated Resident #14 would be teary when talking about her daughter. CNA-T was asked if she ever heard Resident #14 make negative statements such as wanting to die. CNA-T stated she never heard any statements, but if she had, she would have reported it right away because it "needs to be addressed." On [DATE] at 9:20 p.m., Surveyor # spoke with SW-E regarding Resident #14 and her statement of not caring if she died . SW-E stated she was not made aware of the statement on [DATE] and learned about it by accident during a Special Needs Committee meeting. SW-E stated once she learned about the statement, she called the physician and advocated for a review of Resident #14's antidepressant therapy. SW-E was asked if a Temporary Care Plan was developed or if the Comprehensive Care Plan was updated. SW-E stated no care plan was developed. SW-E was asked what her expectation is when residents make statements such as this. SW-E indicated she expects to be notified right away so she can assess and determine what approaches need to be implemented. SW-E was asked what she would normally do if presented with this. SW-E stated she would do a depression screen, put the resident on close supervision, look for objects in the room that they may hurt themselves with, provide counseling, request medication review, and if needed, seek outside psychiatric assistance. The DON was unavailable for interview. Example #3: Resident #1 was admitted to the facility on [DATE] for long term care of dementia, congestive heart failure, atrial fibrillation, and colon cancer. Resident #1 had a Temporary Care Plan dated [DATE] for adjustment difficulty, evidenced by agitation and anger. The nurse's notes include the following: ~[DATE] at 8:21 p.m., "CNA reports standing at top railing (alarm going off) CNA tried to redirect he stated, 'I should jump off and kill myself.' Also stated 'I am going to get rid of my daughter too.'...One on one, call to DON with no reply. Left message. Called to Social Worker and she stated, 'If he gets violent towards himself or others call his daughter...'" Staff initiated 15 minute checks and behavior monitoring and a temporary care plan for agitation. There is no evidence that staff assessed or addressed the underlying cause behind the resident's stated desire to kill himself. The facility completed an admission MDS (Minimum Data Set) for Resident #1 on [DATE] with the following data: ~usually able to make self understood and understand others; ~BIMS (Brief Interview for Mental Status) score of 3 out of 15 indicative of cognitive impairment; ~independent with bed mobility, transfers, ambulation, and toilet use; ~required supervision with locomotion on and off unit and eating; ~required limited assist with dressing and hygiene; ~had steady gait. Resident #1 had another temporary care plan due to a room change dated [DATE]. Resident #1 had a resident to resident altercation with his roommate on [DATE] and was moved from 3rd floor to 2nd floor. Prior to [DATE], Resident #1 was on the 3rd floor in a room located approximately 25 yards away from the stairwell and approximately 40 yards from the elevator. On [DATE], Resident #1 was moved to the 2nd floor in a room which was only 5 feet from the fire exit door. Once through the fire exit door, Resident #1 could exit onto the deck or exit out the north door. Both of these exits were only a few feet past the fire exit door. There were no other entries in Resident #1's notes regarding the suicidal statement or any indication that staff assessed Resident #1's psychosocial needs. There were no updates or revisions to the care plan to address Resident #1's needs. On [DATE], an entry in the nurse's note states, "...Will d/c (discontinue) fu (follow-up) charting r/t (related to) threat of suicide..." Other documentation in the nurse's notes finds that Resident #1 made numerous attempts to leave the building stating he wanted to go home and and wanted to get out of the building. Resident #1 cut off the Wanderguard bands and threw them off the deck. (Cross reference F323.) Surveyor # reviewed the complete medical record for Special Needs Committee notes to address the elopements, the exit seeking behavior, the suicidal ideation, and the Wanderguard interventions for elopements. The Surveyor was unable to locate any Special Needs Committee notes that reviewed any of these behaviors or care plan interventions. Surveyor # requested any information regarding the investigations into Resident #1's elopements, behaviors, temporary care plans, and Wanderguard use from the DON on [DATE] at 4:50 p.m., [DATE] at 8:45 a.m. and 11:25 a.m., and again on [DATE] at 8:00 a.m. No additional information was provided. On [DATE] at 9:53 a.m., Surveyor # interviewed CNA-I (Certified Nursing Assistant) who stated she had cared for Resident #1. CNA-I stated Resident #1 ambulated independently throughout the facility and had a Wanderguard on his ankle. CNA-I stated Resident #1 removed the Wanderguard "more than once." On [DATE] at 4:10 p.m., Surveyor # interviewed RN-J (Registered Nurse) who stated she had cared for Resident #1. RN-J stated Resident #1 had elopement episodes, but was redirected back into the facility. RN-J stated Resident #1 had removed the Wanderguard on more than one occasion. On [DATE] at 1:32 p.m., Surveyor # interviewed the DON regarding Resident #1's elopements. The Surveyor asked what other interventions were tried since the Wanderguard was not effective and the DON stated there were no other interventions tried. The Surveyor asked if alternate room changes had been considered and the DON stated she could not recall. The Surveyor asked why the elopement assessment was not completed upon admission and the DON stated she was unsure. The DON stated the elopement assessment was to be completed upon admission, quarterly, and with any change in status. The DON stated Resident #1 was ambulatory and was unhappy with the Wanderguard bracelet. The DON stated she was aware of Resident #1's elopements and was unsure why no investigations were completed. The DON stated she was unsure why the Special Needs Committee did not address Resident #1's elopements in accordance with the facility policy. The immediate jeopardy that began on [DATE] was not removed at the time of the exit from the survey because the facility has not implemented systemic changes need to identify and address suicidal ideations.

Based on record reviews and interviews, the facility failed to provide medically related social services resulting in risk of serious injury, impairment or death to 3 of 3 residents who made statements related to ending their lives. This is evidenced by: Resident #5 made suicidal statements to family regarding taking her life. Family reported these statements to the facility. The facility did not aggressively act on these statements, nor did they report these to the Social Worker. Seven months later, Resident #5 was found with her call light cord wrapped around her neck. The facility did not immediately report the full and complete details to the Social Worker, only reporting that she was making negative statements. The facility did not inform the Social Worker of the cord light incident so that a thorough assessment and evaluation could be conducted, in order to seek the assistance Resident #5 needed. Resident #14 experienced a significant loss when her daughter died in [DATE]. In [DATE], Resident #14 began to refuse medications and stated, "I don't want those and I don't care if I die." The facility did not inform the Social Worker so that an assessment could be completed and assistance with grief/depression could be provided. Resident #1 was admitted to the facility on [DATE]. On [DATE], Resident #1 stood at the top of the stairs on the 3rd floor and stated, "I should jump off and kill myself." The Social Worker was notified and 15 minute checks were initiated as well as behavior monitoring. There were no interventions implemented to address Resident #1's suicidal statements and to address the root cause of Resident #1's wanting to end his life. The failure to provide ongoing medically related social services increased the likelihood that self-injurious behaviors would occur; in turn, this created a high likelihood that serious injuries, harm, impairment, or death would occur. This resulted in a finding of Immediate Jeopardy, which began on [DATE], when Resident #14 verbalized her desire to die. The facility was notified of this finding on [DATE]. The Immediate Jeopardy was removed on [DATE], by which time: 1. All staff were re-educated on identifying and responding to suicidal ideations; and, 2. New policies and procedures were developed related to responding to suicidal ideations. The deficient practice continues at a scope/severity level of an E (potential for harm that is not immediate jeopardy/pattern). The facility still needs to fully operationalize their plan.

Based on interviews and record reviews, the facility failed to protect 1 of 14 sampled residents from verbal and physical abuse. Resident #12 and #4 were roommates. On 3 separate dates, staff documented that Resident #12 was physically and/or verbally abusive to Resident #4. Staff took no action to ensure Resident #4 was free from potential further abuse. The abuse was allowed to continue. There were no updates to Resident #12's care plan, no discussion on separating the residents, no plan for supervision, and no referral to Social Services to assist with resolution and also aide Resident #4 with coping. The immediate jeopardy began on 11/2/12 when staff failed to protect Resident #4 from abuse and the potential for further abuse. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy at 1:15 p.m. on 8/22/13. The immediate jeopardy was not removed by the exit date of the survey. This is evidenced by: Resident #12 was admitted to the facility on [DATE] for long term care due to [MEDICAL CONDITION], depression, anxiety, arthritis, and diabetes. The facility completed an annual MDS (Minimum Data Set) for Resident #12 on 08/01/12 and noted the following data: ~able to make self understood and understand others; ~BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicative of no cognitive deficits; ~independent with bed mobility, transfers, ambulation, and locomotion; ~no physical or verbal behavior directed toward others. Resident #4 was Resident #12's roommate. Resident #4's MDS assessment dated [DATE] indicated: ~BIMS score of 3 out of 15; ~can understand others and can make self understood; and ~required limited assistance of 1 staff for bed mobility, transfers, and ambulation. On 11/02/12 at 8:35 p.m., LPN-C (Licensed Practical Nurse) documented Resident #12 was yelling at Resident #4 (her roommate) and stated to LPN-C, "She's so dumb. We go over this every night." LPN-C intervened by instructing Resident #12 not to talk to Resident #4 in that manner; however, LPN-C left the room with both residents in the room and did not protect Resident #4 from further potential abuse On 11/02/12 at 10:14 p.m., LPN-C documented CNA staff had reported Resident #12 was frustrated with Resident #4's snoring. Resident #12 had rolled Resident #4 over in bed due to the snoring. LPN-C informed Resident #12 she could not touch Resident #4. Resident #12 punched LPN-C on the side of the head. LPN-C assigned a CNA to stay in the room. LPN-C notified the NHA of Resident #12's behavior and LPN-C completed an employee incident report. On 11/02/12 at 10:45 p.m., Resident #12 was again standing over Resident #4 who was lying in bed. There was no CNA staff providing 1:1 for an unknown length of time. Resident #12 was instructed by LPN-A to go back to bed and not touch Resident #4. The LPN did not protect Resident #12 from further potential abuse. There was no evidence that the facility implemented approaches to keep Resident #4 free from physical and verbal abuse. Resident #4's MDS was completed on 2/12/13 and showed declines. This MDS indicated Resident #4 required extensive assistance with bed mobility and the Brief Interview for Mental Status and Mood interviews could not be completed as Resident #4 is rarely understood. On 02/09/13 at 5:17 a.m., LPN-G documented "...at 0200 (2:00 a.m.) rounds, resident (Resident #12) was overheard yelling at roommate (Resident #4) to 'shut up' repeatedly..." CNA assisted Resident #4 to the bathroom and Resident #12 stated to Resident #4 "you need to be quiet when you come back in here or I'm going to duct tape your mouth shut." Resident #4 was returned to the room and staff continued to hear Resident #12 yelling "shut up" throughout the remainder of the night." Despite Resident #12's threat, Resident #4 was not protected from her aggressor and staff allowed the verbal abuse to continue throughout the night. On 03/30/13 at 4:16 a.m., LPN-G documented Resident #12 was found standing over Resident #4 and shaking her. CNA instructed Resident #12 to stop and return to her bed. Resident #4 remained in the room with her aggressor and was not protected from further verbal or physical abuse. Resident #12's comprehensive care plans did not include any verbal or physical aggression toward peers. There was a total of 17 care plan problems, but none included aggressive behavior toward peers. Also, there were no temporary care plans in the purged medical record to address these 3 episodes of aggression toward peers. On 08/06/13 at 3:30 p.m., Surveyor # interviewed the SW (Social Worker) regarding resident-to-resident altercations. The SW stated she was unaware of Resident #12's aggressive behavior toward her roommate. The SW stated Resident #12 should have been moved to another room immediately following the first altercation in November 2012. The SW stated Resident#12 and Resident #4 continued as roommates. The Surveyor asked the SW when completing an MDS assessment, does the SW review the nurse's notes as part of the record review. The SW stated she only looks at the behavior tracking which did not reflect the physical and verbal behavior toward others. On 08/06/13 at the end of the day, Surveyor # requested the investigations into Resident #12's three separate incidents of resident-to-resident altercations involving Resident #12 and Resident #4. Also requested was any information regarding Resident #4's response to the repeated abuse, including notes or care plans. Surveyor # was not provided with any information. On 08/07/13 at 9:10 a.m., Surveyor # interviewed the NHA (Nursing Home Administrator) regarding abuse investigations. The NHA stated she was unaware of Resident #12's behavior toward her roommate. (Documentation in the nurse's notes indicated the NHA was notified on 11/2/12 of the behaviors.) The NHA stated she expected the DON (Director of Nurses) to read the nurse's notes daily. The NHA stated there had been no investigations into Resident #12's behavior. The NHA stated Resident #12 was moved, but was unsure of the date of the move. The NHA stated Resident #12 was upset because Resident #4 snored and kept her awake. The NHA stated Resident #12 has no problems with her current roommate. Because of the resident's declines, as shown in her 2/12/13 MDS, Resident #4 could not be interviewed. Using the Reasonable Person Concept, it is likely she would have felt frightened and experienced chronic or recurrent fear/anxiety because of the actions of her roommate, her inability to protect herself, and staff failure to protect her. The immediate jeopardy that began on 11/2/12 was not removed at the time of the exit from the survey. Although Resident #12 and #4 were no longer roommates, the facility failed to implement systemic changes needed to prohibit physical and verbal abuse and to implement changes that would protect residents who had been abused from the potential for further abuse.

Based on interview and record review the facility did not provide prescribed medications resulting in worsening illness and the potential for death to 1 out of 14 sampled residents. Resident #1 was diagnosed with [REDACTED]. The physician ordered [MEDICATION NAME] 750 mgs (milligrams) every 48 hours, [MEDICATION NAME] 500 mgs every 12 hours for 7 days, and [MEDICATION NAME] 4 mgs every 6 hours, dispense 10 pills. Resident #1 missed 2 doses of [MEDICATION NAME] (an antibiotic), 5 doses of [MEDICATION NAME] (an antibiotic to treat a bowel infection), and 10 doses of [MEDICATION NAME] (an antinausea medication to treat nausea). The facility administered the first and only dose of [MEDICATION NAME] on 01/08/13 at 7:00 a.m. The facility administered the first of a total of 3 doses of [MEDICATION NAME] on 01/08/13 at 10:00 a.m. The facility did not administer any [MEDICATION NAME]. Documentation demonstrates that Resident #1's condition continued to deteriorate 01/06/13 through 01/09/13 when Resident #1 was readmitted to the hospital with [REDACTED]. The significant medication errors resulted in a finding of immediate jeopardy, which began 01/05/13 when the facility failed to provide the ordered medications. The Nursing Home Administrator, Director of Nursing, Social Worker and LPN-D (Licensed Practical Nurse) were notified of the immediate jeopardy at 11:10 a.m. on 07/31/13. The immediate jeopardy was removed on 08/05/13, but noncompliance remained at the lower scope/severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility needs to fully implement their plan of correction and to ensure that the 10 residents who have White Cross Pharmacy have access to medications outside normal business hours. This is evidenced by: The facility has 2 local pharmacy providers for residents from which to choose. Wakefield Pharmacy is considered the facility consultant pharmacy and provides monthly record review along with contingency medications for Wakefield Pharmacy residents only. The Wakefield Pharmacy also provides 24 hours/day service via an oncall system for after hours services, but again for their pharmacy clients only. The 2nd pharmacy choice is White Cross Pharmacy which provides daily delivery service of routine and new medications. The White Cross Pharmacy no longer stocks a contingency supply of medications and does not provide 24 hours/day service to its clients. The White Cross Pharmacy would fill and deliver new medication orders the following business day when physician orders [REDACTED]. The White Cross Pharmacy is closed at 2:00 p.m. on Saturdays and reopens on Mondays except holidays. At the time of the survey, 18 residents had chosen Wakefield Pharmacy and 10 residents had chosen White Cross Pharmacy. Resident #1 was a White Cross Pharmacy client. Resident #1 had new medication orders received on Saturday at 9:15 p.m. Resident #1 was admitted to the facility on [DATE] for long term care due to dementia and heart failure. Review of the nurses notes for Resident #1 were as follows: ~01/05/13 1:54 p.m., LPN-L wrote Resident #1 had "extreme weakness and confusion...lost 7LBS (pounds) in 4 days...very little urine output..." MD (Medical Doctor) gave orders to send resident to the emergency room and daughter agreed. Resident sent to the emergency room . Resident #1 arrived at the ER (emergency room ) on 01/05/13 at 2:05 p.m. with the following assessment: BP (blood pressure) = 102/29, pulse = 62, respiration = 20, temperature = 97.8, and oxygen saturations of 87% on room air. Resident #1 was given oxygen at 2 liters/min via a nasal cannula. The ER documentation reflects Resident #1 received intravenous fluids for hydration along with intravenous medications to treat nausea. Resident #1 was not given any antibiotics or antifungal medications in the ER. Resident #1 also had a CT scan that showed pneumonia or atelectasis (collapsed lung). Resident #1 had an elevated WBC (White blood count) of 19.5 with normal values 4.0 - 11.0 and also an abnormal WBC differential with a "shift to the left" indicative of an infection. The WBCs combat infections. There are several types of WBCs in our blood stream. Under normal physical health, there are 1.4-6.5 immature WBCs in our blood. The WBC "shift to the left" when there is an increase of immature cells that are called upon by our body when there is an acute infection. Resident #1 had 16.5 immature WBC in the blood. The WBC differential report for Resident #1 showed an increase in these immature WBCs in a response to an acute infection. The ER physician ordered: ~1. push fluids; ~2. [MEDICATION NAME] (an anti-emetic) 4 mgs every 6 hours, dispense 10; ~3. [MEDICATION NAME] (an antibiotic) 500 mgs every 12 hours for 7 days; ~4. [MEDICATION NAME] (an antibiotic) 750 mgs every 48 hours; ~5. Follow up with primary physician; ~6. Return to the ER if condition worsens. Resident #1 was returned to the nursing home on 01/05/13 at 9:15 p.m. with the above orders. Resident #1's nurses notes continued as follows: ~01/05/13, 9:44 p.m., LPN-C wrote Resident #1 returned to the facility at 9:15 p.m. Physician ordered [MEDICATION NAME] 4 mgs (milligrams) every 6 hours, [MEDICATION NAME] 500 mgs every 12 hours, and [MEDICATION NAME] 750 mgs every 48 hours. LPN-C documented the DON (Director of Nurses) was notified of medication orders and that the DON instructed LPN to hold all medications until 01/07/13 as Resident #1's pharmacy had no contingency medications available at the nursing home. On 07/30/13 at 6:10 p.m., Surveyor # interviewed LPN-C via the telephone. LPN-C stated she recalled the night Resident #1 was so ill. LPN-C stated she had been instructed not to take the ordered medication out of contingency because the facility would incur the cost of those medications. LPN-C stated she recalled more than one telephone call to the DON requesting to transport Resident #1 back to the hospital so he could receive the ordered medications. LPN-C stated the DON denied this request. LPN-C stated she wanted to give Resident #1 the ordered medications but did not because she had been instructed not to and was fearful of losing her job if she did not follow orders. Resident #1's condition declined following his readmission to the facility, as follows: ~01/06/13 1:44 a.m., LPN-A wrote Resident #1 had no nausea, vomiting, or diarrhea and had diminished lung sounds. ~01/06/13 at 12:54 p.m., LPN-L wrote Resident #1 had 88% oxygen saturations on room air. BP = 130/60, pulse = 67, respirations = 22, and temperature = 97.4. The resident's pulse oxygenation level, which had usually been in the 90's, has fallen. ~01/06/13 at 8:38 p.m., LPN-C wrote Resident #1 had expiratory wheezes in both lungs. BP =114/68, pulse = 76, respirations = 20, temperature = 97.1, and oxygen saturations = 93% on room air. This is the first reference to expiratory wheezing and suggests a decline. None of the medications ordered at theER on [DATE] were given on 01/06/13. ~01/07/13 at 2:50 a.m., LPN-A wrote Resident #1 had expiratory wheezing in both lungs and was pale with general appearance poor. On 01/07/13 at 3:23 p.m., the primary physician was sent a fax regarding the the ER orders via fax. The fax had an unsigned and undated hand written note that read "*See creat (creatinine) clearance. Do you wish to continue with [MEDICATION NAME] order?" The primary physician responded via fax at 4:01 p.m. to continue with the same [MEDICATION NAME] order. Resident #1 had not received any [MEDICATION NAME], or [MEDICATION NAME]. The question to "continue" with the ER order was inaccurate as Resident #1 could not continue a medication that he had not yet started. None of the medications ordered at theER on [DATE] were given on 01/07/13. According to Resident #1's MAR (Medication Administration Record) for January 2013 Resident #1 received the first of his ordered medications on 01/08/13: ~Resident #1 received the first and only dose of [MEDICATION NAME] on 01/08/13 at 7:00 a.m. ~Resident #1 received the first of a total of 3 doses of [MEDICATION NAME] on 01/08/13 at 10:00 a.m. ~Resident #1 received zero doses of [MEDICATION NAME]. The order for [MEDICATION NAME] was never transcribed onto the MAR. There are no additional comprehensive physical assessments including vital signs, oxygen saturations, lung assessments, or hydration assessments documented on 01/08/13. The next entry in the nurse's notes was 01/09/13 at 11:59 a.m., when LPN-L wrote Resident #1 continued with decline in nutrition, hydration, mental status, and physical strength. The primary physician was consulted and ordered another emergency room evaluation. The family was updated and agreed with ER evaluation. ~01/09/13 at 1:31 p.m., RN-J wrote Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 returned to theER on [DATE]. Review of the admission History and Physical report for Resident #1 noted "The patient came here to the emergency roiagnom on the 5th (01/05/13) because he had been dehydrated. He was started on [MEDICATION NAME] because they found right lower lobe pneumonia and the [MEDICATION NAME] because he was having diarrhea. The patient didn't get better and he was not eating very well at home and so has been more dehydrated." Resident #1 had not received the [MEDICATION NAME], Levoquin, or [MEDICATION NAME] as noted in the admission History and Physical. The ER physician was not alerted to Resident #1 not receiving the previously ordered Levoquin, [MEDICATION NAME], or [MEDICATION NAME]. The admission History and Physical also noted Resident was given a dose of [MEDICATION NAME] at the hospital and "got better after getting the IV medications." Review of the laboratory data for Resident #1 on 01/10/13 noted the following abnormal values: ~elevated WBC of 16.9 (normal 4.0 - 11). Indicative of infection; ~shift to left in WBC differential 14.3 (normal 1.4-6.5). Indicative of infection; ~elevated sodium 148 (normal 134-144). Indicative of dehydration; ~elevated creatinine 1.93 (normal 0.8 - 1.5). Indicative of dehydration; ~elevated BUN (blood urea nitrogen) on 01/05/13 of 87 (normal 9 - 20). Indicative of dehydration. ~elevated lipase 123 (normal 22 - 51). Indicative of pancreatitis; ~elevated amylase 195 (normal 36 - 128). Indicative of pancreatitis. On 08/01/13 at 11:25 a.m., Surveyor # interviewed the MD-DD, Resident #1's primary care physician, via telephone regarding Resident #1. MD-DD stated he had reviewed Resident #1's case at the request of the facility. MD-DD stated Resident #1 had developed nausea, vomiting, and diarrhea on 01/02/13 and was sent to theER on [DATE]. MD-DD noted an elevated WBC with a shift to the left on the WBC differential along with the CT scan that noted atelectasis (collapsed lung) or pneumonia. The Surveyor asked if Resident #1's symptoms of low oxygen saturation, elevated WBC with shift to the left, and the CT results was data to support a [DIAGNOSES REDACTED]. MD-DD stated Resident #1 had problems with swallowing and could have aspirated. The Surveyor stated the facility had not provided evidence of Resident #1's eating or swallowing problems, but in fact had provided evidence that Resident #1 had no problems eating or swallowing. (MDS dated [DATE] noted that Resident #1 had no problems chewing or swallowing.) The Surveyor asked MD-DD if the ER doctor ordered the appropriate dose of [MEDICATION NAME] on 01/05/13 and MD-DD stated he had. MD-DD stated Resident #1 did not receive the medications on 01/05/13 through 01/07/13 and was unsure why. MD-DD was unable to recall if the nursing staff had informed him of withholding the prescribed medications for Resident #1. MD-DD stated Resident #1 was returned to the hospital on [DATE] and treated with [MEDICATION NAME] and [MEDICATION NAME] for pneumonia and Resident #1 did improve. On 07/29/13 at 1:15 p.m., Surveyor # interviewed LPN-D regarding contingency medications. LPN-D stated he had been employed since May 2013. LPN-D stated in the event a contingency medication was needed, there was a limited supply of medications provided by Wakefield Pharmacy. If the resident had White Cross Pharmacy as their pharmacy provided, the medication was removed from Wakefield contingency and the facility was billed the cost of the medication. LPN-D stated White Cross Pharmacy used to have contingency supply, but LPN-D was unsure why the contingency was no longer supplied by White Cross Pharmacy. LPN-D showed Surveyor # the limited supply of medications. Surveyor # noted a signed taped to the contingency box that read "Wakefield Pharmacy use only for our residents." The sign was approximately 2 inches by 4 inches and taped directly in front of the contingency box. Surveyor # noted [MEDICATION NAME], Levoquin, and [MEDICATION NAME] were all medications available in the contingency supply. On 07/30/13 at 1:32 p.m., Surveyor # interviewed the DON regarding Resident #1's care. The DON stated when a resident returns from the ER with new orders, the best approach would be for nursing to have the ER send the medication until pharmacy could fill the new prescriptions. The Surveyor reviewed the nurses note of 01/05/13 where LPN-C alleged the DON instructed her to hold the medications for Resident #1. The DON stated she did not instruct LPN-C to withhold medications. The DON stated LPN-C should have removed the medications from contingency and administered as ordered. The Surveyor asked if the DON recalled any additional information about Resident #1's ER visit and additional phone calls from LPN-C and the DON stated she could not recall any other information or additional phone calls. On 07/30/13 at 3:20 p.m., Surveyor # interviewed the DON regarding the MAR (Medication Administration Record) for Resident #1. The MAR noted [MEDICATION NAME] and [MEDICATION NAME] had a start date of 01/08/13 and not 01/05/13. The [MEDICATION NAME] ordered received 01/05/13 was never transcribed onto the MAR and there were no orders to discontinue [MEDICATION NAME]. The Surveyor asked why the delay in medications and the DON stated she was unsure why the medications were not given and why the MAR had the wrong start date. The failure to give medications as ordered created a finding of immediate jeopardy, which began on 01/05/13. The jeopardy was removed on 08/05/13 when the facility: 1. Re-educated nursing staff on the non-business hours admissions and providing medications; 2. Implemented process for night shift nurse to verify all physician orders [REDACTED]. 3. Reviewed policies and procedures; 4. Reviewed and re-educated nursing on contingency drug use; 5. Re-educated nursing staff on medication errors; 6. Re-education of nursing staff to notify ER physician's of creatinine clearance requirements and have ER physician sign off; 7. Re-educated nursing staff on role of LPNs and RNs and the need for RN assessments.

Based on interview and record review, the facility did not consult a physician when a need to alter treatment should have been identified resulting in an immediate jeopardy situation for 1 of 14 sampled residents (Resident #1). In addition to the resident in immediate jeopardy, the facility failed to consult with the physicians for 2 of 14 sampled residents when a change in condition was noted (Residents #10 and #6). On 01/05/13 at 9:15 p.m., Resident #1 returned to the facility with physician orders [REDACTED]. The facility was unable to provide these medications to Resident #1 from 01/05/13 through 01/07/13. The facility did not consult with the physician when the facility was unable to provide Resident #1 with the ordered medications. The facility did not consult with the physician when Resident #1 showed a decline in physical status, including diminished lung sounds, wheezing, and a decline in oxygen saturation levels. Resident #1 was readmitted to the hospital on [DATE] for pneumonia, [MEDICAL CONDITION], profound dehydration, and pancreatitis. The immediate jeopardy began on 1/05/13 when the facility did not provide Resident #1 with the ordered medications and was identified on 07/31/13. The Nursing Home Administrator, Director of Nursing, Social Worker and LPN-D (Licensed Practical Nurse) were notified of the immediate jeopardy at 11:10 a.m. on 07/31/13. The immediate jeopardy was removed on 08/05/13, but non compliance remained at the lower scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced below. Resident #10 had 3 changes in condition including an adverse reaction to an antibiotic. The facility did not consult with the physician. Instead, faxes were sent delaying change in treatment. Resident #6 had significant changes in condition potentially requiring physician intervention. The facility did not consult with the physician, but instead faxed the information. This led to delays in treatment of [REDACTED]. This is evidenced by: On 07/30/13, the facility provided Surveyor # with a copy of a policy titled "Conditions Reportable to Physician Immediately." The policy stated "THE CHARGE NURSE IS RESPONSIBLE FOR NOTIFYING THE PHYSICIAN AND FAMILY IMMEDIATELY IF THE RESIDENT EXPERIENCES A CHANGE IN STATUS WHICH COULD RESULT IN A NEGATIVE OUTCOME FOR THE RESIDENT." The policy listed examples such as "ANY SIGNS OR SYMPTOMS OF AN INFECTIOUS PROCESS...ANY SIGNS OF ACUTE DISTRESS..." Example #1: Resident #1 was admitted to the facility on [DATE] for long term care due to dementia and heart failure. Historical vital signs for Resident #1 included: 10/2/12: T 97.2; B/P 118/68; P 70; R 18; O2 94% RA (room air). 11/14/12: T 97.6; B/P 126/72; P 72; R 20; O2 95% RA. Resident #1 had symptoms of nausea, vomiting, and diarrhea beginning on 01/02/13. Resident #1 was sent to the ER (emergency room ) on 01/05/13 at 2:05 p.m. with the following assessment: Blood Pressure = 102/29, Pulse = 62, Respiration = 20, Temperature = 97.8, and oxygen saturations of 87% on room air. Resident #1 was given oxygen at 2 liters/min via nasal cannula. The ER documentation reflects intravenous fluids were given for hydration along with intravenous medications to treat nausea. Resident #1 was not given any antibiotics or antifungal medications in the ER. Lab draws completed in the ER found Resident #1 had an elevated WBC (White blood count) of 19.5 with normal values 4.0 - 11.0 and also an abnormal WBC differential with a "shift to the left," indicative of an infection. The WBCs combat infections. Under normal physical health, there are 1.4-6.5 immature WBCs in our blood. The WBC "shift to the left" when there is an increase of immature cells that are called upon by our body when there is an acute infection. Resident #1 had 16.5 immature WBCs in the blood. The WBC differential report for Resident #1 showed an increase in these immature WBCs in a response to an acute infection. While at the hospital, Resident #1 also had a CT scan. The final radiology report stated, "Alveolar filling within bilateral lower lungs (fluid in lungs) may be secondary to atelectasis or pneumonia..." The ER physician ordered: ~1. push fluids; ~2. [MEDICATION NAME] (an anti-emetic) 4 mgs every 6 hours, dispense 10; ~3. [MEDICATION NAME] (an antibiotic) 500 mgs every 12 hours for 7 days; ~4. [MEDICATION NAME] (an antibiotic) 750 mgs every 48 hours; ~5. Follow up with primary physician; ~6. Return to the ER if condition worsens. Resident #1 was returned to the nursing home on Saturday 01/05/13 at 9:15 p.m. Resident #1's nurse's notes continued as follows: ~01/05/13 at 9:44 p.m., LPN-C documented, "Resident returned to facility...ER MD...ordered the following: push fluids, [MEDICATION NAME] 4 (milligrams) PO (by mouth) every 6 hours, [MEDICATION NAME] 500 mgs every 12 hours x 72, Levauin (sic) 750 mgs PO q (every) 48 hours...DON (Director of Nurses) was notified of orders, as facility does not have an emergency back up box from resident's pharmacy. Per DON, ordered medications will not be given at this time and will be cleared up with pharmacy/MD on Monday (01/07/13)..." On 07/30/13 at 6:10 p.m., Surveyor # interviewed LPN-C via the telephone. LPN-C stated she recalled the night Resident #1 was so ill. LPN-C stated she had been instructed not to take the ordered medication out of contingency because the facility would incur the cost of those medications. LPN-C stated she recalled more than one telephone call to the DON requesting to transport Resident #1 back to the hospital so he could receive the ordered medications. LPN-C stated the DON denied this request. LPN-C stated she wanted to give Resident #1 the ordered medications but did not because she had been instructed not to and was fearful of losing her job if she did not follow orders. LPN-C stated she documented on the 24-hour shift report book of Resident #1's medication orders and the information had been passed via shift report. The Surveyor asked LPN-C if she consulted with the ER physician when medications were not given. LPN-C stated she had not. Resident #1 did not receive his ordered medications, including the antibiotics [MEDICATION NAME] and [MEDICATION NAME]. Subsequent nursing notes document Resident #1's condition as follows: ~01/06/13 1:44 a.m., LPN-A wrote Resident #1 had no nausea, vomiting, or diarrhea and had diminished lung sounds. ~01/06/13 at 12:54 p.m., LPN-L wrote Resident #1 had 88% oxygen saturations on room air. BP = 130/60, pulse = 67, respirations = 22, and temperature = 97.4. There is no evidence that LPN-L consulted with the physician regarding the low oxygen saturation level. ~01/06/13 at 8:38 p.m., LPN-C wrote Resident #1 had expiratory wheezes in both lungs. BP =114/68, pulse = 76, respirations = 20, temperature = 97.1, and oxygen saturations = 93% on room air. Despite the development of expiratory wheezing, there is no evidence that LPN-C consulted with a physician regarding the decline and the fact that his medications were not available. ~01/07/13 at 2:50 a.m., LPN-A wrote Resident #1 had expiratory wheezing in both lungs and was pale with general appearance poor. LPN-A did not consult with the physician regarding the expiratory wheezing or the fact that the ordered medications were not available. The first dose of [MEDICATION NAME] was given at 7:00 a.m. on 01/07/13. On 01/07/13 at 3:23 p.m., the primary physician was notified regarding the ER orders via fax. The fax had an unsigned and undated hand written note that read "*See creat (creatinine) clearance. Do you wish to continue with [MEDICATION NAME] order?" The primary physician responded via fax at 4:01 p.m. to continue with the same [MEDICATION NAME] order. Resident #1 had not received any [MEDICATION NAME], or [MEDICATION NAME]. The question to "continue" with the ER order was inaccurate as Resident #1 could not continue a medication that he had not yet started. There were no additional comprehensive physical assessments including vital signs, oxygen saturations, lung assessments, or hydration assessments documented. On 07/31/13 at 8:05 a.m., Surveyor # interviewed the DON. The Surveyor again asked the DON who was responsible to assess residents with a change in status when the facility was staffed with a LPN. The DON stated she was responsible to assess the residents. The Surveyor asked if the DON came into assess Resident #1 at anytime during the weekend and the DON stated "I don't even know if I was in town that weekend." The DON stated if she had assessed Resident #1 she would have documented her assessment. The next entry was 01/09/13 at 11:59 a.m., LPN-L wrote Resident #1 continued with decline in nutrition, hydration, mental status, and physical strength. The primary physician was consulted and ordered another ER evaluation. The family was updated and agreed with an ER evaluation. This note did not include any lung assessments or hydration assessments. ~01/09/13 at 1:31 p.m., RN-J (Registered Nurse) wrote Resident #1 was admitted to the hospital with [REDACTED]. Review of the hospital admission History and Physical report dated 01/09/13 for Resident #1 noted "The patient came here to the emergency roiagnom on the 5th (01/05/13) because he had been dehydrated. He was started on [MEDICATION NAME] ([MEDICATION NAME]) because they found right lower lobe pneumonia and the [MEDICATION NAME] because he was having diarrhea. The patient didn't get better and he was not eating very well at home and so has been more dehydrated." The admission History and Physical also noted Resident was given a dose of [MEDICATION NAME] at the hospital and "got better after getting the IV medications." Resident #1 had not received the [MEDICATION NAME], or [MEDICATION NAME] as noted in the admission History and Physical. The facility did not alert the ER physician to the fact that Resident #1 had not received the previously ordered [MEDICATION NAME], or [MEDICATION NAME]. Review of the laboratory data for Resident #1 on 01/10/13 noted the following abnormal values: ~elevated WBC of 16.9 (normal 4.0 - 11). Indicative of infection; ~shift to left in WBC differential 14.3 (normal 1.4-6.5). Indicative of infection; ~elevated sodium 148 (normal 134-144). Indicative of dehydration; ~elevated creatinine 1.93 (normal 0.8 - 1.5). Indicative of dehydration; ~elevated BUN (blood urea nitrogen) on 01/05/13 of 87 (normal 9 - 20). Indicative of dehydration; ~elevated lipase 123 (normal 22 - 51). Indicative of pancreatitis; ~elevated amylase 195 (normal 36 - 128). Indicative of pancreatitis. On 08/01/13 at 11:25 a.m., Surveyor # interviewed MD-DD (Medical Doctor), who is Resident #1's primary care physician via telephone regarding Resident #1. MD-DD stated he had reviewed Resident #1's case at the request of the facility. MD-DD stated Resident #1 had developed nausea, vomiting, and diarrhea on 01/02/13 and was sent to theER on [DATE]. MD-DD noted an elevated WBC with a shift to the left on the WBC differential along with the CT scan that noted aveloar filling secondary to atelectasis (collapsed lung) or pneumonia. The Surveyor asked if Resident #1's symptoms of low oxygen saturation, elevated WBC with shift to the left, and the CT results was data to support a [DIAGNOSES REDACTED]. The Surveyor asked MD-DD if the ER doctor ordered the appropriate dose of [MEDICATION NAME] on 01/05/13 and MD-DD stated he had. MD-DD stated Resident #1 did not receive the medications on 01/05/13 through 01/07/13 and was unsure why. MD-DD was unable to recall if the nursing staff had informed him of withholding the prescribed medications for Resident #1. MD-DD stated Resident #1 was returned to the hospital on [DATE] and treated with [MEDICATION NAME] and [MEDICATION NAME] for pneumonia and Resident #1 did improve. On 07/31/13 at 8:05 a.m., Surveyor # interviewed the DON. The Surveyor asked to view the 24-hour report sheets. The DON stated that information was not part of the medical record and would be shredded after 3 months. The DON stated the facility alerted MD-DD on 01/07/13 for orders to continue [MEDICATION NAME] for Resident #1 and MD-DD ordered to continue on 01/07/13. The Surveyor again asked why the medications were not given until 01/08/13. The DON had no response. According to Mayo Clinic (<http://www.mayoclinic.com/health/pneumonia/DS /DSECTION=symptoms> ), " For some older adults and people with heart failure or lung ailments, pneumonia can quickly become a life-threatening condition. " The 58-hour delay in giving this resident his ordered antibiotic ([MEDICATION NAME]) combined with the failure to promptly consult with the physician regarding the resident's subsequent changed condition placed the resident in imminent danger of serious harm occurring. The immediate jeopardy that began on 01/05/13 was removed on 08/05/13 when the facility: 1. Re-educated nursing staff on the non-business hours admissions and providing medications; 2. Implemented process for night shift nurse to verify all physician orders [REDACTED]. 3. Reviewed policies and procedures; 4. Reviewed and re-educated nursing on contingency drug use; 5. Re-educated nursing staff on medication errors; 6. Re-education of nursing staff to notify ER physicians of creatinine clearance requirements and have ER physician sign off; 7. Re-educated nursing staff on role of LPNs and RNs and the need for RN assessments. Example #2: Resident #10's current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set), dated 7/19/13, indicated Resident #10's cognition was severely impaired, and required extensive assistance of 1 staff person for bathing, dressing, grooming, toileting, and walking. Surveyor # completed a review of Resident #10's nursing notes and noted the following. On 12/19/12, Resident #10 was placed on an antibiotic for [MEDICAL CONDITION]. On 12/20/12, a nursing note indicated, "...Red, blotchy, warm areas noted to residents chest, thighs and back one small blotch noted to right cheek...MD faxed with update..." Faxing the physician is not equivalent to consulting with the physician. The signs and symptoms displayed is indicative that Resident #10 had an adverse reaction to the antibiotic. This could be a life threatening situation and would require immediate physician consultation and treatment. The physician did not respond to the fax on 12/20/12. On 12/21/12, nursing notes indicated, "...Has reddened inner legs from ankles to groin as well as reddened abdomen and arms...MD was faxed..." On 12/21/12, the physician responded via fax. The physician discontinued the antibiotic, questioned if Resident #10 had other allergies [REDACTED]. On 1/3/13, Resident #10 had a change in condition including shortness of breath, abnormal lung sounds, and weakness. A fax was sent to the physician. The physician returned the fax and ordered lab work as well as a chest x-ray. Resident #10 was subsequently diagnosed with [REDACTED]. On 1/24/13, Resident #10 had a change in condition including a temperature, shortness of breath, abnormal lung sounds, low oxygen saturation, and a higher than normal respiratory rate. These symptoms were indicative of respiratory distress. The physician was sent a fax. The physician returned the fax and ordered lab work and a chest x-ray. On 1/25/13, Resident #10 was admitted to the hospital and diagnosed with [REDACTED]. Example #3: Resident #6's current [DIAGNOSES REDACTED]. The most current MDS, dated [DATE], indicated Resident #6: ~ Had a BIMS score (Brief Interview of Mental Status) of 15 indicating no cognitive deficit; ~ Required the assistance of 1 staff person for bathing, dressing, grooming, toileting, walking, and eating; and ~ Had swallowing problems. Surveyor # completed a review of Resident #6's nursing notes and noted the following. On 9/3/12, Resident #6 had an unresponsive episode while seated on the toilet. There was no indication the physician had been consulted. On 9/21/12, Resident #6 had a fall which resulted in minor injuries. The physician was faxed the information rather than being consulted. ~10/17/12, "...4:22 AM...Resident very gurgly and unable to swallow, cough, or spit out frothy saliva. Resident was suctioned X3 (three times)...HOB (head of bed) elevated throughout shift...BP (blood pressure) 130/72, P (pulse) 76, R (respirations) 20, T (temperature) 97.7, 02 (oxygen saturation)...on RA (room air)...95%..." The physician was not consulted. ~10/17/12, "...10:26 AM...Res (resident) with change in status: noted increased restlessness/anxiety. difficulty expressing needs at times...increased phlegm requiring suctioning x4...142/84 (blood pressure) P 98 R 20 T 98.8 02 sat (oxygen saturation) 93% RA. Confusion at times. LS (lung sounds) diminished at bases. Congestion noted. Fax to MD (Medical Doctor) Reply pending..." This was indicative that Resident #6 was experiencing respiratory distress. The physician was not consulted with. ~10/17/12, "...8:35 PM...Resident transferred to...ED (Emergency department) at 1915 (7:15 p.m.)...BP 156/90, P 104, R 22, T 101.9, 02 90% RA. Suctioned x3...unable to take medications...LS crackles throughout. Resident requested MD be called. Primary MD faxed..." According to the nursing note, a physician was faxed and not consulted with at the request of Resident #6. Resident #6 was seen in the emergency room , diagnosed with [REDACTED]. On 8/7/13 at 1:00 p.m., Surveyor # spoke with LPN-D. LPN-D indicated when a resident had a significant change in condition he would call the physician. On 8/8/13 at 9:30 a.m., Surveyor # spoke with RN-J. RN-J indicated it was typical for the facility to fax information back and forth with the physician. RN-J stated if a resident had an acute change in condition, she would call the physician instead of faxing. On 8/8/13 at 12:00 p.m., Surveyor # spoke with LPN-K. LPN-K indicated she would call a physician instead of faxing if the resident's condition was urgent. On 8/7/13 at 10:50 a.m., Surveyor # spoke with MD-DD. MD-DD stated an RN should complete an assessment any time there was a significant change in a resident's condition, including falls, changes in a cardio-respiratory status, changes in mental and psychosocial status, and symptoms indicating acute illness.

Based on interviews and record reviews, the facility failed to protect 1 of 14 sampled residents from verbal and physical abuse. This is evidenced by: Resident #12 and #4 were roommates. On 3 separate dates, staff documented that Resident #12 was physically and/or verbally abusive to Resident #4. Staff took no action to ensure Resident #4 was free from potential further abuse. The abuse was allowed to continue. There were no updates to Resident #12's care plan, no discussion on separating the residents, no plan for supervision, and no referral to Social Services to assist with resolution and also aide Resident #4 with coping. The failure to identify and address resident to resident abuse increased the likelihood that abuse would continue; in turn, this created a high likelihood that serious psychosocial harm could occur. This resulted in a finding of Immediate Jeopardy, which began on 11/1/12. The facility was notified of this finding on 8/22/13. The Immediate Jeopardy was removed on 8/23/13, by which time: 1. Residents #12 and #4 were separated; 2. Facility staff were re-educated on what constitutes abuse and appropriate interventions to the situation; and, 3. Implemented a new incident/reporting procedure. The deficient practice continues at a scope/severity level of a E (potential for harm that is not immediate jeopardy/pattern). The facility still needs to fully operationalize their plan so that other residents are not affected.

Based on record review and interviews the facility failed to provide appropriate care to 1 of 14 residents (Resident #1). The facility did not provide medications that had been prescribed at the emergency room and did not provide ongoing assessments by an RN (Registered Nurse) as the resident's condition appeared to worsen. This placed the resident at risk for serious harm or death. In addition to the resident in immediate jeopardy, the facility failed to provide appropriate care to 2 of 14 sampled residents who experienced a significant change in condition (Residents #10 and #6). Resident #1 was seen in the ER (emergency room ) on 01/05/13 and received physician orders [REDACTED]. The medications were not provided. Resident #1 was not assessed by an RN (Registered Nurse) over the next 12, eight-hour shifts despite signs of a decline in status. Resident #1 was rehosptalized on [DATE] with pneumonia, [MEDICAL CONDITION], profound dehydration, and pancreatitis. The immediate jeopardy began on 1/05/13 when the facility did not provide Resident #1 with the ordered medications and no RN assessments were completed. The immediate jeopardy was identified on 07/31/13. The Nursing Home Administrator, Director of Nursing, Social Worker and LPN-D (Licensed Practical Nurse) were notified of the immediate jeopardy at 11:10 a.m. on 07/31/13. The immediate jeopardy was removed on 08/05/13, but noncompliance remained at the lower scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated). Residents #10 and #6 had significant changes in condition requiring physician ordered changes in treatment. During the times of acute changes in the residents' conditions, there were no RN assessments completed. An RN assessment would be required in order to appropriately manage and direct staff in the care and services provided to Resident #6 and Resident #10. This is evidenced by: Example #1: Resident #1 was admitted to the facility on [DATE] for long term care due to dementia and heart failure. Review of the quarterly MDS (Minimum Data Set) completed on 01/08/13 for Resident #1 noted the following data: ~usually able to make self understood and understand others; ~BIMS (brief interview for mental status) score of 3 out of 15 which indicated significant impairments in cognition; ~independent in bed mobility, transfers, locomotion on the unit, and ambulation; ~required extensive assist with dressing and hygiene; ~required supervision for locomotion off the unit, eating, and toilet use; ~weight was 142# and no weight loss/gain; ~height was 72" ~had no problems chewing or swallowing; ~was not on any mechanically altered or therapeutic diet. Review of the nurse's notes for Resident #1 indicate that Resident #1 experienced a change in condition for which he was eventually sent to the emergency room for evaluation. Nurse's notes were as follows: ~01/02/13 1:12 p.m., LPN (Licensed Practical Nurse)-L wrote Resident #1 had emesis (vomiting) x6. Oxygen saturations 98% on room air. BP (Blood Pressure) = 132/58, pulse = 66, respirations = 20, and temperature = 97.9. ~01/02/13 at 1:59 p.m., RN-J wrote the physician was consulted via fax (facsimile). ~01/02/13 at 8:44 p.m., RN-J wrote Resident #1 had emesis x2 and liquid stool x3. Oxygen saturations 97% on room air. Temperature = 100.3, pulse = 54, respirations = 18, and BP = 122/60. ~01/03/13 8:41 p.m., LPN-L wrote Temperature = 97.8, pulse = 68, respirations = 18, and BP = 128/48. Resident #1 had no emesis or diarrhea this shift. ~01/05/13 12:29 a.m. RN-J wrote Resident had multiple loose stools, had unsteady gait. BP = 128/60, pulse = 70, respirations = 22, temperature = 96.9, and oxygen saturations = 94% on room air. ~01/05/13 1:54 p.m., LPN-L wrote Resident #1 had "extreme weakness and confusion...lost 7 LBS (pounds) in 4 days...very little urine output..." MD gave orders to send resident to the emergency room and daughter agreed. Resident sent to the emergency room . Resident #1 arrived at the ER (emergency room ) on 01/05/13 at 2:05 p.m. with the following assessment: BP = 102/29, pulse = 62, respiration = 20, temperature = 97.8, and oxygen saturations of 87% on room air. Resident #1 was given oxygen at 2 liters/min via a nasal cannula. The ER documentation reflects intravenous fluids for hydration along with intravenous medications to treat nausea. Resident #1 was not given any antibiotics or antifungal medications in the ER. Resident #1 also had a CT scan. The radiology report indicated aveloar filling (fluid in the lungs) secondary to either pneumonia or atelectasis (collapsed lung). The lab report indicated Resident #1 had an elevated WBC (White blood count) of 19.5 with normal values 4.0 - 11.0 and also an abnormal WBC differential with a "shift to the left" indicative of an infection. The WBCs combat infections. There are several types of WBCs in our blood stream. Under normal physical health, there are 1.4-6.5 immature WBCs in our blood. The WBC "shift to the left" when there is an increase of immature cells that are called upon by our body when there is an acute infection. Resident #1 had 16.5 immature WBC in the blood. The WBC differential report for Resident #1 showed an increase in these immature WBCs in a response to an acute infection. The ER physician ordered: ~1. push fluids; ~2. [MEDICATION NAME] 4 mgs every 6 hours, dispense 10; ~3. [MEDICATION NAME] 500 mgs every 12 hours for 7 days; ~4. [MEDICATION NAME] 750 mgs every 48 hours; ~5. Follow up with primary physician; ~6. Return to the ER if condition worsens. Resident #1 was returned to the nursing home on 01/05/13 at 9:15 p.m. Resident #1's nurses notes continued as follows: ~01/05/13, 9:44 p.m., LPN-C wrote Resident #1 returned to the facility at 9:15 p.m. Physician ordered [MEDICATION NAME] 4 mgs (milligrams) every 6 hours, [MEDICATION NAME] 500 mgs every 12 hours, and [MEDICATION NAME] 750 mgs every 48 hours. The DON (Director of Nurses) was notified of medication orders and instructed LPN to hold all medications until 01/07/13 as Resident #1's pharmacy had no contingency medications available at the nursing home. On 07/30/13 at 6:10 p.m., Surveyor # interviewed LPN-C via the telephone. LPN-C stated she recalled the night Resident #1 was so ill. LPN-C stated she had been instructed not to take the ordered medication out of contingency because the facility would incur the cost of those medications. LPN-C stated she recalled more than one telephone call to the DON requesting to transport Resident #1 back to the hospital so he could receive the ordered medications. LPN-C stated the DON denied this request. LPN-C stated she wanted to give Resident #1 the ordered medications but did not because she had been instructed not to and was fearful of losing her job if she did not follow orders. (The DON on 7/30/13 at 1:32 p/m. denied telling LPN-C not to give the medications. Either way, the ordered medications were not given.) ~01/06/13 1:44 a.m., LPN-A wrote Resident #1 had no nausea, vomiting, or diarrhea and had diminished lung sounds. ~01/06/13 at 12:54 p.m., LPN-L wrote Resident #1 had 88% oxygen saturations on room air. BP = 130/60, pulse = 67, respirations = 22, and temperature = 97.4. ~01/06/13 at 8:38 p.m., LPN-C wrote Resident #1 had expiratory wheezes in both lungs. BP =114/68, pulse = 76, respirations = 20, temperature = 97.1, and oxygen saturations = 93% on room air. ~01/07/13 at 2:50 a.m., LPN-A wrote Resident #1 had expiratory wheezing in both lungs and was pale with general appearance poor. All of the above notes were written by LPNs. There is no evidence that a Registered Nurse completed a comprehensive assessment of Resident #1's condition when a decline was evident, as evidenced by diminished lung sounds, expiratory wheezing, and drop in pulse oxygenation levels. LPNs by virtue of their training and the Nurse Practice Act are not equipped or empowered to assess residents or to develop a plan of action based on that assessment. There are no documented comprehensive physical assessments including vital signs, oxygen saturations, lung assessments, or hydration assessments documented on 01/08/13. The next entry was 01/09/13 at 11:59 a.m., LPN-L wrote Resident #1 continued with decline in nutrition, hydration, mental status, and physical strength. The primary physician was consulted and ordered another ER evaluation. The family was updated and agreed with ER evaluation. This note did not include any lung assessments or hydration assessments. ~01/09/13 at 1:31 p.m., RN-J wrote Resident #1 was admitted to the hospital with [REDACTED]. On 07/30/13 at 3:20 p.m., Surveyor # interviewed the DON The Surveyor asked the DON if she had any follow up, either by phone or in person, with the nursing home on 01/06/13 regarding Resident #1's status and she stated she did not call for a status update on Resident #1. The DON stated she assumed Resident #1 was "status quo." The Surveyor asked if the DON assessed Resident #1 and reviewed care provided on Monday 01/07/13 upon returning to work and the DON stated she did not assess Resident #1 and did not review the care provided for Resident #1 on 01/07/13. On 07/31/13 at 8:05 a.m., Surveyor # re-interviewed the DON. The Surveyor asked to view the 24 hour report sheets and the DON stated that information was not part of the medical record and would be shredded after 3 months. The Surveyor again asked the DON who was responsible to assess residents with a change in status when the facility was staffed with a LPN. The DON stated she was responsible to assess the residents. The Surveyor asked if the DON came into assess Resident #1 at anytime during the weekend and the DON stated "I don't even know if I was in town that weekend." The DON stated if she had assessed Resident #1 she would have documented her assessment. The Surveyor was unable to locate any RN assessments beginning with 01/05/13 2nd shift through 01/09/13 time of transfer to ER. Resident #1 was admitted to the hospital on [DATE] at 4:00 p.m. Review of the admission History and Physical report at theER on [DATE] for Resident #1 noted, "The patient came here to the emergency roiagnom on the 5th because he had been dehydrated. He was started on [MEDICATION NAME] because they found right lower lobe pneumonia and the [MEDICATION NAME] because he was having diarrhea. The patient didn't get better and he was not eating very well at home and so has been more dehydrated." Resident #1 had not received the [MEDICATION NAME], Levoquin, or [MEDICATION NAME] as noted in the admission History and Physical. The ER physician was not alerted to Resident #1 not receiving the previously ordered Levoquin, [MEDICATION NAME], or [MEDICATION NAME]. The admission History and Physical also noted Resident was given a dose of [MEDICATION NAME] and "got better after getting the IV medications." Review of the laboratory data for Resident #1 on 01/10/13 noted the following abnormal values: ~elevated WBC of 16.9 (normal 4.0 - 11). Indicative of infection; ~shift to left in WBC differential 14.3 (normal 1.4-6.5). Indicative of infection; ~elevated sodium 148 (normal 134-144). Indicative of dehydration; ~elevated creatinine 1.93 (normal 0.8 - 1.5). Indicative of dehydration; ~elevated BUN (blood urea nitrogen) on 01/05/13 of 87 (normal 9 - 20). Indicative of dehydration. ~elevated lipase 123 (normal 22 - 51). Indicative of pancreatitis; ~elevated amylase 195 (normal 36 - 128). Indicative of pancreatitis. The failure to ensure RN assessment of a resident whose condition declined and who concomitantly was not being given the medications ordered at theER on [DATE] created a finding of immediate jeopardy. The immediate jeopardy that began on 01/05/13 was removed on 08/05/13 when the facility: 1. Re-educated nursing staff on the non-business hours admissions and providing medications; 2. Implemented process for night shift nurse to verify all physician orders [REDACTED]. 3. Reviewed policies and procedures; 4. Reviewed and re-educated nursing on contingency drug use; 5. Re-educated nursing staff on medication errors; 6. Re-education of nursing staff to notify ER physician's of creatinine clearance requirements and have ER physician sign off; 7. Re-educated nursing staff on role of LPNs and RNs and the need for RN assessments. Example #2 Resident #10's current [DIAGNOSES REDACTED]. The most current MDS was dated 7/19/13 and indicated Resident #10: ~Had severely impaired cognition; ~Required extensive assistance of 1 staff person for bathing, dressing, grooming, toileting, and walking; ~Was not able to maintain balance without staff assistance; ~Was occasionally incontinent of bowels; ~Had a foley catheter; and ~Had 1 non-injury and 1 minor injury fall. Surveyor # completed a review of Resident #10's MDS dated [DATE]. It indicated Resident #10 walked independently with supervision, balance was steady, and was continent of bowels. Surveyor # completed a review of Resident #10's nursing notes and noted the following: On 12/12/12, Resident #10 was noted to have a bruise on the top of his right foot measuring 4 1/2 inches by 3 inches. According to the nursing notes the bruising spread to include the toes, instep, and heel. From 12/12/12 through 12/19/12 there was no RN assessment of Resident #10's foot. On 12/19/12, Resident #10 was sent to the emergency room for an evaluation of the right foot. According to hospital records dated 12/19/12, Resident #10 was diagnosed with [REDACTED]. Resident #10 was started on antibiotics and returned to the facility. On 1/3/13 a nursing note indicated, "...Onset of wheezing and general weakness...LS (Lung sounds) diminished at based. SOB (shortness of breath) with exertion...pedal [MEDICAL CONDITION] per usual...T (temperature) 100.6 02 89% on RA (room air)...Expiratory wheeze noted. Very weak and SOB. Needed w/c (wheel chair) for ambulation to bathroom..." The above assessment were completed by an LPN (Licensed Practical Nurse). There was no evidence of an RN assessment. This indicates a significant change in Resident #10's cardio-respiratory status. On 1/4/13 a nursing note indicated, "...Continues with audible wheeze..." This assessment was completed by an LPN. There were no RN assessments completed of Resident #10's cardio-respiratory status. On 1/4/13, Resident #10 was diagnosed with [REDACTED]. From 1/5/13 through 1/16/13 there were no RN assessment of Resident #10's cardio-respiratory condition. On 1/16/13, Resident #10 had a fall in the bathroom. There was no RN assessment at the time of the fall. From 1/17/13 through 1/24/13 there was no RN assessment of Resident #10's cardio-respiratory status. A nursing note dated 1/24/13 indicated, "...Resident noted with an increase in weakness and SOB with exertion the past couple of days. Decrease in appetitive this am (morning)...T (temperature) 99, 02 (oxygen) 89% on RA. LS diminished with expiratory crackles...was recently treated for [REDACTED]. There was no evidence of an RN assessment. On 1/24/13, Resident #10 had a chest x-ray and was diagnosed with [REDACTED]. On 1/25/13 a nursing note indicated, "...HOB (head of bed) elevated to aide in breathing...energy depleted. Assisted with transfers...w/c secondary to weakness...General decline, SOB, pain but not able to express location..." This indicates a significant change in Resident #10's cardio-respiratory status. From 1/24/13 through 1/25/13, there was no RN assessment of Resident #10's condition on 1/24/13 or 1/25/13. On 1/25/13 Resident #10 was admitted to the hospital and diagnosed with [REDACTED]. On 3/8/13, Resident #10 was readmitted to the facility from a sister facility. A nursing note dated 3/8/13 indicated, "...admitted following a stay for rehab after dx (diagnosis) pneumonia..." From 3/9/13 through 4/8/13, there was no RN assessment of Resident #10's condition. On 4/8/13, a nursing note indicated, "[MEDICAL CONDITION] to RLE (right lower extremity)...crackles to bilateral upper lobes (lung) 8 LB (8 pound) weight gain X 2 weeks (in 2 weeks)...Slight SOB noted on exertion..." This indicates a significant change in Resident #10's cardio-respiratory status. There was no RN assessment completed of Resident #10's cardio-respiratory status. On 6/21/13, Resident #10 had a fall. There was no RN assessment at the time of the fall. On 7/4/13, Resident #10 had a fall. There was no RN assessment at the time of the fall. On 7/9/13, Resident #10 had a fall. There was no RN assessment. On 8/7/13 at 1:00 p.m., Surveyor # spoke with LPN-D. LPN-D indicated he would request an RN to make an assessment if he had any question regarding a residents condition including significant changes in residents conditions. LPN-D indicated this would include things such as shortness of breath, abdominal pain, and suspected pneumonia. On 8/8/13 at 9:30 a.m., Surveyor # spoke with RN-J. RN-J indicated she worked part time. RN-J is the only RN working in the facility aside from the DON (Director of Nursing). Surveyor # asked RN-J if she had had ever been summoned by an LPN to complete an assessment. RN-J stated she had not. On 8/8/13 at 12:00 p.m., Surveyor # spoke with LPN-K. LPN-K indicated she worked full time. LPN-K indicated she would request an RN to make an assessment is she had any questions about a residents condition. Surveyor # asked LPN-K if she had ever asked an RN to make an assessment. LPN-K stated she had not. LPN-K indicated she kept the DON abreast of resident changes via conversation. On 8/7/13 at 10:50 a.m., Surveyor # spoke with the Physician-DD. Physician-DD stated an RN should complete an assessment any time there was a significant change in a residents condition including falls, changes in a cardio-respiratory status, changes in mental and psychosocial status, and symptoms indicating acute illness. Example #3: Surveyor # completed a review of Resident #6's clinical record and noted the following. Resident #6's current [DIAGNOSES REDACTED]. The most current MDS was dated 8/6/13 and indicated Resident #6: ~Had a BIMS score (Brief Interview of Mental Status) of 15 indicating no cognitive deficit; ~Required the assistance of 1 staff person for bathing, dressing, grooming, toileting, walking, and eating; and ~Had swallowing problems. Surveyor # completed a review of Resident #6's nursing notes and noted the following: On 9/3/12, Resident #6 had an unresponsive episode while seating on the toilet. There was no RN assessment. On 9/21/12, Resident #6 had a fall which resulted in minor injuries. There was no RN assessment. On 9/22/12 a nursing note indicated, "...CNA (Certified Nursing Assistant) notified nurse that resident was very 'gurgly'. Upon assessment, Resident had a large amount of thick saliva in mouth and into back of throat. Resident was encouraged to cough, which was unsuccessful. Resident was then successful, leaving mouth and back of throat free of thick secretions..." There was no RN assessment following Resident #6's change in condition. From 9/22/12 through 10/17/12 there was no RN assessment of Resident #6's respiratory status. On 10/17/12 nursing notes indicated; ~ "...4:22 AM...Resident very gurgly and unable to swallow, cough, or spit out frothy saliva. Resident was suctioned X3 (three times)...HOB (head of bed) elevated throughout shift...BP (blood pressure) 130/72, P (pulse) 76, R (respirations) 20, T (temperature) 97.7, 02 (oxygen saturation)...on RA (room air)...95%..." There was no RN assessment of Resident #6's condition. The physician was not contacted. ~ "...10:26 AM...Res (resident) with change in status: noted increased restlessness/anxiety. difficulty expressing needs at times...increased phlegm requiring suctioning x4...142/84 (blood pressure) P 98 R 20 T 98.8 02 sat (oxygen saturation) 93% RA. Confusion at times. LS (lung sounds) diminished at bases. Congestion noted. Fax to MD (Medical Doctor) Reply pending..." This was indicative Resident #6 was experiencing respiratory distress. There was no RN assessment completed. ~ "...8:35 PM...Resident transferred to...ED (Emergency department) at 1915 (7:15 p.m.)...BP 156/90, P104, R 22, T 101.9, 02 90% RA. Suctioned x3...unable to take medications...LS crackles throughout. Resident requested MD be called. Primary MD faxed..." Resident #6 continued experiencing respiratory difficulties. There was no RN assessment completed. Resident #6 was seen in the emergency room , diagnosed with [REDACTED]. On 8/7/13 at 1:00 p.m., Surveyor # spoke with LPN-D. LPN-D indicated he would request an RN to make an assessment if he had any question regarding a residents condition including significant changes in residents conditions. LPN-D indicated this would include things such as shortness of breath, abdominal pain, and suspected pneumonia. On 8/8/13 at 9:30 a.m., Surveyor # spoke with RN-J. RN-J indicated she worked part time. RN-J is the only RN working in the facility aside from the DON (Director of Nursing). Surveyor # asked RN-J if she had had ever been summoned by an LPN to complete an assessment. RN-J stated she had not. On 8/8/13 at 12:00 p.m., Surveyor # spoke with LPN-K. LPN-K indicated she worked full time. LPN-K indicated she would request an RN to make an assessment is she had any questions about a residents condition. Surveyor # asked LPN-K if she had ever asked an RN to make an assessment. LPN-K stated she had not. LPN-K indicated she kept the DON abreast of resident changes via conversation. On 8/7/13 at 10:50 a.m., Surveyor # spoke with the Physician-DD. Physician-DD stated an RN should complete an assessment any time there was a significant change in a residents condition including falls, changes in a cardio-respiratory status, changes in mental and psychosocial status, and symptoms indicating acute illness.

Based on interview and record review, the facility did not provide care to prevent the development of pressure ulcers and/or to promote the healing of existing pressure ulcers for 1 of 1 residents reviewed for pressure ulcers. Resident #14 had a history of [REDACTED]. The facility did not implement approaches to prevent the pressure ulcers from recurring. On 7/3/12, Resident #14 was identified as having a Stage 2 pressure ulcer to the right buttock. There was no treatment ordered for the pressure ulcer and no changes made to the care plan. 20 days later, the pressure ulcer to the right buttock had deteriorated and a second pressure ulcer developed on the left buttock. Both areas continued to deteriorate and increase in size until Resident #14's transfer to the hospital on [DATE]. This is evidenced by: The facility provided Surveyor # with a "Pressure Sore Treatment Protocol" which is undated and without reference. The procedure for a Stage 1 pressure ulcer includes: "A. Notify MD/PA (Medical Doctor/Physician Assistant) "B. Treatment Options, [MEDICATION NAME] ointment...transparent dressing-change every 5 to 7 days or when redness resolves, or when the dressing becomes compromised; or as per MD order." The procedure for a Stage 2 pressure ulcer includes: "A. Notify MD "B. Treatment options...Abrasion or shallow crater, [MEDICATION NAME] for area not requiring frequent dressing change-change dressing every 3 days and PRN (as needed) or per MD order; or, Hydrogel for area if requiring a dressing change more frequently than every 48 hours-apply hydrogel to the affected area sparingly and cover with a non-stick pad....; or, As per MD order..." Resident #14 was originally admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #14's care plan included a problem of "Potential for skin breakdown" dated 12/10/10. Approaches include to reposition and toilet every 2 hours, observe for skin breakdown, provide appropriate perineal cleansing if incontinent, keep linens and clothes wrinkle free. The facility provided Surveyor # with a copy of a "Wound Assessment Report." The report indicated that Resident #14 had a 1.0 x 1.0 cm (centimeter) Stage 2 pressure ulcer to the right buttock on 5/7/12. No other information regarding this area was received. Resident #14 was readmitted after a hospital stay on 6/1/12. Nurse's note on 6/1/12 states, "Resident right buttocks noted with a 1 cm x 1 cm (centimeter) scabbed area...Left buttocks noted with a 0.5 cm x 0.5 cm reddened area that appears scarred..." On 6/4/12, staff documented pressure ulcers on the right and left buttocks. These areas are documented as healed on 6/18/12. There were no changes to Resident #14's care plan to prevent the pressure ulcers from redeveloping. The MDS (Minimum Data Set) assessment, dated 6/7/12 indicates that Resident #14: ~Requires extensive assist for bed mobility; ~Is at risk for developing pressure ulcers; and ~Does not have any pressure ulcers. The facility completed a "Risk of Pressure Ulcer" assessment on 6/12/12. The assessment indicated that Resident #14 was "No-Low Risk." Surveyor # reviewed a "Skin Condition Report" dated 7/3/12. The report indicates that Resident #14 has a "1 cm x 1 cm sore on R (right) buttock with small open area in center." An LPN (Licensed Practical Nurse) faxed the physician with a recommended course of treatment to monitor every shift until resolved and every 2 hours repositioning. There is no evidence of an RN assessment of the pressure ulcer. The physician agreed with the LPN recommendation. Review of the MAR (Medication Administration Record) includes "Monitor pressure sore (sic) to right buttock q shift untilk (sic) resolved. Start date: 7/03/12." There was no dressing or treatment ordered for treating the pressure ulcer. According to 2009 "Pressure Ulcer Treatment Quick Reference Guide" developed by the NPUAP (National Pressure Ulcer Advisory Panel) and the EPUAP (European Pressure Ulcer Advisory Panel), "Wound dressings are a central component of pressure ulcer care. The selection of the dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure." Leaving a pressure ulcer without any dressing is not an accepted standard of practice for wound care. Documentation on Resident #14's pressure ulcer includes the following: 7/16/12 Skin Condition Report - Right buttock 0.8 cm x 0.7 cm, "Pink scab." An alternating air overlay was implemented. 7/23/12 Skin Condition Report - Right buttock 1.0 cm x 1.0 cm. Left buttock 0.2 cm x 0.2 cm. "Scabbed area-pink." A "Donut Hole in Chair" was implemented. 7/23/12 Wound/Skin Healing Record - includes both open areas on one line (the directions for use of this form indicates that a separate sheet should be used for each pressure ulcer cite). Measurements are same as on the Skin Condition Report. Stage 2 is checked, however it is unclear which pressure ulcer is a Stage 2 and which may be unstageable due to "Scabbed area." The form indicates that Care Plan was updated to include "Donut hole to w/c (wheelchair) and recliner. " The right buttock showed signs of deterioration and the left buttock reopened. The description documented does not indicate which pressure ulcer is being described. Review of the nurse's notes finds no evidence that the RD (Registered Dietician) was informed in order to assess Resident #14 needs and implement appropriate nutritional interventions. There is also no evidence that the facility consulted with the physician when deterioration was noted on the right buttock and a new area redeveloped on the left buttock. There was no treatment order and staff continued to monitor the area. On 7/25/12, Resident #14's care plan for "Potential for Skin Breakdown" was updated to include an approach of "Cushion to recliner/wheelchair at all times to prevent skin breakdown. " According to 2009 "Pressure Ulcer Treatment Quick Reference Guide" developed by the NPUAP (National Pressure Ulcer Advisory Panel) and the EPUAP (European Pressure Ulcer Advisory Panel), ring or donut shape devices should not be used for pressure ulcer healing. Review of Resident #14's care plan finds an undated problem of "Pressure Ulcer." The approaches are not individualized and include: ~Administer treatments as ordered by physician and document; ~Administer pain medication prn; ~If no improvement in wound appearance by 14 days after treatment order changed, notify physician and request new treatment order; ~Dietician to evaluate and follow up; ~Provide diet high in protein with inbetween (sic) meal snacks; ~Record food intake % at each meal. Report any decline to physician and dietician. ~Offer food substitutes if resident refuses to eat; ~Use pillows, air mattress, other supportive devices to assist with positioning and while in recliner and wheel chair; ~Avoid use of restrictive clothing; ~Provide perineal cleansing; ~Turn and position every 2 hours as indicated by individual turning schedule; ~Teach resident risk factors for development of pressure ulcers. 7/30/12 Skin Condition Report - Right buttock crease 1.2 cm x 1.2 cm. Left buttock crease 0.5 cm x 0.5 cm. Appearance: "Scabbed area - pink in color." treatment plan: [REDACTED]. " 7/30/12 Wound/Skin Healing Record - Both pressure ulcers are included on the same entry. Stage 2 is checked, however it is unclear which pressure ulcer is a Stage 2 and which may be unstageable due to "Scabbed area." 8/6/12 Skin Condition Report - Right buttock crease 1.5 cm x 1.5 cm. Left buttock crease 1.5 cm x 1.5 cm. "Scabbed areas. Pink in color." treatment plan: 8/6/12 Wound/Skin Health Record - Both pressure ulcers are on the same line. Measurements are the same as on the Skin Condition Report. No stage is indicated. The wounds again show signs of deterioration. There is no evidence that the care plan was changed to include individualized approaches to promote healing. There is no evidence that the physician was consulted regarding the lack of healing and the need to implement a treatment/dressing to assist with healing. There is no evidence that the RD was informed and assessed Resident #14 for nutritional support. 8/13/12 Skin Condition Report - Right buttock crease 1.0 cm x 1.0 cm. Left buttock crease 1.0 cm x 1.0 cm. "Areas scabbed over. Pink. Granulation." There is no way to determine which pressure ulcer is scabbed over, and which has granulation tissue present. 8/13/12 Wound/Skin Healing Record - Indicates same information as the Skin Condition Report. 8/20/12 Skin Condition Report - Right buttock crease 1.0 cm x 1.0 cm. Left buttock crease 1.0 cm x 1.0 cm. "Scabbed. Surrounding tissue pink. Gran (granulation) present. " 8/20/12 Wound/Skin Healing Record - Indicates same information as the Skin Condition Report. From 7/3/12 through 8/28/12, there are no additional nurse's notes related to Resident #14's pressure ulcers. Resident #14 was transferred to the hospital following a fall on 8/27/12. The History and Physical dated 8/28/12 states, "...Does show two sacral decubitus. Left is 1 cm x 0.5 cm, Stage II with 2 cm surrounding [DIAGNOSES REDACTED]. Right is 1 cm x 0.5 cm, Stage I." On 8/7/13, Surveyor # interviewed the Dietary Manager (DM) regarding Resident #14. When asked if she was made aware of Resident #14 having 2 pressure ulcers, the DM indicated that she was not aware of any pressure ulcers. The DM indicated that if she had known Resident #14 had pressure ulcers, she would have notified the RD. On 8/7/13, Surveyor # spoke with RD-CC, the current RD regarding her involvement when a resident develops a pressure ulcer. RD-CC stated that she was not with the facility at the time Resident #14 had the pressure ulcer. RD-CC indicated that if a resident develops a pressure ulcer, she would expect staff to report that to her so nutritional interventions could be implemented. On 8/8/13, Surveyor # and # spoke with RN-J (Registered Nurse) regarding Resident #14. RN-J was asked about the implementation of a donut type cushion for treatment/prevention of a pressure ulcer. RN-J indicated that the cushion was brought from home and that was what Resident #14 used. When asked about the lack of a treatment/dressing, RN-J indicated staff only monitored per physician order. RN-J indicated that Resident #14 had "Lost the will to live," and had a decline in status. (Refer to F250, F325, and F327.) The Director of Nursing was not available for interview.

Based on record review, policy review, and interviews the facility did not ensure an environment free of accidents and hazards and/or appropriate supervision to prevent accidents for 4 out of 14 sampled residents. Resident #7 had a fall on 08/18/12 without any root cause analysis and changes to the care plan to prevent another fall. Resident #7 fell again on 08/24/12 which resulted in a hip fracture and a decline in physical function. Resident #1 had eloped from the facility on 3 separate occasions (07/29/12 twice and 08/02/12). Resident #1 repeatedly removed the Wanderguard device or would elope out of a door not alarmed with the Wanderguard system. The facility did not conduct an elopement assessment until 10/23/12 and did not investigate the 3 elopements. The facility continued with the same ineffective safety devices and did not implement any other changes to the care plan. Resident #5 had 8 falls from 8/1/12 to the present day. Of these eight falls, the facility did not initiate immediate interventions after two of them, in attempts to prevent another fall. Five of the falls occurred while the resident attempted to go to, use, or return from the bathroom and the facility did not re-evaluate Resident #5's toileting plan. Two of the falls appeared to the CNA to be purposeful attempts at falling. The facility did not assess whether these were attempts at self-harm. Resident #10 had a history of [REDACTED]. 2 of the 5 falls resulted in minor injuries. After each fall the facility did not complete a thorough investigation to determine the root cause of the fall in order to implement appropriate interventions to prevent further falls. Additionally 2 of the 5 falls had no investigation. This is evidenced by: On 07/29/13, Surveyor # received and reviewed the facility policy titled "Resident Incident/Accident Policy." The policy read "It is the policy of Avanti Health Systems to assure resident safety through pro-active prevention and safety awareness as well as individualized resident care plans. If, however, a resident should become injured, nursing staff will follow established procedures for investigating the accident or incident consistent with the directives of the facility's Quality Improvement Committee." The policy also reads "After the resident has been treated...the nurse will conduct a preliminary investigation as to the cause of the accident or incident...The DON (Director of Nurses) and/or the administrator will conduct a more thorough investigation following any accident or incident which results in serious injury of death." Example #1: Resident #7 was admitted to the nursing home on 09/04/07 for long term care due to Alzheimer's dementia, arthritis, and congestive heart failure. The MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #7: ~able to make self understood and understand others; ~independent with bed mobility, transfers, ambulation, and toilet use; ~required supervision with locomotion on/off unit, eating, and dressing; ~required extensive assistance with hygiene and bathing; ~had good balance and a steady gait; ~continent of bladder and bowel. The facility completed a fall risk assessment for Resident #7 on 08/03/12 and noted Resident #7 was a low risk for falls. The risk factors identified on the assessment for Resident #7 were impaired vision, limited safety awareness, and the use of a cane for ambulation. Review of the nurses notes dated 08/18/12 at 8:53 p.m., noted Resident #7 was found on the floor in the hallway of 3rd floor. Resident #7 was transferred to the emergency room for evaluation. Resident #7 returned to the facility on [DATE] at 11:20 p.m. with no acute injury. The physician ordered to assist Resident #7 to the bathroom. Review of the care plan titled "Potential for falls..." with an onset date of 08/18/12 listed dementia, arthritis, and macular degeneration as contributing factors. The goal was for no injury due to falls over the next 90 days. The approaches did not include any information regarding the root cause of the fall on 08/18/12. The approaches did not include the use of a cane as an assist device. The approaches were not individualized. The approaches were as follows: ~"Observe & document level of function..." ~"If fall/accident occurs, assess for injury..." ~"Promote staff awareness of potential for falls..." ~"Provide R.O. (reality orientation)...." ~"Call light in reach in own room & bathroom, answer promptly, orient to use & remind to call for assist as needed." ~"Bed in low position except during direct cares..." ~"Assure well lighted clutter free environment." ~"1:1 visits prn (as needed)..." Review of the Special Needs Committee notes dated 08/22/12 noted Resident #7 had a fall on 08/18/12. The change to the care plan identified from the Special Needs Committee note was to remind Resident #7 to use cane while ambulating. These change were not reflected in the care plan listed above. In addition, Resident #7 had Alzheimer's dementia and had impaired short term memory, potentially making a reminder an ineffective intervention. In addition, the recommendation from the physician to assist Resident #5 to the bathroom was also not included on the care plan. On 08/24/12 at 12:20 a.m., Resident #7 had another fall in the hallway on her way to the bathroom. Resident #7 was not provided staff assistance to the bathroom in accordance with the physician order. Resident #7 was transferred to the emergency room and diagnosed with [REDACTED]. Resident #7 sustained a decline in function following the fall and hip fracture. On 07/30/13 at 8:45 a.m., Surveyor # interviewed the DON (Director of Nurses) regarding Resident #7's fall. The Surveyor asked what was the root cause of Resident #7's fall on 08/18/12 and the DON was unsure. The Surveyor asked what changes to the care plan happened after the fall on 08/18/12 and the DON stated Resident #7 did not have a fall care plan prior to 08/18/12. The Surveyor asked what individualized fall care plan interventions were in place for Resident #7 and the DON stated she was unsure. The Surveyor asked the DON on 07/29/13 at 4:50 p.m. and 07/30/13 at 11:35 a.m. for the falls investigation for Resident #7's fall on 08/18/12 and 08/24/12. The Surveyor was not provided with any information. Example #2: On 07/30/13, Surveyor # requested and reviewed the policy titled "Elopement." The purpose of the policy was "To assure documentation of elopement attempts and interventions initiated to maintain safety." The policy reads, "Report residents attempt to leave facility...to charge nurse...charge nurse will initiate temporary elopement care plan...apply Wanderguard and refer to Special Needs. Initiate every 1/2 hr (Hour) monitoring as needed...attempts to leave facility unaccompanied to be reviewed by Special Needs Committee. Special Needs to review interventions placed and implement plan of care." Resident #1 was admitted to the facility on [DATE] for long term care of dementia, congestive heart failure, atrial fibrillation, and colon cancer. The facility completed an admission MDS (Minimum Data Set) for Resident #1 on 07/27/12 with the following data: ~usually able to make self understood and understand others; ~BIMS (Brief Interview for Mental Status) score of 3 out of 15 indicative of cognitive impairment; ~no wandering behaviors; ~independent with bed mobility, transfers, ambulation, and toilet use; ~required supervision with locomotion on and off unit and eating; ~required limited assist with dressing and hygiene; ~had steady gait. Resident #1 had a temporary care plan dated 07/16/12; however there was no mention of the Wanderguard use or suicidal behaviors. Resident #1 had another temporary care plan due to a room change dated 07/28/12 and again there was no mention of the Wanderguard. The care plan is incomplete as evidenced by no measurable goals and no individualized approaches. Resident #1 had a resident to resident altercation with room mate on 07/28/12 and was moved from 3rd floor to 2nd floor. Resident #1 does have a care plan titled "Potential for wandering..." and does include the use of a Wanderguard; however the care plan does not have an implementation date and has no individualized approaches for Resident #1. The facility completed the first elopement assessment dated [DATE] for Resident #1. The facility identified Resident #1 was at risk for elopement and placed on the elopement risk protocol. The facility completed the second elopement assessment dated [DATE] for Resident #1. The facility concluded Resident #1 was at a moderate risk for elopement and continued with the elopement risk protocol. Entries in the nurses notes are as follows: ~07/17/12 Wanderguard placed on Resident #1 due to statements of wanting to go home and exit seeking behavior. ~07/19/12 at 9:29 p.m., Resident #1 was restless and wanting to cut off Wanderguard and exit building. ~07/21/12 at 8:21 p.m., Resident #1 was standing at the 3rd floor railing threatening to jump off and kill self. Staff called the DON and left message. Staff called the SW (Social Worker) who stated to contact Resident #1's daughter if Resident #1 can not be redirected. Staff implemented 15 minute checks and a temporary care plan for agitation. ~07/24/12 at 8:44 p.m., Resident #1 was attempting to cut off Wanderguard by using pliers. ~07/29/12 at 8:59 p.m., Resident #1 had exited the north door twice during shift. ~08/02/12 9:21 p.m., Resident #1 left the facility and became angry with redirection. ~08/04/12 7:54 p.m., Resident #1 found without Wanderguard on and stated he would remove other Wanderguards and throw it off of the deck like he did the previous Wanderguards. ~08/06/12 at 8:08 p.m., Resident #1 was attempting to remove the Wanderguard and was demanding it be removed. Wanderguard eventually came off on that shift. ~10/16/12 at 8:23 p.m., Resident #1 was pulling on Wanderguard and stating he was getting out of here and going home. ~11/22/12 at 3:24 a.m., Resident #1 was without Wanderguard. Staff was unable to locate another Wanderguard. Staff frequently observed Resident #1 for the remainder of the shift. ~12/09/12 at 11:07 p.m., Resident #1 was without Wanderguard. New Wanderguard applied. ~12/18/12 at 12:18 a.m., Resident #1 was without Wanderguard. Staff was unable to locate another Wanderguard. Staff frequently observed Resident #1 for the remainder of the shift. Surveyor # reviewed the complete medical record for Special Needs Committee notes to address the 3 elopements, the exit seeking behavior, the suicidal ideation, and the Wanderguard interventions for elopements. The Surveyor was unable to locate any Special Needs Committee notes that reviewed any of these behaviors or care plan interventions. Surveyor # requested any information regarding the investigations into Resident #1's elopements, behaviors, temporary care plans, and Wanderguard use from the DON on 07/29/13 at 4:50 p.m., 07/30/13 at 8:45 a.m. and 11:25 a.m., and again on 07/31/13 at 8:00 a.m. No additional information was provided. On 07/29/13 at 9:53 a.m., Surveyor # interviewed CNA-I (Certified Nursing Assistant) who stated she had cared for Resident #1. CNA-I stated Resident #1 ambulated independently throughout the facility and had a Wanderguard on his ankle. CNA-I stated Resident #1 removed the Wanderguard "more than once." CNA-I stated Resident #1 would wander out of the building through the north exit door. The north exit door does not have a Wanderguard system. The Wanderguard system is located on the main entrance door on the 2nd floor. On 07/29/13 at 10:18 a.m., Surveyor # interviewed CNA-M who stated she had cared for Resident #1. CNA-M stated the Wanderguard was checked daily for placement and function for Resident #1. CNA-M stated Resident #1 had removed the Wanderguard "a few times." On 07/29/13 at 4:10 p.m., Surveyor # interviewed RN-J (Registered Nurse) who stated she had cared for Resident #1. RN-J stated Resident #1 had elopement episodes, but was redirected back into the facility. RN-J stated Resident #1 had removed the Wanderguard on more than one occasion. On 07/30/13 at 8:10 a.m., Surveyor # interviewed MS-P (Maintenance Staff) regarding the Wanderguard system. MS-P stated the Wanderguard system was on the main entrance door on 2nd floor and the other exit doors were alarmed, but open. MS-P stated the 4 other exit doors were on the alarm panel located across from the nurses station and would continue to sound until the alarm was manually reset. The north door was on the alarm panel and was checked by Surveyor # and MS-P along with the other 3 doors. All doors triggered the alarm system. Prior to 07/28/12, Resident #1 was on the 3rd floor in a room located approximately 25 yards away from the stairwell and approximately 40 yards from the elevator. On 07/28/12, Resident #1 was moved to the 2nd floor in a room which was only 5 feet from the fire exit door. Once through the fire exit door, Resident #1 could exit onto the deck or exit out the north door. Both of these exits were only a few feet past the fire exit door. On 07/30/13 at 1:54 p.m., Surveyor # interviewed LPN-L (Licensed Practical Nurse) who reported caring for Resident #1. LPN-L stated Resident #1 had more than one elopement episode and removed the Wanderguard bracelet on more than one occasion. LPN-L stated Resident #1 was found outside twice on 07/29/12 at the junction of the sidewalk from the north exit door and the parking lot. LPN-L stated Resident #1 was leaving the building and wanted to go home. LPN-L stated Resident #1 was very fast with ambulation. LPN-L stated Resident #1 "hated the Wanderguard." On 07/30/13 at 1:32 p.m., Surveyor # interviewed the DON regarding Resident #1's elopements. The Surveyor asked what other interventions were tried since the Wanderguard was not effective and the DON stated there were no other interventions tried. The Surveyor asked if alternate room changes had been considered and the DON stated she could not recall. The Surveyor asked why the elopement assessment was not completed upon admission and the DON stated she was unsure. The DON stated the elopement assessment was to be completed upon admission, quarterly, and with any change in status. The DON stated Resident #1 was ambulatory and was unhappy with the Wanderguard bracelet. The DON stated she was aware of Resident #1's elopements and was unsure why no investigations were completed. The DON stated she was unsure why the Special Needs Committee did not address Resident #1's elopements in accordance with the facility policy. Example #3: Resident #5 has medical [DIAGNOSES REDACTED]. Resident #5 had 4 falls prior to an event on 02/11/13 in which staff found her with a call cord wrapped around her neck (8/1/12, 9/19/12, 10/8/12, and 12/30/12), and continued to have five more falls following this event (2/21/13, 4/3/13, 6/2/13, 6/12/13, and 7/1/13), as evidenced below: ~ 8/1/12 at 7:10 p.m.: Resident #5 was up ambulating herself to the bathroom, lost her balance and fell on to her right side. The facility initiated a walker for the resident's use. ~ 9/19/12 at 8:05 a.m.: Resident #5 was returning from the bathroom, went to sit on the side of the bed and missed the bed, slipping to the floor. The approach the facility initiated was to remind Resident #5 to use the walker. ~ 10/8/12 at 6:15 p.m.: Resident #5 had a fall in the bathroom while getting ready for bed. She slipped and hit her head on the porcelain toilet. The approach the facility initiated was to encourage Resident #5 to ask for assistance with evening cares, use non-skid footwear, and not to be left unattended with cares. ~ 12/30/12 at 4:30 p.m.: Staff heard Resident #5 cry out for help. Upon arriving to her room, staff found the resident laying on her right side. The resident's roommate stated that Resident #5 was backing herself up without the walker. The resident stated that she hit her head on the floor. The facility approach was the removal of clutter in the resident's room. ~ 2/21/13 at 6:30 p.m.: Resident #5 had transferred herself out of bed and activated the pressure alarm. Staff responded to the alarm and found the resident sitting on the floor against her bed and nightstand. A 13 cm (centimeter) x 7 cm lump was noted on the resident's left upper buttocks, with bruising beginning to form. The facility did not initiate any immediate intervention. However, on 2/27/13 the Special Needs Committee met and initiated a mobility clip alarm while in bed, in addition to the stationary pressure alarms already in place in bed and chair. ~ 4/3/13 at 5:35 p.m.: Resident #5 was in the bathroom on the toilet and slid from the toilet to the floor, striking her right shoulder. There was no immediate intervention. However, on 4/10/13 the Special Needs Committee initiated to not leave Resident #5 unattended in the bathroom. This intervention was implemented with the 10/8/12 fall in which the resident was to not be left alone with evening cares. ~6/2/13 at 12:31 a.m.: Staff heard a "thump," the mobility alarm sounding, and the resident's cry for help at the same time. Upon investigating, staff found Resident #5 on her hands and knees with her head between the bed and the nightstand. Resident #5 was moaning and requesting help up from the floor. The resident was confused and stated that she had bumped her head. The immediate response of the facility was to move the nightstand away from the bed and repositioned the resident so that her knees were against the wall versus the side of the bed away from the wall. A floor mat was also placed beside the non-wall side of the bed. At 3:59 a.m., the nurse documented that bruising was forming over the resident's nose a size of 1.5 cm going from the bridge of her nose to the inner corner of her right eye. ~6/11/13 at 11:20 p.m.: Resident put on her call light, but not waiting for assistance, self-transferred to the bathroom. Staff responded to the call light, and upon hearing a "thud" entered the room and found the resident laying on her right side on the floor mat with her head facing the foot of the bed. The immediate response was placing the resident on 15 minute checks. The resident's room was changed the following morning to be closer to the nurses station. On 6/19/13 a physical therapy evaluation was conducted. A foam wedge and concave mattress were also initiated in bed to prevent the resident from falling out of bed. At least five of the resident's falls (8/1/12, 9/9/12, 10/8/12, 4/3/13, 6/11/13) occurred while the resident was attempting to go to the bathroom, while she was in the bathroom, or when she was returning from the bathroom. (The facility did not assess whether the falls on 12/30/12, 2/21/13, or 6/2/13 were related to attempts to use the bathroom.) The facility did not reassess this resident's toileting program and did not implement an individualized plan to proactively ask the resident if she needed to use the bathroom or to offer the resident assistance with going to the bathroom. The resident's 2/14/13 OBRA Admission assessment, the 5/7/13 quarterly assessment, and the 6/28/13 significant change assessment all indicate "No toileting program." On 8/8/13 at 1:30 p.m., Surveyor # asked CNA-T (Certified Nursing Assistant) about her knowledge of Resident #5. CNA-T stated that prior to the incident of 2/11/13, she had been ambulating Resident #5 and noticed Resident #5 to just let go of the walker and push herself back, "...like she was doing the Nestea plunge..." She stated that she reported it verbally to the nurse, but could not recall which nurse it was. CNA-T then stated that it happened a second time after the call-light cord incident and she reported this to the nurse as well. She was unable to recall the date. The facility did not assess whether these falls/attempted falls were an attempt at self-harm. Example #4: Resident #10's current [DIAGNOSES REDACTED]. The most current MDS was dated 7/19/13 and indicated Resident #10: ~Required extensive assistance of 1 staff person for bathing, dressing, grooming, toileting, and walking; ~Was not able to maintain balance without staff assistance; ~Was occasionally incontinent of bowels; and ~Had 1 non-injury and 1 minor injury fall. Resident #10's most current CAA's (Care Area Assessment summary) for falls was dated 7/24/13. It indicated Resident #10's gait had become more unsteady, and was requiring staff assistance for transferring and walking. The CAA also indicated a care plan would be developed. Surveyor # requested all of Resident #10's care plans back to 1/1/13. Resident #10's most current fall care plan was dated 3/8/13. The care plan had the following approaches; ~Undated, "...Call light in reach...remind to call for assist...Bed in low locked position...Assure well lighted clutter free environment..." ~4/10/13, "...Gripper pad to recliner at all times..." ~7/4/13, "...Pressure Alarm...at all times..." Surveyor # completed a review of a fall care plan dated 1/17/13. The care plan included all the approaches as listed on the care plan of 3/8/13 except the use of a gripper pad to the recliner. The care plan also referenced alarms on both bed and chair however did not specify type. All approaches were undated. Resident #10's most current fall risk assessment was dated 6/4/13. It indicated Resident #10 was at high risk for falls. Surveyor # completed a review of Resident #10's nursing notes and noted the following; ~ 1/16/13, "...Resident was in bathroom attempting to self transfer himself off the toilet, and must have lost has balance...was found sitting on the floor between the toilet and the wall...sm (small) reddened area to top middle of back..." Surveyor # completed a review of an "Incident Investigation" dated 1/17/13. It indicated, "...unwitnessed fall while in bathroom. Resident is mainly independent with toileting but does require assist for emptying urinary drainage bag...Interventions to include stand by assist with transfers/ambulation/toileting..." There was no indication the facility attempted to determine the cause of Resident #10's fall. There were no new approaches added to Resident #10's plan of care to prevent further falls based on the cause of the fall. Nursing notes continue; ~ 4/10/13, "...Was found by CNA (Certified Nursing Assistant) on floor in front of recliner where he had been sitting...gripper sheet added to chair..." Surveyor # completed a review of an "Incident Investigation" dated 4/22/13. This was 12 days after Resident #10's fall. The investigation indicated, "...Resident with fall without head injury, No s/s (signs and symptoms) of injury. Gripper sheet added to recliner..." The information gathered during the fall itself was incomplete. There was no account of how Resident #10 was found. According to the care plan dated 1/17/13, Resident #10 was to have an alarm on both the bed and chair and stand-by assistance for all transfers and ambulation. There was no indication of the status of the alarm. While the facility added a gripper sheet to Resident #10's recliner, there was no indication the facility investigated the actual cause of the fall. Nursing notes continue; ~ 6/21/13, "...Another resident reported that resident was on floor. Resident found on floor in day room area with back against the wall. No injury was noted..." ~ 7/1/13, "...Special needs committee met on 6/26/13 to discuss resident fall on 6/21/13. Resident has been noted to be self transferring more frequently...Resident gait fluctuates...at times loses balance. After fall staff applied mobility alarm..." Surveyor # completed a review of an "Incident Investigation" dated 7/9/13. The investigation indicated, "...unwitnessed incident near elevator area in day room. Resident unable to recall events leading up to incident...It is apparent resident had been self transferring/ambulating. Resident had taken off clip alarm...staff to assure clip alarm on at all times..." There were no new approaches added to Resident #10's plan of care to prevent further falls. Nursing notes continue; ~ 7/4/13, "...Dietary notified writer that Res found on floor in elevator. Upon assessment Resident lying on back. Clip alarm intact and attached to resident...Pressure alarm put on chair to replace clip alarm...superficial abrasion to left elbow size of dime..." Surveyor # requested the investigation into the fall of 7/4/13. None was received. Nursing notes continue; ~ 7/10/13, "...Late entry for 7/9/13...Resident fell in his room while ambulating. CNA reported 'that right before his bed he lost balance and very slowly fell backwards to the floor.' Resident landed on his left hip and shoulder..complained of knee discomfort this evening...received order... for PT (physical therapy) eval..." ~ 7/11/13, "...Resident c/o (complained of) some left lower back pain today..." Surveyor # requested the investigation into the fall of 7/10/13. None was received. It was uncertain how Resident #10 fell with staff in attendance. There were no new approaches added to Resident #10's plan of care to prevent further falls. On 8/7/13 at 9:15 a.m., Surveyor # observed the recliner in Resident #10's room. There was no gripper material on the seat of the recliner. On 8/7/13 at 1:00 p.m., Surveyor # spoke with LPN-D (Licensed Practical Nurse) about the facility's fall prevention program. LPN-D indicated the nurses on the floor were responsible to assess a resident after a fall, start an investigation on the cause of the fall by talking with the resident and any staff who witnessed the fall. LPN-D indicated the nurses were also responsible to implement new approaches as indicated. LPN-D stated this information was directed to the DON (Director of Nursing) who then completed the investigation. On 8/7/13 at 8:30 a.m., Surveyor # spoke with the DON via phone about the facility's fall prevention program. The DON indicated falls were discussed daily at their daily interdisciplinary meetings as well as weekly. The DON indicated the nurses on the floor were responsible to begin an investigation and she completes it. Surveyor # asked the DON about Resident #10's falls. The DON stated because she was not in the facility she did not have access to the information Surveyor # asked. No additional information was received from the facility regarding Resident #10's falls.

Based on interviews and record reviews, the facility did not ensure that 1 of 9 residents reviewed for hydration was provided with sufficient fluids to meet assessed needs. Resident #14 was hospitalized with a [DIAGNOSES REDACTED]. Upon readmission, the Registered Dietician (RD) assessed Resident #14's fluid needs and initiated fluid intake monitoring. Resident #14 consistently took less than her assessed fluid needs. Beginning 6/26/12, Resident #14 had a significant decline in fluid intakes. There is no evidence that staff analyzed the daily fluid intakes, alerted the RD to the low intakes and/or implemented approaches to assist Resident #14 in meeting her daily fluid needs. On 8/27/12, Resident #14 was transferred to the hospital following a fall at the facility. Admitting [DIAGNOSES REDACTED]. This is evidenced by: On 8/8/13, Surveyor # received a copy of the facility's "Resident Hydration and Prevention of Dehydration" policy and procedure dated December 2011. The following is noted: "The Dietitian will assess all residents for hydration adequacy at least quarterly and more often as necessary per resident need...Nursing staff will assess for signs and symptoms of dehydration during daily care...The Dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake...Nursing will monitor and document fluid intake and the Dietitian will be kept informed of status. Interdisciplinary Team will update care plan and document resident responses to interventions until team agrees that fluid intake and relating factors are resolved." Resident #14 was readmitted to the facility on [DATE] from the hospital. [DIAGNOSES REDACTED]. On 6/6/12, the RD documents the following assessment in the Departmental Notes: "Resident #14 recently returned from the hospital with DC (discharge) dx (diagnosis) acute [MEDICAL CONDITION] r/t dehydration and UTI (urinary tract infection)...Fluid intake ranges from 60-360 cc (cubic centimeter) per meal. She is on I&O (Intake and Output), fluid needs at current weight of 155.5# estimated at ~ (approximately) 2000cc/day..." Resident #14's care plan includes a problem of "Potential for alteration in nutrition, less than body requirements and dehydration" which is dated 3/12/12. Approaches related to hydration include, "Observe for s/s (signs and symptoms) of dehydration, if present state I&O update MD (Medical Doctor) prn (as needed)...Encourage adequate food and fluid intake at meals as needed...Fresh water at bedside accessible to resident, offer fluids between meals..." There is no evidence that the care plan was updated once Resident #14 returned from the hospital with a [DIAGNOSES REDACTED]. A Dehydration Potential Assessment was completed by the DON (Director of Nursing) on 6/12/12 indicating that Resident #14 scored a "2" and was considered "Low Risk" Surveyor # received a copy of Resident #14's "Intake and Output Roster." ~From 6/21/12 through 6/30/12, Resident #14's average daily intake was 1,166 cc. On 6/26/12, 6/27/12, and 6/30/12, Resident #14's intakes were significantly below her assessed needs at 930 cc, 760 cc, and 920 cc respectively. Review of the Departmental Notes finds no evidence that the RD was notified of the significant decline in fluid intake or when output exceeded intake. ~From 7/1/12 through 7/31/12, Resident #14's average daily intake was 1,072 cc, which is 46% below her estimated daily fluid needs. On the following dates, Resident #14's intakes were significantly below her daily fluid needs and as noted output exceeded intakes: 7/1/12 - 900 cc 7/3/12 - 400 cc. Output 810 cc 7/8/12 - 630 cc 7/9/12 - 920 cc 7/13/12 - 760 cc 7/17/12 - 600 cc. Output 650cc 7/20/12 - 880 cc 7/21/12 - 720 cc. Output 950 cc 7/24/12 - 740 cc. Output 950 cc 7/30/12 - 750 cc 7/31/12 - 960 cc On 7/3/12, Resident #14 developed a Stage 2 pressure ulcer and a second pressure ulcer 13 days later. On 7/10/12 was diagnosed with [REDACTED]. Infections and wounds increase the amount of fluids needed by the body. Review of the Departmental Notes finds no evidence that the RD was notified of development of pressure ulcers, infection, significant decline in fluid intakes or when outputs exceeded intake. The DM (Dietary Manager) made a note on 7/11/12 indicating average fluid intake over the last 10 days was 1,122 cc. There is no indication that the DM notified the RD or made recommendations to increase Resident #14's fluid intake. There were no hydration assessments documented by nursing (skin turgor, mucous membranes, etc.) and no changes to Resident #14's care plan. ~From 8/1/12 through 8/27/12, Resident #14's average intake was 930 cc per day, or 53.5% below her assessed daily fluid needs. 8/1/12 - 900 cc 8/5/12 - 980 cc 8/8/12 - 640 cc 8/11/12 - 685 cc 8/13/12 - 960 cc 8/15/12 - 820 cc 8/16/12 - 750 cc 8/19/12 - 840 cc 8/20/12 - 830 cc 8/21/12 - 920 cc 8/22/12 - 200 cc 8/24/12 - 600 cc 8/25/12 - 400 cc 8/26/12 - 620 cc Review of Resident #14's weights also finds a 9 pound weight loss from 8/1/12 through 8/20/12. On 7/31/12, the facility sent the physician a fax asking if he would like to order lab work following a pharmacy recommendation. Order was received and on 8/6/12, the lab work was completed. Based on those lab values, Resident #14 had a Serum Osmolarity of 341 which may be indicative of dehydration. (A normal range is 278 to 300.) The BUN to Creatinine ratio is 21:1, which may also be indicative of dehydration. Despite a history of dehydration, low intakes since readmission to the facility, development of an active infection, development of 2 pressure ulcers, weight loss and abnormal lab results, the facility made no changes to ensure Resident #14 was receiving sufficient fluids to meet her assessed daily needs. The DM made entries on 8/15/12 and 8/22/12. The entries do not review the low fluid intakes, or a plan to try to increase the fluid intakes. There was also no evidence that the RD was notified of the low intakes. Nurses document throughout the month of August that fluids are "encouraged" but there were no changes to Resident #14's care plan to outline approaches to increase Resident #14's fluid intakes. On 8/27/12, Resident #14 fell and was transferred to the hospital. The History and Physical dated 8/28/12 states, "...Patient's labs on admission show evidence of multiple medical issues...glucose is high at 420. She is hyponatremic with a sodium of 125 although this may represent at least somewhat false [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Potassium is elevated at 7.7. BUN and creatinine are elevated at 84 and 4.86...White count elevated at 24.4...Urine is yellow, cloudy with large amounts of blood, leukocytes, 3+ bacteria...Dry ORAL MUCOSA...Does show two sacral decubitus. Left is 1 cm x 0.5 cm, Stage II with 2 cm surrounding [DIAGNOSES REDACTED]. Right is 1 cm x 0.5 cm, Stage I... "Assessment: Urinary Tract Infection [MEDICAL CONDITION]. Dehydration with acute [MEDICAL CONDITIONS], and [MEDICAL CONDITION] "Plan:...We will continue the patient on normal saline at 200 ml (milliliters) per hour..." On 8/7/13 at 10:20 a.m., Surveyor # spoke with RD-CC, the current RD regarding Resident #14. When asked about the historical [DIAGNOSES REDACTED]. RD-CC indicated she was not at the facility during that time, and thought the DM would have knowledge of Resident #14. On 8/7/13 at approximately 10:30 a.m., Surveyor # spoke with the DM about Resident #14. The DM recalled that the facility tried different things to increase Resident #14's food intakes, but did not recall any specific changes in fluids. The DM stated that if a resident has a decrease in intakes, it is flagged and the RD would look at. The DM did not recall notifying the RD of the need to assess Resident #14 and found no documentation indicated that the RD had assessed Resident #14. On 8/8/13, Surveyors # and # spoke with RN-J (Registered Nurse) regarding Resident #14. RN-J indicated that Resident #14 had "lost the will to live" and staff noted a decline in her intakes. RN-J stated that she personally had offered Resident #14 soda in an attempt to get her to drink more. RN-J reviewed Resident #14's care plan and indicated that no changes were made related to hydration after staff noted the decline. RN-J was asked if the RD was involved. RN-J reviewed the notes and indicated that she did not see an entry from the RD. RN-J stated there was an entry in the nurse's notes that Resident #14's daughter stated her mother had given up and that was fine with whatever nursing staff decided to do. Review of that entry on 8/11/12 indicates that the discussion was related to medication refusals, poor appetite, and not wanting to walk. There was no evidence that fluid intakes were discussed or options explored. RN-J was asked what the facility protocol was when staff are to monitor intakes and outputs on a resident. RN-J stated that the staff enter the amounts of fluids taken on all shifts. When asked what is done with that information, RN-J stated she was unsure. RN-J was asked if anyone was analyzing the documentation to determine if residents are receiving appropriate fluids. RN-J stated, "I guess night shift would do that." RN-J was asked who updates the care plans with problems and interventions. RN-J stated the DON (Director of Nursing) is the only person who updates the care plans. RN-J stated the nurses on the floor only follow the care plan. The DON was unavailable for interview.

Based on interviews, observations, and record reviews, the facility did not ensure the environment for 6 of 22 residents (#1, #2, #3, #4, #5, and #6) was as free of accident hazards as possible. Interviews reveal that it was the facility's regular practice to leave the stairway doors open at all times. On 8/23/10, after morning cares were complete, Resident #1 was left in the hall while staff went to get a hair pick. Resident #1 propelled herself and left that area of the hall. Staff were unable to locate the resident. Staff responded to an alarm sounding and found Resident #1 lying on the first landing of the East stairwell after falling down 6 steps in her wheelchair. Resident #1 was diagnosed as having a cervical fracture, wrist fracture, and questionable rib fractures. The facility's failure to provide a safe environment - by failing to ensure that confused, wheelchair-bound residents could not get into the stairwells - resulted in a finding of immediate jeopardy, which began on 8/23/10. The facility was notified of this finding on 9/2/10. The immediate jeopardy was removed on 8/23/10, however the deficient practice continues at a scope severity level of an E (potential for more than minimal harm/pattern) as the facility still has to implement a system to ensure that all stairwell doors remain closed. This is evidenced by: There are currently 22 residents that live in the facility. Of these, the following was noted: ~ 4 are alert and oriented; ~ 9 are mildly confused with 1 in a wheelchair; ~ 7 are moderately confused with 4 in wheelchairs; and, ~ 2 are severely confused with 1 in a wheelchair. The confused, wheelchair-bound residents were Residents #1 through #6. The building itself is three levels: 1st level: Basement area. In this level, the residents' Main Dining Room is located. 2nd level: This level consists of Resident rooms, Dayroom, and Nurse's Station. 3rd level: This level consists of additional resident rooms. Resident #1 is [AGE] years old with medical [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE]. Resident #1 resided on the second level. A Significant Change Minimum Data Set assessment dated [DATE], indicates Resident #1: ~Has both short and long-term memory impairment; ~Moderately impaired daily decision making skills; ~No mood or behavioral tendencies; and, ~Is independent with transfers, ambulation and locomotion. According to the Resident Assessment Protocols (RAPS) related to falls, Resident #1 had a recent decline related to a UTI but was returning to her formal strength and once again was becoming independent. Nurse's notes on 8/14/10, indicate Resident #1 had 2 falls: The first at 2:45 p.m. when she was found by staff lying on the floor in her room. The resident could not state the reason for the fall. According to the documentation, Resident #1 had manifested an increase of pacing behaviors "...the last few days..." Magnetic alarms were placed in the wheelchair to alert staff of attempts of self-transfers. The second fall at 11:00 p.m. The resident was found in the hallway outside her room. The resident was placed on an antibiotic and a bed alarm was then added. On 8/15/10, she was lowered to the floor by staff related to weakness in her knees. The resident was confused and required frequent trips to the bathroom with the production of dark yellow urine with a foul odor. Documentation also indicates Resident #1 had a "...shaky..." gait pattern. Resident #1 complained to staff that she did not feel well but was unable to elaborate on the cause. On 8/18/10, the resident remained weak, unsteady, and restless with upper body shakiness. On 8/19/10, the restlessness continued and Resident #1 was "...up in the wheelchair all night due to restlessness..." The antibiotic was continued for an additional 7 days. On 8/23/10 at 6:30 a.m., an entry in the nurse's notes states that Resident #1 was found "...on the landing of the back stairwell after the CNA responded to the sound of the pad alarm. The resident was found lying on her left side with her wheelchair next to her after apparently falling down the top flight of stairs..." On 9/2/10 at 10:05 a.m., Surveyor # spoke with CNA-A (Certified Nursing Assistant). CNA-A stated she had assisted Resident #1 with morning cares on 8/23/10. CNA-A stated she had positioned the resident in her wheelchair just outside and across the hall from the bathroom. She then went to the nurse's desk to retrieve a hair pick and directed the resident to remain in the hall until she returned. CNA-A indicated she was gone for what "...seemed like seconds..." When she returned she was unable to locate Resident #1. CNA-A then completed a building check of other resident rooms. Still unable to locate Resident #1, she asked CNA-B if she had seen the resident. CNA-B indicated that she had not. CNA-A then began to search the building a second time when she heard an alarm sound. She followed the sound of the alarm to the East stairwell, where Resident #1 was located at the bottom of the first flight of stairs. The East side of the building contains the only elevator in the building and a stairwell. The elevator is the primary means of transporting residents to the dining room in the basement level. The stairwell, just to the left of the elevator, consists of two sets of stairs leading to the lower level and one set of stairs leading to the third level of the building. Of the steps leading to the lower level, there are 6 steps, a landing of approximately 4 feet, then a second set of steps. Resident #1 had fallen down the first set of 6 stairs and was located at the bottom of the 6th step. Resident #1's back was to the stairs and she was positioned on her left side. The resident's wheelchair was located in front of her and approximately 2 feet away on the landing itself. According to the facility's investigation, the summation was that the resident propelled her wheelchair over the carpeted surface of approximately 40 feet down the hallway, to the Dayroom. She then turned right at the end of the hall and propelled her wheelchair another 25 feet to the elevator and the East stairwell. The stairwell door was held open by a magnetic device. The investigation concludes that Resident #1 then propelled her wheelchair through the open door and down the steps. Resident #1 was transferred to the hospital where she was diagnosed with [REDACTED]. There was also questioning of possible left rib fractures. On 9/2/10 at 9:20 a.m., Surveyor # spoke with the DON (Director of Nursing). The DON stated that on the day of Resident #1's fall, the doors to the stairway were opened. The DON stated the doors to all the stairways are always open. The facility's failure to provide a safe environment for its residents - by failing to ensure that confused, wheelchair-bound residents could not get into the stairwell - created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 8/23/10 when: 1. The East stairwell door was closed; and, 2. Staff were informed at the beginning of the shifts that the door must remained closed.