Every finding on record at Skyline Transitional Care Center

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided respiratory services consistent with professional standards of practice. This was true for 4 of 5 residents (#9, #23, #26, and #28) whose respiratory devices were not stored properly and 1 of 5 residents (#89) reviewed for physician orders for oxygen therapy. This deficient practice created the potential for residents to develop infection and to receive too little or too much oxygen. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD is an ongoing lung condition that makes it difficult to breathe), chronic respiratory failure, and generalized muscle weakness. On 6/8/26 at 2:18 PM, Resident #9's nebulizer mask was observed laying on the bed. CNA #2 stated nebulizer masks should be stored in a plastic bag and it should not have been laying on the bed. On 6/10/26 at 8:53 AM, Resident #9's nebulizer mask was observed laying on the bed. LPN #4 stated the nebulizer mask should not have been laying on the bed and should have been stored in a plastic bag. LPN #4 replaced the mask and tubing and put it in a labeled bag for storage. 2. Resident #26 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including COPD, respiratory failure, and pulmonary embolism (PE- Occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). On 6/10/26 at 9:08 AM, Resident #26 was observed sitting on the right side of the bed. Her nasal cannula was observed on the right side of the bed on the floor and Resident #26 was observed stepping on the nasal cannula. On 6/10/26 at 9:26 AM, LPN #1 was asked about respiratory device storage. LPN #1 stated respiratory devices such as nasal cannulas should be stored in a bag. LPN #1 then accompanied the Surveyor to Resident #26's room and confirmed Resident #26's nasal cannula was on the floor at the bedside. LPN #1 stated Resident #26's nasal cannula should have been stored in a bag and replaced the oxygen tubing. 3. Resident #23 was readmitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure, pulmonary edema (fluid build up in the lungs), and need for assistance with personal care. A physician order dated 6/9/26 documented: -Oxygen at 2-5 liters via nasal cannula continuously. On 6/11/26 at 10:07 AM, NA #1 was observed pushing Resident #23 in his wheelchair. Upon entering the room, NA #1 removed Resident #23's nasal portable cannula and reached toward the bed to retrieve a nasal cannula lying directly on top of the resident's blankets. NA #1 then applied the cannula to Resident #23. On 6/11/26 at 10:13 AM, NA #1 confirmed the nasal cannula was not stored appropriately. NA #1 stated she applied the cannula but intended to obtain a new one afterward. 4. Resident #28 was admitted to the facility on [DATE] with multiple diagnoses including respiratory disorder, end stage renal disease, and need for assistance with personal care. Resident #28's physician orders documented the following: -Oxygen at 2 liters as needed for shortness of breath or respiratory distress, with physician notification (initiated 4/21/26). -Oxygen at 2 liters via nasal cannula continuously at bedtime (initiated 4/21/26). On 6/8/26 at 9:34 AM, Resident #28 was observed sitting in his wheelchair in his room. His nasal cannula was lying directly on his bed sheets. On 6/8/26 at 10:01 AM, LPN #3 stated nasal cannulas should be stored in a bag labeled with the date. LPN #3 confirmed Resident #28's cannula was not stored appropriately. 5. An NIH article, titled Bench-to-bedside review: Oxygen as a drug, Critical Care, dated Feb. 24, 2009, stated, 'Oxygen is one of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific biochemical and physiologic actions, a distinct range of effective doses, and well-defined adverse effects at high doses.' The facility's policy and procedure titled, Administration of Medication, revised 4/2025, stated, it is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. Resident #89 was readmitted to the facility on [DATE] with multiple diagnoses including COPD, chronic respiratory failure (a long term condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide) and bronchiectasis (a chronic lung disease where the airways become permanently damaged, widened and scarred). Resident #89's physician's orders included the following: -oxygen at 2 liters via nasal cannula continuously, dated 6/1/26 On 6/8/26 at 2:50 PM, Resident #89 was observed in his room with the nasal cannula in his nares, oxygen set at 3.5 liters per minute. On 6/8/26 at 2:56 PM, LPN #3 checked Resident #89's orders and stated, oxygen should be set at 2 liters per minute. LPN #3 came into room and confirmed oxygen is set at 3.5 liters per minute and it should be at 2 liters per minute and corrected the flow rate.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure adherence to infection control and prevention practices, consistent with professional standards of practice. This was true for 3 of 3 residents (#6, #48, and #64) when staff did not follow hand hygiene protocols when going from a dirty to a clean environment during wound care and activities of daily living (ADL's), and 1 of 3 residents (Resident #6) observed for not following enhanced barrier precautions (EBP) during wound care. This deficient practice created the potential for harm to the residents due to cross-contamination and increased risk for infection. Findings include: Facility policy titled, Infection Control Prevention and Control Program-Hand Hygiene, reviewed 2/2025, documented, Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents. -Before preparing or handling medications, before moving from a contaminated body site to a clean body site during resident care. -After contact with a resident's intact skin, after contact with bodily fluids. -After handling dressings, contaminated equipment (e.g. medical equipment) in the immediate vicinity of the resident. -After removing gloves. 1. Resident #48 was admitted to the facility on [DATE] with multiple diagnoses including dementia (a decline in mental ability severe enough to interfere with daily life), COPD, and muscle weakness. Resident #48's physician's orders included the following: -Venelex External Ointment, apply to affected area topically every day and night for skin integrity, dated 6/9/26. On 6/11/26 at 9:28 AM, LPN #2 was observed to perform hand hygiene, put on gloves and applied Venelex cream to buttocks bilaterally, she did not remove dirty gloves and handed Resident #48 the Biotene Mouth Moisturizer sitting on the bedside table. On 6/11/26 at 9:40 AM, LPN #2 stated, I should have removed gloves and washed my hands before handing her the Biotene. 2. Resident #64 was readmitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, dementia, and need for assistance with personal care. On 6/11/26 at 12:28 PM, CNA #1 was observed providing incontinence care to Resident #64. CNA #1 was observed wearing gloves and unfastened Resident #64's incontinence brief and wiped her genital area. CNA #1 then threw away dirty wipes, and instructed Resident #64 to roll onto her left side. CNA #1 assisted Resident #64 to roll onto her side and then used wipes to clean Resident #64's bottom. CNA #1 then threw away the dirty wipes, removed the dirty incontinence brief and disposable chucks pad and placed it in the garbage next to Resident #64's bed. CNA #1 then grabbed a clean disposable chucks pad and clean incontinence brief from Resident #64's bedside table. CNA #1 then placed the new disposable chucks pad and incontinence brief under Resident #64 and assisted her to roll onto her right side and pulled the new chucks pad and incontinence brief out from under Resident #64. CNA #1 then assisted the resident to roll onto her back and fastened the new incontinence brief and pulled down Resident #64's shirt. CNA #1 then removed their gloves, performed hand hygiene at the sink, donned clean gloves, and covered Resident #64 with a clean sheet and blanket. CNA #1 was not observed to change their dirty gloves or perform hand hygiene before placing the new disposable chucks pad and incontinence brief. On 6/11/26 at 12:35 PM, when asked when gloves are changed, CNA #1 stated gloves are changed when dirty and further stated they should have changed their gloves after performing incontinence care. 3. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including severe protein calorie malnutrition, major depressive disorder, anxiety disorder, and dementia. On 6/9/26 at 9:56 AM, RN #1 was observed entering Resident #6's room carrying wound care supplies. RN #1 placed a barrier on the bedside table and set the supplies on the barrier. RN #1 then returned to the entryway, performed hand hygiene, and donned gloves followed by a gown. RN #1 approached Resident #6, adjusted the bed using the remote, and removed the resident's blankets. RN #1 and Unit Manager #1 repositioned Resident #6. RN #1 cleansed the wound with wound cleanser, patted the area dry, applied a contact layer and Ancef gel, placed a collagen pad over the wound bed, applied skin prep around the wound, and completed the dressing. During the procedure, RN #1 was not observed performing hand hygiene or donning and doffing gloves prior to initiating wound care, despite having touched the bed controls and resident linens. On 6/9/26 at 10:11 AM, Unit Manager #1 stated RN #1 should have applied the gown before donning gloves. Unit Manager #1 further stated that RN #1 should have performed hand hygiene after adjusting the bed and the resident's blankets, prior to beginning wound care.

Based on record review and staff interview, it was determined the facility failed to ensure residents were transferred to the hospital with all required documentation. This was true for 1 of 5 residents (Resident #64) whose hospital transfers were reviewed. This failure placed Residents #64 at risk for harm when the receiving healthcare institution were not provided the residents' care plan goals. The SOM, Appendix PP, revised 7/23/25 documented:When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.(iii) Information provided to the receiving provider must include a minimum of the following:(A) Contact information of the practitioner responsible for the care of the resident.(B) Resident representative information including contact information (C) Advance Directive information (D) All special instructions or precautions for ongoing care, as appropriate. (E) Comprehensive care plan goals; (F) All other necessary information, including a copy of the resident's discharge summary, consistent with S483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care. 1. Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including muscle weakness, dementia, and left femur fracture.A review of Resident #64's medical record documented, she was admitted to the hospital on [DATE] after sustaining injuries from a ground level fall.A Progress Note dated 2/15/26 at 10:09 AM documented, Resident #64's Physician Orders for Scope of Treatment (POST- a medical order translating preferences for life-sustaining treatments into actionable instructions for healthcare providers), face sheet, and medication list were sent with the paramedics.Resident #64's medical record did not include documentation Resident #64's care plan goals were provided to the receiving healthcare institution.On 6/12/26 at 11:42 AM, when asked what documents were sent with residents when they transfer to the hospital, the DON stated bed hold agreements, face sheets, POST / advanced directive, history and physical, recent labs / imaging, medication list, 2 copies of electronic medication administration records (EMAR) were to be sent to the receiving healthcare institutions. She added, a call from the facility is made to the receiving healthcare institution to give a report. When asked what documents were sent when Resident #64 transferred to the hospital on 2/15/26, the DON stated the POST, Facesheet, & medication list were sent. When asked if Resident #64's care plan goals were sent, the DON and the CRN stated they did not see anything in the record documenting care plan goals were sent.

Based on record review and staff interview, it was determined the facility failed to ensure the required Preadmission Screening and Resident Review (PASRR) process was completed accurately for a resident with mental health diagnoses. This was true for 1 of 2 residents (Resident #6) reviewed for PASRRs. This failure created the potential for the residents' mental health needs or need for specialized services to go undectected if PASRRs were inaccurate. Findings Include:Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including a primary diagnosis of severe protein-calorie malnutrition, major depressive disorder, anxiety disorder, and dementia.Resident #6's PASRR level 1 dated 5/19/26, documented she had an anxiety disorder, mood disorder and a primary diagnosis of dementia.On 6/12/26 at 10:35 AM, the Social Services Manager confirmed Resident #6 did not have a primary diagnosis of dementia and stated she would complete a new PASRR level I.

Based on record review and staff interview, it was determined the facility failed to ensure a comprehensive, person centered care plan was developed to reflect the resident's diagnosed needs. This was true for 1 of 19 residents (Resident #27) reviewed for person-centered care plans. The failure to include Resident #27's Post Traumatic Stress Disorder (PTSD) diagnosis and related triggers in the care plan created the potential for unaddressed psychosocial needs and triggering of traumatic stress responses. Findings include:Resident #27 was admitted to the facility on [DATE] with multiple diagnoses including Post-Traumatic Stress Disorder (PTSD), schizoaffective disorder, major depressive disorder, and bipolar disorder.A Social Services Assessment/Evaluation, dated 5/27/26 documented in Section III, Question B ( Experience of trauma or history of trauma?) the response documented was NO.A review of Resident #27's comprehensive person centered care plan showed no care area addressing PTSD, despite the diagnosis being present in the medical record.On 6/12/26 at 10:33 AM, the Social Services Manager confirmed Resident #27's care plan did not address their diagnosis of PTSD or how to care for Resident #27's PTSD.

Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure necessary pressure relieving boots were consistently applied as ordered to prevent development of pressure injuries and promote skin integrity. This was true for 1 of 5 residents (Resident #1) reviewed for pressure-injury prevention. This failure placed Resident #1 at increased risk for harm related to pressure-related skin breakdown. Findings includeThe facility's Skin and Wound Monitoring and Management Policy, revised 4/2025 documented:1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and 2. A resident having pressure injury(s) receives necessary and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses, including end stage renal disease, diabetes, and a pressure ulcer of the left heel.A review of Resident #1's care plan, revised 1/14/26, directed staff to apply Prevalon boots (a medical offloading devices designed to elevate the heel completely off the mattress to prevent pressure ulcers).A physician order dated 3/9/26 documented: [Prevalon] boots while in bed every shift for Skin integrity.On 6/10/26 at 2:17 PM and 3:33 PM, Resident #1 was observed sleeping in bed without Prevalon boots on. The Prevalon boots were noted on the floor at the end of Resident #1's bed.On 6/10/26 at 3:44 PM, LPN #1 was asked about the physician order for the Prevalon boots. LPN #1 confirmed Resident #1's Prevalon boots should be worn while in bed every shift for skin integrity per the physician's order. LPN #1 then accompanied the Surveyor to Resident #1's room and stated Resident #1 was not wearing the Prevalon boots and stated the resident should be wearing them while in bed.

Based on record review and staff interview, it was determined the facility failed to follow up on the dialysis centers recommendations for a resident receiving dialysis services. This was true for 1 of 1 resident (Resident #28) reviewed for dialysis services. The failure to act on dialysis recommendations created the potential for adverse outcomes related to fluid management, a critical component of care for residents with end stage renal disease. Findings include:Resident #28 was admitted to the facility on [DATE] with multiple diagnoses including respiratory disorder, end-stage renal disease, and the need for assistance with personal care.A physician order dated 4/24/26 documented a 2,000 mL/day fluid restriction, broken down as follows:-Kitchen to provide 920 mL/day of drinks on tray-Nursing to provide 1,080 mL/[NAME] review of Resident #28's dialysis record dated 6/1/26, documented under Recommendations:Fluid restriction of 1 liter (1,000 ml/day.)On 6/11/26 at 2:37 PM, the DON stated, when the facility received recommendations, the facility will review and implement them. Upon review of Resident #28's record, the DON stated the dialysis center's recommendation was not processed by the facility.

Based on record review and staff interview, it was determined the facility failed to ensure trauma informed care services were provided in accordance with professional standards of practice and in a manner that accounted for the resident's experiences and preferences. This was true for 1 of 1 resident (Resident #27) reviewed for trauma informed care. The facility's failure to identify and address trauma related needs created the potential for exposure to triggers and re traumatization. Findings include:Resident #27 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder.A review of Resident #27's comprehensive care plan did not document a focused care area addressing PTSD or triggers that may cause re-traumatization.A review of Resident #27's record showed no trauma informed care evaluation, including:-No documentation of the resident's trauma history-No identification of trauma triggers-No documentation of preferences or refusals related to discussing traumaA review of the record also showed no documentation indicating that Resident #27:-Declined to discuss trauma history, or-Was offered the opportunity to discuss trauma related triggersOn 6/11/26 at 2:23 PM, the DON confirmed that Resident #27's record did not include a trauma informed care evaluation.On 6/12/26 at 10:33 AM, the Social Services Manager stated she had evaluated the resident but did not complete a trauma informed care evaluation. The Social Service Manager stated PTSD related triggers were not included because the resident did not wish to talk about it. She confirmed she did not document the resident's stated preference or refusal to discuss trauma related triggers in the medical record.

Based on record review and staff interview, it was determined the facility failed to ensure residents were receiving medication with adequate monitoring. This was true for 3 of 6 residents (#19, #24, and #27) whose records were reviewed for unnecessary medications. This deficiency placed Residents #19 and #27 at risk for overmedication when their pain medication orders did not include parameters for administration and placed Resident #19, #24, and #27, at risk to suffer from side effects due to the lack of opioid side effect monitors. Findings include: 1. Resident #24 was admitted [DATE] with multiple diagnoses including diabetes (a condition that happens when blood sugars are too high), depression, and hypertension. Resident #24's physician's orders included the following: -Hydrocodone-Acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain, dated 3/17/26. A review of the record showed no documentation of opioid side-effect monitoring such as: -Sedation -Dizziness -Nausea -Vomiting -Constipation On 6/12/26 at 12:59 PM, the DON confirmed Resident #26 did not have monitoring in place for adverse side effects related to opioid use and stated, they leave it up to the nurse to assess. 2. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses including chronic pain syndrome and bladder cancer. Resident #19's medical record documented the following physician orders, dated 4/24/26 -Morphine Sulfate Oral Tablet 30 MG, Give 30 mg by mouth every 6 hours as needed for Pain -Oxycodone HCl Oral Tablet 5 MG, Give 10 mg by mouth every 4 hours as needed for Pain -Tylenol Tablet 325 MG, Give 2 tablet by mouth every 6 hours as needed for Pain Resident #19's medical record did not include documentation the facility was monitoring for side effects from the opioid pain medications prescribed. On 6/12/2026 at 9:54 AM, the DON stated Resident #19's pain medications orders should have been clarified to direct staff which medication to use for the reported level of pain. The DON stated Resident #19 did not have monitors in place to assess for opioid side effects. 3. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, schizoaffective disorder, major depressive disorder, and bipolar disorder. a. Resident #27's record documented the following as needed (PRN) pain medications: -Acetaminophen 325 mg, 2 tablets by mouth every 6 hours as needed for pain (initiated 2/26/26). -Oxycodone 5 mg, 1 tablet by mouth every 6 hours as needed for pain (initiated 3/2/26). -Hydrocodone Acetaminophen 10 325 mg, 1 tablet by mouth every 6 hours as needed for moderate to severe pain (initiated 4/20/26). A review of Resident #27's orders showed no instructions indicating: -Which PRN medication should be attempted first -Under what circumstances each medication should be used -Escalation steps for pain management On 6/11/26 at 2:25 PM, the DON confirmed the orders did not specify which medication should be given first. The DON stated the resident will request what she thinks she needs. B. Resident #27's record documented the following as needed pain medications: -Oxycodone 5 mg, 1 tablet by mouth every 6 hours as needed for pain (initiated 3/2/26). -Hydrocodone Acetaminophen 10 325 mg, 1 tablet by mouth every 6 hours as needed for moderate to severe pain (initiated 4/20/26). A review of the record showed no documentation of opioid side effect monitoring. On 6/11/26 at 2:36 PM, the DON confirmed Resident #27 did not have monitoring in place for adverse side effects related to opioid use.

Based on observation and staff interview, it was determined the facility failed to ensure the cleaning and sanitation of kitchen cookware. This deficiency had the potential to affect the 64 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment. Findings include: The Food Drug Administration (FDA) Code Section 4-602.12 Cooking and Baking Equipment documented: Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. On 3/6/25 at 3:34 PM, baking sheets and frying pans were observed with the Certified Dietary Manager (CDM) and Registered Dietitian to have a crusted black residue. They stated the cookware was cleaned and sanitized using appropriate food service methods; however, it was not cleaned thoroughly as the CDM was able to scratch off the crusted black residue with her fingernail.

Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 4 of 16 residents (#1, #8, #25, and #27) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI, revised 10/1/2024, documents section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition. 1. Resident #1 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a major mental mood disorder), depression, anxiety opioid dependence, and tobacco use. Resident #1's PASRR Level II dated 6/6/23, and PASRR Level II dated 8/23/24, documented she had a diagnosis of bipolar disorder, depression, anxiety, opioid dependence and tobacco dependence. Resident #1's annual MDS assessment, dated 3/11/24, and significant change MDS dated [DATE], documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there were two PASRR Level II's found in her electronic medical record dated 6/6/23, and 8/23/24. On 3/5/25 at 3:30 PM the MDS Coordinator stated Resident #1's MDS assessments were coded that the resident did not receive a PASRR Level II screening because she believed the form HW0090 Abbreviated Level II PASRR screening form was not considered a true level 2 screening. 2. Resident #25 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, severe with psychotic symptoms, paranoid schizophrenia (mental disorder involving chronic or recurrent psychosis), and anxiety. Resident #25's admission MDS assessment, dated 2/4/25, documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR Level II found in her electronic medical record dated 1/29/25, which documented she had a diagnosis of schizophrenia (a diagnosis categorized as a major mental illness). On 3/5/25 at 3:35 PM the MDS Coordinator stated Resident #25's MDS assessments were coded that the resident did not receive a PASRR Level II screening because she believed the form HW0090 Abbreviated Level II PASRR screening form was not considered a true PASRR Level II screening. 36193 3. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including schizoaffective disorder, bipolar type (a mental health condition characterized by bouts of hypomania [stated of heightened or irritable mood and unusually increased energy or activity that is similar to but less intense than mania] or mania and sometimes depression). Resident #27's record documented a PASRR Level II, dated 1/19/23, was completed. An annual MDS assessment, section A1500, dated 7/17/24, documented, No Resident #27 did not have a completed PASRR Level II. On 3/4/25 at 1:20 PM, the MDS Coordinator stated Resident #27's MDS was coded No on his annual MDS section A1500 because his PASRR Level II documented, no further evaluation was required. 50603 4. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar disorder (a chronic mental condition characterized by extreme shifts in mood, energy, and behavior), depression, and problems with communication due to difficulties of thinking clearly. The annual MDS assessment, section A1500, dated 9/20/24, documented Resident #8 did not have a PASRR Level II. A PASRR Level II, dated 9/19/24, was completed for Resident #8, and provided to the facility. On 3/5/25 at 2:00 PM, the MDS Coordinator stated, she did not code the MDS assessment a PASRR Level II had been completed for Resident #8. At 3:27 PM, the Social Worker confirmed a PASRR Level II had been completed for Resident #8, and the MDS Coordinator should have coded the MDS assessment appropriately.

Based on record review, resident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 2 residents (Resident #12) reviewed for bowel and bladder incontinence. This failed practice created the potential for Resident #12 to experience bowel obstruction when her medications were not administered according to the physician's order. Findings include: Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure and chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues). A physician's order, documented Resident #12 was to receive the following medications: - Colace capsule 100 mg (milligrams), one capsule by mouth every 12 hours as needed for constipation, ordered 2/24/25. -Milk of Magnesia (MOM) Suspension 400 mg/5 ml (milliliter), give 30 ml by mouth every 24 hours as needed for bowel care if no bowel movement for 3 days, ordered 7/1/24. - Dulcolax suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel care if no results from MOM, ordered 7/1/24. - Fleet Enema 7-19 gm/118 ml, insert one application rectally every 24 hours as needed for bowel care if no results from Dulcolax, ordered 7/1/24. Resident #12's Bowel Movement Records, dated 2/5/25 through 3/6/25, documented she did not have a bowel movement from: - 2/15/25 through 2/19/25 (5 days). - 2/25/25 through 2/27/25 (3 days). There was no documentation in Resident #12's record that she was administered MOM suspension when she did not have a bowel movement for 3 days. On 3/3/25 at 1:06 PM, Resident #12 stated she was experiencing constipation. On 3/5/25 at 12:06 PM, the DON reviewed Resident #12's record and stated Resident #12 should have been given MOM suspension when she did not have a bowel movement for 3 days.

Based on observation, policy and record review, it was determined the facility failed to ensure that prior to placement of bed rails, residents were thoroughly assessed for the risk of entrapment. This was true for 1 of 1 resident (Resident #115) reviewed for bed rails. This deficient practice created the potential for harm from entrapment or injury related to use of bed rails. The facility's Bed Rails policy and procedure, revised 12/2023 documented the following: - The facility would attempt to use appropriate alternatives prior to installing a side or bed rail. - If it was determined that these alternatives failed to meet the resident's assessed needs, the interdisciplinary team would assess the resident for risk of entrapment. - The risks and benefits regarding the use of bed rails would be considered for each resident. - The facility would obtain an informed consent form from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use. On 3/3/25 at 3:36 PM and 3/6/25 at 9:00 AM, Resident #115 was observed in his bed in his room with two mobility bars in an upright position. Resident #115's record did not include documentation that he was assessed for the use of the mobility bars. On 3/6/25 at 10:15 AM, the DON stated Resident #115 was not assessed for the use of his mobility bars. The DON stated Resident #115 should have been assessed prior to installation of his mobility bars.

Based on record review, review of facility's policy and procedure, review of Incidents and Accidents (I&As) reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 2 of 2 residents (#116 and #117) reviewed for medication errors. The facility's Six Rights of Medication Administration, revised May 2024, documented the following in order to ensure safety and accuracy of medication administration. - Right resident - Right time - Right medication - Right dose - Right route - Right documentation The facility's Medication Errors and Adverse Reactions policy and procedure, revised January 2025 documented resident's condition must be monitored for 72 hours or as may be directed and detailed account of the incident must be recorded on an incident report. Clinically relevant information about follow-up of the resident should be recorded in the chart including: - The kind of medication error or adverse reaction. - The date and time the physician was contacted. - The physician orders. The policy also stated resident's condition and response to treatment must be recorded during the monitoring period. 1. Resident #116 was admitted to the facility on [DATE], with multiple diagnoses including diabetes. Resident #116's physician's orders included the following: - Insulin Lispro (rapid acting insulin) solution 100 unit/ml (milliliter), inject 18 units subcutaneously with meals for diabetes, ordered 4/4/24. - Insulin Glargine (long acting insulin) solution 100 unit/ml, inject 33 units subcutaneously two times a day for diabetes, ordered 4/14/24. - Glucose gel 40%, 15 mg orally as needed for blood sugar below 70. Recheck blood sugar in 15 minutes and notify the physician. If blood sugar remains below 70 may repeat for a total of three doses. If blood glucose is below 70 after glucose gel, provide snack/meal and recheck in one hour, ordered 4/1/24. An I&A report, dated 5/10/24 at 7:05 AM, documented Resident #116 was administered 33 units of Novolog (a rapid acting insulin) instead of Lantus. Immediate action taken documented Resident #116 was given glucose gel and OJ (orange juice) x2 along with peanut butter and cottage cheese, and her blood glucose was taken every 15 - 30 minutes for four hours. The I&A report documented Resident #116's blood glucose became stable. The report documented Resident #116's initial blood glucose was 171 and ending blood glucose was 152. Resident's representative and physician were notified of the medication error. The I&A report did not include documentation of how and why the medication error occurred, and what Resident #116's signs and symptoms were before she was given glucose gel and OJ x2 along with peanut butter and cottage cheese. Resident #116's record did not include documentation her blood glucose was monitored every 15 - 30 minutes, as stated on the I&A. On 3/6/25 at 12:19 PM, the DON together with UM #1, stated LPN #1 was training MAC #1(Medication Assistant Certified) on how to prepare the insulin injection. When asked why Resident #116 was given glucose gel and OJ x2 along with peanut butter and cottage cheese, the DON stated, I would say it was a nursing judgment not wanting her blood glucose to drop. When asked about what it meant, Resident #116's blood glucose became stable as stated in the I&A, the DON stated Resident #116 was placed on alert charting for 72-hours and she did not show signs and symptoms of hypoglycemia. When asked about documentation of blood glucose monitoring every 15-30 minutes, the DON stated it was monitored but it was not documented, and it should have been documented. The DON stated LPN #1 was provided education regarding medication administration. Documentation of education provided to LPN #1 was requested from the DON. A nurse practitioner progress note, dated 6/3/24 at 4:45 PM, documented Resident #116 had . with one episode of low blood sugar several weeks ago that she is fearful of repeating. The nurse practitioner's assessment and plan documented, Hypoglycemia, unspecified: Patient had an episode of hypoglycemia due to missed meal after administering short-acting insuli[n] several weeks ago, plan to adjust only long acting insulin at this time. Documentation of LPN #1's education regarding medication administration after this incident was not received prior to the exit conference on 3/7/25. 2. Resident #117 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including diabetes and schizophrenia (a diagnosis categorized as a major mental illness). An I&A report, dated 10/26/24 at 6:50 PM, documented Resident #117 received a medication error. The provider was notified and ordered to put Resident #117 on alert charting and to hold her scheduled Seroquel (antipsychotic medication) for possible side effects with incorrect medications. Resident #117 denied any signs and symptoms. The I&A report did not include documentation how and why the medication error occurred, and what medication was administered to Resident #117 which resulted in a medication error. On 3/6/25 at 11:56 AM, the DON together with UM #1, stated LPN #1 self-reported the medication error. When asked what medication was administered to Resident #117, the DON stated it was oxycodone (narcotic pain medication) 5 mg. The DON stated LPN #1 was preparing Resident #117's medication when another resident requested her pain medication. The DON stated LPN #1 discovered the medication error during reconciliation of narcotic medication. The DON provided documentation LPN #1 was educated of the six rights of medication administration, and random medication audits were conducted by the nurse manager.

Based on policy review, record review, review of Incidents and Accidents (I&A) reports and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #24) reviewed for falls. This resulted in harm to Resident #24 when, after a fall she sustained a puncture wound and hematoma (bruise) to the back part of her head, which required application of surgical staples to close the wound. Findings include: The facility's Fall Management System policy and procedure, revised 6/2018, documented residents would be provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. This policy was not followed. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including [CONDITION(S)] (paralysis of both arms and legs). An annual MDS assessment, dated 2/14/22, documented Resident #24 was severely cognitively impaired, received [CONDITION(S)] (a surgical opening that is made through the front of the neck into the windpipe or trachea) care, and required two person assistance for bed mobility, transfer, toileting, and personal hygiene. A care plan, revised 12/29/21, documented Resident #24 was usually dependent on staff for ADLs related to her [CONDITION(S)]. The care plan did not include the number of staff required for bed mobility and toileting as indicated in her MDS assessment. An I&A report, dated 2/17/22 at 6:40 AM, stated CNA #1 was performing a complete linen change of Resident #24's bed. The report documented CNA #1 positioned Resident #24 on her side and CNA #1 reached for a clean fitted sheet when Resident #24 rolled out of bed onto the floor. A nurse's note, dated 2/17/22 at 7:20 AM, documented Resident #24 rolled off her bed onto the floor during cares. There was bleeding from the back of Resident #24's head and two soft spots were felt on the left side of the back of her head. Resident #24 was sent to the hospital for evaluation. A nurse's note, dated 2/17/22 at 7:42 AM, documented Resident #24 returned from the hospital. Resident #24 was noted to have a hematoma (a collection or pooling of blood outside the blood vessel) and a puncture wound with two staples on the left side of the back of her head. Resident #24's ADL care plan, revised on 2/20/22, documented she required participation of two staff members to reposition and turn her in bed. The care plan also directed staff to provide her with a bariatric mattress. On 5/9/22 at 5:00 PM, CNA #1 stated he positioned Resident #24 to her right side and he was reaching for a clean incontinence brief which was on the chair when Resident #24 rolled off her bed onto the floor. CNA #1 stated he did not hold onto Resident #24's left side. When asked how many staff Resident #24 required for bed mobility and toileting, CNA #1 stated I think one person, but I am not sure. On 5/10/22 at 11:07 AM, the DON stated CNA #1 positioned Resident #24 on her right side during cares and CNA #1 turned away to grab a sheet when Resident #24 rolled off her bed and fell on to the floor. When asked why Resident #24 was assisted by only one staff when her MDS indicated she required two-person assistance with her bed mobility and toileting, the DON stated she did not know. When asked if Resident #24 should have been assisted by two staff members during cares, the DON stated yes. The facility did not provide adequate supervision to Resident #24 to prevent her fall.

Based on observation, staff interview, record review, and policy review, it was determined the facility failed to ensure residents' privacy was maintained during cares and treatment information was protected in their room. This was true for 1 of 12 residents (Resident #44) reviewed for privacy and confidentiality. This deficient practice placed residents at risk of embarrassment and loss of control over their personal information. Findings include: 1. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 was observed in her room on 5/9/22 at 2:46 PM, 5/10/22 at 8:20 AM, 5/11/22 at 11:00 AM and 5/12/22 at 2:48 PM. Two signs were posted on the wall above Resident #44's bed which stated: Please be careful of knees on wall. Do not use any pre-moistened wipes. Please use only dry wipes with water!!! On 5/12/22 at 2:48 PM, the DON was present in Resident #44's room and observed the signs above Resident #44's bed. When asked about the signs, the DON stated the signs should not be there. The DON stated the signs should be placed behind Resident #44's closet door. The facility failed to ensure residents' privacy was maintained during cares and treatment information was protected in rooms.

Based on policy review, resident and staff interview, review of Incident and Accident reports (I&As), and record review, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 3 of 15 Residents (#4, #23, and #36) reviewed for potential abuse and/or neglect. Resident #4 experienced neglect resulting in emotional distress and mental anguish when the facility failed to ensure he was provided with an alternative communication system to enable him to effectively express himself. Resident #23 also experienced neglect resulting emotional distress and mental anguish when the facility failed to ensure she had an augmentative or alternative communication system to enable her to file grievances and clearly communicate with staff and others following a stroke. This failure also resulted in Resident #36 being subjected to verbal abuse from another resident. Findings include: The facility policy, titled Resident Protection during an Abuse Investigation, documented the facility would not condone abuse of any type by anyone, including staff members, other residents, volunteers, family, legal guardians, friends, visitors, or other individuals. 1. Resident #23 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, the loss of ability to express speech, [CONDITION(S)] (is difficulty initiating and executing voluntary movement patterns necessary to produce speech when there is no paralysis or weakness of speech muscles. It may cause difficulty producing the desired speech sound and using the correct rhythm and rate of speaking), paralysis of the right side of her body, and diabetes. Resident #23's Annual MDS assessment, dated 11/11/21, documented she had normal cognitive functioning, was usually understood, and could make herself understood to others, but had no verbal communication. A speech and language pathology note, documented on her admitted [DATE], stated Resident #23 would have a communication book to increase her ability to communicate with others. A nutritional note, dated 7/30/21 at 2:34 PM, documented Resident #23 was aphasic (the loss of ability to speak) and answered questions by nodding or shaking her head. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented her MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented the provider suspected it was because the medication was to be given on an as-needed basis, and Resident #23 could not ask for it. A social services note, dated 8/19/21 at 11:17 AM, documented Resident #23 continued to need work on expressive communication, and this needed to be added to her care plan. A nursing care note, dated 8/22/21 at 10:39 PM, documented Resident #23 had not been seen socializing with other residents or staff and staying in her room for several days. Additionally, it documented she had [CONDITION(S)] and sometimes showed her frustration when not able to be understood. Resident #23's care plan for communication, dated 12/1/21, documented she would be able to make her basic needs known daily, and staff were to assist with word-finding as needed. Under the focus of ineffective coping related to loss of speech, the intervention was to encourage Resident #23 to make choices and participate in her care and scheduled activities. There was no documentation describing how she would communicate her choices. On 1/19/22 at 2:30 PM, Resident #23 nodded yes when asked if she had been in the facility for 14 months. She shook her head no when asked if she had a communication device. She shook her head no when asked if she had ever had a communication device. She shook her head no when asked if she could write or communicate her wants to facility staff. When asked if people understood her and met her needs, she shook her head no. When asked if she had pushed her call light for staff and they were unable to understand her needs and left without helping her, she nodded yes. When asked if her lack of ability to communicate made her feel frustrated, she nodded yes. When asked if she was frustrated with staff because she could not communicate, she nodded yes. On 1/21/22 at 8:35 AM, CNA #3 stated Resident #23 was smiling and interacting less and less with staff. Additionally, she stated she would often not nod yes or no to staff when asked direct questions. A communication device or communication book was not observed in Resident #23's room during the survey. Resident #23 was not observed using a communication device during the survey. On 1/24/22 at 11:15 AM, the DON was interviewed about communication devices for non-verbal residents. She stated if a communication device were ordered, she would expect the resident to have one. At 11:35 AM, the DON approached Resident #23 with the Social Services Manager's iPad. She stated Resident #23 had been using the Social Services Manager's iPad. When asked if assistive communication programs were on the iPad, Resident #23 shook her head no. When asked if she could communicate better with the iPad as an assistive device, Resident #23 shook her head no. The DON stated she could use the iPad to call her sister and play solitaire. When asked how Resident #23 talked to her sister using an iPad, the DON stated she did not know, but her sister could speak to her. On 1/24/22 at 10:23 AM, the Administrator was asked how residents who have concerns about their care would let staff know. The Administrator stated she would assume they would write it up in a grievance. Resident #23's communication needs were neglected, impeding her ability to effectively communicate with staff, family, and others, resulting ongoing frustration, mental anguish, and emotional distress. 2. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses, including spastic quadriplegic [CONDITION(S)] (damage to a child's brain or nervous system which does not cause paralysis but results in difficulty controlling movements in the arms and the legs, facial muscles may also twitch or become tight and interfere with speech and eating ability), muscle wasting (loss of muscle mass), and severe protein-calorie malnutrition (when you are not consuming enough protein and calories, which can lead to muscle loss, fat loss, and your body not working as it usually would). Resident #4's care plan for psychosocial well-being, dated 10/1/21, documented the facility would help increase communication between Resident #4 and the facility about his care and living environment. Resident #4's care plan for cognitive stimulation, dated 11/11/21, documented the facility would ensure adaptive equipment was provided to Resident #4 and would be present for him to use in the facility and be functional. A physician note, dated 11/29/21, documented Resident #4 answered to yes and no questions by shaking his head. On 1/21/22 at 8:40 AM, CNA #3 stated Resident #4 communicated with staff by nodding yes or no to their questions. She said he would stick out his tongue when he thought something was funny and would bump elbows when he wanted to agree with an opinion expressed by staff. She stated his head nods are appropriate answers to the questions being asked of him. She said the question/answer sessions guided his daily care regarding getting out of bed, bathing, eating, watching TV, and interacting on his iPad. On 1/21/22 at 11:16 AM, Resident #4 nodded yes when asked if he could use his iPad independently after it was set up for him. He then demonstrated changing the YouTube channel he was watching twice by tapping the screen with his right hand. He shook his head no when asked if he had trouble switching through programs on his iPad. He shook his head no when asked if he had to ask others to pick programs for him and nodded yes when asked if he decided his programs for himself. He shook his head no when asked if there were any communication applications on his iPad for him to use to communicate his thoughts more clearly to staff. He nodded yes when asked if communication tools to increase his communication with others would be something he would like. He shook his head no when asked if he had been offered communication tools or alternative devices to increase his communication ability. The lack of communication tools or devices impeded Resident #4's ability to communicate feelings related to depression and refusals of food and fluid intake, examples include: * A progress note, dated 10/4/21 at 11:41 AM, documented Resident #4 was noted to be in a poor mood, refused the morning meal and was refusing to get out of bed for the noon meal and to shower. Resident #4 was approached by different staff with the same results. The note documented Resident #4 became tearful and staff were unable to console or redirect him. * A progress note, dated 10/18/21 at 12:08 PM, documented Resident #4 refused his shower and was crying uncontrollably. * An IDT review to address Resident #4's nutritional status, dated 12/28/21, documented an appetite stimulant was added to Resident #4's medication regimen on 12/10/21. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note stated Resident #4's antidepressant medication had been increased in hopes that may help. Resident #4's communication needs were neglected for over 2 years (12/19/19 - 1/24/22), impeding his ability to communicate with staff, family, and others, resulting ongoing frustration, mental anguish, and emotional distress. 3. Verbal abuse of Resident #36 by Resident #3: *Resident #36 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 9/14/21, documented Resident #36 was cognitively intact. *Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident and Accident (I&A) report, dated 9/29/21, documented Resident #36 stated she did not want to be in the same room with Resident #3. Resident #36 stated Resident #3 called her a [OBSCENITY] ing [OBSCENITY] and said she was going to kill her. The report documented Resident #3 and Resident #36 argued and Resident #36 also called Resident #3 a [OBSCENITY] ing [OBSCENITY] in return. The I&A report also documented Resident #3 was interviewed and stated Resident #36 was a [OBSCENITY] and she probably told Resident #36 she was going to kill her because Resident #36 was a mean and nasty lady. The facility's investigation of the 9/29/21 incident documented Resident #36 was called names by Resident #3. Resident #3 was moved to a different room. On 1/20/22 at 9:02 AM, CNA #1 stated Resident #3 had mood swings and could be verbally aggressive. CNA #1 stated Resident #3 was moved to her current room due to an altercation with another resident and since then Resident #3 was not provided with another roommate. On 1/20/22 at 5:26 PM, Resident #3 stated she used to have a roommate but preferred to have a room to herself. When asked if she had a concern with her previous roommate, Resident #3 stated no. Resident #3 stated she liked her new room and would not like to have a roommate. On 1/21/22 at 9:36 AM, Resident #36 stated she used to have a different roommate and did not like her. Resident #36 stated her previous roommate called her a [OBSCENITY] and said she was going to kill her. Resident #36 stated her previous roommate was moved to another room but she did not know which room her roommate was moved to. Resident #36 stated she liked her new roommate and had no concern. The facility failed to ensure Resident #36 was free from verbal abuse from Resident #3.

Based on record review and staff interview, it was determined the facility failed to ensure a resident received appropriate care to prevent and treat pressure ulcers. This was true for 1 of 3 residents (Resident #12) reviewed for pressure ulcer care. This deficient practice resulted in harm to Resident #12 when she developed new Stage 3 and Stage 4 pressure ulcers, and the pressure ulcer she was admitted with, worsened. Findings include: The National Pressure Injury Advisory Panel website, accessed on 1/31/22, defined pressure ulcer staging as follows: Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate (a small area that usually occurs under a bony prominence where pressure is at its peak and heat build-up causes excessive sweat) and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled edges), are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. The facility's policy for Skin Management System, revised December 2019, documented the facility would have preventive measures taken to ensure residents did not develop pressure ulcers or signs and symptoms of wound infection. High-risk residents would have a plan of care developed to address assessment elements that put the resident at risk of skin breakdown. This policy was not followed: Resident #12 was admitted to the facility on [DATE], with multiple diagnoses, including left-sided [CONDITION(S)] (weakness of one entire side of the body that can affect the arms, legs, and facial muscle due to neurological damage). Resident #12's admission MDS assessment, dated 7/22/20, documented she had one Stage 4 pressure ulcer. The assessment did not include the location of the pressure ulcer. Resident #12's annual MDS assessment, dated 8/2/21, documented she had unhealed pressure ulcers. The assessment did not include the number and stage of the pressure ulcers. A physician order, dated 9/29/21, documented the following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] * Clean wound with cleanser, pat dry. * Apply skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes), let air dry. * Apply collagen powder (a protein powder that promotes wound healing) directly to wound base and cover with an [MEDICATION(S)] gentle faced dressing (waterproof foam dressing that has a silicone adhesive border). * Change the dressing 3 times a week every Monday, Wednesday, and Friday and as needed. Resident #12's TARs documented the physician ordered treatment was not provided, as follows: * Her December 2021 TAR documented treatment was not provided on 12/22/21. A 12/24/21 TAR note stated, hold, see nurse note. Resident #12 received wound treatment on 12/20/21, and her next treatment was on 12/27/21, 7 days later. * Her January 2022 TAR stated on 1/10/22 to hold, see nurse note. The TAR documented treatment was not provided on 1/12/22. Resident #12 received wound treatment on 1/7/22 and her next treatment on 1/14/22, 7 days later. Resident #12's TARs and nursing notes did not include documentation related to why wound care was held. Resident #12's TAR also did not include documentation the as-needed wound care was provided as ordered. Resident #12's quarterly MDS assessment, dated 11/1/21, documented she had a Foley catheter (indwelling catheter) and was incontinent of bowel. The MDS assessment documented she had two Stage 4 pressure ulcers, one of which was present upon admission. A weekly pressure ulcer report, dated 12/2/21 at 12:38 PM, documented the Treatment Nurse noted Resident #12's pressure ulcer recently declined. The report documented it might be a direct result of Resident #12's weight increase. The documentation stated increased slough in Resident #12's IT wound continued, and the sacrum (tailbone) wound gained a thin layer of epithelized (skin) tissue. The report also documented the new pressure ulcer on her IT was at Stage 4. The sacrum Stage 4 pressure ulcer size measured 1 x 6 x 0.4 cm (length x width x depth) and the IT Stage 4 pressure ulcer size measured 5 x 2 x 0.5 cm. A weekly pressure ulcer report, dated 12/8/21 at 10:08 AM, documented the Treatment Nurse noted Resident #12's wounds had recently declined. The report documented it might be a direct result of the increase in Resident #12's weight. The report also documented the increased slough in her IT wound continued, and the sacrum wound had increased slough. The documented measurements were the sacrum Stage 4 pressure ulcer size was 1.5 x 6 x 0.4 cm (increased in size from prior assessment on 12/2/21) and the IT Stage 4 pressure ulcer size measured 5 x 2 x 0.5 cm. A physician order, dated 12/27/21, documented to provide Resident #12 side to side positioning every 1 hour, every shift, reduce pressure on bony prominences, and to keep pressure off Resident #12's wound. Resident #12's January 2022 TARs documented side to side positioning was scheduled 2 times a day on morning and night shift and not every 1 hour per the physician order. Resident #12's January 2022 TARs documented she was not repositioned on the day shift on 1/3/22, 1/6/22, 1/8/22, 1/9/22, and 1/12/22. A weekly pressure ulcer report, dated 1/5/22 at 12:19 PM, documented the Treatment Nurse noted Resident #12's wound was currently being impacted by the removal of Resident #12's Foley catheter due to incontinence and her resistance to cares. The report stated this resulted in more frequent dressing changes and removing the fragile epithelial tissue. Her sacrum Stage 4 pressure ulcer size measured 2 x 4 x 0.4 cm (increased in size from prior assessment on 12/8/21) and her IT Stage 4 pressure ulcer size measured 2 x 1 x 0.4 cm. On 1/24/22 beginning at 1:00 PM, the Treatment Nurse said there was no recent wound measurement after 1/5/22 because Resident #12 refused wound treatment. She said Resident #12 gained about 4 pounds in about 3 to 4 weeks, and the weight gain added some pressure to the pressure ulcers, which was the cause of the pressure ulcer decline. On 1/24/22 at 2:00 PM, the Treatment Nurse said the facility did not have documentation Resident #12's positioning times were changed from once every hour to every 2 to 3 hours. When asked about the TAR documentation and dates that were blank, she stated there should have been documentation. The facility failed to ensure Resident #12 received appropriate care to prevent pressure ulcers.

Based on policy review, record review, review of Incidents and Accidents (I&A) reports and staff interview, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 3 residents (Resident #24) reviewed for falls. This resulted in harm to Resident #24 when, after a fall she sustained a puncture wound and hematoma (bruise) to the back part of her head, which required application of surgical staples to close the wound. Findings include: The facility's Fall Management System policy and procedure, revised 6/2018, documented residents would be provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. This policy was not followed. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including [CONDITION(S)] (paralysis of both arms and legs). An annual MDS assessment, dated 2/14/22, documented Resident #24 was severely cognitively impaired, received [CONDITION(S)] (a surgical opening that is made through the front of the neck into the windpipe or trachea) care, and required two person assistance for bed mobility, transfer, toileting, and personal hygiene. A care plan, revised 12/29/21, documented Resident #24 was usually dependent on staff for ADLs related to her [CONDITION(S)]. The care plan did not include the number of staff required for bed mobility and toileting as indicated in her MDS assessment. An I&A report, dated 2/17/22 at 6:40 AM, stated CNA #1 was performing a complete linen change of Resident #24's bed. The report documented CNA #1 positioned Resident #24 on her side and CNA #1 reached for a clean fitted sheet when Resident #24 rolled out of bed onto the floor. A nurse's note, dated 2/17/22 at 7:20 AM, documented Resident #24 rolled off her bed onto the floor during cares. There was bleeding from the back of Resident #24's head and two soft spots were felt on the left side of the back of her head. Resident #24 was sent to the hospital for evaluation. A nurse's note, dated 2/17/22 at 7:42 AM, documented Resident #24 returned from the hospital. Resident #24 was noted to have a hematoma (a collection or pooling of blood outside the blood vessel) and a puncture wound with two staples on the left side of the back of her head. Resident #24's ADL care plan, revised on 2/20/22, documented she required participation of two staff members to reposition and turn her in bed. The care plan also directed staff to provide her with a bariatric mattress. On 5/9/22 at 5:00 PM, CNA #1 stated he positioned Resident #24 to her right side and he was reaching for a clean incontinence brief which was on the chair when Resident #24 rolled off her bed onto the floor. CNA #1 stated he did not hold onto Resident #24's left side. When asked how many staff Resident #24 required for bed mobility and toileting, CNA #1 stated I think one person, but I am not sure. On 5/10/22 at 11:07 AM, the DON stated CNA #1 positioned Resident #24 on her right side during cares and CNA #1 turned away to grab a sheet when Resident #24 rolled off her bed and fell on to the floor. When asked why Resident #24 was assisted by only one staff when her MDS indicated she required two-person assistance with her bed mobility and toileting, the DON stated she did not know. When asked if Resident #24 should have been assisted by two staff members during cares, the DON stated yes. The facility did not provide adequate supervision to Resident #24 to prevent her fall.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents, their representatives, and families were updated regarding the number of new COVID-19 positive cases for residents and staff, the cumulative number of COVID-19 cases for residents and staff, and the mitigating factors the facility was used to help control/stop the spread of the virus by 5:00 PM the next day. This was true for all 58 residents who resided in the facility. This systemic failure had the potential to deprive the resident representatives and families of each of the residents in the facility of the extent of COVID-19 cases in the facility and the opportunity to advocate for the resident and assist the resident in choosing whether to remain in the facility. Findings include: The facility's policy for Notification and Reporting of Suspected or Positive COVID-19, dated June 2021, stated the facility electronically reported information about COVID-19 in a standard format, which included the following: * The facility electronically informed residents' representatives and families by 5:00 PM on the next calendar day following the occurrence of each single confirmed COVID-19 infection or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. * The notification must include information on mitigation actions implemented to prevent or reduce the risk of transmission, including if operations of the facility were altered. The notice must include any cumulative updates at least weekly. This policy was not followed. The facility's Residents' and Employees' COVID-19 positive test tracking report, dated 12/28/21 to 1/15/22, documented three staff members tested positive for COVID-19, as follows: * 12/28/21 - 1 housekeeper * 1/12/22 - 1 nurse * 1/15/21 - 1 CNA The Facility's Voice Broadcast Transcripts and residents' representatives and families' telephone logs, dated 12/28/21 to 1/15/22 included the following: * On 12/29/21, the Voice Broadcast Transcript documented the facility notified residents' representatives and families that one contract staff member tested positive for COVID-19 on 12/28/21. The staff member did not have symptoms and was sent home from the facility after working one shift. The staff wore a mask and eye protection the entire time when working in the facility. The Transcript documented the facility began COVID-19 testing protocols. The facility's Voice Broadcast Transcript did not include the COVID-19 cumulative updates. * On 1/12/22, the Voice Broadcast Transcripts documented the facility notified residents' representatives and families the facility had one staff member test positive for COVID-19 on 1/12/22. The staff member was not working at the time of the positive test and was not symptomatic on the last shift worked on 1/10/22. The staff member was removed from the schedule. The facility continued the outbreak protocols put in place. The facility's Voice Broadcast Transcript did not include the COVID-19 cumulative updates. * On 1/18/22, the Voice Broadcast Transcript documented the facility notified residents' representatives and families one more staff member tested positive on 1/15/22 for COVID-19. The Transcript documented the facility continued outbreak protocols. The facility did not notify residents' representatives and families by 5:00 PM the next calendar day after confirming one COVID-19 infection on 1/15/22. The facility's Voice Broadcast Transcripts also did not include information on mitigation actions implemented to prevent or reduce the risk of transmission and the COVID-19 cumulative updates. On 1/19/22 at 4:09 PM, the Administrator said he had the impression the facility was only required to notify residents' representatives and families weekly. The facility did not notify residents' representatives and families on 1/16/22 and 1/17/22. On 1/21/22 at 10:25 AM, the Administrator said the facility's policy required COVID-19 notification be completed by 5:00 PM the next calendar day. On 1/22/22 at 10:50 AM, CRN #2 said the Voice Broadcast Transcripts did not include the COVID 19 cumulative updates.

Based on observation, review of nursing schedules, review of the facility's COVID-19 testing results, resident and staff interview, and policy review, it was determined the facility failed to ensure a) Designated staff were assigned each shift to work only with COVID-19 positive residents to prevent the transmission of COVID-19, b) Appropriate Personal Protective Equipment (PPE) was used and disinfected to prevent the spread of COVID-19 and other infections, c) hand hygiene was completed consistent with the facility's policies and standards of practice, and d) Residents' laundry was transported in a manner to protect against cross-contamination of infectious pathogens. COVID-19 is a new coronavirus caused by [MEDICAL CONDITION] that can spread person to person. This new virus has currently spread throughout the world. Symptoms range from mild to severe illness and even death. The failure of the facility to designate staff to work only with residents who were COVID-19 positive, placed all staff who tested negative for COVID-19 and 47 of 47 residents residing in the facility who tested negative for COVID-19, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: 1. The facility's Infection Prevention and Control Manual, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated 10/20/20, documented the facility would have dedicated staff or consistent staff assigned to the unit/wing or room assignment of residents who tested positive for COVID-19 and those staff would not be rotated to mitigate the risk of transmission. The Centers for Disease Control and Prevention (CDC) website, accessed on 11/30/20, included the following guidance: * Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, which documented facilities were to assign dedicated health care professionals (HCP) to work only on the COVID-19 care unit. At a minimum this should have included primary nursing assistants and nurses assigned to care for these residents. * Preparing for COVID-19 in Nursing Homes, updated 11/20/20, which documented facilities were to identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that would be used to cohort residents with COVID-19. And, the facility was to identify HCP who would be assigned to work only the COVID-19 care unit when it was in use. This policy and guidance were not followed. On 11/5/20, four residents tested positive for COVID-19 and were transferred to the 100 Hall, as follows: * Resident #24 had a positive POC test and was transferred to the 100 Hall on 11/4/20, and had a positive PCR test on 11/5/20, and returned to the 300 Hall on 11/18/20. * Resident #25 tested positive and was transferred to the 100 Hall on 11/5/20 and was transferred to the hospital on [DATE] and returned to the 100 Hall on 11/18/19 and remained under quarantine as of 11/25/20. * Resident #26 tested positive and was transferred to the 100 Hall on 11/5/20 and was discharged from quarantine on 11/19/20 and returned to the 300 Hall. * Resident #27 tested positive and was transferred to the 100 Hall on 11/5/20 and was transferred back to the 300 Hall on 11/20/20. The facility's Daily Staffing Sheets, dated 11/4/20 through 11/20/20, documented one RN was scheduled to care for all residents on the 100 Hall. The same staffing sheets documented the CNA assigned to the 200 Hall was to assist the CNA on the 100 Hall if only one CNA was scheduled for the 100 Hall every shift. On the 11/9/20 and 11/16/20 day shifts, the staffing sheets documented the CNA assigned to the 300 Hall was to assist the CNA on the 100 Hall if there was only one CNA scheduled for the 100 Hall. The facility's staffing schedule, dated 11/23/20, documented 1 CNA and 1 RN were scheduled to work each shift on the 100 Hall that day. On 11/23/20 at 8:25 AM and 8:48 AM, RCM #2 said the facility did not have a COVID unit. RCM #2 said there were a total of 6 residents currently on the 100 Hall. RCM #2 said there were three residents on isolation, Resident #14, a resident who tested positive for COVID-19, and Resident #25 and Resident #28, who both came from the hospital and were under 14-day quarantine. At 11:10 AM, RCM #2 said RN #1 was the 100 Hall RN who provided medications to the resident who tested positive for COVID-19 and the other 5 residents on the 100 Hall. RCM #2 said when RN #1 was done on the 100 Hall she went to other units to assist. On 11/23/20 at 11:50 AM, RN #1 said she was the RN for the 100 Hall and was always assigned that hall. RN #1 said there were 3 residents under quarantine on the 100 Hall, Resident #25 and Resident #28, and Resident #14 who was COVID-19 positive. RN #1 said Resident #13 resided on the 100 Hall permanently, and Resident #23 and Resident #29 were done with their 14-day quarantine and were receiving rehabilitation services. On 11/23/20 at 2:00 PM, the Administrator, with the DON present, said the 100 Hall was the short stay hall where rehabilitation services were provided and where residents resided who were COVID-19 positive, residents who were new admissions or readmissions resided for 14-day quarantine, and where some residents with non-COVID-19 issues resided. During the same interview, the DON said the 100 Hall was not currently considered a COVID-19 hall as it was in May or June. The DON said the RN and CNA were assigned to the 100 Hall but might go to other halls to assist. The DON said the CNA on the 100 Hall was available to go to the 200 Hall if needed, to assist with a transfer for example, and nothing precluded the 100 Hall RN or CNA from working another hall. The DON said they did not have dedicated staff on the 100 Hall. The DON said dedicated staff were not necessary for one COVID-19 positive resident, and if the staff wore the required PPE the facility did not need dedicated staff. The DON said two weeks ago they had 4 residents with COVID-19 at one time and they had quarantined the 4 residents on the 100 Hall. The DON said the facility currently did not have a shortage of staff, and they had enough staff to care for the current number of residents. The DON said the RCM, ICP and DON were available to work the 100 Hall if needed. The DON said the facility had enough PPE and was not conserving PPE. The Administrator said if the staff was donning the correct PPE and performing hand hygiene for the COVID-19 positive resident then there was no reason to provide dedicated COVID-19 staff. The facility failed to ensure designated staff were assigned each shift to residents who tested positive for COVID-19. This deficient practice placed staff and residents who had tested negative for COVID-19, at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death related to the infection. On 11/23/20 at 5:26 PM, the Administrator, DON and ICP were informed by written notification of a determination of Immediate Jeopardy (IJ). On 11/24/20 at 5:30 PM, the facility provided a plan to remove the immediacy. The facility alleged the plan to remove the immediacy was implemented 11/24/20 at 5:00 PM. The plan was accepted on 11/25/20 at 8:14 AM. The facility's IJ removal plan documented the facility will assign dedicated staff to work with residents that are presumptive or confirmed to have COVID-19. Surveyors completed onsite verification of the implementation of the facility's Immediate Jeopardy removal plan and confirmed the immediacy was removed as of 11/25/20 at 11:15 AM and the Administrator was informed. 2. The facility's Infection Prevention and Control Manual, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated 10/20/20, directed staff in the event of a facility outbreak, to institute outbreak management protocols including limiting only essential personnel to enter the room with appropriate PPE and respiratory protection, including eye protection, and: * to remove the eye protection before leaving the resident room * to clean and disinfect reusable eye protection according to manufacturer's recommendation. The CDC website, accessed on 11/23/20, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 11/4/20, documented the PPE recommended when caring for a patient with suspected or confirmed COVID-19 included eye protection, and to: * remove eye protection after leaving the patient room or care area, unless implementing extended use * reusable eye protection must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. On 11/23/20 at 12:10 PM, with a surgical mask over her N95 and face shield already on, RN #1 donned a gown and gloves outside Resident #14's room. Resident #14 was in isolation due to testing positive for COVID-19. RN #1 entered Resident #14's room and set her lunch tray on her overbed table and set up her meal. RN #1 exited the room after doffing the gown and gloves and changing her surgical mask. She did not remove or sanitize her face shield. On 11/23/20 at 12:45 PM, the Administrator walked by when RN #1 was asked if she sanitized her face shield when exiting Resident #14's room. The Administrator said the staff wore one face shield per shift and cleaned the face shield if it became visibly soiled. On 11/23/20 at 2:00 PM, the DON said the face shield was cleaned at the end or start of the shift or if it was visibly soiled. The DON said there was no expectation to clean the face shield when leaving the room. On 11/23/20 at 3:40 PM, the Administrator said the face shields were to be cleaned per the manufacturer's instructions. The Administrator said the facility's policy did not require the face shield be cleaned after every use. On 11/24/20 at 12:06 PM, the Administrator said the facility did not have the manufacturer's recommendations for cleaning the face shield. 3. The CDC website, accessed on 11/24/20, titled Hand Hygiene in Healthcare Settings, dated 3/15/16, documented patients should clean their hands before preparing and eating food and after using the restroom. This guidance was not followed: a. On 11/23/20 at 11:40 AM, Resident #2 was sitting on the toilet and RN #1 was next to her. When Resident #2 was finished RN #1 assisted her to stand up. Resident #2 held on to the handle bar and took some toilet paper and wiped her genitalia using her right hand. RN #1 then helped Resident #2 back to her room. RN #1 did not offer hand hygiene to Resident #2 after using the toilet. Resident #2 then asked for water and RN #1 handed Resident #2 her water mug with a straw in it. Resident #2 took the water mug and sipped water through the straw while holding the straw with her right hand. RN #1 then said she would take Resident #2 to the shower room. On 11/23/20 at 12:40 PM, RN #1 said she did not offer hand hygiene to Resident #2 after she used the restroom. RN #1 said her plan was to take Resident #2 to the shower room after she used the restroom when Resident #2 asked for water to drink. RN #1 said she should have offered hand hygiene to Resident #2 after she used the toilet. b. On 11/23/20 from 12:25 PM to 12:36 PM, lunch trays were delivered to the residents in the 200 Hall. During delivery of the lunch trays the following was observed: -At 12:25 PM, CNA #3 delivered and set up Resident #3's meal for him on his overbed table in his room. CNA #3 did not offer hand hygiene to Resident #3 before his meal. -At 12:26 PM, CNA #4 delivered and set up Resident #4's meal for her on her overbed table in her room. CNA #4 did not offer hand hygiene to Resident #4 before her meal. -At 12:28 PM, CNA #3 and CNA #4 delivered and set up Resident #5 and Resident #6's meals on their overbed table in their room. CNA #3 and CNA #4 did not offer hand hygiene to Resident #5 and Resident #6 before their meals. -At 12:29 PM, CNA #3 delivered and set up Resident #7's meal on his overbed table. Resident #7 handed his half full urinal to CNA #3. CNA #3 then brought the urinal to the restroom and performed hand hygiene. CNA #3 did not offer hand hygiene to Resident #7 before his meal. -At 12:30 PM, RN #3 and CNA #4 delivered and set up Resident #8's and Resident #9's meals on their overbed tables. RN #3 and CNA #4 did not offer hand hygiene to Resident #8 and Resident #9 before their meals. -At 12:30 PM, the OT entered Resident #23's room and placed her lunch tray in front of her chair then set up her table and meal in front of the TV at Resident #23's request. The OT did not remind or offer Resident #23 hand hygiene before she ate her meal. Resident #23 said the OT did not remind or offer her hand hygiene before her meal. -At 12:34 PM, CNA #4 delivered and set up Resident #10's meal on her table. CNA #4 did not offer hand hygiene to Resident #10 before her meal. -At 12:35 PM, CNA #3 delivered and set up Resident #11's meal on his overbed table. CNA #3 did not offer hand hygiene to Resident #11 before his meal. -At 12:36 PM, CNA #4 delivered and set up Resident #12's meal on his overbed table. CNA #4 did not offer hand hygiene to Resident #12 before his meal. On 11/23/20 at 12:45 PM, CNA #4 said she did not offer hand hygiene to the residents when she delivered their meals. CNA #4 said she should have offered hand hygiene to the residents when she delivered their meals. On 11/23/20 at 12:55 PM, CNA #3 said she did not offer hand hygiene to the residents when she delivered their meals. On 11/23/20 at 5:00 PM, the ICP said residents should be offered hand hygiene before every meal. 4. The facility's Handwashing/Hand Hygiene policy, revised 8/2015, directed staff to perform hand hygiene before preparing or handling medications and after removing gloves. This policy was not followed: a. On 11/23/20 at 11:15 AM, RN #1 performed pericare on Resident #1. She removed her gloves and put on new gloves. RN #1 did not perform hand hygiene before putting on new gloves. RN #1 then applied Prevalon boots (pressure relief) to Resident #1's feet and pulled his sheet up to his waist when Resident #1's personal belongings fell on the floor. RN #1 knelt on the floor, placed her gloved right hand on the floor to support herself, and picked up Resident #1's personal belongings from the floor. RN #1 put the belongings on Resident #1's table and positioned his bed to his liking using the bed remote control. RN #1 then removed her gloves, performed hand hygiene, and left the room. RN #1 did not clean/sanitize the bed remote control prior to leaving Resident #1's room. On 11/23/20 at 12:40 PM, RN #1 said she did not perform hand hygiene in between glove changes. RN #1 said she performed hand hygiene after she completed the task. RN #1 also said she did not clean/sanitize Resident #1's bed remote control after she touched it with her dirty gloves. RN #1 said she should have wiped the bed remote control before she left the room. b. On 11/23/20 at 9:30 AM, Resident #15 approached RN #2 while she was preparing Resident #27's medications. RN #2 stopped and handed Resident #15 a medication cup containing his medications. RN #2 then continued to prepare Resident #27's medications. RN #2 did not perform hand hygiene after she administered Resident #15's medications. RN #2 said she did not perform hand hygiene after she handed Resident #15's medication cup to him. RN #2 said there was no policy regarding hand hygiene between handling one medication cup and another medication cup. c. On 11/23/20 at 9:48 AM, CNA #1 put on a gown, then put a glove on her left hand when a paper fell on the floor. CNA #1 with her non-gloved right hand picked up the paper and threw it in the trash can. CNA #1 continued to put a glove on her right hand and entered Resident #28's room. CNA #1 did not change her gloves or use hand sanitizer after she picked the paper up from the floor. On 11/23/20 at 11:50 AM, RN #1 said CNA #1 should have removed the glove from her left hand after she picked the paper up from the floor, performed hand hygiene and donned a fresh pair of gloves. 5. The facility's Delivery of Clean Linen policy and procedure, revised 9/5/17, documented clean linen must be covered during delivery to prevent potential contamination. This policy was not followed: On 11/23/20 at 10:13 AM, Housekeeper #1 was observed as she delivered residents' clothing to residents' rooms on the 300 Hall. The laundry rack was in the hall as residents' clothing was taken to their rooms. The back and both sides of the laundry rack were covered, and the front was completely open. Housekeeper #1 said the laundry rack was for 300 Hall residents only and she did not pull the cover down when she distributed the residents' clothing on the 300 Hall. On 11/23/20 at approximately 10:45 AM, the Housekeeping Manager said she expected the laundry rack to be covered completely on all sides when it was out in the hallway. On 11/23/20 at 5:00 PM, the ICP said she expected the laundry rack to be covered on all sides when it was in the hallway.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms of cough, fever, and in severe cases difficulty breathing that could result in severe impairment or death. The facility's COVID-19 unit (Hall 300) had fans blowing throughout the unit and towards the non-COVID-19 units (Hall 200 and Hall 100), COVID-19 unit did not have consistent staff assigned as evidenced by staffing schedule showing 12 staff members (Certified Nursing Assistant (CNA) 1, CNA2, CNA10, CNA13, CNA16, CNA26, CNA25, CNA27, Licensed Nurse (LN) 4, LN8, LN9, LN16) had worked on the COVID-19 unit and the next day worked on non-COVID-19 unit, including CNA2 who reported COVID-19 symptoms the day after working on COVID-19 unit and then non-COVID-19 unit and subsequently tested COVID-19 positive. In addition, 1 of 1 staff (CNA1) observed did not properly re-don personal protective equipment (PPE) and this was not addressed in staff training or postings, and 2 of 3 staff (CNA1 and CNA24) observed failed to properly clean and disinfect pulse oximeter after use on several residents on both COVID-19 and non COVID-19 units. In addition, the disinfectant used was not effective against emerging [MEDICAL CONDITION] pathogens and human coronavirus. These failures increased the likelihood for serious injury, serious harm, or death and required immediate action to prevent transmission of COVID-19 from positive and/or presumptive COVID-19 residents to negative COVID-19 residents and staff. The facility census was 57; which included 18 known or presumed COVID-19 positive residents in Hall 300 COVID-19 unit and 2 known COVID-19 positive residents in non-COVID-19 units. This is in addition to 2 residents who died from COVID-19 and 4 current residents who were COVID-19 positive and since recovered. There were 15 staff who were COVID-19 positive and either returned to work or were still out and one staff member had COVID-19 symptoms with test results pending. On [DATE] at 3:47 PM the Administrator, Director of Nursing (DON), Infection Preventionist Nurse (IP), and Corporate Nurse (CN) was informed of Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (F880) and the IJ template was emailed on [DATE]. On [DATE] at 3:05 PM the DON was informed it was determined the immediacy was removed based on onsite verification that IJ removal plan was implemented. The Administrator was not present in the facility. Additionally, After using glucometer to check blood sugar for 1 of 2 blood sugar testing observations, staff did not use a barrier to protect used glucometer from contaminating non sampled resident (R) (R10)'s room environment. Findings include: Record review of Midnight Census Report showed the facility census was 48. 300 Hall Census Sheet, COVID-19 Resident and Staff Line Listing showed 18 known or presumed COVID-19 positive residents in Hall 300 COVID-19 unit and 2 known COVID-19 positive residents in non-COVID-19 Hall 100. This is in addition to 2 residents who died from COVID-19 and 4 current residents who were COVID-19 positive and since recovered. The majority of the residents had multiple room changes from Hall ,[DATE] to Hall 300 and sometimes back to Hall ,[DATE]. There were 15 staff who were COVID-19 positive and either returned to work or were still out and one staff member had COVID-19 symptoms with test results pending. 1. Fans in COVID-19 unit During an interview on [DATE] at 7:40 AM, LN23, who was also a Resident Care Manager (RCM), stated that Hall 300 was designated as a COVID-19 unit ,[DATE] weeks ago, with residents having mild to moderate COVID-19 symptoms in late March. All staff wear a gown, mask (either surgical mask or N95), eye protection, and gloves, enough PPE supplies are available, N95 masks are worn in Hall 300 since opening but N95 masks only started in Hall 100 and Hall 200 about a week ago. Observation on [DATE] at 7:50 AM showed facility was configured in a cross pattern, with Hall 200 at the top of the cross, conference room and kitchen at the bottom of the cross, Hall 100 on the left side of the cross and Hall 300 on the right side of the cross. The entry to Hall 300 had closed heavy metal doors and special droplet/contact transmission-based precaution signs on the doors. LN23 stated that anyone that entered Hall 300 could not go to other parts of the facility that same day. Two staff members, CNA1 and LN9, on Hall 300 wore eye protection, surgical mask, N95 mask, long gown, and gloves. It was notably hotter in Hall 300. Observed four fans blowing air in Hall 300; all four fans were facing COVID-19 Hall 300 entrance doors in the direction of non-COVID-19 Hall 100 and Hall 200 on the other side of the doors. Hall 300 had residents residing in rooms 305, 307, 309, 311, 313, 315 and 317 on the left side of the hall and rooms 310, 312, 314, and 316 on the right side of the hall. The room numbers became higher the further away from the entrance doors. Record review of 300 Hall Census Sheet and COVID-19 Resident Line Listing and observation showed on the left side of Hall 300 was: *room [ROOM NUMBER]: this was the first room closest to the entrance door. R6 and R7, both presumed COVID-19 positive, resided here. The room door was opened. *room [ROOM NUMBER]: R8 and R9, both COVID-19 positive, resided here. The room door was closed. A large standing fan, blowing in the direction of the entrance doors, was outside the room. The fan was about 15 feet from the Hall 300 entrance doors. *room [ROOM NUMBER]: R12, COVID-19 positive, resided here. The room door was open. *room [ROOM NUMBER]: R15, COVID-19 positive, resided here. The room door was open. *room [ROOM NUMBER]: R18, COVID-19 positive, resided here. The room door was open. *room [ROOM NUMBER]: R20 and R21, both COVID-19 positive, resided here. The room door was closed. *room [ROOM NUMBER]: R24, COVID-19 negative but symptomatic on [DATE] and R25, COVID-19 negative but symptomatic on [DATE], resided here. The room door was open. A large standing fan, blowing in the direction of the entrance doors, was outside the room. On the right side of Hall 300 was: *room [ROOM NUMBER]: R13, COVID-19 positive, and R14, presumed COVID-19 positive, resided here. The room door was open. *room [ROOM NUMBER]: R16 and R17, both COVID-19 positive, resided here. The room door was open. *room [ROOM NUMBER]: R19, COVID-19 positive, resided here. The room door was closed. A commercial carpet drying fan, labeled Hawk air mover, was outside the room. Fan used for drying carpets; designed take dry air from above and direct it across the floor, working at high-velocity airflow rates. *room [ROOM NUMBER]: R22 and R23, both COVID-19 positive, resided here. The room door was opened. A large standing fan, blowing in the direction of the entrance doors, was outside the room. During concurrent observation and interview on [DATE] at about 8:00 AM, CNA1's face was flushed with perspiration on face and stated it's very warm here the building is old, built in the 50's. The fans have been here for three weeks, think it's very warm when the (Hall 300) doors are closed. Observation on [DATE] at about 8:00 AM showed Hall 300 doors opened for about 5 minutes while staff transferred each meal tray into a meal cart that was already in Hall 300. 18 residents resided in Hall 300. Observation on [DATE] from 8:00 AM to 9:30 AM showed surveyor's hair blowing continuously, when standing near room [ROOM NUMBER], from one or all three fans blowing forcible air located outside room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. A table with masks, cleaning solutions, tissue boxes, papers and manila folders was located outside Social Services office across from room [ROOM NUMBER] and 309. The manila folder and papers were observed flapping from the forcible air blown from fans. CNA1 moved large trash barrel lined with plastic bag down the hall, plastic bag was heard making a very loud crinkly noise and was observed moving vigorously when passing standing fans. CNA1 and LN9 was overheard stating how hot it was and observed wiping their foreheads which glistened and appeared wet. During a concurrent observation and interview on [DATE] at 8:35 AM in the social services office on Hall 300, DON stated that all residents on COVID-19 Hall 300 were known or presumed COVID-19 positive. DON further stated that the fans have been in place since COVID-19 Hall 300 opened on [DATE]. When asked about concerns with fans blowing in COVID-19 Hall 300 and towards non-COVID Halls 100 and 200, DON stated that facility's regional team has seen the fans without any concerns. Surveyor pointed to the wall of social services office where multiple papers taped to the wall was observed to be moving and flapping around from the forcible air blown from the fans. When asked if DON saw papers flapping from the fans, DON nodded his head in acknowledgment. DON stated that in March, Hall 300 was under construction and no residents resided here but facility was allowed to finish construction 7 days before [DATE] and opened Hall 300 as their dedicated COVID-19 unit on [DATE]. Prior to [DATE], known or presumed positive COVID-19 residents resided on Halls 100 and 200 with transfer to Hall 300 on or after [DATE] when construction was completed. During an interview on [DATE] at 9:50 AM with DON and IP, IP stated that Hall 300 has a separate air handling system and fans are for staff comfort because it is too hot, especially with PPE. During an interview on [DATE] at 2:40 PM with Administrator, DON, and IP, Administrator stated that the building was built in 1974 and the windows and siding are old which makes it hot inside the building. Fans in Hall 300 are for staff and resident comfort and temperatures cannot be regulated in each resident room, each hall has its own runs and there is no co-mingling of air between runs. Observation on [DATE] at 3:15 PM showed two unknown staff members talking with Hall 300 doors opened. The doors were opened at least several minutes. Overheard over staff walkie system on [DATE] at 3:20 PM move fans, can't be pointed towards fire door, needs to be pointed the other way. During concurrent record review and interview on [DATE] at 5:20 PM when asked about facility's policy, Infection Prevention and Control Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated [DATE], which showed, a resident with known or suspected COVID-19, immediate infection and control measures will be put in place. Resident will be placed in an Airborne Infection Isolation Room (AIIR) that is constructed and maintained in accordance with current guidelines .If no AIIR is available in the facility, the resident should be transferred as soon as possible to a facility with an AIIR. While awaiting transfer, place a facemask on the resident and place resident in a private room with the door closed, preferably not in a room where room exhaust is recirculated within the building without HEPA filtration . IP stated that the facility did not have any AIIRs, residents were offered transfer to facility with AIIRs, facility COVID-19 outbreak started on [DATE], and fans are not blowing far enough past Hall 300 doors and there is no direct bleed from Hall 300 to Hall ,[DATE]. During concurrent observation and interview on [DATE] at 5:45PM showed Hall 300 fans were pointed away from Hall 300 entrance doors and towards exit. Surveyor and IP agreed and pointed fans towards Hall 300 entrance doors to conduct tissue test (rudimentary test where tissue is placed at the bottom of closed doors to assess pressure differences between two areas; tissue should move from positive to negative pressure). At about 6:00 PM, IP placed tissue at the bottom of closed doors and the tissue moved in the direction of the Hall 300; this indicated that air was not moving from Hall 300 to Halls ,[DATE], although sufficient time may not have been allowed to conduct tissue test. During interview on [DATE] at 7:05 AM Maintenance Director stated that at least one fan is usually blowing in Hall 300 and was unaware four fans were currently in use in Hall 300. Maintenance Director stated that the commercial carpet drying fan was from housekeeping and not Maintenance. During interview on [DATE] at 8:30 AM with Maintenance Director, Admission staff who used to work in Maintenance, DON, Administrator, Corporate Nurse, IP, and Idaho State survey team members including Life Safety surveyor, Survey Director and managers, Maintenance Director stated that the Hall 300 temperature measured 68 to 72.5 degrees Fahrenheit this morning, there's one thermostat in one room that controls temperature for the entire hall, observed four fans in Hall 300 this morning and the fans were pointed in all different directions; some were pointed towards the Hall 300 entrance doors and others were pointed towards the exit, the direction of the fans seemed to be based on where staff are standing, the fans are facing towards nursing carts, where nurses are standing at the cart, some are facing towards the corridor (Hall 300 entrance) and others facing towards the exit. Maintenance Director further stated that the heat was turned off and staff turned on and off the heat all the time. When asked if the air conditioner was on, Maintenance Director stated, no, still in heat mode. Not an automated system. System needed to be manually put into a cool mode to drop the temperature. DON stated it's very hot with all PPE on and that's why the fans are there. Review of temperature for Boise area on [DATE] showed a high temperature of 82 degrees Fahrenheit, accessed [DATE], https://w2.weather.gov/climate/getclimate.php?wfo=boi. Record review of facility's policy, Infection Prevention and Control Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated [DATE], showed, it is the policy of this facility to minimize exposures to respiratory pathogens .and adhere to Standard, Contact and Airborne Precautions . The Centers for Disease Control and Prevention (CDC)'s Guidelines for Environmental Infection Control in Health-Care Facilities, updated [DATE], accessed [DATE], https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, showed airflow between two different areas such as rooms or hallways should be from clean-to-dirty airflow. The COVID-19 Hall 300 is considered dirty and the four fans blowing forced air towards the non-COVID-19 Hall 100 and Hall 200 was not aligned with the principle of clean-to-dirty airflow. CDC's Nursing Home Infection Preventionist Training Course Environmental Cleaning module, accessed [DATE], https://www.train.org/cdctrain/training_plan/3814, showed infection prevention principle of clean-to-dirty work flow to prevent contamination. State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revision [DATE], stated if using fans in laundry processing areas, prevent cross-contamination of clean linens from air blowing from soiled processing areas (i.e., the ventilation should not flow from soiled processing areas to clean laundry areas). This reference outlines basic infection prevention principle from clean-to-dirty airflow direction to prevent contamination. CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Mode of transmission, accessed [DATE], https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, states current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. The contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to close proximity transmission is currently uncertain. 2. Consistent staff assigned to COVID unit Record review of facility's policy, Infection Prevention and Control Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated [DATE], showed, in the event of a facility outbreak when AIIR rooms are not available in the community, institute outbreak management protocols: 7. Implement consistent assignment of employees. Policy attachment, COVID-19 Proactive Preparation Planning showed .10. Review and identify staff deployment (i.e. consistent assignment). CDC's Preparing for COVID-19: Long-term Care Facilities, Nursing Homes, accessed [DATE], https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html, showed Dedicate Space in the Facility to Monitor and Care for Residents with COVID-19: dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Assign dedicated HCP to work only in this area of the facility. In addition, HCP (health care professionals) continue to be sources of introduction of COVID-19 into nursing homes . Recent experience with outbreaks in nursing homes has also reinforced that residents with COVID-19 may not report typical symptoms such as fever or respiratory symptoms; some may not report any symptoms. Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings. During an interview on [DATE] at 8:35 AM DON stated that staff who work on Hall 300 have to leave the facility and are not allowed in other parts of the building until the next day. Staff can work on the Hall 300 on one day and work Hall 100 or Hall 200 the next day. Staff can work on the Hall ,[DATE] and then work on Hall 300 on the same day but cannot work on Hall 300 and then work on Hall ,[DATE] on the same day. The general rule is when you come to Hall 300 you leave from Hall 300 and don't re-enter the building. During an interview on [DATE] at 9:50 AM IP stated that staff who work on Hall 300 can work on Hall 100 or Hall 200 the next day as long as staff passes screening at the start of their shift. During an interview on [DATE] at about 7:45 AM CNA24 stated she works where she is assigned; there is no specific staff assigned to Hall 300. She stated she worked Hall 100 yesterday for 8 hours and then worked Hall 300 for 4 hours. During an interview on [DATE] at 9:05 AM IP stated that CNA26 was first staff member with COVID-19 symptoms on [DATE] and then on [DATE] R2 was the first resident with COVID-19 symptoms. Subsequently, multiple residents and staff had COVID-19 symptoms, several residents and staff were COVID-19 positive. IP stated that several residents continued to go out to appointments as well as out in the community. IP stated that facility recommended residents not going out into the community and practice social distancing but these were elements outside their control. Staff were also lax in infection control and prevention and were counseled and re-educated. IP stated that CNA26 was patient zero. Initially, the facility didn't have PPE, used cloth masks when Hall 300 COVID-19 unit opened on [DATE] as couldn't get surgical face masks or N95 masks despite calling several community and government entities. Record review of COVID-19 Resident and Staff Line Listing and R2's progress notes showed CNA26 was ill at work on [DATE] and was sent home for self-monitoring. CNA26 had a cough and reported direct exposure to known COVID-19 positive person, date of exposure was not documented. CNA26 tested positive for COVID-19 on [DATE]. On [DATE], R2, who resided on Hall 200, had fever and low oxygen saturation levels with suspected COVID-19. On [DATE], R2 was transferred to the hospital and tested positive for COVID-19 on [DATE]. R2 was intubated in the ICU, recovered and readmitted to facility on [DATE]. Record review of Daily Staffing Sheet showed CNA26 was assigned to work as a restorative nursing aide ([DATE], 23, 24, 2020) as well as Hall 100 ([DATE] and 18, 2020). During an interview on [DATE] at 10:00 AM Staffing Coordinator (SC) stated that he schedules staff and makes staffing assignments. When asked how staff assignments are made, SC stated use of new software program based on a template. When asked if there are any parameters or guidelines for scheduling staff on Hall 300, SC stated that he tries first to use a list of staff who have volunteered to work on Hall 300 and also refers to list of staff who requested not to work on Hall 300. SC stated that we try to keep consistent staffing best we can but we had a lot of people out. We use whoever we can find. When asked if a staff could work on Hall 300 on Monday and then Hall 200 on Tuesday, SC stated, I don't see why we wouldn't allow that. Maybe staff want to work on another hall, not burn them out. Once staff goes into Hall 300, they can't come back out through the building, but if they go home after their shift, they can work any hall the next day. During concurrent record review and interview on [DATE] at 11:55 AM with DON, IP, Corporate Nurse, MDS Coordinator, facility policy, Infection Prevention and Control Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated [DATE], was reviewed which showed, in the event of a facility outbreak when AIIR rooms are not available in the community, institute outbreak management protocols: 7. Implement consistent assignment of employees. DON and IP nodded their heads and stated consistent assignment of staff is achieved by asking which staff are willing and unwilling to work on Hall 300 and try to keep staff consistent to the best of their ability, which is especially difficult with staff being out. DON stated that nursing leadership has all worked the floors recently to supplement staffing. DON further stated that think we do 90% consistent staffing, if staff work on Hall 300 they only work on Hall 300 and only time we pull someone off is when we have a crisis. We want consistent staffing in Hall 300 to prevent staff from spreading COVID-19. IP stated our staffing requires staff to work Hall 300 and then have 16 hours in between and then come back next calendar day. We haven't done that, instead staff who work Hall 300 have two day break and then return to work and then they are allowed to work Hall ,[DATE], this gives time for symptoms to develop after working Hall 300. When asked how facility defines consistent assignment of employees or consistent staffing as outlined in their policy and if CMS Guide to Improving Nursing Home Employee Satisfaction which references Pioneer Network's definition of consistent assignment (sometimes called primary or permanent assignment) that refers to the same caregivers (RNs, LPNs, CNAs) consistently caring for the same residents almost (80% of their shifts) every time they are on duty is used, DON, IP, Corporate Nurse nodded their heads and said yes that meets the intent of their policy. When asked if use of consistent staffing helps ensures staff are familiar with the resident to identify subtle changes of conditions with COVID-19 symptoms, IP stated, yes and also staff could be vector for transmitting COVID-19 when staff work on COVID-19 Hall 300 on one day and Hall ,[DATE] the next day. When asked how facility addresses pre-symptomatic or asymptomatic COVID-19 amongst staff, for which daily staff screening of assessing temperature and symptoms would not detect, IP stated that consistent staffing is to the best of our ability, we can't see if there are no symptoms. *LN9 Observation on [DATE] between 7:50 AM and 12:45 PM showed LN9 on COVID-19 Hall 300 administering medications, checking blood sugars and transferring resident with hoyer lift with CNA1. LN9 was the only LN working on the COVID-19 Hall 300. Concurrent observation and interview on [DATE] at 7:45 AM showed LN9 on non-COVID-19 Hall 100 administering medications. LN9 stated that she worked on the COVID-19 Hall 300 yesterday and was working on the non-COVID Hall 100 today. Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed LN9 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. *CNA1 Observation on [DATE] between 7:50 AM and 12:45 PM showed CNA1 on COVID-19 Hall 300 providing cares. During an interview on [DATE] at 9:30 AM CNA1 stated that she works solely on Hall 300 since Hall 300 was opened as a COVID-19 unit. CNA1 mentioned two CNAS work Hall 300 on her days off. Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA1 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 200. *CNA2 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA2 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 200. Record review of COVID-19 Staff Line Listing showed CNA2 had COVID symptoms, date of suspected illness, on [DATE], the day after working on Hall 300 and then working on Hall 200. On [DATE], CNA2 reported she had a sore throat 3 days ago ([DATE]-[DATE]) and was tested on [DATE] for COVID-19. Test results on [DATE] showed CNA2 was COVID-19 positive. *CNA10 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA10 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall ,[DATE]. CNA10 again worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. *CNA13 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA13 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 200. CNA13 again worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. *CNA16 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA16 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. CNA16 again worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. *CNA20 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA26 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall ,[DATE]. *CNA25 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA25 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 200. *CNA27 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed CNA27 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. *LN4 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed LN4 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall ,[DATE]. *LN8 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showed LN8 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall ,[DATE]. *LN16 Record review of Daily Staffing Sheet for [DATE] (start date for Hall 300) to [DATE] showeLN16 worked Hall 300 on [DATE] and the following day, [DATE], worked on Hall 100. 3. Re-donning PPE Record review of facility's policy, Infection Prevention and Control Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated [DATE], showed, it is the policy of this facility to minimize exposures to respiratory pathogens .and adhere to Standard, Contact and Airborne Precautions Policy attachment, COVID-19 Proactive Preparation Planning showed .12. Re-train all employees on Infection Prevention and Control: hand hygiene, PPE Observation on [DATE] between 7:50 AM and 12:45 PM showed CNA1 on COVID-19 Hall 300 providing cares wearing long lab coat/gown surgical mask, N95 mask and eye protection. Observation on [DATE] at 12:45 showed CNA1 returning from break and re-donning PPE in the COVID-19 changing 318 room. With bare hands, CNA1 donned previously worn long lab coat/gown with buttons present on the length of the gown. CNA1 placed one arm into the lab coat/gown and then placed the other arm through and then fastened each button. CNA1 then placed walkie talkie ear piece around ear, donned previously worn N95 mask, surgical face mask and eye protection. CNA1 touched multiple surfaces of the masks and eye protection. Hand hygiene with hand sanitizer was observed after all PPE was donned. However, no hand hygiene was observed after donning previously worn, and therefore contaminated, lab coat/gown before touching ear piece, masks and eye protection. During concurrent observation, interview and record review on [DATE] at 2:35 PM when asked how staff should re-don PPE after returning from a break during their shift, IP stated staff should wear gloves or do hand hygiene to prevent contaminating themselves or their PPE. When informed that staff was using bare hands to re-don PPE and did not perform hand hygiene after touching contaminated gown and before touching multiple surfaces of masks and eye protection, IP stated that staff were re-educated on donning/doffing PPE but additional education is needed. Surveyor and IP reviewed inservice, Donning and Doffing Protected PPE, dated [DATE], that was posted outside COVID-19 Hall 300 which showed how to remove a gown for reuse: while wearing clean gloves, carefully untie the gown and remove it The inservice also had a infographic with basic overview of how to safely don and doff PPE equipment, however the inservice did not cover the process for re-donning which staff did daily after breaks because of extended and reuse of PPE. IP stated that education and posters for donning and doffing did not cover re-donning process and that will need to be addressed. Record review of PPE In-Service for Clinical Staff, dated [DATE], presented by DON showed 300 Hall is our COVID-19 Unit. While on this hall staff are to wear a gown, gloves, face shield or goggles, N95 mask and surgical mask over the N95 we have cloth, reusable and washable, gowns to sue and disposable ones. You can choose to wear either one .Once you (sic) shift is over you go into room [ROOM NUMBER] and change out of your PPE, observing correct donning and doffing procedures for reusable and disposable PPE 4. Cleaning and disinfection of reusable medical equipment Observation on [DATE] at 12:20 PM showed CNA1 on COVID-19 Hall 300 taking R12's temperature and oxygen saturation with pulse oximeter. CNA1 wiped pulse oximeter with Microkill Plus (red top) sani-cloth wipes, performed hand hygiene and then entered R8's room. Two minutes did not lapse between exiting R12's room and entering R8's room. CNA1 took R8's temperature and oxygen saturation with pulse oximeter. CNA1 wiped pulse oximeter with Microkill sani-cloth wipes, performed hand hygiene and 20 seconds after took R9's temperature and oxygen saturation. CNA1 wiped pulse oximeter with Microkill sani-cloth wipes, performed hand hygiene and 10 seconds later entered R6's room and proceeded to take R6's temperature and oxygen saturation using the process above. 40 seconds was time between wiping pulse oximeter and using it on R7. After taking R7's pulse and oxygen saturation, CNA1 wiped pulse oximeter. After pulse oximeter was used on R7, the pulse oximeter was not observed to be wet for 2 minutes. During an interview on [DATE] at 12:40 when asked about the contact time for sani-wipes used, CNA1 was not aware of a contact time. CNA1 stated that she thinks the pulse oximeter is wet for about 15 to 30 seconds. LN9 joined the conversation and stated that there's a dwell time. Surveyor, CNA1 and LN9 reviewed s(TRUNCATED)

Based on policy review, record review, and staff interview, it was determined the facility failed to notify the physician of a resident's change of condition in a timely manner. This was true for 1 of 1 resident (Resident #19) reviewed for change of condition. Resident #19 was harmed when the facility did not call the physician immediately when he presented with low blood pressure, slurred speech, and difficulty responding to requests. Resident #19 was subsequently admitted to the intensive care unit of the hospital for septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention). Findings include: The facility's policy for Change in a Resident's Condition or Status, revised April 2011, stated .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: . A significant change in the resident's physical/emotional/mental condition; . A need to transfer the resident to a hospital/treatment center. This policy was not followed. The website www.mayoclinic.org, accessed on 3/19/20, documented the following [MEDICAL CONDITION] and septic shock: To be diagnosed with [REDACTED]. * Change in mental status * A first (upper) number in a blood pressure reading - also called the systolic pressure - that's less than or equal to 100 millimeters of mercury (mm Hg) * Respiratory rate higher than or equal to 22 breaths a minute Sepsis can progress to septic shock when certain changes in the circulatory system, the body's cells and how the body uses energy become more abnormal. Septic shock is more likely to cause death [MEDICAL CONDITION] is. To be diagnosed with [REDACTED]. * The need for medication to maintain blood pressure greater than or equal to 65 millimeters of mercury (mm Hg). * High levels of lactic acid in your blood (serum [MEDICATION NAME]) after you have received adequate fluid replacement. Having too much lactic acid in your blood means that your cells aren't using oxygen properly. Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 11/13/19, documented Resident #19 was cognitively intact, had no difficulty with swallowing, his speech was clear, and he was able to understand others. A Progress Note for Resident #19, dated 11/30/19 at 2:00 PM, documented .(Resident #19) had a difficult day. Mid morning he began hyperventilating (rapid breathing) and had systolic (top number in blood pressure) BP (blood pressures) in the low 70's and diastolic (bottom number in blood pressure) BP (blood pressures) in the low 40's, now WNL (within normal limits) .He is alert but with slurred, difficult to understand speech .Responds to verbal requests but sometimes with difficulty . There was no documentation that Resident #19's physician was notified of his low blood pressures, slurred speech, and difficulty responding to verbal requests. A Progress Note for Resident #19, dated 11/30/2019 at 6:45 PM, documented Resident #19 was typically alert and oriented to person, time, and place, and was able to follow commands. The note also stated Resident #19's urine was typically amber with sediment in it. The note documented Resident #19's status at that time was Resident urine is red, Decrease in LOC (level of consciousness), and murmured speech, Resident has an increase in respiratory rate (shallow). Resident does not recall the time or facility that they are located in. The urine in the (F)oley (catheter bag) is red. Resident unable to swallow food. Resident states pain in chest and stomach. Request: hospitalization for evaluation of condition A Progress Note, dated 11/30/2019 at 7:39 PM, documented .(Resident #19's Physician) recommended transfer to (the) hospital. Patient picked up at 19:00 (7:00 PM) by emergent transport, taken to (Hospital). Resident #19's Hospital History and Physical, dated 11/30/19 at 11:00 PM, documented the physician's impression was Septic shock present on admission presumed in relation to urinary tract infection versus possible healthcare acquired right lower lobe pneumonia (lung inflammation caused by bacterial or [MEDICAL CONDITION] infection) . The physician's plan stated, .The patient is critically ill . A Progress Note for Resident #19, dated 12/1/19 at 1:07 AM, documented .Received call from (Hospital) stating patient has been admitted for severe urosepsis (harmful organisms in the blood or other tissues that is caused by an infection in the urinary tract) . Resident #19's Hospital Discharge Summary, dated 12/6/19 at 8:00 PM, when Resident #19 was discharged back to the long term care facility, documented while at the hospital he was admitted to the Intensive Care Unit due to his [MEDICAL CONDITION] (low blood pressure). During an interview with the DON on 3/5/20 at 11:01 AM, he was asked if he would consider a resident with a systolic blood pressure in the low 70s and diastolic blood pressure in the low 40s, along with slurred speech and difficulty responding to verbal requests, to have a change of condition. The DON stated, I would assume a change of condition. When asked if he would expect Resident #19's physician to be notified regarding the change in his condition, the DON stated, Yes. When asked how soon the physician should be notified about a resident with the above listed symptoms, the DON stated, As soon as possible. The DON was asked to review the Progress Notes documented above and to determine the time Resident #19's physician was notified. He read the notes and stated, He (Resident #19) was picked up at 7:00 PM. It doesn't say what time she (Resident #19's physician) was notified. When asked what time the Progress Notes documented Resident #19's symptoms of low blood pressure, slurred speech, and difficulty responding to verbal requests were first documented, he stated, Mid-morning. The DON was asked, according to the documentation in the Progress Notes, if licensed staff recognized Resident #19 was in an emergent state mid-morning. He stated, It doesn't seem like it. When asked if the resident's physician should have been notified of the change of condition in the morning, he stated, I would have, yes. During an interview on 3/5/20 at 2:22 PM, Resident #19's the Medical Director was asked if she would expect to be notified if a resident's blood pressure was in the 70s/40s and he had slurred speech and difficulty responding to verbal requests. She stated, Yes. When asked how soon after the symptoms were noted she would expect staff to notify her, she stated, Immediately.

Based on record review, policy review, and staff interview, the facility failed to obtain emergent care in a timely manner. This was true for 1 of 1 resident (Resident #19) reviewed for Quality of Care related to a change of condition. Resident #19 was harmed when the facility when nursing staff failed to recognize and act on significant changes in condition such as low blood pressure, slurred speech, and difficulty responding to requests. Resident #19 was subsequently admitted to the intensive care unit of the hospital for septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention). Findings include: The facility's policy for Transfer or Discharge, Emergency, revised December 2012, stated: Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. The facility's policy for Change in a Resident's Condition or Status, revised April 2011, stated .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . A significant change in the resident's physical/emotional/mental condition; . A need to transfer the resident to a hospital/treatment center. These policies were not followed. The website www.mayoclinic.org, accessed on 3/19/20, documented the following [MEDICAL CONDITION] and septic shock: To be diagnosed with [REDACTED]. * Change in mental status * A first (upper) number in a blood pressure reading - also called the systolic pressure - that's less than or equal to 100 millimeters of mercury (mm Hg) * Respiratory rate higher than or equal to 22 breaths a minute Sepsis can progress to septic shock when certain changes in the circulatory system, the body's cells and how the body uses energy become more abnormal. Septic shock is more likely to cause death [MEDICAL CONDITION] is. To be diagnosed with [REDACTED]. * The need for medication to maintain blood pressure greater than or equal to 65 millimeters of mercury (mm Hg). * High levels of lactic acid in your blood (serum [MEDICATION NAME]) after you have received adequate fluid replacement. Having too much lactic acid in your blood means that your cells aren't using oxygen properly. Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 11/13/19, documented Resident #19 was cognitively intact, had no difficulty with swallowing, his speech was clear, and he was able to understand others. A Progress Note for Resident #19, dated 11/30/19 at 2:00 PM, documented .(Resident #19) had a difficult day. Mid morning he began hyperventilating (rapid breathing) and had systolic (top number in blood pressure) BP (blood pressures) in the low 70's and diastolic (bottom number in blood pressure) BP (blood pressures) in the low 40's, now WNL (within normal limits) .He is alert but with slurred, difficult to understand speech .Responds to verbal requests but sometimes with difficulty . There was no documentation that Resident #19's physician was notified of his low blood pressures, slurred speech, and difficulty responding to verbal requests. A Progress Note for Resident #19, dated 11/30/2019 at 6:45 PM, documented Resident #19 was typically alert and oriented to person, time, and place, and was able to follow commands. The note also stated Resident #19's urine was typically amber with sediment in it. The note documented Resident #19's status at that time was Resident urine is red, Decrease in LOC (level of consciousness), and murmured speech, Resident has an increase in respiratory rate (shallow). Resident does not recall the time or facility that they are located in. The urine in the (F)oley (catheter bag) is red. Resident unable to swallow food. Resident states pain in chest and stomach. Request: hospitalization for evaluation of condition A Progress Note, dated 11/30/2019 at 7:39 PM, documented .(Resident #19's Physician) recommended transfer to (the) hospital. Patient picked up at 19:00 (7:00 PM) by emergent transport, taken to (Hospital). Resident #19's Hospital History and Physical, dated 11/30/19 at 11:00 PM, documented the physician's impression was Septic shock present on admission presumed in relation to urinary tract infection versus possible healthcare acquired right lower lobe pneumonia (lung inflammation caused by bacterial or [MEDICAL CONDITION] infection) . The physician's plan stated, .The patient is critically ill . A Progress Note for Resident #19, dated 12/1/19 at 1:07 AM, documented .Received call from (Hospital) stating patient has been admitted for severe urosepsis (harmful organisms in the blood or other tissues that is caused by an infection in the urinary tract) . Resident #19's Hospital Discharge Summary, dated 12/6/19 at 8:00 PM, when Resident #19 was discharged back to the long term care facility, documented while at the hospital he was admitted to the Intensive Care Unit due to his [MEDICAL CONDITION] (low blood pressure). During an interview with the DON on 3/5/20 at 11:01 AM, he was asked if he would consider a resident with a systolic blood pressure in the low 70s and diastolic blood pressure in the low 40s, along with slurred speech and difficulty responding to verbal requests, to have a change of condition. The DON stated, I would assume a change of condition. When asked if he would expect Resident #19's physician to be notified regarding the change in his condition, the DON stated, Yes. When asked how soon the physician should be notified about a resident with the above listed symptoms, the DON stated, As soon as possible. The DON was asked to review the Progress Notes documented above and to determine the time Resident #19's physician was notified. He read the notes and stated, He (Resident #19) was picked up at 7:00 PM. It doesn't say what time she (Resident #19's physician) was notified. When asked what time the Progress Notes documented Resident #19's symptoms of low blood pressure, slurred speech, and difficulty responding to verbal requests were first documented, he stated, Mid-morning. The DON was asked, according to the documentation in the Progress Notes, if licensed staff recognized Resident #19 was in an emergent state mid-morning. He stated, It doesn't seem like it. During an interview on 3/5/20 at 2:22 PM, the Medical Director was asked if she would expect to be notified if a resident's blood pressure was in the 70s/40s and he had slurred speech and difficulty responding to verbal requests. She stated, Yes. When asked how soon after the symptoms were noted she would expect staff to notify her, she stated, Immediately.

Based on observation, resident, staff, and resident group interview, review of facility policies and procedures, and resident records, it was determined facility administration failed to ensure effective oversight and management of the facility's resources to enable each resident to attain or maintain his/her highest practicable well-being. The facility's administration failed to ensure a) systems were in place to protect residents from environmental risks, b) care and services were provided to effectively manage residents with diabetes, and c) the facility's QAA identified, took action to resolve, and monitored risks to residents. These pervasive, systemic failures placed the health and safety of 10 of 23 sampled residents (#3, #6, #9, #10, #13, #15, #17, #18, #19, and #20) residing in the facility, and all other residents residing in the facility, in immediate jeopardy of serious harm, impairment, or death. Findings include: The following systemic deficiencies were identified which placed the health and safety of residents in immediate jeopardy of serious harm, impairment, or death: a. Quality of Care: Refer to F309 as it relates to the facility's failure to ensure 4 of 4 (#6, #9, #10, and #15) residents whose diabetic care was reviewed, and the other 36 residents in the facility with a [DIAGNOSES REDACTED]. The deficient practices described at F309 reflect the failure of the facility's administration to ensure: * The care plans and physician orders [REDACTED]. * Staff followed the facility's diabetes policies and procedures. * Policies and procedures related to [MEDICAL CONDITION] were in place to provide guidance to staff. * Policies related to diabetic management were updated to reflect current standards of practice. b. Quality of Care: Refer to F323 as it relates to: - The facility's failure to ensure the health and safety of 7 of 7 (#3, #10, #13, #17, #18, #19, and #20) sampled residents residing in the facility who smoked, were not placed in immediate jeopardy of serious harm, impairment, or death due to burns, fire, and/or smoke inhalation. - The facility's failure to ensure medication and treatment carts were locked at all times when unattended. This deficient practice created the potential for independently mobile residents with cognitive impairments to access and ingest medications in excessive doses and/or contraindicated combinations, or to which they were allergic, thereby, placing their health and safety in immediate jeopardy of serious harm or death. It also created the potential for visitors, staff, and residents, to mix, or abscond with, residents' medications, resulting in serious adverse medication events or leaving residents without medications necessary to avoid physical and/or mental decline. The deficient practices described at F323 reflect the failure of the facility's administration to ensure: * Residents' smoking safety evaluations were completed and updated. * The facility's policies and guidelines related to resident smoking practices, including but not limited to, the need for residents to sign out when leaving the facility to smoke, and sign in when returning, and the need to leave smoking materials at the nurses' station, were followed and enforced. * Residents who did not require supervision while smoking were provided access to the facility's designated smoking area. * The facility provided sufficient numbers of smoking aprons to meet the needs of residents. * Nursing staff locked medication and treatment carts and followed applicable policies. c. F520 for the failure of the facility's QAA committee to identify systemic failures and risks to residents, take actions to resolve issues identified in a timely manner; and provide sufficient monitoring and oversight to maintain regulatory compliance. The deficient practices described at F520 reflect the failure of the facility's administration to ensure: * An effective, ongoing, facility-wide, QAA program was in place which identified quality deficiencies, developed and implemented plans to correct deficient areas, monitored the effectiveness of the plan, if necessary, revised the plan to achieve greater success, and assessed for ongoing compliance with quality standards. The administration also failed to ensure previously cited deficient practices did not recur. Examples include: * F280 - Noncompliance was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey, related to the failure of facility administration to ensure care plans were updated and revised to reflect the status and needs of residents. * F353 - Noncompliance was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey, related to the failure of facility administration to ensure sufficient numbers of staff were available supervise residents, meet residents' needs, and protect their health and safety. * F368 - Noncompliance was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey, related to the failure of facility administration to ensure residents were offered and received bedtime snacks. The current survey also identifies the failure of administration to develop a comprehensive policy to guide staff in snack distribution. * F441 - Noncompliance was identified during the 10/10/14 recertification survey, 3/4/16 recertification survey, and the current 11/4/16 complaint survey, related to the failure of administration to ensure infection control standards of practice were followed. On 11/1/16 at 3:55 pm, the DNS stated the issue of residents, who did not require supervision when smoking, leaving the facility without signing out and not signing in when they returned, had been a concern. The DNS said the unsupervised residents were to sign out and in using the book by the Nurses' Station. The DNS also said the unsupervised smokers were get their cigarettes and lighters from the nurses station. The DNS stated the same residents were to smoke off of facility property. The DNS said the smoking area on facility property was for supervised smokers only. The DNS stated if unsupervised smokers were discovered breaking the rules they were educated by the nurses. Residents clinical records did not include documentation that residents had been educated when observed breaking the smoking rules. On 11/2/16 at 8:50 am, the DNS said the medication and treatment carts should be locked always and when they were unlocked a nurse should be present. She said the risk of leaving a medication or treatment cart unlocked and unattended was residents, visitors or staff could take medications from the cart or mix up medications. On 11/3/16 at 9:58 am, the DNS stated if residents had high or low BG levels the staff should call the physician and if the physicians' ordered further medication the staff should administer it. In addition, she stated the staff should follow treatment guidelines for the management of hypo/hyperglycemic episodes. On 11/4/16 at 9:45 am, the DNS stated the facility was aware of the staffing issues, smoking; to include residents not signing in and out, and transportation for off-site resident appointments. She said the facility QA committee had been working on resolving these issues through the QA process. The DNS (Acting Administrator) was informed of the Immediate Jeopardy, and the need to develop and implement an acceptable plan to remove the Immediacy, at 1:00 pm on 11/4/16. On 11/10/16 at 7:45 am, the facility provided evidence that an acceptable plan to remove the immediacy had been developed. The plan included: * The Administrator and DNS would identify concerns from staff residents, and families through their QAA process and quarterly audit tools, facility rounds, incident reports, regional consultant reports, grievance logs, missing item reports, resident council minutes, and other document feedback. The concerns would be documented in corresponding log books and addressed at the next QAA meeting. * The administrator or DNS would conduct a daily review of plans or correction and audits that had been approved and implemented to correct immediacy issues in resident smoking, resident safety, (locked carts) and diabetic management. Smoking and medication/treatment carts were checked by the administrator or DNS or designee at least one time per shift. Diabetic management would be reviewed no less than twice per week. The Administrator or DNS would continue the reviews for no less than 90 days. * The Administrator or DNS would review any new resident, family, staff concerns with the IDT to determine if they required immediate interventions to protect the resident's safety, rights, or care needs. The Administrator or DNS would determine if new concerns are singular or widespread and would intervene to protect the residents. The facility would document the process in their QAA binder and run it through their process in the next meeting. * The QA process would be increased in frequency and participation to daily weekly and monthly basis. * The Regional Director of Operations and Regional Nurse Consultant would conduct a weekly phone call for 4 weeks and then monthly to ensure the QAA program was working. The phone calls would include the Administrator and DNS in which they review resident, staff, family concerns and ensure the concerns are resolved. Along with the action plan, the facility provided proof the action plans for the QAA were in place and the diabetes management were in place. After everything was validated, the Administrator and DNS were informed the Immediate Jeopardy was removed on 11/14/16.

Based on observation, resident and staff interview, and review of resident records, and facility's policy and procedure, it was determined the facility failed to ensure its Quality Assessment and Assurance Program (QAA) identified deficient practices, and develop and implement effective plans of action, to protect residents. The QAA program failed to identify and/or correct systemic deficient practices related to diabetic management, unsafe smoking practices, and unlocked medication and treatment carts, that placed the health and safety of 10 of 23 sampled residents (#3, #6, #9, #10, #13, #15, #17, #18, #19, and #20) residing in the facility, in immediate jeopardy of serious harm, impairment or death. The QAA program additionally failed to ensure prior deficient practice did not recur. The lack of an effective ongoing QAA process, placed all residents in the facility at risk of serious harm, impairment, or death. Findings include: The following deficiencies were identified at Immediate Jeopardy during the survey: * Quality of Care: Refer to F309 as it relates to the facility's failure to ensure 4 of 4 (#6, #9, #10, and #15) residents whose diabetic care was reviewed, and the other 36 residents in the facility with a [DIAGNOSES REDACTED]. * Quality of Care: Refer to F323 as it relates to: - The facility's failure to ensure the health and safety of 7 of 7 (#3, #10, #13, #17, #18, #19, and #20) sampled residents residing in the facility who smoked, were not placed in immediate jeopardy of serious harm, impairment, or death due to burns, fire, and/or smoke inhalation. - The facility's failure to ensure medication and treatment carts were locked at all times when unattended. This deficient practice created the potential for independently mobile residents with cognitive impairments to access and ingest medications in excessive doses and/or contraindicated combinations, or to which they were allergic, thereby, placing their health and safety in immediate jeopardy of serious harm or death. It also created the potential for visitors, staff, and residents, to mix, or abscond with, residents' medications, resulting in serious adverse medication events or leaving residents without medications necessary to avoid physical and/or mental decline. *Administration: Refer to F490 as it relates to the failure of the facility's administration to ensure resources were administered in a manner to enable each resident to effectively attain or maintain the highest practicable well-being and protected them from serious, imminent risks to their health and safety. On 11/4/16 at 9:45 am, in the presence of the Regional Director, the DNS said the Administrator was on vacation and she was the Acting Administrator. She said the QAA meetings were held monthly and attended by the Medical Director, Administrator, DNS, and all of the departmental supervisors. She said there were also subcommittee meetings which included participation of housekeeping and CNAs. The DNS said the facility was aware of the staffing, smoking, and transportation issues. When asked how the QA identified the issues or concern in the facility, the DNS said the staff could inform the QA of the concerns in the facility verbally, in writing, or via email. The DNS said the facility was aware of the ongoing concerns regarding residents who smoked not signing in and out when leaving the facility and returning. She said they were not aware of residents smoking just outside the front door. The DNS said the issues regarding smoking had been discussed during QAA meeting. When asked what was done and why it was still an ongoing issue, the DNS said the residents who smoke were assessed and educated regarding the importance of safety smoking practices. When asked if the QAA had analyzed the root cause of the smoking issue, and if the QAA had developed and implemented new plans to correct the ongoing issue, the Regional Director asked that the DNS be given some time to gather her thoughts regarding the concerns. On 11/4/16 at 12:30 pm, the DNS provided a copy of a QAPI (QAA) Recap. The QAPI Recap documented the smoking issues were presented to the committee on 4/28/16. It also stated The administrator met with residents who smoke as a group and reviewed resident's choice to smoke off campus if independent. Continued supervised smoking. Reviewed results in each subsequent QAPI since. Other issues documented were staffing and concerns related to showers presented to QAPI on 3/17/16, and transportation issues presented to QAPI on 8/18/16. These ongoing issues were not resolved prior to the survey. Additionally, the facility's QAA program did not provide sufficient monitoring to maintain ongoing compliance, as follows: * F280 was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey. * F353 was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey. * F368 was identified during the 3/4/16 recertification survey and the current 11/4/16 complaint survey. * F441 was identified during the 10/10/14 recertification survey, 3/4/16 recertification survey, and the current 11/4/16 complaint survey. The facility failed to implement the QAA process, including identification, analysis, and development and implementation of new plans of action to resolve the ongoing issues, in timely manner. The facility also failed to provide sufficient monitoring and oversight to maintain regulatory compliance. Removal of Immediate Jeopardy: The facility was notified in writing of the Immediate Jeopardy and the need to develop and implement a plan to remove the immediacy on 11/4/16 at 1:00 pm. On 11/9/16 at 3:48 pm, the facility provided an acceptable plan to removed the immediacy. The removal plan included: * DNS conducted a subcommittee QAPI meeting on 11/4/16. This meeting address the following: Transportation, medication carts lock, diabetic management, smoking and resident satisfaction. * The Administrator and/or DNS or designee will review any new resident, family and staff concerns daily with the IDT to determine if they require immediate interventions to protect residents's safety, rights, or care needs. * A weekly QAPI subcommittee, consisting of Administrator and/or DNS and IDT will be held. * Full QAPI committee meetings will resume on 11/8/16 and continue no less than monthly. * QAPI committee will review trends and concerns brought to the committee through completing audit tools as well as facility logs, tracking forms, incident reports and consultant reports and other items brought to QAPI committee's attention from staff, residents, family members, vendors, and state agencies. * QAPI committee will use this monthly process to identify risks to residents, identify systemic failures and maintain regulatory compliance. Once any of these areas are identified, the QAPI committee will immediately develop plans of correction, implement them, monitor them monthly with audit tools, and evaluate these plans of correction on a monthly basis for improvement or to see if they need to be modified. * Regional Director of Operations and Regional Nurse Consultant will conduct a weekly phone call for 4 weeks and then monthly to ensure the facility's QAPI program is in place. An IJ follow up survey was completed on 11/14/16. Implementation of the above plan was verified and it was determined the immediate jeopardy was removed. The Administrator and DNS were informed the IJ was removed on 11/14/16 at 1:20 pm.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure: a) Residents who were diabetic received care consistent with their needs, care plans, current standards of practice, and the facility's policies. This was true for 4 of 4 (#6, #9, #10, and #15) residents whose diabetic care was reviewed. As a result, residents' BG levels were not monitored consistent with physicians orders; out of range high and low BG levels were not reported to the residents' physicians; the facility's [DIAGNOSES REDACTED] policy was not followed and a [MEDICAL CONDITION] policy was not developed; and physician orders [REDACTED]. These systemic and pervasive negative practices, placed the health and safety of sampled residents, and the other 36 residents in the facility with a [DIAGNOSES REDACTED]. b) 3 of 28 (#1, #3, and #4) sampled residents received appropriate care and equipment necessary for optimal physical and psychosocial health. Resident #3 did not receive [MEDICATION NAME] care as ordered by her physician which may have contributed to her subsequent hospitalization with [DIAGNOSES REDACTED]. Resident #1 was discharged to home with a PICC line still in place, and Resident #4 did not receive an electric wheelchair as recommended. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10's admission MDS assessment, dated 9/16/16, documented he had no cognitive impairment and received insulin all 7 days in the assessment period. Resident #10's [MEDICAL CONDITION] and [DIAGNOSES REDACTED] Care Plan, revised 9/30/16, documented goals that he would not experience signs and symptoms of hyper/[DIAGNOSES REDACTED] and he would be able to report these signs and symptoms to his doctor. Interventions included: * Staff was to check Resident #10's BG levels per MD orders. In addition staff was to notify the MD of any BG levels out of established parameters, beginning on 9/14/16. * Staff was to educate Resident #10 on glucose monitoring, medications, diet, insulin administration, s/s of hypo/[MEDICAL CONDITION], and skin care, beginning 9/14/16. * Staff was to follow the facility's protocol if Resident #10 experienced any episodes of hypo/[MEDICAL CONDITION], beginning 9/14/16. Resident #10's November 2016 Physicians' Recapitalization Orders included: * Resident #10 was to have an HS BG level check at bedtime related to DM type 1, beginning 10/19/16. * Resident #10 was to have PRN BG levels checked as needed for DM type 1, beginning 10/20/16. * Current insulin orders, dated 10/19/16, were: Insulin [MEDICATION NAME] solution before meals per sliding scale of: 0 - 140 = 0 units; 141 - 190 = 2 units; 191 - 240 = 4 units; 241 - 290 = 6 units; 291 - 340 = 8 units; 341 - 999 = 10 units, and call MD. * Staff was to inject 9 units of scheduled Insulin [MEDICATION NAME] Solution before meals. Staff was to hold the scheduled insulin if BG levels were less than 60 mg/dl and was instructed to give the scheduled insulin after meals if BG levels were 60-110 mg/dl. * Resident #10 was to receive 30 units of Insulin [MEDICATION NAME] Solution at bedtime, beginning 11/3/16. Staff was to hold the insulin if BG levels were less than 60 mg/dl. Diabetic monitoring orders found on the 9/9/16 through 11/3/16 MAR's, which were not included on his November 2016 Physicians' Recapitalization Orders report, included: * For hypoglycemic episodes, staff was to give 15 grams of carbohydrates for BG levels less than 70 mg/dl. Staff was to wait 15 minutes and recheck the BG level. If the BG level remained below 70 mg/dl staff was to give another 15 grams of carbohydrates, wait 15 minutes and recheck the BG level. If the BG level was still less than 70 mg/dl staff was to notify the physician, beginning 9/8/16. * For hyperglycemic episodes, staff was to notify the physician after two consecutive BG levels greater than 300 mg/dl, beginning 9/8/16. Resident #10's 9/9/16 through 9/30/16 MAR documented: * Resident #10's 9/9/16 through 9/30/16 MAR, documented he experienced BG levels ranging 67 - 540 mg/dl. * Resident #10's 9/9/16 through 9/30/16 MAR, documented he experienced 8 episodes of BG levels greater than 341 mg/dl. * Resident #10's 9/9/16 through 9/30/16 MAR, documented 4 times he experienced 2 consecutive BG levels greater than 300 mg/dl. * On 9/20/16 at 8:00 pm, Resident #10's 9/9/16 through 9/30/16 MAR documented he experienced a low BG level of 67 mg/dl. * On 9/23/16 at 8:00 pm, Resident #10's 9/9/16 through 9/30/16 MAR documented his BG level was not checked and 2 units of insulin was administered. * On 9/25/16 at 4:00 pm, Resident #10's 9/9/16 through 9/30/16 MAR did not include documentation that his BG level was checked or insulin administered. Resident #10's October 2016 MAR documented: * Resident #10's October 2016 MAR, documented he experienced BG levels ranging 39 - 593 mg/dl. * Resident #10's October 2016 MAR, documented he experienced 17 episodes of BG levels greater than 341 mg/dl. * Resident #10's October 2016 MAR, documented 7 times he experienced 2 consecutive BG levels greater than 300 mg/dl. *Resident #10's October 2016 MAR, documented he experienced 3 episodes of BG levels less than 70 mg/dl. * On 10/17/16, a PRN BG level was checked and Resident #10's October 2016 MAR documented he experienced a low BG level of 39 mg/dl. * Resident #10's October 2016 MAR from 10/18/16 at 4:00 pm through 10/20/16 at 8:00 am, documented 6 consecutive BG levels greater than 300 mg/dl. * Resident #10's October 2016 MAR from 10/25/16 at 7:00 pm through 10/26/16 at 11:00 am, documented 3 consecutive BG levels greater than 300 mg/dl. * On 10/26/16 at 8:00 am, Resident #10's October 2016 MAR, documented he experienced a high BG level of 593 mg/dl. * On 10/28/16 at 8:00 am, Resident #10's October 2016 MAR did not include documentation that his BG level was checked or insulin administered. Resident #10's 9/9/16 through 9/30/16 and October 2016 MARs' documented 40 opportunities for the staff to notify the MD of BG levels outside of the specific parameters ordered by the physician. On 11/2/16 at 1:09 pm, the DNS stated she would look for the physician notifications of the high and low blood sugars. She stated the notifications would be in the nursing notes section. She said would also get a copy of the facility's policy and procedure. On 11/2/16 at 4:25 pm, Resident #10 entered his room with LN #4. He stated he felt like his BG level was low. LN #4 checked Resident #10's BG level and it was 64 mg/dl. LN #4 stated she would be right back with some orange juice. At 4:30 pm, LN #4 returned with 120 mL of orange juice and gave this to the resident, which he drank. LN #4 stated she would return in 15 minutes and recheck the BG. At 4:32 pm, LN #4 returned and gave Resident #10 a small cup of pears and two mozzarella cheese sticks. Resident #10 ate these items. At 4:40 pm, LN #4 returned again and checked the BG which was 69 mg/dl. She went out and returned with another 120 mL of orange juice. Resident #10 drank the orange juice. Resident #10's Nurses' Note, dated 11/2/16 at 5:00 pm, documented the observation above. The note did not contain documentation that a snack was given to Resident #10 after his BG level returned above 70 mg/dl. On 11/2/16 at 5:20 pm, the DNS indicated she could not find the notifications of the low or high blood sugars. She stated there was a note on 10/19/16 that the nurse practitioner had reviewed Resident #10's DAR but she could not find the documentation showing the physician was notified of out of the high and low BG levels. The DNS was also unable find documentation the BG levels were rechecked or documentation staff followed the facility's hypo/hyperglycemic protocols. On 11/3/16 at 9:58 am, the DNS stated if residents had high or low BG levels the staff should call the physician and if the physician ordered additional medication the staff should administer it. On 11/3/16 at 12:50 pm, the Medical Director stated he would expect staff to follow the hypoglycemic and hyperglycemic protocols and for them to call the physician when BG levels are outside of established parameters. He stated the parameters are individualized for each resident. He stated the risk to residents could be acute hospitalization from DKA or low BG levels. He could not remember a specific instance of being called and notified of the high or low blood glucose levels for Resident #10, but said it was possible because he received many phone calls in a day. In addition, the Medical Director stated that he does sign off on policies and procedures and he was sure he signed off on them years ago. On 11/4/16 at 1:46 pm, Resident #10 was sitting in his room and his lunch tray was delivered while the surveyor was in the room. He stated he was really hungry and getting his meal this late was not his preference. He stated he was concerned because he had experienced a low BG earlier that day and no snack was provided to him after his BG had returned to normal. He stated he had been a Type 1 Diabetic for [AGE] years and stated he knew he was to eat something within an hour of a low BG level. His explanation of the event was as follows: Resident #10 stated earlier today at 12:00 pm, he felt like his BG level was low. He had a nurse check his BG and it was 49 mg/dl. He stated at 12:07 pm she returned to his room with a small cup of orange juice and 2 sugar packets. He stated she left the room and he did not know if she was coming back. Resident #10 stated he was scared she would not come back because she had left the room without saying if or when she would return. He stated he had emergency soda in his room for when he experienced low BG levels. He stated he drank one after about 10 minutes. Resident #10 stated the nurse returned at 12:15 pm and rechecked his BG level which was 100 mg/dl. He stated she did not give him a snack and said lunch would be here shortly. In addition, Resident #10 stated the reason for having soda in his room was for when he experienced low BG levels in the night. He stated he had experienced a few low BG levels at night and had told the nurses. When asked how he knew he had the low blood glucose levels, he stated he had his own glucose meter in his room and used it to test his blood. He stated he had asked the facility to provide him snacks throughout the day on a routine basis and they had not. He stated occasionally the facility offered him snacks at about 8:00 pm and his dinner had barely been delivered, so he would refuse the snack. Resident #10 stated he had not received or was offered training/education from the facility on diabetes management. He stated he had education years ago multiple times from different places. Resident #10's clinical records did not contain documentation that the facility rechecked his BG levels after he experienced hyperglycemic and hypoglycemic episodes. In addition, his clinical records did not contain documentation that the physician was notified of his hyperglycemic and hypoglycemic episodes, as ordered. Resident #10's clinical records did not contain documentation that the facility ensured the hypoglycemic and hyperglycemic protocols were followed for treating his high and low BG levels. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's admission MDS assessment, dated 10/3/16, documented she had no cognitive impairment and received insulin all 7 days in the assessment period. Resident #9's [MEDICAL CONDITION] and [DIAGNOSES REDACTED] Care Plan, revised 9/28/16, documented goals to include; she would not experience signs and symptoms of hyper/[DIAGNOSES REDACTED] and she would be able to report these signs and symptoms to her doctor. Interventions included: * Staff was to check Resident #9's BG levels per MD orders. In addition staff was to notify the MD of any BG levels out of established parameters, beginning on 9/28/16. * Staff was to educate Resident #9 on glucose monitoring, medications, diet, insulin administration, s/s of hypo/[MEDICAL CONDITION], and skin care, beginning 9/28/16. * Staff was follow the facility's protocol if Resident #9 experienced any episodes of hypo/[MEDICAL CONDITION], beginning 9/28/16. Resident #9's November 2016 Physicians' Orders included: * Resident #9 was to have BG level check QID before meals and at bedtime related to DM type II, beginning 10/12/16. * Resident #9 was to have PRN BG levels checked as needed for DM type II, beginning 11/2/16. * For hypoglycemic episodes, staff was to give 15 grams of carbohydrates for BG levels less than 70 mg/dl. Staff was to wait 15 minutes and recheck the BG level. If the BG level remained below 70 mg/dl staff was to give another 15 grams of carbohydrates, wait 15 minutes and recheck the BG level. If the BG level was still less than 70 mg/dl staff was to notify the physician, beginning 9/26/16. * For hyperglycemic episodes, staff was to notify the physician after two consecutive BG levels greater than 300 mg/dl, beginning 9/26/16. There were no Physicians' orders for parameters of when staff was to notify the physician of single high BG levels. * Current insulin orders, dated 10/19/16, were: Insulin [MEDICATION NAME] Solution Pen-injector 100 unit/mL; inject 20 units subcutaneously; inject 20 units subcutaneously; and inject 5 units subcutaneously, related to DM Type II. The order did not include scheduled times for when staff was to administer the three doses. * Resident #9 was to receive 75 units of [MEDICATION NAME] Solution 100 unit/mL (Insulin [MEDICATION NAME]) subcutaneously one time a day, beginning 10/26/16 for DM type II. The order did not include a scheduled time for when staff was to administer the dose. Resident #9's October 2016 MAR documented: * Resident #9's October 2016 MAR, documented she experienced BG levels ranging 71 - 437 mg/dl. * Resident #9's October 2016 MAR, documented 8 times she experienced 2 consecutive BG levels greater than 300 mg/dl. The MAR documented the physician was notified once of the 2 consecutive BG levels on 10/12/16. * Resident #9's October 2016 MAR from 10/19/16 at 11:00 am through 10/19/16 at 9:00 pm, documented 3 consecutive BG levels greater than 300 mg/dl. * On 10/28/16 at 8:00 am and 11:00 am, Resident #9's October 2016 MAR did not include documentation that her BG level was checked or insulin administered. * Resident #9's October 2016 MAR, documented she experienced 5 episodes of BG levels greater than 400 mg/dl. * Resident #9's October 2016 MAR, documented she experienced 20 episodes of BG levels greater than 300 mg/dl. * Resident #9's 9/26/16 through 11/2/16 MAR did not contain a order for staff to document PRN BG level checks. On 10/31/16 at 8:10 am, the breakfast meal trays were being delivered to the 100 hall. Resident #9's meal tray arrived to her room at 8:10 am and she started to eat the meal. LN #1 entered the room at 8:16 am and stated she needed to get the residents BG level. LN #1 took the BG and stated it was 145 mg/dl, exited the room, and stated she would be back with Resident #9's insulin. LN #1 returned at 8:20 am with Resident #1's insulin and administered it. On 11/2/16 at 1:09 pm, the DNS stated she would look for the physician notifications of the high BG levels. She stated the notifications would be in the nursing notes section. She would also get a copy of the facility's policy and procedure. On 11/2/16 at 3:45 pm, Resident #9 stated she was educated on her diabetes years ago. She had a medical background so she knew what to do for hyperglycemic episodes. She stated she knew nurses are supposed to check BG levels as ordered, notify the physicians as needed, and give insulin coverage as per MD orders. Resident #9 stated she gets a snack if she asks for them. On 11/3/16 at 9:58 am, the DNS stated if residents had high or low BG levels the staff should call the physician and if the physicians ordered anything the staff should administer it. She stated she was still looking for Resident #9's physician notifications. This information was not provided to the surveyor prior to exit. On 11/3/16 at 12:50 pm, the Medical Director stated he would expect staff to follow the hypoglycemic and hyperglycemic protocols and for them to call the physician when BG levels are outside of established parameters. He stated the parameters are individualized for each resident. He stated the risk to residents could be acute hospitalization from DKA or low BG levels. He could not remember a specific instance of being called and notified of the high BG levels for Resident #9, but said it was possible because he receives many phone calls in a day. Resident #9's clinical records did not contain documentation that the facility rechecked her BG levels after she experienced hyperglycemic episodes. In addition, her clinical records contained documentation that the physicians' orders were followed 1 out of 8 opportunities (10/12/16) with notification to the physician of two consecutive BG levels greater than 300 mg/dl. Resident #10's clinical records did not contain documentation that the facility ensured its hyperglycemic protocol was followed; BG levels were checked prior to eating; parameters were ordered for when to notify the physician of single high BG levels; and both insulin orders contained a scheduled times of when staff was to administer them. In addition, the facility failed to check Resident #9's BG level prior to the start of her meal on 10/31/16. 3. Resident #15's record was reviewed on 11/3/16 at 10:20 am. Resident #15's [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#15 was to be administered [MEDICATION NAME]per her glucometer blood sugar results. The insulin scale reads as followed: 90 - 150 = 2 units 151 - 200 = 3 units 201 - 250 = 4 units 251 - 300 =5 units 301 - 350 = 6 units 351 - 999 = 7 units notify MD Resident #15's MAR, dated October 2016, documented she had a blood sugar result of 369 on 10/31/16 at 4:00 pm. Resident #15's October 2016 MAR and Nurses' Notes, documented she was administered 7 units of insulin on 10/31/16 at 4:00 pm. Resident #15's record did not include documentation that her physician was notified of the the high blood sugar level of 369. Additionally, or if the facility had followed the policy for hyperglycemic reactions. During an interview with the DNS, on 11/3/16 at 11:35 am, she could not provide information of Resident #15's physician being notified of the blood sugar result of 369 or if staff had followed the policy for [MEDICAL CONDITION]. 4. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #6's admission MDS assessment, dated 8/12/16, documented he had a mild cognitive impairment and received insulin all 7 days in the assessment period. Resident #6's [MEDICAL CONDITION] and [DIAGNOSES REDACTED] Care Plan, revised 9/7/16, documented goals that he would not experience signs and symptoms of hyper/[DIAGNOSES REDACTED] and he would be able to report these signs and symptoms to his doctor. Interventions included: * Staff was to check Resident #6's BG levels per MD orders. In addition staff was to notify the MD of any BG levels out of established parameters, beginning on 8/9/16. * Staff was to educate Resident #6 on glucose monitoring, medications, diet, insulin administration, s/s of hypo/[MEDICAL CONDITION], and skin care, beginning 8/9/16. * Staff was follow the facility's protocol if Resident #6 experienced any episodes of hypo/[MEDICAL CONDITION], beginning 8/9/16. Resident #6's, 8/5/16 through 9/1/16 Physicians' Order summary report included: * For hypoglycemic episodes, staff was to give 15 grams of carbohydrates for BG levels less than 70 mg/dl. Staff was to wait 15 minutes and recheck the BG level. If the BG level remained below 70 mg/dl staff was to give another 15 grams of carbohydrates, wait 15 minutes and recheck the BG level. If the BG level was still less than 70 mg/dl staff was to notify the physician, beginning 8/5/16. * For hyperglycemic episodes, staff was to notify the physician after two consecutive BG levels greater than 300 mg/dl, beginning 8/5/16. * Insulin orders, dated 8/5/16, were: Insulin [MEDICATION NAME] solution before meals and at bedtime per sliding scale of: 0 - 60 = 0 units, give juice and call MD; 61 - 200 = 0 units; 201 - 260 = 5 units; 261 - 320 = 7 units; 321 - 400 = 9 units; 401 - 999 = 11 units, and call MD. * Resident #6 was to receive 10 units of [MEDICATION NAME] one time a day related to DM Type II, beginning on 8/9/16. The order did not include a scheduled time for staff to administer the dose. * Resident #6 was to receive 12 units of [MEDICATION NAME] one time a day related to DM Type II, beginning on 8/9/16. The order did not include a scheduled time for staff to administer the dose. Resident #6's August 2016 MAR documented: * Resident #6's August 2016 MAR, documented he experienced BG levels ranging 79 - 404 mg/dl. * On 8/6/16 at 4:00 pm, Resident #6's August 2016 MAR, documented he experienced a high BG level of 404 mg/dl. * On 8/6/16 at 4:00 pm and 9:00 pm, Resident #6's August 2016 MAR documented he experienced a high BG level of 404 mg/dl and a consecutive high BG level of 369 mg/dl. * On 8/11/16 at 4:00 pm and 9:00 pm, Resident #6's August 2016 MAR documented he experienced a high BG level of 313 mg/dl and a consecutive high BG level of 319 mg/dl. * On 8/25/16 at 9:00 pm, Resident #6's August 2016 MAR did not include documentation that his BG level was checked or insulin administered. Resident #6's Nurses' Note dated 8/11/16 at 9:48 pm, documented his DM was managed and SSI was given for the BG of 313 mg/dl and 319 mg/dl and he did not have s/s of hyper/[DIAGNOSES REDACTED]. The note did not document the physician was notified or if BG levels were rechecked. On 11/2/16 at 1:09 pm, the DNS stated she would look for the physician notifications of the high BG levels. She stated the notifications would be in the nursing notes section. She would also get a copy of the facility's policy and procedure. On 11/3/16 at 9:58 am, the DNS stated if residents had high or low BG levels the staff should call the physician and if the physicians ordered anything the staff should administer it. She stated she was still looking for Resident #6's physician notifications. This information was not provided to the surveyor prior to exit. On 11/4/16 at 8:45 am, the DNS stated if residents were educated about diabetes and or insulin administration it would be located in the nursing notes. She stated she would look to see if it was completed. The paperwork was not provided prior to exit. Resident #6's clinical records did not contain documentation that the facility rechecked his BG levels after he experienced hyperglycemic episodes. In addition, his clinical records did not contained documentation that the physician was notified of hypo/hyperglycemic episodes, as ordered. Resident #6's clinical records did not contain documentation that facility staff followed the facility's hyperglycemic protocol and insulin orders contained scheduled times of when staff was to administer the insulin. 5. Policy Review: On 11/2/16 at 1:09 pm, the DNS stated she get a copy of the facility's policy and procedure on diabetes management. On 11/2/16 at 1:50 pm, the facility provided a copy of its policy and procedure, The Diabetes Clinical Protocol, from Nursing Services Policy and Procedure Manual; copy-write 2005 MED-PASS (revised October 2010). The protocol did not address how staff was to manage residents with hyperglycemic episodes. In addition, the [DIAGNOSES REDACTED] protocol was not updated with current clinical standards of practice. The protocol stated appropriate treatment of [REDACTED]. On 11/3/16 at 9:58 am, the DNS and RCM #1 stated the Medical director had signed off on the diabetes management policy and procedure. The RCM stated the Dietitian added the example treatment plan of the protein source with the carbohydrate for correcting hypoglycemic episodes. The DNS stated she would try and find a P&P that addressed [MEDICAL CONDITION]. On 11/3/16 at 11:00 am the facility provided a policy and procedure titled, Nursing Care of the Resident with Diabetes Mellitus. This policy did not include a protocol for how staff was to manage and treat hyperglycemic episodes. According to the American Diabetes Association, Standards of Medical Care in Diabetes - 2016, from the Diabetes Care Journal, Volume 39 Supplement 1; carbohydrate sources high in protein should not be used to treat [DIAGNOSES REDACTED] . Added fat may retard and prolong acute glycemic response . treatment for [REDACTED]. In addition, once the BG returned to normal an individual should consume a meal or snack containing protein. On 11/4/16 at 9:30 am, the facility provided a Hyperglycemic Treatment Guidelines. The guidelines did not include their standing order for staff to notify the MD of 2 consecutive BG levels greater than 300 mg/dl or instruction for staff to recheck BG levels. A position statement from the American Diabetes Association documented, LTC facility's need to increase the frequency of glucose monitoring, call the practitioner, and confirm the high glucose value by laboratory testing. These steps were to be completed if residents experienced BG's greater than 300 during all or part of 2 consecutive days. Munshi, M. N., Florez, H., Huang, E. S., et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, vol. 39, Feb. 2016, pp. 308-318. On 11/4/16 at 3:10 pm, the facility provided their Change in a Resident's Condition or Status policy and procedure. The policy stated the Nurse supervisor/charge nurse would notify the residents attending physician if there were instructions to notify the physician of changes in a resident's condition. The facility failed to ensure its policies and procedures were updated to reflect current standards of practice. Outdated and incomplete policies created the potential for residents to receive inappropriate intervention or no interventions for hyper/hypoglycemic episodes. The combined effect of the facility's prevalent negative diabetic management practices, placed the above residents, and the other 36 residents residing in the facility with [DIAGNOSES REDACTED]. Removal of Immediate Jeopardy: Facility Administration was informed of the Immediate Jeopardy and the need to develop and implement an acceptable plan to remove the Immediacy at 11:52 pm on 11/3/16. On 11/9/16 at 2:06 pm, the facility provided evidence that an acceptable plan to remove the immediacy had been developed and implemented. The plan included: * The DNS or designee would review all current diabetic records and the residents' physicians would be notified of any BG levels out of established parameters. * The facility staff would assess any resident whose BG level was outside of established parameter for signs and symptoms of ill effects. The facility would follow their policies and procedures for residents when they experienced hypoglycemic and hyperglycemic episodes. * The DNS or designee would provide education to all nursing staff related to hypo/hyperglycemic signs and symptoms; the importance of following MD orders to check BG levels; notifying the physician when BG levels are out of physician established parameters; and the new hypoglycemic and hyperglycemic policies and procedures. The information would be provided to the staff prior to their next shift they worked. The facility's hypoglycemic treatment was updated to say: for hypoglycemic episodes, staff was to give 15 grams of carbohydrates for BG levels less than 70 mg/dl. Staff was to wait 15 minutes and recheck the BG level. If the BG level remained below 70 mg/dl staff was to give another 15 grams of carbohydrates, wait 15 minutes and recheck the BG level. If the BG level was still less than 70 mg/dl staff was to notify the physician. In addition, after the BG level returned to normal an individual should consume a snack containing protein. For hyperglycemic episodes, staff was to notify the physician after two consecutive BG levels greater than 300 mg/dL. * The facility diabetic management policy would be revised to instruct staff to give residents a snack which included protein after the resident had received the hypoglycemic treatment and their BG level was greater than 70 mg/dL. The education would be reviewed annually and kept in an in-service book. * The DNS or designee would review all current diabetic residents twice per week to ensure the nursing staff was following the revised diabetic management policy. The facility documented the results on a Diabetic monitoring audit sheet. * The facility would be in compliance with the removal plan on 11/9/16 at 6:00 am. An on-site IJ follow up survey was completed on 11/14/16. Implementation and compliance with the above IJ removal plan was verified and the Administrator and DNS were informed the Immediate Jeopardy was removed effective 11/14/16. 6. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses, [MEDICAL CONDITION] resulting from [MEDICAL CONDITION] (severe kidney infection), and [MEDICATION NAME] (inflammation of the large and small intestines) due to [MEDICAL CONDITION]. Resident #1's Interagency/Interfacility Physician order [REDACTED]. Resident #1's Hospital Discharge Prescription included an order for [REDACTED]. Resident #1's March 2016, recapitulated physician's orders [REDACTED]. * PICC line care per protocol for 6 more days then dc line. * [MEDICATION NAME] solution reconstituted 3.375 mg IV q 8 hours for 6 days. *Change PICC dressing q week and PRN when soiled or loose every Tuesday morning * [MEDICATION NAME] Lock flush solution 10 unit/ml, use 5 ml intravenously as needed .5 ml [MEDICATION NAME] after second normal saline after each intermittent IV medication . * Normal saline flush solution 0.9% (sodium chloride flush) use 5 ml intravenously before and after each intermittent IV medication. Resident #1's NP documented the following: *3/14/16, .to see (resident name) today secondary to her having some complaints of pain in her right middle finger and also her left ring finger. There has also been some swelling and redness noted I am going to go ahead and obtain some laboratory studies to include uric acid, ESR, CRP, CBC, CMP, hemoglobin A1C *3/18/16, Apparently she has been having a significant amount of pain in her hands .The labs came back with white blood cell count of 11.3 . (name of rheumatologist) called back and stated that he felt like her labs were more related to infection (TRUNCATED)

Based on observation, resident and staff interview, and review of records and policies and procedures, it was determined the facility failed to ensure: a) Residents were provided with a safe smoking area and safe smoking practices were demonstrated and enforced. * Residents who were independent smokers were not provided access to the designated smoking area on the facility premises. * Residents' smoking assessments were not accurate and current. * Residents who smoked unsupervised off of facility property did not sign out before leaving the facility to smoke or sign in upon return. * Residents kept smoking materials in their rooms or clothing, instead of returning their smoking materials to the nurses' station when finished smoking. * Residents smoked in nondesignated smoking areas. * Residents were not provided with the level of supervision necessary for safety. These systemic deficient practices placed the health and safety of 7 of 7 (#3, #10, #13, #17, #18, #19, and #20) sampled residents residing in the facility who smoked, in immediate jeopardy of serious harm, impairment, or death due to burns, fire, and/or smoke inhalation. b) The facility also failed to ensure medication and treatment carts were locked at all times when unattended. This deficient practice created the potential for independently mobile residents with cognitive impairments to access and ingest medications in excessive doses and/or contraindicated combinations, or to which they were allergic, thereby, placing their health and safety in immediate jeopardy of serious harm or death. It also created the potential for visitors, staff, and residents, to mix, or abscond with, residents' medications, resulting in serious adverse medication events or leaving residents without medications necessary to avoid physical and/or mental decline. Findings include: 1. The facility's Smoking Guidelines, dated 11/10, provided on 11/1/16 at 11:30 am, documented, the Purpose was to provide a safe environment for all residents living in the facility and to reduce the risk of injury to a resident while smoking. The Guidelines included: * Residents who smoke will be evaluated by a LN for smoking safety using the Smoking Safety Evaluation prior to being able to smoke at the facility. Evaluation will be upon Admission, Quarterly, with a Significant Change, if a non-smoking resident chooses to start smoking or if the resident has a smoking related incident. * If a resident is evaluated to be safe to smoke the LN will: - Determine if the resident is independent or to be supervised. - Verbally review the Acknowledgement of Smoking Risks and obtain a signed copy of the Acknowledgement. - Review the smoking Guidelines and Smoking times with the resident. Provide the resident or assign the resident needed safety devices (smoking blanket or smoking apron). - Initiate a smoking care plan that identifies dependence status, risks safety devices needed and other interventions determined by the Smoking Safety Evaluation. - Educate resident and/or responsible party that at no time can they provide another resident with smoking materials related the (sic) safety risks for the other resident. * The facility will provide a smoking area for the resident in compliance with the State law and will: - Provide Type-A fire extinguishers in the smoking areas and needed safety devices (smoking blanket or smoking apron) will be available. - Provide safe storage of smoking materials. - Keep a list of residents that smoke in the 24 hour report book. - Will actively supervise residents that are evaluated to not be safe to smoke independently. * If a resident has a smoking related incident or does not follow facility Smoking Guidelines: - The resident will be assessed for injury (if smoking related incident). - The responsible party, Physician, DNS and/or Administrator will be notified. - The resident will be assessed for safety; if the resident is determined to be unsafe the resident will be notified, smoking cessation will be reviewed with the resident and offered. - The DNS and/or Administrator will determine further action/s needed. - An incident report will be initiated. Each resident's level of smoking supervision on or off the facility premises will be based on an assessment conducted by facility staff. All smoking materials are to be locked at all times when not being used for smoking. Additionally, the Smoking Resident Statement of Agreement residents were required to sign, stated, I also understand that should I choose to leave the premises to smoke I must sign out and will ultimately be personally responsible for any injury sustained as a result of this action. The facility failed to ensure the above guidelines and agreement were followed. Examples include: a. Resident #17's record was reviewed on 11/2/16 at 11:20 am. Resident #17's [DIAGNOSES REDACTED]. Resident #17's care plan, dated 10/25/16 and revised on 11/2/16, documented, Resident is able to smoke safely and independently. The goal of the care plan was, Resident is able to smoke safely without injury to self or others. Will verbally state understanding of rules and storage of smoking materials. The interventions included, Complete smoking assessment. Educate resident on smoking areas and smoking schedule. Educate resident on smoking rules and obtain acknowledgement signature. Review acknowledgement of Safety Risks with resident. Smoking assessment to be completed if changes in cognition or functional abilities occur. An Admission Nurses' Note, dated 10/20/16 at 2:20 pm, documented Admission Note (Resident #17) was admitted to room (room number) from (name of hospital) with [DIAGNOSES REDACTED].Resident is Oriented x (times) 4 (person, place, time and situation), has minimal difficulty hearing and clear speech . Nurses' Notes, dated 10/27/16 at 10:11 pm, and 10/30/16 at 6:01 pm, indicated Resident #17 was alert and oriented times four with forgetfulness and was easily upset. A Smoking Safety Evaluation, dated 10/25/16, documented Resident #17's cognitive skills were moderately impaired. A Nurses' Note, dated 10/22/16 at 11:48 am, documented Spoke to (Resident #17) regarding his desire to go out of the facility. We discussed the smoking opportunities at the facility and the times we have supervised smoking and our procedure for smoking when not at a supervised time. I asked and was given without incident his cigarettes to be placed in the smoking box and the combination of asking for his cigarettes and signing out in the log book. He expressed understanding and will attempt to be more compliant in the future. Resident #17 had been non-compliant with giving his cigarettes back to the nurse. A Release Of Responsibility For Leave of Absence, noted Resident #17 had signed out of the facility on 11/1/16 at 9:30 (no am or pm), 11/2/16 at 4:00 am, 11/2/16 at 6:00 am, 11/2/16 at 8:00 am, and 11/2/16 at 9:00 am. There was no entry of Resident #17 signing in or out of the facility on 10/31/16. Resident #17 was observed on 10/31/16 at 2:20 pm, smoking out in front of the facility. When he finished the cigarette he was observed to go back into the facility. Resident #17 did not stop and sign back into the facility nor did he give his smoking materials to the nurse. Resident #17 was observed to take his smoking materials to his room. Resident #17 was observed on 10/31/16 at 3:30 pm, to exit the front door of the facility and walk out to sit on the bench located inside a wooden structure. Resident #17 was observed to sit on the bench and smoke his cigarette directly under the NO SMOKING sign. When he finished Resident #17 was observed to return to his room without signing back in and he kept his smoking materials with him. Two staff members were at the medication cart near his room, both staff members said hello to the resident. The staff members did not ask for his smoking materials or if he had turned his smoking materials in at the Nurses' Station. Resident #17 was observed on 11/1/16 at 6:50 am, to come out the front entrance and light a cigarette. Resident #17 was observed to stand by the front entrance and smoke his cigarette. This was not a designated smoking area and he was not 25 feet from the facility entrance door. Resident #17 was observed on 11/1/16 at 7:50 am, to walk down the hallway towards the front entrance and exit facility. He was observed to light his cigarette and smoke while standing right outside the front entrance door. This area was not a designated smoking area. Resident #17 was not observed to sign in or out of the facility and kept his smoking materials on him and returned to his room. Resident #17 was observed on 11/1/16 at 10:05 am, sitting on a bench butted up against a gazebo. He was sitting on the outside of the gazebo. Resident #17 said he smoked out here and signed in and out when he came out to smoke. Resident #17 stated, You can't be underneath the gazebo to smoke. During an interview on 11/1/16 at 2:25 pm, Resident #17 indicated he got his smoking materials from the nurse in the morning and keeps them all day and gives them back to the nurse at night. He said he sometimes keeps his smoking materials in his nightstand. Resident #17 indicated, It's a pain in the butt getting them from the nurse all the time. During an interview on 11/2/16 at 1:00 pm, the Director of Nursing Services (DNS) when asked about Resident #17 smoking in non-designated areas said I haven't seen him myself, but wouldn't put it passed him. When asked, the DNS said Resident #17's smoking assessment was incorrect, when it documented Resident #17's cognitive skills were moderately impaired. The DNS said Resident #17 was alert and oriented. She stated if the nurses observed unsafe smoking they were to educate the resident. She said residents who could smoke unsupervised were to smoke off campus. During an interview with CNA #5, on 11/2/16 at 8:28 am, she said Resident #17 had a tendency to be non-compliant with smoking in designated areas and returning his smoking materials. She indicated, He gets agitated. b. Resident #13's record was reviewed on 11/2/16 at 8:55 am. Resident #13's [DIAGNOSES REDACTED]. A Nurses' Note, dated 7/2/16 at 10:40 am, indicated, Trying to find pt. (patient) location this am to provide Tx (treatment) before he goes to dialysis. Found pt. outside in front of the building asleep in his w/c with a lit cigarette & (and) a long tail of ash still connected to the cigarette. Woke pt. up & discussed with him that he was sleeping with a lit cigarette in his hand, that this is not only dangerous because he could burn himself but this is not following facility policy for smoking rules. He denied this happened, states was not sleeping & refused to come inside for wound care. Reported this event to weekend supervisor. A Nurses' Note in Resident #13's record, dated 7/6/16 at 2:50 pm, documented Resident has been observed by facility staff practicing unsafe smoking technique. Resident informed he would need to wear smoking apron even while independent smoking . Resident #13's Quarterly MDS, dated [DATE], documented he did not have cognitive impairments. Resident #13's Smoking Safety Evaluation, dated 8/14/16, noted his decision making was moderately impaired. The evaluation stated he was independent with smoking but used of a smoking apron. Resident #13's care plan for smoking, dated 9/9/15, with a target date of 1/3/17, indicated he was able to smoke with supervision. An intervention on the care plan stated, Educate and provide resident with smoking safety devices. Requires smoking apron. Smoking apron to be in personal bag on resident w/c (wheelchair). Resident #13 was observed smoking under the wooden gazebo on 10/31/16 at 4:25 pm. Resident #13 was sitting in a wheelchair, there were no staff present, and he was not observed to have a smoking apron in place. There was a no smoking sign on the right wall of the gazebo, a long necked ashtray was observed by the left side of the wall. There were no fire extinguishers present in the gazebo. Resident #13 indicated he normally smoked out there alone. A Release Of Responsibility For Leave Of Absence form, showed the last time Resident #13 signed in or out was on 9/4/16. The form did not indicate where he was going or if he was going out to smoke. On 11/1/16 at 3:00 pm, CNA #8 stated two residents required smoking aprons in the facility, Resident #13 and Resident #3. She stated PT did the assessments for the smoking aprons and they kept the spare smoking aprons in the PT office. On 11/1/16 at 3:05 pm, the physical therapist stated they did not do the smoking assessments and PT did not have smoking aprons in its supply. She stated central supply might have the spare aprons. On 11/1/16 at 3:10 pm, CNA #8 asked the Business Office individual where smoking aprons were located. The Business Office individual stated the facility did not have spare aprons and some were going to be ordered. On 11/1/16 at 4:00 pm, the DNS stated the nurses did the smoking assessments on admission. On 11/1/16 at 4:37 pm, Resident #13 was dropped off by a transportation van outside of the gazebo off-campus. The gazebo was boarded up with 2 by 4's which prevented him from going through the pathway back into the facility. Before entering the facility, Resident #13 pulled a cigarette and lighter out of his pocket and started smoking. Resident #13 was not wearing a smoking apron. On 11/1/16 at 4:47 pm, RCM #2 exited the facility with a smoking apron in hand and placed the smoking apron into a bag at the back of Resident #13's w/c and re-entered the facility. On 11/1/16 at 4:51 pm, Resident #13 started wheeling himself down the road between the LTC facility and an Assisted Living facility. The road had a slight incline to it and he lifted his legs to get down it. He crossed into the LTC facility's parking lot and had to push himself up the incline to get to the facility's front door. Resident #13 reached the front door at 5:00 pm. During an interview on 11/1/16 at 8:20 pm, Resident #13 stated he did not smoke all of the time. He said he was trying to quit. Resident #13 said a family member brought his cigarettes into the facility and gave them to him. During an interview on 11/2/16 at 8:32 am, a CNA stated Resident #13 goes out front to smoke and knows he's not supposed to. She said she had seen burn holes in his pants about a year ago. During an interview on 11/1/16 at 3:55 pm, the DNS stated the issue of unsupervised residents who smoked not signing in or out, had been a concern. The DNS said unsupervised residents who smoke were to sign in and out in the book by the Nurses' Station and get their cigarettes and lighters from the nurses. The DNS said the unsupervised residents were to smoke off of facility property. The DNS said the smoking area on the facility property was for supervised smokers only. The DNS said if unsupervised smokers were discovered breaking the rules they were educated by the nurses. c. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses, including chronic obstructive pulmonary disease. On 11/2/16 at 7:45 am, the Resident #19 was observed to retrieve her smoking material from inside of the upper left pocket of her vest and smoke directly outside the facility's front entrance. When she was done smoking she was observed to extinguished her cigarette and put the unburned portion of the the cigarette back to her vest pocket. On 11/2/16 at 10:40 am, Resident #19 was observed returning a cigarette and a lighter to the CNA at the nurses' station. When asked how often she smoked each day, Resident #19 said she smoked at least 3-4 cigarettes a day. Resident #19 said she was aware of the smoking area but preferred to smoke out front because the smoking area had a designated time to smoke. Resident #19 also said she was to sign in and out in the book by the nurses' station to go outside to smoke, but sometimes she forgot. On 11/2/16 at 11:20 am, CNA #3 said she was not aware of any resident smoking just outside the front door. CNA #3 said the residents who were allowed to smoke unsupervised should go off the property to smoke. She said residents should walk outside of the covered area by the front door to smoke. d. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #18's admission MDS assessment, dated 10/25/16, documented he had no cognitive impairments and was a current tobacco user. Resident #18's Safe Smoking Care Plan, initiated 11/1/16, documented he was able to smoke safely and independently without supervision. Interventions included: * Staff was to complete a smoking assessment for Resident #18's ability to smoke safely, beginning 11/1/16. * Staff was to educate Resident #18 on where the designated smoking area was at, beginning 11/2/16. * Staff was to educate Resident #18 on the smoking rules, beginning 11/2/16. Resident #18's Smoking Safety Evaluation was completed 11/1/16. The evaluation documented he was independent to smoke. On 11/1/16 at 10:05 am, Resident #18 stated he smoked about 7-8 cigarettes a day and he was to sign in and out on the Sign out Sheet. He stated the Administrator told him he needed to smoke off campus because he was an independent smoker. Resident #18 indicated he knew he was not to smoke under the gazebo. On 11/1/16 at 2:35 pm, Resident #18 stated he kept his smoking materials in his drawer while not in use. He stated he was told by the nursing staff that if he wanted to use the designated smoking area he would have to do it at designated times and with a staff member present. Resident #18's Sign out Sheet was completed for the first time on 11/2/16 at 10:15 am. Resident #18 did not have a Sign out Sheet in the book when surveyors first asked for it at 9:00 am on 11/2/16. On 11/2/16 at 10:20 am, CNA #3 stated the Sign out Sheet was just put into the book for Resident #18 to use. e. Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #10's admission MDS assessment, dated 9/16/16, documented he had no cognitive impairment and was a current tobacco user. Resident #10's Safe Smoking Care Plan, initiated 11/2/16, documented he was able to smoke safely and independently without supervision. Interventions included: * Staff was to complete a smoking assessment for Resident #10's ability to smoke safely, beginning 11/2/16. * Staff was to educate Resident #10 on where the designated smoking area was at, beginning 11/2/16. * Staff was to educate Resident #10 on the smoking rules, beginning 11/2/16. Resident #10's Smoking Safety Evaluation was completed 11/2/16, almost 2 months after his admission to the facility. The evaluation documented he was independent to smoke. On 11/4/16 at 1:46 pm, Resident #10 stated he smoked occasionally and he would go out front of the facility off campus to smoke. He said he had his smoking materials in his room until a little bit ago and staff came in and took them. f. Resident #20 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #20's readmission MDS assessment, dated 9/1/16, documented he had no cognitive impairment and the question on tobacco use was not filled out. On 11/2/16 at 10:35 am, Resident #20 said he could not go back to the smoking area on hall 200 because it was for supervised residents only. He said it would be much easier for him to be able to smoke in that area. He said he was to sign in and out to go outside for smoking but he did not always do that. Resident #20 also said since the facility boarded up the wooden gazebo in the front of the facility he had to wheel himself through the entire parking lot to get to the other side to smoke. On 11/2/16 at 11:00 am, Resident #20's clinical record was reviewed and a smoking assessment was not found in his chart. g. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses, including congestive heart failure and diabetes mellitus. Resident #3's Smoking care plan documented she was able to smoke safely with supervision. Intervention included: * Check clothing and hands for burns * Complete smoking assessment * Educate and provide resident with smoking safety devices * Educate resident on smoking rules and obtain acknowledgement signature * Facility storage of tobacco and fire materials: nurses' station * Resident is to wear smoking apron while smoking at all time during supervised smoking. Review of Resident #3's clinical record included two smoking assessment since admission, dated 1/27/16 and 11/1/16. On 11/2/16 at 8:26 am, the DNS said the smoking assessment was done upon admission and quarterly thereafter. Resident #3's smoking assessments were not completed quarterly. The facility failed to ensure residents who smoked, and all other residents residing in the facility, were protected from serious harm, impairment, or death, due to unsafe smoking practices. Removal of Immediate Jeopardy: Smoking Safety On 11/2/16 at 3:33 pm, the facility was notified of the Immediate Jeopardy related to unsafe smoking practices and failure to provide residents who smoked independently, accessibility to the facility's designated smoking area. The facility was notified of the need to formulate and implement a plan to remove the immediate jeopardy. An acceptable was received which included: * DNS and/or designee to provide education to all smoking residents' regarding smoking at the facility. * All nursing home staff to be educated regarding smoking policy and proper storage of smoking materials. * Facility will now allow residents who are independent in smoking to smoke in the designated smoking area. * All smokers have been reviewed to ensure that the residents had current smoking assessments and care plans reviewed for accuracy. * Prior to admission, all residents will be screened for smoking related concerns and notified of smoking policy. * If a current resident that smoked had a change in condition that rendered them unsafe to smoke independently, a new smoking assessment will be completed and the resident will be grandfathered into supervised smoking if needs can be met. * All residents who smoke were reviewed for any smoking material being kept in rooms and this was documented on room safety audit. Smoking materials are stored in nursing carts or medication room. * Residents who smoke will have monitors in place each shift to monitor compliance with the smoking policy. * Results of these audits will be reviewed monthly in QAPI for no less than 2 quarters. On 11/4/16 the above actions were verified and the facility notified the health and safety of residents was no longer in immediate jeopardy due to unsafe smoking practices. 2. During an observation on 11/1/16 at 8:50 am, the medication cart on Hall 100 was unlocked, a nurse was not present, and a staff person came up to the cart to leave a note. The unlocked cart was unattended for 5 minutes. Residents were observed walking and/or in wheelchairs in the hall by the unattended medication cart. During an interview on 11/1/16 at 8:55 am, LN #1 said she should not have left the medication cart unlocked because someone could get into it. During an observation on 11/1/16 from 8:49 pm to 8:59 pm, the medication cart on Hall 200 was left unlocked and unattended. The staff were providing care in a resident's room. Residents were observed walking and/or in wheelchairs in the hall by the unattended medication cart. During an interview on 11/1/16 at 9:00 pm, LN #4, stated she thought she had locked the medication cart. LN #4 stated, I used the key. No, it's not locked. During an observation on 11/2/16 at 8:13 am, the treatment cart was left unlocked and unattended. When the surveyor pulled the drawer, it opened. Resident Care Manager #1 witnessed the surveyor pulling the drawer open and stated Oh, is that unlocked? I will address this with the wound nurse. Residents were observed in the hallway at the time. Residents were observed walking and/or in wheelchairs in the hall by the unattended treatment cart. During an interview on 11/2/16 at 8:50 am, the DNS said the medication and treatment carts should always be locked and when they are unlocked a nurse should be present. She said the risk of leaving a medication or treatment cart unlocked and unattended was that residents, visitors, or staff could take medications from the cart or mix up medications. The facility's Medication Storage in the Facility policy, dated September 2011, included, Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. Removal of Immediate Jeopardy - Medication Cart: On 11/2/16 at 3:33 pm, the facility was notified of the Immediate Jeopardy related to unlocked medication and treatment carts. The facility was notified of the need to formulate and implement a plan to remove the immediate jeopardy. On 11/4/16 at 2:15 pm, the facility provided an acceptable plan to remove the immediate jeopardy related to unlocked medication carts. The plan included: * Nursing Staff has been educated on keeping carts locked and potential risks that may occur when leaving them unlocked and unattended. * Medications carts were reviewed for locking mechanisms completed on 11/2/16 prior to IJ. *Medication cart and treatment cart have had key pad disarmed so that the only access will be via key. Completed 11/2/16 prior to IJ notification. *Carts will be reviewed to ensure that staff are keeping medication carts secured. DNS designee will complete review once per shift. *Daily review of findings will be conducted by Administrator, DNS, or designee. *Results of these audits will be reviewed monthly in QAPI for no less than 2 quarters. On 11/4/16 the above actions were verified and the facility notified the health and safety of residents was no longer in immediate jeopardy due to unlocked medication and treatment carts. 3. The facility failed to ensure residents who left the property for appointments signed in and out the facility to ensure facility staff were aware of their whereabouts. a. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #23's admit MDS assessment, dated 7/30/16, documented she had no cognitive impairments and required limited assistance of one staff member for transfers, dressing, and personal hygiene. On 11/1/16 at 10:27 am, Resident #23 was waiting for a ride to her follow-up appointment. She stated her appointment was in 15 minutes and the company did not send a w/c accessible van. Resident #23's doctor's office was 30 minutes away and she was going to be late. She asked the front office to call her physician and let them know she was going to be late. Resident #23 left the facility in a transportation company van at 10:50 am. Resident #23's Sign out Sheet was not filled out for her appointment. The sheet was blank. In addition, there was no nurses' note which documented she was not in the facility and at an appointment. b. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #27's quarterly MDS assessment, dated 8/6/16, documented he had no cognitive impairments and required limited assistance of one staff member for transfers and hygiene. On 11/1/16 at 10:27 am, Resident #27 was waiting for a ride to his follow-up appointment. He left the facility at 10:27 am in a transportation van. Resident #27's Sign out Sheet was not filled out for his appointment on 11/1/16. The last entry was dated 10/29/16 at 11:45 am. In addition, there was no nurses' note which documented he was not in the facility and at an appointment.

Based on staff interview and record review, the facility failed to ensure physicians orders were followed for a resident receiving [MEDICATION NAME]. As a result, resident #14 was harmed when the facility failed to hold ordered [MEDICATION NAME] and she was emergently transferred to the hospital where she died . The failure to follow physician's orders [REDACTED]. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a physician's orders [REDACTED]." The physician ordered a PT/INR ([MEDICATION NAME] Time and International Normalized Ratio) to be done on [DATE]. The results were 55XXX,[DATE].6 (Normal = ,[DATE] seconds/2 to 3.) The Nurse Practitioner ordered, on [DATE], ( Note: No time on the order), the facility to hold the [MEDICATION NAME] 5 mg for two days and then start [MEDICATION NAME] 4 mg on [DATE]. The DON was interviewed on [DATE] at 10 a.m. and the following information was obtained. The facility had converted to computer documentation for medications on [DATE]. The medication hold information on the MAR indicated [REDACTED]. LN #2 entered the medication hold order and failed to input the information correctly, as a result the [MEDICATION NAME] was not held. LN #2 input the new order for the [MEDICATION NAME] 4 mg to restart in two days ([DATE]). The "Significant Event Investigation Conclusions & Plan for Prevention" submitted to the Bureau of Facility Standards on [DATE] and the [DATE] MAR indicated [REDACTED]. [MEDICATION NAME] 5 mg continued to be administered on [DATE] and [DATE]. On [DATE] the resident received both [MEDICATION NAME] 5 mg and [MEDICATION NAME] 4 mg. On ,[DATE], 25 and ,[DATE] the resident received 4 mg of [MEDICATION NAME]. On [DATE] at 5:20 a.m. a nurse documented, "Pt (Patient) noted by CNA to be incont(inent) of (large) amount of liquid wine tinged stool. Asked this nurse for help. Pt noted (with) copious amount of wine colored loose stool, Hemacult (+) for blood, 911 called and en Route." On [DATE] at 10:00 a.m. the DON was interviewed about the resident receiving the medications without following the physician's orders [REDACTED]. The "Corrective Action Plan Time Line" submitted to Certification Bureau on [DATE] documented: "1. Patients on anticoagulants have been reviewed to evaluate their most recent INR and validate their current physician orders. Physicians will be contacted as needed if there are any identified concerns or discrepancies. 2. physician's orders [REDACTED]. 3. LN will be re-educated on management of known and potential medication errors including investigation, reporting via medication error report and notification of physician and responsible party. 4. Nurses have been re-educated and return demonstration / competency validated for management of EMAR system. 5. Abnormal lab results will be communicated between nurses during change of shift report. New physician orders [REDACTED]. 6. LN will be educated on potential drug interactions of anticoagulants and other medications. 7. Facility routine / standing orders for [MEDICATION NAME] management will be reviewed with facility LN. 8. New physician orders [REDACTED]." The Administrator and DON, in an interview on [DATE] at 3:30 p.m., stated the facility management company had taken over the facility on [DATE]. The policies from the previous company continued to be in place for 90 days. The policy for "[MEDICATION NAME] Dosing" dated [DATE], did not have information on what to do for an Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility failed to develop a policy and a comprehensive procedure/process for documenting and making changes in the EMAR.

Based on observation, staff interview, and record review, the facility failed to ensure a resident having pressure sores received necessary treatment and services to prevent new sores from developing. This affected 1 of 13 (#2) sampled residents reviewed for pressure ulcers. Resident #2 was harmed when he experienced a reoccurring Stage II pressure ulcer to his right ischial tuberosity and a Stage II pressure ulcer to his left 4th ring finger. Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 also had an implanted [MEDICATION NAME] pump that was refilled on 5/28/13. Resident #2's 3/22/13 Annual MDS documented in part: -BIMS Score of 9, moderately impaired -Total assistance with bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and bathing -Extensive assistance for personal hygiene -Functional limitations on both sides of his upper and lower extremity -Always incontinent of bowel and bladder -Received Scheduled pain medication -Had 1 stage 2 pressure ulcer -Had a pressure reducing device for chair and bed, was on a turning/repositioning program, -The annual MDS triggered a CAA for pressure ulcer and was checked for care plan, indicating pressure ulcer would be care planned Resident #2's 6/22/13 Quarterly MDS documented in part: -The same information as the above Annual MDS but with a BIMS Score of 11, moderately impaired and -Had a 1 Stage 2 pressure ulcer Resident #2's 6/22/13 "Braden Scale for Predicting Pressure Sore Risk", total score was 15, low risk. A) Resident #2 developed a Stage II pressure ulcer to his left 4th ring finger as follows: Resident #2's "Occupational Therapy Progress Report" documented in part: -2/5/13 "New skin issue with left hand focus of Tx (treatment) was orthotic modification with decrease pressure to wound area..." -2/13/13 "Fitted with orthotic for decreased pressure on finger per NRS (nursing) request and wound team" Resident #2's Weekly Pressure Ulcer BWAT (Bates Wound Assessment Tool) Report documented weekly entries from 2/7/13 to 6/17/13 and was signed by wound care team licensed nurses. It documented in part: -"2/7/13-Left 4th ring finger, anterior DIP (distal interphalangeal) joint, Stage II, [MEDICAL CONDITIONS], continue with PolyMem Ag QOD (every other day). -"2/11/13-Left 4th ring finger, anterior DIP joint, Stage II, [MEDICAL CONDITIONS], ulcer remains stable, PT evaled (evaluated) and tx with soft brace to left hand, continue current tx per PT." -"2/25/13-pt verbalizes less pain to ulcer when brace applied cont (continue) to monitor + (and) tx ulcer" -"5/27/13-Left 4th ring finger DIP Joint, intact, skin is now intact, continue current tx to protect skin integrity" -"6/3/13-Finger remains intact. Pt conts (continues) to wear finger/palm protector for pressure reduction" -"6/17/13- monitor d/c'd (discontinued) on 6/15/13 area remains intact (with) pink scar tissue" Resident #2's "Resident Progress Notes" documented in part: -"3/7/13 Left ring finger Stg 2 (Stage II) improving" -"5/28/13 Left ring finger now intact will continue with current dressing for protection" -"6/15/13 Left 4th finger has been monitored x 14 days and remains intact. order to d/c on 6/15/13" The facility's care plans were difficult to follow. On 7/16/13 at 2:30 pm, the surveyor asked the MDS Coordinator to explain Resident #2's care plan and how information was discontinued or added to it. The MDS Coordinator stated, "We can't put anything in the computer care plan right now. We are going through computer changes.We normally get a "3 part" from staff and the 3 part counts as an add on to the care plan." The MDS Coordinator said that often the 3 part was not accurate or complete. She said she tried to update the care plan by writing items in and crossing items out, but agreed the care plan was difficult to follow and understand. Note: The "3 part" was a care plan update form that consisted of an original and two duplicates. It was placed on a "Care Plan Update Posting Sheet" and documented problems, goals, and approachs. Resident #2's "Care Plan Update Posting Sheet" documented in part: -2/5/13-"Problem: Left 4th finger ant (anterior) DIP joint superficial skin loss, Goal: Heal (without) complication, Approach: monitor (and) tx as ordered" -2/7/13-"Problem: Stg II P/U (pressure ulcer) left 4th finger-anterior DIP joint, Goal: Resolve without complication, Approach: Tx/ monitor as ordered" -2/8/13-"Problem: #7 Skin integrity, Goal: no pressure areas on left hand/fingers, Approach: apply left hand orthotic when awake, remove Q shift for hygiene, remove e (sic) night for cleaning, ..." -6/1/13-"Problem: R IT Stg II P/U, Goal: Heal (without) complications, Approach: Monitor (and) tx as ordered" -6/15/13-"L (left) 4th finger,Goal: skin intact area resolved, Approach:" (No approaches were identified)" Resident #2's 12/27/12 Care Plan identified the following problems and approaches in part: Problem: "Physical Mobility, Impaired" with approaches listed as follows: -"L neuroflex splint when out of bed" (this information was written in ink and not dated) -"Dependent with turning & repositioning Q 2 hours" -"Gentle PROM (passive range of motion) to bilateral UE (upper extremity) before donning splints on both hands. Wear splints at night up to 12 hours." Note: The care plan documented evidence Resident #2 had hand splints in place before the pressure ulcer on his left 4th ring finger developed on 2/7/13. "Skin Integrity, Impaired: Potential" with approaches listed as follows: -"Report any red or open areas" -"SAR (Skin at Risk) checks Q Week D/T High Risk for Skin Breakdown" -"R palm protector in hand when OOB (out of bed), remove Q shift for hygiene and wash in sink at night and leave for dry" (this information was written in ink and dated 2/8/13) Resident #2's July 2013 Order Summary Report (Physician Recapitulation) documented in part: -04/09/2013 "Left hand orthotic to be placed when awake, off at HS (hour of sleep) and washed two times a day" -04/09/2013 "Resting hand splints to both hands on @ HS for up to 12 HRS every evening shift" -04/09/2013 "Right hand palm protector to be placed when awake, off at HS and washed two times daily" -04/08/2013 "Remove both hand splints/orthotic/palm protector QS (every shift) for hand hygiene then replace every shift" On 7/16/13 at 1:35 pm, the wound team was asked about the wound Resident #2 previously had on his left 4th ring finger. Wound Nurse #7 stated, "It was from pressure." The Wound Nurse #7 said Resident #2 had a hand splint on his left hand before the pressure ulcer occurred. She said the OT made changes to the splint after the pressure ulcer was discovered.Wound Nurse #7 said the wound on Resident #2's left 4th ring finger had healed on 6/15/13. Note: The facility failed to identify that the hand splint was causing a pressure ulcer until it had progressed to a Stage II. B) Resident #2 developed a reoccurring Stage II pressure ulcer to his right ischial tuberosity (IT) and it was documented as follows: Resident #2's "Weekly Pressure Ulcer BWAT Report" documented in part: -"6/1/13 ischial tuberosity R, Stage II, 0.9x0.7, Base is firm with 100% granulation. Edges well defined and adhered and regular. Ulcer presents over pink scar tissue. Multiple preventative in place. See progress note 6/1/13" -"6/9/13 ischial tuberosity R, Stage II, 0.9x0.7, Base firm 100% pink shiny tissue. Edges regular and adhered. Continue current treatment" -"6/17/13 ischial tuberosity R, 0.5x0.3, Ulcer remains stable and decreased in size. Epithelizlized tissue to margins. Surrounding skin pink and blanching" -"6/21/13 ischial tuberosity R, intact, Continue to monitor area has remained newly intact" Resident #2's 12/27/12 Care Plan documented in part: "Physical Mobility, Impaired" with approaches listed as follows: -"Dependent with turning & repositioning Q 2 hours" -"Bariatric long bed D/T (due to) height" -"Evaluate for appropriate seating & or device" -"High Profile ROHO Cushion to wheelchair" Toileting Deficit" with approaches listed as follows: -"Check attends Q2 HRS, change PRN, Peri-care after each incontinence" -"Provide incontinence protection: Large attends briefs" "Skin Integrity, Impaired: Potential" with approaches listed as follows: -"Report any red or open areas" -"Peri care with PH balanced cleanser after each incontinent episodes" -"Minimize skin exposure to incontinence by using a moisture barrier" -"SAR checks Q Week D/T High Risk for Skin Breakdown" -"Bariatric Bed" Resident #2's July 2013 Order Summary Report (Physician Recapitulation) documented in part: -Apply barrier cream QS and PRN every shift and PRN -Bariatric bed in place to help maintain skin integrity -Foam W/C cushion to be used for pressure redistribution Note: Resident #2's care plan documented "High Profile ROHO Cushion to wheelchair" On 7/16/13 at 12:10 pm, CNA#4 and CNA#8 were observed providing cares for Resident #2. When Resident #2 was rolled to his right side for peri-care, the surveyor discovered a small wound on his right buttock. The surveyor asked CNA# 4 if that was an open area? CNA#4 replied, "I haven't seen it that bad lately" and "I will tell the nurse." On 7/16/13 at 1:35 pm, the surveyor met with the wound team regarding Resident #2. The surveyor asked about Resident #2's wound on his right ischial tuberosity. Wound Nurse #7 stated, "that (right ischial tuberosity) is healed and intact, and monitoring was discontinued on 7/2/13." The surveyor informed the Wound Team of the observation of the wound on the resident's buttocks, during resident cares, at 12:10 pm, earlier in the day. Wound Nurse #7 said they were not aware of a present wound on Resident #2's buttocks. The wound team said they would look at the wound and perform an assessment right away. Wound Nurse #6 said, "He's had an issue on his IT before and he has scar tissue in that area." At 1:50 pm the same day, the surveyor observed the wound team as they assessed Resident #2's wound on his right ischial tuberosity. Wound Nurse #6 stated, "That's the same area as before, see the previous scar tissue? That's in the same spot." The surveyor asked if she would call that a Stage II pressure ulcer? Wound Nurse #6 said, "Yes, it's 0.7x1.5 cm and is less that 0.1 cm in depth." Resident #2's broda chair was observed up against the wall at the foot of his bed. The broda chair had a thin vinyl pad on the straps of the seat of the chair. Note: Resident #2 had a broda chair with a thin vinyl pad with a strapping system for the seat. The Physicians Orders documented a foam wheelchair cushion for pressure redistribution was to be used, and the Care Plan documented a High Profile ROHO cushion was to be provided to the wheelchair. Resident #2's "Interdisciplinary Progress Notes" dated 7/17/13 documented in part: "IDT review for event on 7/16/13. Pt (patient) noted to have a stage II p/u to right IT. Pt is dependent on others for all cares and incontinent of bowel and bladder. Resident had denuded skin to same area starting 5/20/13 with partial thickness skin loss. On 6/1/13 wound team notified via SAR to decline to area. Upon assessment, area presented as stage II p/u and was reclassified as such - MD notified and new appropriate treatment was initiated. Resident was care planned for limited seating, last up/first down, and Q 2 hour repositioning was continued as previously care planned. Wound team assumed treatment and monitoring of pressure area and it was noted to be intact on 6/21/13. On 6/26/13 new orders were initiated for [MEDICATION NAME] boarder dressing to protect fragile/friable newly intact scar tissue. Area remained intact and on 7/2/13 treatment/daily monitoring by LN was discontinued. From that time forward daily skin checks by CNA's during ADLs were completed as care planned and were negative for skin impairment to right IT. Last LN skin check was completed 7/15/13 and was negative for right IT as well. Resident currently using Broda 758 specialty w/c with corresponding seat pad and back pad. Seat pad is attached to w/c seat with adjustable straps. Wound team staff member recreated seating shortly with-in .5 hr of event notification and was able to determine that there was enough play in attachment strap that the cushion was non stationary and easily misplaced, allowing for the right IT to become pinched between the specially designed seat straps. Also noted at time of event, that terrycloth seat and back covers were not in place. Straps have been readjusted/tightened and cushion was verified to be stationary. Strap length to be fixated at appropriate length to assure they won't loosen again. Will pursue the possibility of pressure mapping to eval current seating system. Last up/first down seating restrictions reinstated. Treatment initiated and wound team following daily. Terrycloth covers have been replaced to seat and back cushions." Resident #2's "Interdisciplinary Progress Notes" documented as follows: -7/16/13 (1:50 pm), "Wound tx notified of open area to right IT. Upon assessment noted Stg II PU to R IT 0.7x1.5 (less than ) 0.1 cm. Wound bed pink, regular edges, peri-wound with recently intact scar tissue red and blanching. Scant serous drainage, NP (nurse practitioner) notified tx orders received and initiated. Patient with [MEDICAL CONDITION] and dependent for cares and mobility, DM and TBI" Note: On 7/16/13 at 12:10 pm, The surveyor discovered a open wound on Resident #2's right ischial tuberosity while staff were observed performing cares for the resident. The surveyor informed the wound team on 7/16/13 at 1:35 pm of the wound, which they were not aware of. -7/9/13 (1:56 pm), "F/U wound and nutrition. Stg II p/u to right IT remains stable and intact..." -6/25/13 ( no time documented), "Right IT with 100% [MEDICATION NAME]. Will continue with protective dressing at this time." -6/11/13 (2:40 pm), "IT wound improving with decreased measurements. Resident continues with limited seating and is to be last up first down for meals".. -6/1/13 (no time documented), "Nursing request to asses right inner buttock denuded skin r/t (related to) decline. Upon assessment noted denuded skin now presents as Stg II p/u 0.9x0.7x (less than) .1. Edges well defined and adhered. Base is firm ulcer present over pink scar tissue that is anatomically marked R IT (ischial tuberosity)" Resident #2's "Resident Progress Notes" documented as follows: -5/20/13, 1:00 pm-"Wound tx notified via SAR of denuded skin to right buttock. Upon assessment red blanchable area of superficial skin loss 0.7x0.5cm edges irregular and adhered. Nursing initiated order to cleans with NS and apply [MEDICATION NAME] with each incontinence episode. Nursing to continue to tx" -5/20/13, 10:45-"CNA reported to this nurse that patient had an old area to inner right buttocks that opened back up upon assessment area was noted to be 0.2x0.1cm with small amt (amount) of bloody drainage, denuded skin was cleansed with NS (normal saline) and antiseptic applied" Note: Resident #2 had a broda chair with a thin vinyl pad over the seat straps and no terrycloth covers were observed. The Physicians Orders documented a foam wheelchair cushion for pressure redistribution was to be used, and the Care Plan documented a High Profile ROHO cushion was to be provided to the wheelchair. Note: The facility failed to provide the physicians ordered foam wheelchair cushion for pressure redistribution, and failed to ensure Resident #2's broda chair seat straps were properly attached, causing a Stage II pressure ulcer to reoccur to the resident's right ischial tuberosity. Additionally, the facility failed to identify or have any type of documentation for the Stage II pressure ulcer until the surveyor brought it to their attention. Resident #2 had also received a Stage II pressure ulcer to his left 4th ring finger. On 7/18/13 at 1:30 pm, the Administrator and DNS were informed of the reoccurring Stage II right ischial tuberosity pressure ulcer and the acquired Stage II pressure ulcer on the left 4th ring finger for Resident #2. No information or documentation was provided that resolved the issue.

Based on observation, record review, resident interview, and staff interview, it was determined the facility failed to provide adequate supervision to prevent falls. This was true of 1 of 9 residents (#7) sampled for falls. Resident #7 was harmed when she fell and received a right ankle fracture requiring surgical intervention. In addition, peri-wash, sunscreen & sani-wipes were observed in an unlocked linen closet, and deodorant, shampoo, lotion, peri-wash and hand sanitizer were found in an unlocked cupboard in an unlocked storage room. This had the potential of harm to the cognitively impaired residents who resided in the facility and who may have wandered into these areas using the items for other than their specific purpose. Findings included: 1. Resident #7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident experienced a fall on 5/10/13 in the facility and was admitted to the hospital on [DATE] for a right ankle fracture. Resident #7's 2/28/13 Quarterly MDS documented in part: -BIMS Score of 15, cognitively intact -Extensive assistance of one person for transfers, bathing and toileting -Limited assistance of one person for walking in the corridor and dressing -Independent for locomotion on and off the unit -Supervision and set up for personal hygiene -Functional limitation impairment on one side, lower extremity -Occasional pain and received PRN pain medication Resident #7's 5/23/13 significant Change MDS, documented in part: -BIMS Score 15, cognitively intact -Total dependent of one person for transfer and toileting -Walk in Corridor did not occur -Limited assistance of one person for locomotion on the unit and hygiene -Extensive assistance of one person for locomotion off the unit and dressing -Extensive assistance of two persons for bathing -Functional limitation impairment on both sides, lower extremity -Occasional pain and received PRN pain medication Resident #7's 3/20/13 Care Plan documented in part: "Potential for trauma related to fall risk, history of falls, unsteady gait : Will be free from falls with injury" Approaches included: -"9/11/2012 PT (patient) has long history of getting out of bed or chair down to the floor and then standing. This was her prior level of function and continues to do so despite attempts to educate or redirect." -"8/28/2012 Anticipate needs with: offer fluids with each care contact, personal items within reach, sharp edged items away from bed, nonstationary items away from bed, eliminate room clutter, non skid socks." -"1/29/2013 Falling Star Program." "Self Care Deficit: ADL's related to history of falls and R ankle fx (right ankle fracture)" "Will be able to transfer self to and from w/c independently, will ambulate 150 ft (feet) to 250 ft with supervision using FWW (front wheeled walker), Will retrieve clothing from closet independently." Approaches included: "5/14/13 Right mobility bar to assist with bed mobility." "5/14/13 Transfer with mechanical lift NWB R LE (non weight baring right lower extremity)." "5/16/13 WBAT (weight baring as tolerated) Note: Resident #7 received a right ankle fracture from a fall in the facility on 5/10/13. She was hospitalized and returned to the facility on [DATE]. Resident #7 was non-weight bearing status when she returned to the facility. The update to the care plan on 5/28/13 documented the resident required a mechanical lift for transfers, but there was also an approach on the care plan dated 5/16/13 that documented the resident was weight bearing as tolerated. The resident's care plans were difficult to follow and had multiple cross outs. It was difficult to determine when and what items were added or discontinued from the care plan. However, the care plans did not include any interventions about increasing the supervision for Resident #7 and the facility did not provide documented evidence of increased monitoring or supervision for Resident #7. The facility failed to provide documented evidence Resident #7 was monitored daily for falls and lack of falls, as directed by the facility's "Falling Stars Policy". It could not be determined that the Falling Stars Program was effective for Resident #7. NOTE: Federal guidance at F323 indicated, "...'Supervision/Adequate Supervision' refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident..." There were 12 "Resident Event Report Worksheets" for Resident #7 from her admission on 8/28/2012 until her fall with an ankle fracture on 5/10/13. They were summarized in part as follows: -9/19/12 at 6:30 am-Resident #7 got out of bed and ambulated to her closet with a FWW. She retrieved her clothes from the closet and walked back to her bed, lost her balance and fell , leaving her FWW at the closet. The PI (Performance Improvement) recommendations were to continue PT and OT. -12/5/12 at 6:15 pm-Resident #7 stood up to close the blinds in her room and fell to her knees while holding on to a stationary chair. The PI recommendations were to encourage resident to request assistance and to modify the pull string to the blinds. -12/8/12 at 9:40 am-Resident #7 was assisted with her shower in the shower room. Resident #7 stood up so that her buttocks could be washed. When the CNA tried to assist Resident #7 back into the shower chair, the shower chair moved and Resident #7 was assisted to the floor by the CNA. The shower chair was found to have a broken lock on the left rear wheel. The PI recommendations were to educate staff, repair the shower chair, and maintenance to check all other shower chairs. -12/12/12 at 3:00 pm-Resident #7 was attempting to empty her catheter bag into the toilet in the bathroom when she lost her balance. She went down slowly to the floor. The PI recommendations were to refer to PT and OT. -1/28/13 at 2:50 pm- Resident #7 fell in her room and was found sitting on the floor. Resident stated she was attempting to push her wheelchair out of her way to go to bed. The PI recommendations were to add Resident #7 to the "Falling Stars Program". -2/8/13 at 3:30 pm- Resident #7 said she got out of her wheelchair and crawled under her bed to get the alarm clock. PI recommendations were were none, and Resident #7 had been educated to call for assistance when retrieving items off the floor. -3/7/13 at 2:15 am- Resident #7 said she was trying to put her pants on by herself and sat down on the floor. Resident #7 was found on the floor with her back against the head of her bed. PI recommendations were to have the Nurse Practitioner review and discontinue Ambien and increase the Trazadone. Note: Resident started Ambien on 3/4/13 and was discontinued on approximately 3/7/13, and Trazadone was increased from 50 mg to 100 mg at that time per Progress notes dated 3/7/13. -3/11/13 at 9:20 pm- Resident #7 utilized her call light but stood up and was reaching to lower her window blinds when she lost her balance and fell . PI recommendations were to x-ray the right ankle, perform a UA, and check the cord on the blinds. The x-ray revealed there was no fracture to Resident #7's right ankle. Resident #7 received an ankle strain and began PT. -4/30/13 at 3:30 pm- Resident #7 stood up from the wheelchair and was attempting to get clothes out of her closet. She lost her balance and lowered herself to the floor. The call light was not on. PI recommendations were not listed but the report indicated that therapy services would continue for increased strengthening and "resident continues to attempt to maintain independence despite education to request assistance." -5/4/13 at 13:15 pm- Resident #7 was sitting in her wheelchair in the lobby. She stood up and tried to get her her bag with belongings from the back of her wheelchair. She fell to the floor on her knees. PI recommendations were to continue with therapy for strengthening. Interdisciplinary Team follow up notes stated in part: "Resident with hx of falls r/t not requesting assistance d/t desire to maintain independence." -5/10/13 at 4:15 pm- Resident #7 wheeled herself out of the dining room to her bathroom in her room. She turned on the call light and tried to transfer herself onto the toilet. Resident #7 was found with her back up against the wall facing the toilet. PI recommendations were to x-ray the ankle and for PT and OT. Resident #7 received a right ankle fracture resulting in a ORIF (open reduction internal fixation) of the right ankle. Resident #7's 5/15/2013 History and Physical stated in part: "1. Right ankle fracture with surgical reduction and fixation 5/13/13." "2. Longstanding moderate paresis of both legs of unclear etiology, worse involving the left leg for approximately [AGE] years. Etiology is unclear." On 7/15/13 at 2:15 pm, Resident #7 was observed sitting in a wheelchair in her room, next to her bed. She had a black, knee high cast type boot on her right leg, and a clear AFO (ankle foot orthotic) brace on her left leg. The surveyor asked the resident what had happened to her legs. Resident # 7 said she had turned the call light on in the bathroom for assistance but it took a while for the staff to help her. She had attempted to get onto the toilet independently when she fell . She said she had broken her right ankle and stated, "And that was my good leg, my left leg is practically paralyzed." On 7/16/13 at 9:15 am, the Physical Therapist #10 was asked if Resident #7 experienced a functional decline due to her right ankle fracture. The Physical therapist replied, "Of course." The Physical Therapist said Resident #7 was independent and transferred on her own before her ankle fracture, although the staff encouraged her to get assistance to transfer. After her fall, Resident #7 was placed on non weight bearing status and required a hoyer lift for tranfers. On 7/16/13 at 9:45 am, the DNS reviewed Resident #7's falls and provided the time line for the falls mentioned above. She was asked about the Falling Star Program. The DNS said the Falling Star Program included a star magnet placed outside the resident's door. When staff walk by that room, they looked in the room to see if the resident needed assistance. Note: On 1/28/13, Resident #7 was placed on the "Falling Stars Program", and had 6 additional falls after that time. Although Resident #7 attempted to remain independent, she had a history of [REDACTED]. She had a history of [REDACTED].#7 and Resident #7 experienced a fall resulting in a right ankle fracture. Resident #7 required surgical intervention and experienced a functional decline. Resident #7 required a mechanical lift for transfers and was no longer able to ambulate in the corridor with assistance. She also required total assistance with toileting and limited assistance with hygiene where as before her fall she only required limited assistance with toileting and set up assistance for hygiene. On 7/18/13 at 1:30 pm, the Administrator and DNS were informed of the fall with a fracture concern with Resident #7. No other information or documentation was provided which resolved the issue. 2. During the environmental tour conducted on 7/16/13 at 8:45 a.m., the clean linen closet on the 200 hallway was not secured. Inside the closet, which would be accessible to residents, the following chemicals were found on the shelf: - 2 bottles of antiseptic peri-wash which had an active ingredient of Benzethonium Chloride 0.2%, - 1 tube of sunscreen with active ingredients of: Octinoxate, 7.50%; Homosalate, 5.0%; Octisalate, 5.0 % and Benzophenone -3, 3.0%, - 1 container of PDI Sani-wipes with active ingredients of n-alkyl dimethyl ethylbenzyl ammonium chloride, and n-alkyl dimethyl benzyl ammonium chloride. The products were collected and the staff development coordinator, who was at the nursing station, was given the items to secure. 3. During the environmental tour conducted on 7/16/13 at 9:10 a.m., the storage room on the 300 hallway had a wooden cupboard which had a sign which read "keep locked all times." The cupboard was checked and it was not locked. Inside the cupboard were: - 14 bottles of liquid deodorant, - 2 bottles of shampoo, - 2 bottles of lotion, - 3 bottles of peri-cleaner, and - 3 bottles of alcohol hand sanitizer (4 ounces). The surveyors informed RN#1 at 9:15 a.m., who then locked the cupboard. The Administrator and DON were informed of the chemicals not being secured on 7/16/13 at 3:45 p.m. No further information was provided.

Based on a complaint from the public, observation, record review and staff interview it was determined the facility failed to ensure the highest level of functioning and well being for 5 of 15 residents, (#1, # 2, #5, #7 & #14). *Resident #1 was harmed due to sustaining bilateral femur fractures as the result of being found on the floor after an unwitnessed fall. The responsible LN did not complete an incident report, document an initial or ongoing assessment of the resident's condition after the fall or report the fall to the next shift of oncoming nursing staff. This resulted in a delay of treatment of [REDACTED]. *Resident #7 was harmed when he was not adequately assessed for constipation and subsequently was hospitalized for [REDACTED]. *Resident #5 did not receive an ordered evaluation by a hand specialist. *Resident #2 had a fecal impaction which required digital disimpaction, in addition to not receiving care-planned vital signs related to receiving a beta blocker medication. *Resident #14 had ongoing issues with constipation without appropriate intervention to address bowel care. Findings included: A complaint from the public included an allegation that the facility failed to immediately notify the legal representative of a fall with injury which resulted in the resident's hospitalization and subsequent death. 1. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A facility reported incident, submitted to the BFS on [DATE], documented details of an investigation into an unwitnessed fall sustained by Resident #1 on [DATE] between 12:30 p.m. and 1:00 p.m., when she was found on the floor of her room with her legs bent under her after a fall from her wheelchair. CNA #1 reportedly called for the assistance of LN #2 and the resident was assisted to bed. According to the CNA, LN #2 then assessed the resident and noted no abnormalities. According to the investigation report, LN #2 failed to notify the physician or the legal representative of the event. An incident report was not filled out on the fall, and information that the fall occurred was not communicated to on-coming staff at the end of LN #2's shift. The full, completed investigation report, provided by the facility on [DATE], included a statement by CNA #1, which included the following details: Resident #1 was found on the floor in her room in a sitting position with her legs bent under her to her right side. The resident stated she was looking for something in her dresser, and she wanted to go back to bed. CNA #1 went to the hall and informed LN #2 she needed assistance with the resident. CNA #1 stated that LN #2 assessed the resident, stated she was "OK" and assisted the CNA to lift the resident into bed. The resident reportedly stated when she was put into bed, that she "had pulled some ligaments in her legs because they were hurting." CNA #1 stated, "I asked (LN #2) about (an) event or incident report. She stated (she) really didn't want to but she should." The LN further stated she would take care of the report, but was going to lunch. CNA #1 wrote that the resident flinched when incontinence care/repositioning was provided later in the shift and the resident told the CNA her back and legs hurt. Toward the end of shift, the CNA told LN #2 that the resident complained of pain, to which the LN replied, "Probably should get an x-ray." CNA #1 also documented she did not inform on-coming staff of the fall at shift change. Review of Resident Progress Notes showed an entry for [DATE] at 1:20 a.m. which stated the resident was resting quietly all shift with no complaints of pain or discomfort. No entry from any shift for [DATE] was in the notes. An entry for [DATE] at 6:00 a.m. documented, "Resident has lg (large) bruise to inner (right) thigh (with) swelling noted to thigh. Resident very resistant to any repositioning of leg as it is very painful. Was not able to tell us how it happened. Emesis x 2. Temp(erature) 98.2. Refused any pain med(ication)." Resident #1's ,[DATE] physician's orders [REDACTED]. No other "as needed" pain medication was ordered for the resident. The investigation report further stated, in reference to the morning of [DATE], "During shift report (LN #2) identified that (Resident #1) had slid or fallen from her wheelchair to the floor the day prior and that it had not been communicated on the 24-hour report. The physician was contacted, orders received for x-rays. Results showed bilateral femur fractures below edge of her bilateral hip prosthesis..." The report did not include which staff or discipline LN #2 communicated the information to the morning of [DATE]. The conclusion of the investigation included statements that the resident was assessed and treated appropriately after the fall, that there had been a delay in notification to the family related to the delay in documentation, and that "appropriate care of (Resident #1) was provided." NOTE: The facility concluded that the resident was assessed and treated appropriately after the fall; however, there was no evidence that information surrounding the fall, including ongoing assessment of the resident's condition was documented in the record or passed on to night shift staff. Further, the CNA reported that shortly after the fall the resident "flinched" when incontinence care/repositioning was provided and said that her back and legs hurt. There was no evidence that facility staff responded to the resident's complaints of pain for approximately 18 hours. The facility concluded the investigation report with a plan to prevent further occurrences, which stated, "LN was not completely forthright in admitting her reporting error - LN terminated. CNA did not convey (Resident #1's) fall to oncoming shift - CNA counseled. Nursing staff re-educated on management of falls, events, and unusual occupancies." According to Resident Progress Notes dated [DATE], (no time entered) paramedics arrived at the facility on 11:15 a.m. IV fluids and pain medication were administered at that time and the resident was transported via ambulance to the hospital. Hospital records obtained and reviewed on [DATE] stated the resident had been seen in the emergency roiagnom on [DATE] and diagnosed with [REDACTED]. Resident #1 died in the hospital on [DATE] at 11:15 a.m. The Administrator and clinical RN consultant were interviewed on [DATE] at 1:30 p.m. When asked for further clarification on the lack of documentation and communication after the resident's fall, they stated the bulk of the problem was with LN #2, and she had been terminated. When asked if the LN had shared why she had not reported the fall, they said the LN stated there had not been an event report form available at the nurse's station. The RN consultant stated there were always forms available in a drawer. When asked why the night nurse did not call anyone when the bruising was discovered, they stated it had not been discovered until 4:30 a.m. The facility's failure to ensure appropriate reporting, assessment and treatment following an unwitnessed fall resulted in harm to Resident #1 who sustained bilateral femur fractures. The resident experienced a delay in treatment of [REDACTED]. 2. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated [DATE], documented the following: * Bowel sounds present, abdomen distended * Experiencing pain, pain management prescriptions * Extensive assist requiring one person for assistance for toilet use * Supervision for eating * Disoriented occasionally * Regular diet type with regular consistency * Independent fluid and eating intake * No weight loss * No risk factors for dehydration, refusing fluids On readmission after hospitalization , on [DATE], the resident was assessed as having bowel sounds present, with a non-tender, soft abdomen. On [DATE], after his second readmission following a hospitalization for amputation of his left lower leg, the resident was assessed as the same. The resident's admission MDS assessment, dated [DATE], documented the following: * Moderate difficulty with hearing * Moderately impaired vision * Severe cognitive impairment * Independent - requiring set up help only for eating * Extensive assistance requiring one person for physical assistance for toilet use * Occasionally incontinent of bladder and bowel The resident's Triggered CAAs, dated [DATE], documented the following: * Behavioral Symptoms - "Resident had hx (history) of dehydration" (handwritten note) * Dehydration/Fluid Maintenance - Behavioral disturbance that interferes with intake * Dehydration/Fluid Maintenance - "Res is an (sic) 94 y old (year old) male, HOH (hard of hearing), legally blind, [MEDICAL CONDITIONS],[MEDICAL CONDITION](hypertension), atherosclorosis (sic) to LLE (left lower extremity), multiple ulcer, confused at times. Need to cont (continue) care plan to encourage and offer fluid to maintain good skin turgor and moist mucosa." (handwritten note) The Medical Nutrition Therapy Assessment for Resident #7, dated [DATE], documented estimated fluid needs of 1800 cc (cubic centimeters) intake daily. Meal monitors and MARs (health shakes ordered twice daily on [DATE]) for Resident #7 documented the following fluid intake: [DATE] 900 cc and 0 = 900 cc [DATE] 750 cc and 0 = 750 cc [DATE] 240 cc and 0 = 240 cc [DATE] 660 cc and 0 = 660 cc [DATE] 880 cc and 0 = 880 cc [DATE] 540 cc and 0 = 540 cc [DATE] 960 cc and 0 = 960 cc [DATE] 840 cc and 0 = 840 cc [DATE] 700 cc and 0 = 700 cc [DATE] 480 cc and 0 = 480 cc [DATE] 600 cc and 240 cc = 840 cc [DATE] 960 cc and 240 cc = 1200 cc [DATE] 720 cc and 240 cc = 960 cc [DATE] 600 cc and 240 cc = 840 cc [DATE] 680 cc and 240 cc = 920 cc [DATE] 720 cc and 240 cc = 960 cc [DATE] 740 cc and 240 cc = 980 cc [DATE] 720 cc and 240 cc = 960 cc [DATE] 600 cc and 240 cc = 840 cc [DATE] 600 cc and 240 cc = 840 cc [DATE] 480 cc and 240 cc = 720 cc [DATE] 480 cc and 240 cc = 720 cc [DATE] 640 cc and 240 cc = 880 cc [DATE] 360 cc and 240 cc = 600 cc [DATE] 360 cc and 240 cc = 600 cc [DATE] unknown cc and 180 cc = 180 cc [DATE] unknown cc and 60 cc = 60 cc [DATE] unknown cc and 90 cc = 90 cc [DATE] unknown cc and 60 cc = 60 cc [DATE] unknown cc and 0 cc = 0 cc [DATE] Transferred to hospital [DATE] In hospital [DATE] readmitted at 2:30 pm, Could not find documentation of health shakes on MAR given as ordered after readmission [DATE] unknown cc and 0 cc = 0 cc [DATE] unknown cc and 0 cc = 0 cc NOTE: The meal monitor information for [DATE]-[DATE] and [DATE]-[DATE] was requested three times from the facility and was not received. [DATE] Transferred to hospital at 11:30 am ,[DATE]-[DATE] readmitted to facility from hospital at 11:50 am [DATE] Documented refusals [DATE] 360 cc and 0 cc = 360 cc [DATE] 240 cc and 0 cc = 240 cc [DATE] 600 cc and 0 cc = 600 cc [DATE] 240 cc and 0 cc = 240 cc [DATE] 480 cc and 0 cc = 480 cc [DATE] 190 cc and 0 cc = 190 cc The physician's orders [REDACTED]. * [MEDICATION NAME] 25 mcg (micrograms) ER (extended release) topical patch, ordered [DATE] * [MEDICATION NAME] with [MEDICATION NAME] ,[DATE] mg (milligrams) prn (as needed), ordered [DATE], common side effect [MEDICATION NAME] with [MEDICATION NAME] ,[DATE] mg, was documented as given on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. The Resident Progress Notes, documented the following: * [DATE] 6:00 am, "...at 0530 (5:30 am) this am, enema given 0530 due to constipation..." * [DATE] 3:05 am, "...voided no bm (bowel movement) tonight..." * [DATE] Status change form "...Pt (patient) with constipation since admit. Not on anything for bowels routinely. Orders received for [MEDICATION NAME] for pain and [MEDICATION NAME] for bowels." * [DATE] 11:00 pm "...has troubles with his bowels. Sometimes he 'just can't go.' Sometimes he 'has a little'..." * [DATE] 10:00 pm "...Incontinent of stool while in bed..." * [DATE] Status change form "Res (resident) cont (continues) to state he has pain in his abdomen (illegible) hasn't had much of an appetite. Order received to x-ray abdomen on suggestion from ST (speech therapy)." NOTE: The bedside x-ray of the resident's abdomen documented moderate constipation on [DATE]. * [DATE] Status change form "(nurse practitioner) here to see pt. New orders received for [MEDICATION NAME] 15 mg PO (by mouth) Q hs (every evening) for anorexia, Senna-S one (tablet) BID (twice daily) for constipation." * [DATE] Status change form "Pt with (positive) hemoccult. (Nurse practitioner) notified. Labs ordered..." * [DATE] 2:30 am "...Pain? Indicated lower abd (abdomen)..." * [DATE] Late Entry Status change form "(Nurse practitioner) notified of labs. Rec (received) push PO fluids now...Pt noted to have small amt (amount) frank blood from rectum this AM. No discomfort. No external hemorrhoids noted..." * [DATE] Late Entry 12:30 am "Late Entry: Pt to (hospital) ER (emergency room ) via (ambulance company)..." Bowel records for the resident documented the following: No bowel movements on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] In addition, the following were noted on days where a bowel movement occurred:,[DATE] 2 small bowel movements ,[DATE] 1 loose and 1 small bowel movement ,[DATE] 1 small bowel movement ,[DATE] 1 loose and 1 small bowel movement ,[DATE] 1 small bowel movement ,[DATE] 1 small and 1 loose bowel movement [DATE] 1 small and loose bowel movement [DATE] 2 small bowel movements [DATE] 2 small bowel movements [DATE] 1 medium loose bowel movement [DATE] 3 small bowel movements [DATE] 1 small bowel movement According to the Encyclopedia of Nursing and Allied Health, fecal impaction is the result of extreme constipation. It further states that the possibility that a "patient has a fecal impaction should be considered if he or she shows any or all of the following symptoms: * complaints of inability to have a bowel movement despite frequently feeling the urge to defecate * upon defecation, the stool appears to be either diarrheic or thin and pencil-like * abdominal pain * bloating and a swollen or hard abdomen * anorexia, or lack of appetite; nausea; and vomiting" The documented bowel movements described as "small" and/or "loose" should have been considered as possible indicators of fecal impaction, since in spite of having these bowel movements, the resident continued to report abdominal pain, anorexia, and constipation. Resident #7's Speech Pathology-Dysphagia Discharge Summary, dated [DATE], documented the resident had been referred for evaluation due to failure to thrive and cognitive deficits limiting comprehension of effects of nutritional deficits on ability to maintain health/function. Noted in the progress summary, "A major barrier was perseveration on feelings of constipation which were addressed by nursing with bowel programming and eventually lead to evaluation in the acute setting and discharge from the facility." Hospital records for Resident #7, dated [DATE], indicated he was admitted to the hospital with [REDACTED]. On [DATE] at 4:00 am, Resident Progress Notes for the resident documented, "2200 (10:00 pm): Pt awake. C/O (complains of) needing something for bowels. Gave 30 cc MOM alone." Physician Telephone Orders form, dated ",[DATE]-,[DATE]," (sic) documented standing orders for Milk of Magnesia 30 ml (milliliters) by mouth daily as needed for constipation, [MEDICATION NAME] suppository 10 mg per rectum daily for constipation, Fleets enema per rectum as needed for constipation, evidenced by no bowel movement in three days. It also documented to notify the physician if no results from the enema. These orders for [MEDICATION NAME] and the Fleets enema were discontinued on [DATE] due to non-use. On [DATE], there was a new telephone order for Milk of Magnesia 30 mg (possible error) daily as needed for constipation and [MEDICATION NAME] suppository 10 mg per rectum daily for constipation. On readmission to the facility on [DATE], there was an order for [REDACTED]. Bowel records for the resident documented the following: * ,[DATE]-,[DATE], ,[DATE], ,[DATE]-15, ,[DATE], ,[DATE], No bowel movements. The following bowel medications were documented as given in the MAR: * ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE], [DATE] Milk of Magnesia 30 ml * ,[DATE] Fleets Enema * [DATE]-[DATE] [MEDICATION NAME] 100 mg twice daily * ,[DATE]-[DATE] Senna Plus twice daily * ,[DATE]-[DATE], ,[DATE]-,[DATE] [MEDICATION NAME] 17 gm daily A Progress Note, dated [DATE], by the nurse practitioner, documented, "...In speaking with staff they report he's been constipated off and on, that he states that the constipation is affecting his appetite and that he's not been eating well..." Orders for a bedside x-ray of the resident's abdomen were received, as well as orders for [MEDICATION NAME] for anorexia and Senna-S twice daily for constipation. The facility's Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents documented the following: * Abdominal pain - Immediate (High Alert-within 1 hour) Abrupt onset severe pain or distention, OR With fever, vomiting * Abdominal pain - Non-Immediate (Medium Alert with ,[DATE] hours) Moderate diffuse or localized pain, unrelieved by antacids or laxatives * Abdominal Pain - Routine (Low Alert-one day to 72 hours) Persistent mild to moderate discomfort, without associated symptoms * Abdominal distention - Immediate (High Alert-within 1 hour) Rapid onset, OR Presence of marked tenderness, fever, vomiting, GI (gastrointestinal) bleeding * Abdominal distention - Non-Immediate (Medium Alert within ,[DATE] hours) Progressive or persistent distention not associated with other acute symptoms * Abdominal distention - Routine (Low Alert-one day to 72 hours) Gradual increase in abdominal girth not associated with acute symptoms On [DATE] at 2:00 pm, the Registered Nurse Consultant, Acting DON and RD #11 were interviewed with regards to the care of Resident #7. The Acting DON informed the surveyor there was not an admission Care Plan for constipation, even though the resident was admitted with the [DIAGNOSES REDACTED]. The resident had voiced ongoing complaints of abdominal pain and was consuming less than 50 percent of his daily assessed fluid intake prior to being hospitalized for [REDACTED]. The Speech Pathology note indicated perseveration on feelings of constipation by the resident, and also in the Progress Note by the nurse practitioner on [DATE], where it indicated that staff had stated the resident was having problems with constipation and abdominal pain. The lack of an appropriate Care Plan for constipation on admission to the facility, coupled with the resident's lack of appropriate and sufficient hydration status, led to the resident having been harmed and subsequently, hospitalized . Even with classifying the resident's abdominal pain and constipation as "Routine," it is unclear the physician was aware of the chronic problem with constipation and its relation to the hydration status of the resident in a timely manner. The Registered Nurse Consultant, Acting DON and the Administrator were informed of this issue on [DATE]. No further information was received. 3. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated [DATE], documented the following: * Short and long term memory problem * Extensive assistance requiring one person physical assist for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and bathing. * Total dependence requiring one person physical assist for eating and toilet use * Frequently incontinent of bladder * Always continent of bowel The resident's Care Plan, dated [DATE], documented the problem, "Nutrition...r/t (related to) constipation," with no approach outlined specifically for this problem. One approach listed, "Encourage PO intake and fluids," could apply. The resident was ordered the following medications that list constipation as a side effect: * [MEDICATION NAME] 300 mg PO AM * [MEDICATION NAME] 2.5 mg PO QD (every day)-common side effect * [MEDICATION NAME] 15 mg PO QD The Physician order [REDACTED]. This order was later discontinued on [DATE] and [MEDICATION NAME] 30 cc by mouth every day, for constipation, was ordered. On [DATE], [MEDICATION NAME] 10 mg suppositories were ordered, per rectum, daily, as needed for three days, for constipation. Milk of Magnesia 30 cc PO daily as needed was ordered on [DATE]. As needed medications for constipation were administered as follows: * [DATE] [MEDICATION NAME] 10 mg suppository * [DATE] Milk of Magnesia * [DATE] [MEDICATION NAME] 10 mg suppository * [DATE] [MEDICATION NAME] 10 mg suppository * [DATE] Milk of Magnesia * [DATE] [MEDICATION NAME] 10 mg suppository Resident #14 went the following periods of time without a bowel movement: * ,[DATE]-,[DATE] 3 days * ,[DATE]-,[DATE] 13 days * ,[DATE]-,[DATE] 3 days * ,[DATE]-,[DATE] 4 days * ,[DATE]-,[DATE] 3 days * ,[DATE]-,[DATE] 3 days * ,[DATE]-,[DATE] 12 days * ,[DATE]-,[DATE] 3 days * ,[DATE]-,[DATE] 4 days * ,[DATE]-,[DATE] 4 days * ,[DATE]-,[DATE] 3 days Effective management of the resident's ongoing problem with constipation was not addressed in the original care plan nor was there documentation the physician was notified in a timely manner, as evidenced by no change in medications until the middle of December, after the resident had experienced two extreme periods without a bowel movement. The Administrator, Acting DON and Registered Nurse Consultant were informed of these issues on [DATE]. No further information was received. 4. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent quarterly MDS assessment, dated [DATE], documented the following: * Independent cognitive skills for daily decision making * No range-of-motion limitations to the upper extremities, including the wrists and hands * Required set-up assistance only for eating A Physician's Progress Note, dated [DATE], documented, " ... she (Resident #5) reports she is having some [MEDICAL CONDITION] in her hands.... She also reports that she has some numbness and tingling in her hands that feels like the [MEDICAL CONDITION] that she's had in the past. The patient is on 300 mg (milligrams) of [MEDICATION NAME] bid (twice daily), will increase up to 600 (mg) and continue to work with the patient." Resident Progress Notes for Resident #5 documented the following: * [DATE] - "C/o (Complaints of) numbness to hands in morning...." * [DATE] - "Pt (Patient) (with) increased c/o neuropathic pain in hands. Describes as 'burning, tingling.' Currently receives [MEDICATION NAME] 600 mg BID." * [DATE] (12:45 a.m.) - "Pt resting watching TV. Offers no c/o pain or discomfort (with) hands. (No) s/s (signs or symptoms) of any side effects of (increase) in [MEDICATION NAME]. Continue to monitor (and) medicate prn (as needed)." * [DATE] (9:00 a.m.) - "Res(ident) has increased numbness (and) swelling noted to hand." * [DATE] - "Pt states she was independent with [MEDICAL CONDITION]/[MEDICATION NAME] cares until this week. Also reports inability to hold coffee cup (and) silverware yesterday or dress self. Change due to (increased) pain/numbness to (left) hand/arm." * [DATE] - "Res(ident) has had a (sic) acute episode of flare up r/t (related to) neuropathic pain in hands (with increased) swelling to hands. Res(ident) having (increased) problems holding onto cups, silverware. OT (Occupational Therapy) to eval(uate) (and treat) for gloves." An undated and unsigned Care Plan Update located in Resident #5's medical record documented, "Problem: Comfort r/t carpal tunnel (syndrome). Approach: Bilat(eral) hand splints (at) NOC (night)." NOTE: Neither the recapitulated Physician order [REDACTED].#5 with bilateral hand splints at night. Resident #5's Occupational Therapy Care Plan, dated [DATE], documented, "Pt will tolerate wearing (bilateral) [MEDICAL CONDITION] gloves (for) 8 hrs (hours)." NOTE: The OT Care Plan intervention did not specify whether the eight-hour tolerance period was to be on a trial basis, per 24-hours, or over a longer period of time. An OT Rehab Addendum Note documented the following: * [DATE] - "Retrograde massage with P/AAROM (passive and active assistance range-of-motion). She reports pain ,[DATE] (at a '6' on a 10-point scale). Wore Isotoner gloves (size small) for (approximately) 1 hr (hour). Didn't seem tight at the time, but seams (and) hem on cuff left impression. Cut off hem and label. We'll try again." * [DATE] - "Little [MEDICAL CONDITION] in hand. Thumb seems most swollen. She reports swelling 'coming back.' Finger joints are hyper mobile (sic) and easily attain full PROM (passive range-of-motion). She seems to have some difficulty moving them through full range or to touch each finger to thumb. Reports tingles (and) burning (and) general pain. Discussed alternate silverware grasp. She could demo it. (Illegible) (with) larger handle on fork. Will try ultrasound in water for discomfort relief." A Physician Telephone Order, dated [DATE], documented, "Refer to neurology - dx (diagnosis) [MEDICAL CONDITION]." A hand drawn line with initials was drawn through the order. Written underneath the redacted order, the Physician Telephone Order documented, "Refer to hand specialist - dx carpal tunnel. Bilat(eral) splints to hands (at) NOC." Resident #5 was observed on [DATE] at 7:20 a.m. in bed without hand splints on or visible in the resident's room. On [DATE], at 1:45 p.m., Resident #5 was observed in a motorized wheelchair in the 100-hallway just outside the facility's therapy suite. The surveyor approached the resident and, noticing a splint to her right hand, asked Resident #5 about the splint. The resident stated, "I just got it." On [DATE], at 1:50 p.m., COTA #3 (Certified Occupational Therapist Aide) provided the surveyor with an Occupational Therapy Evaluation, dated [DATE], and a Resident Evaluation/Treatment Prior Approval Form (RETPAF), dated [DATE]. The RETPAF documented a request for federal funding to provide OT services to the resident three times per week for two weeks. The RETPAF documented, "Expected Functional Outcome: (Decreased) [MEDICAL CONDITION] in (bilateral) UE's (upper extremities) through modality use (and) [MEDICAL CONDITION] gloves to (increase) function (with) ADLs." Following a review of the two documents, the surveyor asked COTA #3 to describe the OT services Resident #5 had received to date for the reported pain and [MEDICAL CONDITION] in her hands. COTA #3 stated the resident had been given ultrasound treatments in water to decrease the pain and [MEDICAL CONDITION], however the Isotoner gloves were discontinued after "one hour" due to associated pain reported by the resident. When asked why Resident #5 had a splint only to her right hand, COTA #3 stated, "This is trial and error so we're doing only the right hand at this time. If we're successful we'll do the left hand and then both (hands)." COTA #3 was then shown and asked about the [DATE] physician's orders [REDACTED]. COTA #3 stated, "I didn't see that order to give her splints or for the hand specialist; I was just following OTR (directions from a Registered Occupational Therapist)." On [DATE], at 2:45 p.m., the DON was interviewed and asked whether she knew why the facility's OT department did not receive and the assessment/treatment was not provided per the [DATE] physician's orders [REDACTED].#5. The DON stated, "I do not (know)." On [DATE], at 8:20 a.m., the DON informed the surveyor that the facility staff member who scheduled outside services for residents was "having difficulty" locating a provider who accepted the resident's insurance coverage, but had just secured an appointment for the resident for [DATE]. When asked again why the facility's OT did not know about the [DATE] physician's orders [REDACTED]. PT (Physical Therapy) did an evaluation for [MEDICAL CONDITION] and that's when they found out she had the issues with her hands also (and proceeded with the coincidental evaluation and ultrasound/Isotoner glove treatments)." The facility was unaware of a [DATE] physician order [REDACTED]. Additionally, the facility failed to schedule an appointment for the resident with a hand specialist, as physician ordered on [DATE], and could not provide documentation that any effort to arrange that consultation had been attempted prior to the facility's annual re-certification and licensure survey. This delay in treatment had the potential to cause the resident harm in that the physician's orders [REDACTED].#5's pain and assist with maintaining the resident's highest practicable level of physical functioning. 5. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] annual MDS assessment coded extensive assistance by 2 or more staff for toilet use, and 1 person physical assistance for personal hygiene; continent of bowel, without constipation or fecal impaction - regular bowel elimination pattern, at least one movement every 3 days; [MEDICAL CONDITION], hypertension, and [MEDICAL CONDITION]; and moderate back pain less than daily. The resident's [DATE] quarterly MDS assessment coded extensive assistance by 1 staff for toilet use, and limited assistance by 1 staff for personal hygiene, no pain, and continent of bowel without constipation. A. The resident's [DATE] Comprehensive Care Plan Report documented the following: Problem: Bowel elimination, impaired: constipation R/T hx (history); X-ray showed "large fecal impaction" although resident has regular BMs (bowel movements). R/T hx of fecal impaction. R/T hx of constipation from age 21 (implemented [DATE]). Goal: Resident will have no further bowel complications (implemented [DATE]). Goal: Will pass soft, formed stools every ,[DATE] days (implemented [DATE]). Approach: Administer bowel medications as ordered (implemented [DATE]). Approach: Record all bowel movements (implemented [DATE]).

Based on observation, record review, resident and staff interview, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop recurrent Stage II pressure ulcers. The facility failed to revise or implement care plans and/or respond timely with changes in treatment for [REDACTED].#14). Resident #14 was admitted with a Stage I pressure ulcer on her coccyx that healed but continued to reoccur, developing into a Stage II. Findings include: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14's most recent quarterly MDS assessment, dated 12/2/10, documented the following: * Short and long term memory problem * Extensive assistance requiring one person physical assist for bed mobility, transfer, locomotion on and off the unit, dressing, personal hygiene, and bathing * Total dependence requiring one person physical assist for toilet use and eating * Wheelchair for mobility * Frequently incontinent of urine * Always continent of bowel * At risk for developing pressure ulcers * No unhealed pressure ulcers at Stage 1 or higher (NOTE: This appears to be in error and contradicts the medical record) * Pressure reducing device for chair and bed * Turning/repositioning program The resident's MDS assessments for the past year documented the following: * Quarterly assessment, dated 12/13/09 - no pressure ulcers * Quarterly assessment, dated 3/15/10 - two Stage 2 pressure ulcers * Quarterly assessment, dated 5/31/10 - two Stage 2 pressure ulcers * Annual assessment, dated 8/31/10 - one Stage 2 pressure ulcer Resident #14's admission assessment, dated 9/9/09, documented multiple wounds, including: * Right Stage 1 coccyx pressure ulcer, measuring 0.9 cm (centimeters) by 0.8 cm * Resolving right heel blister (scabbed over) * Left buttock rash with raised, blistered area * Callouses on the right second toe, left second and third toes and right foot callous pads. Skin assessments documented the coccyx pressure ulcer was resolved on 9/28/09. It was later documented to reoccur on 3/20/10. After the pressure ulcer reoccurred, the following was documented on the facility's Weekly Pressure Ulcer BWAT Reports: * 3/29/10-0.7 x 1.0 size in cm, with full thickness skin loss, progress noted as deteriorated, treatment changed * 4/5/10 - 0.7 x 0.9 size in cm, with partial thickness skin loss, progress noted as improved, continue treatment * 4/16/10 - 1.0 x 0.9 size in cm, with partial thickness skin loss, progress noted as deteriorated, continue treatment * 4/23/10 - no measurement noted, with partial thickness skin loss, progress noted as no change, treatment changed, with a handwritten note to see the back page for the note. It read, "DC (discontinue) previous tx (treatment) to coccyx and then change to clean coccyx stg (stage) II p/u (pressure ulcer) w/NS (with normal saline) and apply [MEDICATION NAME] and cover with foam, secure QD and prn (daily and as needed). Pressure documentation sheet started." * 4/30/10 - 0.6 x 0.3 x 0.1 size in cm, Stage 2, less than 25% of wound covered * 5/7/10 - 0.7 x 0.5 x 0.1 size in cm, Stage 2, less than 25% of wound covered * 5/14/10 - 0.8 x 0.5 x <0.1 size in cm, Stage 2, 75%-less than 100% wound covered * 5/20/10 - intact with no size measurement, Stage 2, 100% wound covered, surface intact * 5/27/10 - 0.2 x 0.4 x <0.1 size in cm, Stage 2, 50%-less than 75% wound covered, discontinued current treatment, "area is reoccurring," noted to have applied [MEDICATION NAME] and covered with foam * 6/2/10 - 0.2 x 0.4 x <0.1 size in cm, Stage 2, 75-100% of wound filled and/or tissue overgrowth * 6/9-6/23/10 - intact, no size measurement, Stage 2, 100% of wound covered * 6/30/10 - 0.5 x 0.3 size in cm, Stage 2, less than 25% of wound covered, no change in treatment * 7/7 & 14/10 - scab 0.2 x 0.2 size in cm, Stage 2, 25-less than 50% of wound covered * 7/21-7/28/10 - intact, no size measurement, Stage 2, 100% of wound covered * 8/4/10 - 0.2 x 0.1 x <0.1 size in cm, Stage 2, 50-less than 75% of wound covered, noted that dressing came off at night and was the probable cause of wound deterioration * 8/11/10 - 1.2 x 0.9 x <0.1 size in cm, Stage 2, 50-less than 75% of wound covered * 8/18/10 - 1.1 x 0.9 x <0.1 size in cm, Stage 2, 75-less than 100% of wound covered * 8/25/10 - 0.3 x 0.3 x <0.1 size in cm, Stage 2, 75-less than 100% of wound covered * No discernible change in size or condition through 10/20/10 * 10/27/10 - intact with no size measurement, Stage 2,100% of wound covered * 11/3/10 - [MEDICATION NAME] with no size measurement, Stage 2, 100% of wound covered * 11/10-11/24/10 - intact with no size measurement, Stage 2, 100% of wound covered * 12/1/10 - 0.4 x 0.2 size in cm, Stage 2, 75-less than 100% of wound covered * 12/8/10 - 0.7 x 0.5 size in cm, Stage 2, 100% of wound covered * 12/15/10 - 0.6 x 0.3 x 0.1 size in cm, Stage 2, less than 25% of wound covered * 12/22/10 - 0.5 x 0.9 x 0.1 size in cm, Stage 2, 25-less than 50% of wound covered * 12/29/10 - 1.0 x 0.8 x 0.1 size in cm, Stage 2, 25-less than 50% of wound covered * 1/5/10 - 0.6 x 0.8 x 0.1 size in cm, Stage 2, 50-less than 75% of wound covered * 1/12/11 - intact with no size measurement, Stage 2, 100% of wound covered * 1/19/11 - intact with no size measurement, Stage 2, 100% of wound covered The initial Care Plan for Resident #14, dated 9/9/09, with a goal date of 10/9/09, documented the problem of impaired skin integrity, related to a stage 1 pressure ulcer to the right coccyx. The latter note for the stage 1 pressure ulcer was a handwritten note. It had a line drawn through it with no initials or date. Approaches included: * Turn and reposition Q2hrs (every 2 hours) when in bed. Avoid skin on skin contact. Use pillows as needed. * When resident is out of bed, change position q 2 hrs by toileting, boosting, shifting of weight, ambulating, or return to bed for rest. * Treatment as per MD (physician) Order. Notify MD of adverse changes in healing process. * Float heels on pillows/feet when in bed (sic) * Pressure reduction cushion to bedside chair and/or wheelchair. * Specialized Mattress: Stat IV airbed * Daily pressure ulcer monitoring by LN to include dressing status, skin surrounding ulcer, peripheral tissue [MEDICAL CONDITION] and pain associated with pressure ulcer. The next updated Care Plan for potential skin integrity impairment, dated 9/9/09, the same date as earlier but with a goal date of 12/9/09, and documented the following changes in approaches: * Turn and reposition when in bed. Avoid skin on skin contact. Use pillows as needed. * Apply protective barrier cream with [MEDICATION NAME] 24 to (blank) after each incontinence and/or with AM & PM (morning and evening) cares. * Daily skin inspection during cares. Notify LN of skin integrity impairments. * Weekly check for "bottoming out" in w/c (wheelchair) and/or bed. NOTE: The directive to reposition every 2 hours had been deleted, as well as the need to notify the physician of any adverse changes in the healing process. The next updated Care Plan for impaired skin integrity, dated 10/8/09, had a line drawn through it, with a handwritten note that stated "d/c (discontinue) all per (staff name) 1/28/10." In the same Care Plan was the problem of potential of skin/tissue integrity impairment, related to a history of pressure ulcers. Again, the approach of turning and repositioning when in bed was included, but not every 2 hours. A Care Plan update, dated 5/23/10, for the problem of impaired skin integrity, reoccurring Stage 2 pressure ulcer to the coccyx, included the following updated approaches: * Change w/c cushion to ROHO * Repositioning Q 2 hours The next Care Plan in the medical record for the resident, dated 9/15/10, documented the problem of skin/tissue integrity impairment, related to a Stage 2 coccyx pressure ulcer, with the following changes in approaches: * Low airloss airbed placed, dated 12/9/10 (handwritten note) The next Care Plan in the medical record for the resident, dated 12/21/10, documented the problem of skin/tissue integrity impairment, related to Stage 2 pressure ulcer to the coccyx. Changed approaches included: * Use turn sheet for repositioning in bed. Do not grab skin. The resident's Care Plan, dated 9/9/09, called for boosting and shifting of weight when up in her wheelchair or bedside chair. NOTE: Federal guidance for F314 states there is not sufficient evidence that momentary pressure relief, sometimes referred to as boosting, followed by return to the same position (that is a "microshift" of five or 10 degrees or a 10-15 second lift from a seated position) is beneficial. This approach does not allow for sufficient capillary refill and tissue perfusion for the resident at risk of developing pressure ulcers. It further states that if a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. The treatment plan should be re-evaluated, including determining whether to continue or modify the current interventions. This pressure ulcer had been present since 3/20/10 and was not documented as healed until 1/12/11. The ROHO cushion for the wheelchair and repositioning every two hours were not ordered until two months after the pressure ulcer reoccurred and the low airloss airbed mattress was not ordered until nine months after the wound reoccurred. The facility failed to evaluate the care plan approaches for effectiveness in a timely manner, or implement changes to expedite healing of the pressure ulcer for Resident #14. Since the resident was admitted with the pressure ulcer, the facility was aware of the risk for impairment and failed to take the necessary actions to prevent its reoccurrence. It is unclear, whether the wound's progression and deterioration over the ten month period was due to the care-planned interventions not being performed by staff, or to a lack of new interventions to promote healing. The RN Consultant, Administrator, and LN #10 were interviewed regarding the resident's recurrent pressure ulcer on 1/24/10 at 11:25 am. It was noted the resident was admitted with a Stage 1 pressure ulcer to her coccyx, which developed into a Stage 2 pressure ulcer. No further information was received.

Based on observation, record review and staff interview, it was determined that the facility failed to put effective interventions in place and/or revise care plans to prevent falls. This was true for 4 of 15 (#s 7, 9, 11, and 12 )sampled residents and one random resident (#17) and resulted in harm to Resident #9. *Resident #9 was harmed when he fell and sustained a nondisplaced fracture of his pelvis bone. He suffered severe pain and loss of functioning related to the fracture. *Resident #7 fell out of bed when his care-planned body pillow was not in place. *Although care planned otherwise, Resident #12 fell when she was left unattended in the bathroom. *Resident #11 fell 7 times between [DATE] and [DATE] and sustained nondisplaced fractures of the toes on two occasions. *Resident #17 had an unsecured, small, green oxygen tank left by his bedside. Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with the [DIAGNOSES REDACTED]. The resident's [DATE] admission Nursing Assessment/Full in the "Risk - Falls - Range" section, documented decreased sensory or coordination in extremities and visual sensory deficit. The resident was considered to be a high risk for falls. Resident #9's Physical Therapy Evaluation, dated [DATE], documented, "Skilled PT (physical therapy) req'd (required) to focus on BLE (bilateral lower extremity) strength/endurance." The evaluation staed he was alert and oriented X4 with occasional memory problems and indicated he required stand by assistance for transfers. Resident #9's record documented he fell 4 times between [DATE] and [DATE]. a. A Resident Event Report Worksheet (RERW) documented a witnessed fall dated [DATE], the day after his first admission. The Report section stated that Resident #9 heard his roommate fall and went to the hall to get help. A Condition Change Form documented the Interdisciplinary Team (IDT) reviewed the information and determined the resident was weak and he had removed his oxygen. The IDT documented the resident was educated to use his call light and to leave his oxygen on. The resident's Comprehensive Care Plan Report (care plan) identified a [DATE] goal area of "Will be free from falls with injury." "Approaches" were: respond to call light promptly, keep call light within reach, needs are to be anticipated by staff, environment assessed for clutter, observe for signs of agitation, and assess pain management. A "Care Plan Update" dated [DATE] repeated to have the call button within reach, a low bed, encourage to call for help, offer food and fluids, to monitor oxygen saturation levels and the results of any laboratory tests. An "Approach" to "Lock Bed Brakes" was dated [DATE]. The care plan interventions did not include ensuring Resident #9 was wearing his oxygen nor did it address increased supervision for transfers or ambulation to address the bilateral lower extremity weakness identified on the [DATE] PT evaluation. b. A RERW, dated [DATE], documented that the resident was "walking behind w/c (wheelchair)-holding w/c handles and pushing w/c when this LN approached pt (patient) to sit in w/c. Pt stated he was ok and then knees gave way and pt fell ..." Vital signs were documented as: blood glucose 161, blood pressure ,[DATE] and oxygen saturation level 93%. The report further stated, "PT (patient) with poor safety awareness, no call for assistance with transfers and mobility....Pt got weak and fell to floor" and "no c/o (complaint) of pain." Resident #9's Physical Therapy Evaluation, dated [DATE], documented that the resident had been in the hospital ,[DATE]-,[DATE] and according to the resident, he fell while at the hospital and presented with a contusion on the right eye. The evaluation stated the resident required "CGA (care giver assist) with sit to stand and pivot transfers...." and had "poor strength, endurance and balance." Resident #9's Progress Notes documented on [DATE] he was "independent with ADL's (activities of daily living) and transfers." However, a [DATE] Condition Change form from the IDT documented "Pt is 1 pers (person) assist for ambulation and transfers." Resident #9's care plan documented interventions on [DATE] as: reposition the resident while in bed, PT evaluation, ambulate to the bathroom and transfer with limited assistance using a front wheel walker (fww). A Physical Therapy Discharge Summary, dated [DATE], documented, the resident had met his highest level of functioning within room and facility. It stated he was moderately independent with a wheelchair but needed cues to lock the wheelchar brakes and "....cognitive impairments from anoxic episode during MI (myocardial infarction) greatly impact pt's decision making skills and safety awareness." c. A RERW, dated [DATE] at 5:40 a.m., documented "Heard resident's roommate call for help. Found resident sitting up on floor on right side of bed with back to bed, stated he was reaching for a board that was floating by. Denies any injury or pain, some soreness to bottom." Vital signs were documented as: blood pressure 120/ 60 and the oxygen saturation level 96%. The report stated, stated "Resident becoming confused @ noc ((night shift) after starting Ativan for tremors, also taking PRN pain med(ication)." A Condition Change form, dated [DATE], documented ".... Resident attempting to quit smoking, having sig (significant) difficult time with noted increased anxiety, tremors and tearfulness. Has prn nicotine patch, Wellbutrin ordered [DATE]. PRN Ativan dose increased [DATE] x 7 days. Receives prn pain mgmt (management) for chronic pain prn. Ativan reduced back to 0.5 mg higher dosing causing increased confusion. Pt wearing socks when fell - educated staff to use non skid socks." Resident #9's care plan was revised on [DATE] to include non-skid socks while in bed, however it did not include any revisions for increased supervision or other assistive devices despite documentation of increased confusion, anxiety, tremors and tearfulness. His medication record documented the Ativan was reduced from 1 mg to .5 mg on [DATE]. d. A RERW, dated [DATE] at 4:50 p.m., documented, "Thump heard went into room - Resident was on the floor between his bed and his room mates - on his back holding his left shoulder with his right hand. C/o shoulder ("Hit the other bed") pain and hip pain." The Condition Change Form documented "... States he was transferring self into bed lost balance, got dizzy and fell . C/o hip tender with movement....call to (physician name) and order for x-ray hip." Resident #9's hospital report, dated [DATE], documented the history of present illness as "....male who just recently suffered an MI. He has been at a skilled nursing facility and he stood up suddenly, he stumbled and fell on to his left side.....Since that time he has not been able to ambulate. He complains of moderate to severe pain to his left pelvic area. It is worse with weightbearing or movement. He denies injury to head, neck or back. He comes to ER (emergency room ) for evaluation, as the pain is severe." The ER report documented it offered hospital admission for pain control but the resident preferred not to be admitted to the hospital. The Diagnostic Impression documented "Nondisplaced superior and inferior left-sided pubic rami fractures, nonoperative management..." Interventions on Resident #9's Care Plan, dated [DATE], were to have nonskid socks or shoes on at all times, daily blood pressure checks, assistance of 1 to transfer, remind to ask for assistance, discontinue Hydralazine (side effect of dizziness), Physical therapy evaluation and position the bed against the wall. A Condition Change Form for Resident #9 documented, on [DATE], "Received wet read x ray- nondisplaced fracture of inferior and superior L (left) Pubic Rami - call placed to MD. Resident refusing to go back to the hospital x 3 - new order received for Norco ,[DATE] Q (every) 4 hours PRN Pain - Monitor closely and if Res (resident) agreeable send to hospital." Resident #9's [DATE] hospital ER report documented he suffered with severe pain. Physcian telephone orders, dated [DATE], documented his order for PRN pain medication was increased from Norco ,[DATE] (5 mg hydrocodone with 325 mg acetaminophen) to Norco ,[DATE] (the narcotic pain medication was doubled) for "tx (treatment) pubic fx (fracture)." Resident #9 received pain medication 33 times in January, 23 were documented for hip/back pain and 10 times the pain medication was documented as general, severe or the documentation of pain type was illegible. Daily blood pressure checks were added to the interventions, however, the care plan for falls did not include what to do if the blood pressure was not within normal range. Resident #9's Physical Therapy Evaluation, dated [DATE], documented, "Bed mobility - maximum (assistance) x2 -very painful."and "L (left) hip range of motion very painful." The Clinical Summary and Reason for Referral section stated, "Pt. with significant pain and decline of LOF (level of functioning). Would benefit from PT to restore function." A Physical Therapy Progress note dated [DATE] documented "Pt continues to complain of severe pain in L hip/groin (with) any mvmnt (movement) or WB-ing (weight bearing). The clinical RN consultant was asked if alarms or a mat by the bed had been considered for Resident #9. The consultant stated the MDS assessments indicated Resident #9 was "cognitively with it" and they did not think it would be the solution. The consultant stated they had reviewed Resident #9's medications (Ativan and hydralazine) and discontinued them. Resident #9 had 4 falls between ,[DATE] and [DATE]. The fall on ,[DATE] resulted in a nondisplaced fracture of his pelvis bone. He suffered severe pain and loss of functioning related to the fracture. Although he was noted to have increased anxiety, tremors and tearfulness as well as decreased decision making and safety awareness, the facility failed to increase supervision or implement other interventions to address increased fall risks. 2. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12's Comprehensive Care Plan Report (CCPR) included in the Problem section, "Resident is at risk for falls." Included in the "Approach" section, dated [DATE], was "Do not leave alone in bathroom." A RERW, dated [DATE] at 11:45 a.m., was included in his record. It documented "Pt attempted to self transfer from toilet to w/c. Call light was on - Pt did not wait for assist (assistance). Small scratch....top back L (left) side of head." The Condition Change Form, dated [DATE], documented (reviewed by the IDT), "Pt had fall [DATE] at 11:45. Resident with dx (diagnosis) dementia with poor judgment and safety awareness. Pt attempted self transfer off toilet and fell . At time of fall staff had been summoned for an emergent medication. Staff reports pt having variable transfer ability since teeth have been pulled." The acting DON stated on [DATE] at 12:00 p.m. the incident happened during lunch and there was a licensed nurse and a CNA on the floor. Another resident was having a seizure and both the LN and the CNA were required to assist the other resident. The facility failed to ensure Resident #12 was not left alone while in the bathroom. 3. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's [DATE] significant change MDS assessment coded: short term memory impairment with modified independence for cognitive skills, independent bed mobility, supervision required for walking in room and corridor, independent with set up assistance required for transfers, unsteady but able to rebalance self without physical support while standing, independent balance while sitting, limited range of motion in one foot, and fell in prior ,[DATE] days. The resident's [DATE] quarterly MDS assessment coded: cognitively intact; independent with bed mobility, transfers, and walking in room; not steady but able to stabilize without human assistance for moving from seating to standing position, walking, turning around, and surface-to-surface transfer; impaired range of motion on one lower extremity; walker and wheelchair used for mobility; no fall history prior to admission; and falls since admission to the facility. Resident #11 fell 7 times between [DATE] and [DATE]. The facility's Resident Event Report Worksheets documented: * [DATE] - Self-transferred from wheelchair while brakes were not locked; No significant injury. * [DATE] - fell over while petting a dog, due to not wearing orthotic device. The Event Adverse Effect section documented that the resident sustained [REDACTED]. PI (Performance Improvement) Recommendations: monitor. IDT (Interdisciplinary Team) Event Review: Will monitor. NOTE: Neither the PI Committee nor the IDT addressed the fact that the resident was not wearing her orthotic device. The care plan was not updated. * [DATE] - fell off edge of bed after falling asleep while sitting on edge of bed. The resident sustained [REDACTED]. IDT Event Review: Physician ordered soft shoe. Resident frequently walks in stocking feet; provided multiple pairs non-skid socks and boot. Educated resident, who verbalized understanding. Urinalysis done. Care plan updated. * [DATE] - fell off edge of bed after falling asleep while sitting on edge of bed. Resident complained of back pain. No significant injury. PI Recommendations: Clip call light to left side of bed. OT (occupational therapy) evaluation and treatment for [REDACTED]. Call light to be placed on left side of bed. (Question mark) for OT to evaluate and treat for bed mobility. Xray done. The box to indicate "Care plan updated" was checked. NOTE: Although the resident had previously fallen and sustained a fracture in a virtually identical fall, there was no evidence that the care plan was updated with any changes until after the [DATE] fall. * [DATE] - fell in bathroom, due to not wearing orthotic device. No significant injury. PI Recommendations: 1 person assist with transfers until approved by therapy for independence. Nonskid socks. Orthostatic blood pressure checks each shift for 3 days. Sign on walls to remind resident to ask for help. IDT Event Review: OT evaluation done ,[DATE], therapy to begin ,[DATE]. Requested resident call for help with transfers until further therapy can be initiated. Reminded to wear non-skid socks. Sign on wall to remind resident to ask for help. NOTE: Neither the PI Committee nor the IDT addressed the fact that the resident was not wearing her orthotic device. The box to indicate "care plan updated" was not marked, and there were no written statements to indicate that the care plan had been updated after this fall. There were no changes to the care plan until after the [DATE] fall. * [DATE] - fell off edge of bed after falling asleep while sitting on edge of bed. No significant injury. PI Recommendations: Ensure non-skid socks in good condition. Bedside commode. Check hourly after resident goes to bed. IDT Event Review: Currently working with OT for bed mobility. Non-skid socks were on but worn. Reviewed all socks in drawers and replaced as needed. Resident stated she can't wait when she needs to use restroom. Will add bedside commode, and add hourly checks at night. Care plan updated. * [DATE] - fell off edge of bed after falling asleep while sitting on edge of bed. The resident sustained [REDACTED]. IDT Event Review: Resident had been on 30 minute checks, and was known to sit at bedside and fall asleep. Continue current plan and add bed alarm, PT. Resident already on OT case load. Body pillow added while resident in bed. Care plan updated. The resident's [DATE] Comprehensive Care Plan Report documented the [DATE] problem, "At risk for falls related to history of falls," with "related to falls asleep sitting at edge of bed, and lower extremity instability" added on [DATE]. Approaches (interventions) for this problem were: * Implemented [DATE]: Lock bed brakes; administer and monitor effectiveness of antidepressant; monitor for side effects. * Implemented [DATE]: Ensure nonskid socks are in good condition; monitor traction pattern; replace as needed. * Implemented [DATE]: Falling Star Program; if sitting on edge of bed, encourage to lay down or sit in chair; monitor and assist to eliminate room clutter; and no furniture with sharp edges placed next to bed. * Implemented [DATE]: Pressure pad alarm to bed; body pillow on left side when in bed; toilet at midnight and 3 AM during the night; ensure patient toilets before going to bed. NOTE: At the beginning of the survey, the resident's medical record contained an 18 page Comprehensive Care Plan effective [DATE], on which multiple items had been discontinued or changed. There were also hand written entries scattered throughout the care plan. 7 Care Plan Update slips layered on one separate sheet of paper, and a Care Plan Circle Sheet - Physical Therapy were also attached. It was extremely difficult to determine what the current care plan was or was not supposed to include, and the Regional Consultant was asked to update and reprint the care plan to include all the changes made since [DATE]. This was provided on [DATE], and is referenced above. The resident's [DATE] Comprehensive Care Plan and Care Plan Update slips included the following entries which had been changed or discontinued, related to the resident's risk for falls. NOTE: No rationale was provided as to why these interventions were discontinued, when the resident was documented to be a high fall risk with multiple falls including 2 fractures. * In effect [DATE]-[DATE]: Needs verbal cues to use FWW (front wheeled walker) at all times; keep adjustable bed in low position for safe transfers. * In effect [DATE]-[DATE]: Evaluate for appropriate seating and/or devices; assess cause and pattern of previous falls and act upon resolvable factors. * In effect [DATE]-[DATE]: Educate resident to ask for help prior to ambulating and transferring. * In effect [DATE]-[DATE]: (Orthotic device) to right ankle when out of bed. NOTE: The resident had a history of [REDACTED]. * In effect [DATE]-[DATE]: Wear non-skid socks. On [DATE], the following was added: monitor for traction wear patterns; replace as needed." * In effect [DATE]-[DATE]: Remember (sic) resident to lock brakes on wheelchair. * In effect [DATE]-[DATE]: Resident instructed not to sit on side of bed during the night for very long. * In effect [DATE]-[DATE]: Start (neurological checks) and alert charting, and monitor for 7 days; continue to educate on dangers about sleeping on side of bed. * In effect [DATE]-[DATE]: Bedside commode; hourly checks at night. * In effect [DATE]-?: Change to 30 minute checks at night. NOTE: This update was not carried over to the [DATE] updated care plan. No explanation was provided. * In effect [DATE]-[DATE] - Neurological checks for 72 hours. Alert charting and monitor for 7 days. 30 minute checks at night. Non-skid socks. "Bedside commode might help." NOTE: Non-skid socks were added to the care plan on [DATE], and updated to include replacement when worn, on [DATE]. Thirty minute checks at night were added to the care plan on [DATE], but were not carried over to the [DATE] updated care plan. The bedside commode was added to the care plan on [DATE] and discontinued on [DATE]. The resident's Care Plan Circle Sheet - Physical Therapy, dated [DATE], documented the following circled items. Problems: falls, weakness, unsteady gait, fatigue, fracture of (right) 4th metatarsal. Approaches: assess and begin program for therapeutic exercise, bed mobility and transfer training, sitting/standing balance, progressive gait training, and wheelchair mobility; transfer with 1 (contact guard assist); use appropriate seating and/or devices when (out of bed), specifically (right orthotic device); and refer to Restorative Program as needed. A Nursing Assessment - Partial, dated [DATE], documented a Risk Assessment - Falls score of 23, where a score of 14 or higher indicated "High Risk." NOTE: The facility's Falling Star Program documented: "Update and/or implement Falling Stars interventions if the resident is identified at high risk or has a history of falls (past or current). Primary nursing assistant is responsible to check alarms, fall mats, and safety devices (every 2 hours) during each care contact. Licensed nurses are to be aware of all residents on Falling Star status and monitor for safety intervention implementation." The program did not specify which interventions should be utilized for individual residents. Radiology reports documented: * [DATE] - "Evidence of an avulsion fracture involving the proximal medial aspect of the proximal phalanx of the great toe." * [DATE] - "Soft tissue swelling and a nondisplaced fracture involving the distal fourth metatarsal." Resident Progress Notes documented: * [DATE] - "Cont(inue) to remind res(ident) about sleeping on bedside, res(ident) denies doing it." * [DATE] - "Furniture was moved (and) room re-organized giving (resident) a recliner where she could rest instead of sitting on the edge of bed, (decreasing) the likelihood of slips (and) falls. Continue to monitor." * [DATE] - "IDT review and analysis of 6 month fall trends.... Fall trends appear related to weakness and lower extremities 'giving out' and/or resident falling asleep while sitting on the edge of her bed and sliding to the floor.... Encourage resident to sit in recliner instead of edge of bed for more stability and safety if falls asleep while sitting up...." * [DATE] - (Resident) given body pillow to lay with to help remind her not to get up on her own." The acting DON and Regional Consultant were interviewed about Resident #11's fall history and care plan updates on [DATE] at 3:30 PM. The updated care plan was provided on [DATE], but no further information was provided. While the IDT reviewed each of the resident's falls as they happened, they did not meet to specifically review the fall trends as the care plan required, until the resident had fallen 6 times and sustained a fracture. The resident was known to have a habit of falling asleep while sitting at the side of the bed, but interventions to reduce the resident's fall risk were insufficient and many were removed from the care plan without documented rationale. The resident fell again and sustained a second fracture. 4. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], and again on [DATE], with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated [DATE], documented the following: * Bowel sounds present, abdomen distended * Experiencing pain, pain management prescriptions * Extensive assist requiring one person for assistance for toilet use * Supervision for eating * Disoriented occasionally * Falls Risk Assessment score of 21, 14 and higher equals high risk The resident's admission MDS assessment, dated [DATE], documented the following: * Moderate difficulty with hearing * Moderately impaired vision * Severe cognitive impairment * Limited assistance requiring one person for physical assistance for bed mobility * Extensive assistance requiring one person for physical assistance for transfer, locomotion on and off the unit, dressing, bathing, and toilet use * History of falls in the last month to six months prior to admission, with no fractures * Occasionally incontinent of bladder and bowel The resident's Triggered CAAs, dated [DATE], documented the following: * Falls -History of falling: "Res. (resident) had multiple falls at other care facility prior to hospital stay." (handwritten note) -Physical performance limitations: balance, gait, strength, muscle endurance: "Impaired Balance d/t (due to) wounds on LLE (left lower extremity)" (handwritten note) -Analysis of Findings: "Dx (diagnosis): Atherosclerosis to LLE, multiple ulcers to L (left) foot, HTN (hypertension), HOH (hard of hearing), leg. (legally) blind, COPD (chronic obstructive pulmonary disease). Hx (history) of multiple falls prior to admit. At times confused cont (continue) to care plan d/t (due to) (increased) fall risk. To prevent fall current (sic) working with PT (physical therapy) and OT (occupational therapy) to (increase) strength and (increase) ADL function." (handwritten note) The resident's Care Plan, dated [DATE], documented the problem, "Resident is at risk for falls r/t gangrene to left LE, r/t WBAT (weight bearing as tolerated) for transfers only, r/t weakness, r/t poor balance," with a problem date of [DATE]. One goal listed for these problems included, "Body pillow in bed to assist resident with positioning self in bed." Resident #7 sustained an unwitnessed fall on [DATE]. Documented in a Resident Event Report Worksheet, dated [DATE], were as follows: Condition Change Form, dated [DATE], IDT (Interdisciplinary Team) review of fall from bed to (illegible), Status Change - "...Cont (continues) to state he wasn't trying to get up but just slid OOB (out of bed). Uses low bed for safety. Body pillow not in room? in laundry for cleaning?..." The resident further reported the same, that he slid out of bed. There were no injuries. The Acting DON and Administrator were informed of this issue on [DATE] at 2:00 pm. No further information was received. 5. Resident #17 was observed on [DATE] at 7:45 am, during the surveyor's initial tour of the facility. Observed next to his bed was a small, green oxygen tank, sitting unsecured on the floor. The gauge read empty and no tubing was attached to the tank. It was observed again, in the same location, at 2:50 pm that same day. The surveyor observed the tank had been removed from the resident's room by the next day, at 7:15 am. The Acting DON and the Administrator were informed of this issue on [DATE] at 2:00 pm. No further information was received.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure acceptable parameters of nutritional status for 2 of 15 (#7 and #13) sampled residents. Residents #7 and #13 both sustained severe weight loss, Resident #7 in a one month period, and Resident #13, in a three month period, resulting in harm to the residents. The facility documented the residents had histories of nutritional deficiency but failed to monitor and evaluate the residents' responses to the care-planned nutrition interventions. Findings included: 1. Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE] and again on 1/17/11, with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 12/6/10, documented the following: * Bowel sounds present, abdomen distended * Experiencing pain, pain management prescriptions * Extensive assist requiring one person for assistance for toilet use * Supervision for eating * Disoriented occasionally * Regular diet type with regular consistency * Independent fluid and eating intake * No weight loss * No risk factors for dehydration, refusing fluids * Dehydration Risk Assessment Score of 3 -10 indicates high risk potential for dehydration On readmission after hospitalization , on 1/8/11, the resident was assessed as having a history of dehydration, with a Dehydration Risk Assessment Score of 10, which represented the resident was assessed as a high risk potential for dehydration. This was after the resident had been diagnosed with [REDACTED]. In addition, it documented three pounds weight loss in one month and limited physical assistance required for eating. NOTE: The resident had already sustained a greater than three pound weight loss and should have been scored higher due to this fact. On 1/17/11, after his second readmission following a hospitalization for amputation of his left lower leg, the resident was assessed with [REDACTED]. The resident's admission MDS assessment, dated 12/13/10, documented the following: * Moderate difficulty with hearing * Moderately impaired vision * Severe cognitive impairment * Independent requiring set up help only for eating * Extensive assistance requiring one person for physical assistance for toilet use * Occasionally incontinent of bladder and bowel The resident's Triggered CAAs, dated 12/15/10, documented the following: * Behavioral Symptoms - "Resident had hx (history) of dehydration" (handwritten note) * Dehydration/Fluid Maintenance - Behavioral disturbance that interferes with intake * Dehydration/Fluid Maintenance - "Res is an (sic) 94 y old (year old) male, HOH (hard of hearing), legally blind, [MEDICAL CONDITIONS],[MEDICAL CONDITION](hypertension), atherosclorosis (sic) to LLE (left lower extremity), multiple ulcer, confused at times. Need to cont (continue) care plan to encourage and offer fluid to maintain good skin turgor and moist mucosa." (handwritten note) The resident's Care Plan, dated 1/3/11, documented the problem, "Nutrition, r/t leaves 25% or more uneaten, r/t weight loss/gain, r/t pressure wound, r/t refusal to eat at times, r/t at nutritional risk d/t hx prostate (cancer),[MEDICAL CONDITION](hypertension)", with a problem date of 12/14/10. Goals listed for these problems included: *"Resident will have not significant weight change-gradual repletion desired," * "Resident will consume >50-75% of meals," * "Labs will be within acceptable range," * "Resident will maintain nutrition/hydration on reg/thin with set up only." Approaches included: * "Monitor weight weekly x 4 (for four weeks), then monthly if stable." * "Monitor lab values as ordered" * "Review at IDT Nutrition at Risk Meeting" * "Encourage PO intake and fluids-ongoing" Resident Progress Notes for Nutrition as Risk documented the following: * 12/9/10 "Referred to mtg (meeting) d/t decrease wts (weights) and skin issues...Will start enhanced meals, consider assisted dining. Will monitor." * 12/16/10 "...Regular calorie enhanced. PO intakes 57 (percent eaten of breakfast)/62 (percent eaten of lunch)/65 (percent eaten of dinner) with 280 cc/meal. Show improvement...Wt with decline. Will start H shakes (health shakes) bid (twice daily) between meals and monitor." * 12/23/10 "...PO intakes 37/65/(illegible) with 240 cc/meal. H shakes started. Bowels working better. Will continue to monitor." * 1/6/11 "...PO intakes 12/25/29 (illegible)...Wt showing a decline. (illegible) Regular calorie enhanced H shakes BID between meals. Intakes remain poor and show a decline. Resident with hemoccult (positive). Pt to ER at this time for evaluation. Will await results and monitor." The Medical Nutrition Therapy Review form for Resident #7 documented the following: * 14 day 12/21/10 Average Food and Beverage Intake: Meals 60/50/50 Beverage 240/300/240 "F/U (follow up) on overall status, resident wts cont to remain poor with loss noted from admit. Intakes fair at this time, started on hs (12/17/10) - monitor for tolerance/acceptance. Cont to be followed (illegible) skin issues. No new labs..." * 30 day 1/4/11 Average Food and Beverage Intake: Meals 20/30/50 Beverage 200/120/120 Accepts HS "F/U on overall status -slight increase in wt presently. Overall remains poor per IBW (ideal body weight) and decrease from admit but gradual repletion desirable. Intakes remain poor to fair - Resident will accept HS...No new labs..." NOTE: IBW is listed as 166 to 176 pounds per this form. The Medical Nutrition Therapy Assessment for Resident #7, dated 12/14/10, documented estimated fluid needs of 1800 cc (cubic centimeters) and nutrition of 1800-2200 calories intake daily. Meal monitors and MARs (health shakes ordered twice daily on 12/17/10) for Resident #7 documented the following fluid intake and meal refusals: 12/7/10 900 cc and 0 = 900 cc Lunch documented as refused 12/8/10 750 cc and 0 = 750 cc 12/9/10 240 cc and 0 = 240 cc Breakfast and Dinner documented as refused 12/10/10 660 cc and 0 = 660 cc 12/11/10 880 cc and 0 = 880 cc Lunch documented as refused 12/12/10 540 cc and 0 = 540 cc 12/13/10 960 cc and 0 = 960 cc 12/14/10 840 cc and 0 = 840 cc 12/15/10 700 cc and 0 = 700 cc 12/16/10 480 cc and 0 = 480 cc 12/17/10 600 cc and 240 cc = 840 cc 12/18/10 960 cc and 240 cc = 1200 cc 12/19/10 720 cc and 240 cc = 960 cc Lunch documented as refused 12/20/10 600 cc and 240 cc = 840 cc 12/21/10 680 cc and 240 cc = 920 cc 12/22/10 720 cc and 240 cc = 960 cc 12/23/10 740 cc and 240 cc = 980 cc 12/24/10 720 cc and 240 cc = 960 cc 12/25/10 600 cc and 240 cc = 840 cc 12/26/10 600 cc and 240 cc = 840 cc Lunch documented as refused 12/27/10 480 cc and 240 cc = 720 cc Dinner documented as refused 12/28/10 480 cc and 240 cc = 720 cc 12/29/10 640 cc and 240 cc = 880 cc 12/30/10 360 cc and 240 cc = 600 cc Breakfast documented as refused 12/31/10 360 cc and 240 cc = 600 cc 1/1/11 unknown cc and 180 cc = 180 cc Documentation requested, not received 1/2/11 unknown cc and 60 cc = 60 cc Documentation requested, not received 1/3/11 unknown cc and 90 cc = 90 cc Documentation requested, not received 1/4/11 unknown cc and 60 cc = 60 cc Documentation requested, not received 1/5/11 unknown cc and 0 cc = 0 cc Documentation requested, not received 1/6/11 Transferred to hospital 1/7/11 In hospital 1/8/11 readmitted at 2:30 pm NOTE: Could not find documentation of health shakes on MAR given as ordered after readmission 1/8/11 unknown cc and 0 cc = 0 cc 1/9/11 unknown cc and 0 cc = 0 cc NOTE: The meal monitor information for 1/1/11-1/6/11 and 1/8/11-1/9/11 was requested three times from the facility and was not received. 1/10/11 Transferred to hospital at 11:30 am, (amputation of LLE occurred during this hospitalization ) 1/10-1/17/11 readmitted to facility from hospital at 11:50 am 1/17/11 Documented refusals 1/18/11 360 cc and 0 cc = 360 cc Lunch documented as refused 1/19/11 240 cc and 0 cc = 240 cc 1/20/11 600 cc and 0 cc = 600 cc 1/21/11 240 cc and 0 cc = 240 cc Lunch documented as refused 1/22/11 480 cc and 0 cc = 480 cc 1/23/11 190 cc and 0 cc = 190 cc Dinner documented as refused Meal monitors and MARs documented the following fluid/meal intake and meal and bedtime snack refusals: December 6-31: Breakfast - 25% or less eaten 10 times; Lunch - 25% or less eaten 8 times; Dinner - 25% or less eaten 12 times; Bedtime snack - refused 19 times January 1-6, 8-10, 17-23 Breakfast/Lunch/Dinner - Complete documentation not received; Bedtime snack - Refused 7 times Meal monitors documented on multiple days, "R" for refusal but documented some intake so these were not counted in the refusals. The Acting DON was asked if there was any documentation on the back of the meal monitors for Resident #7, to indicate whether staff attempted to encourage or assist the resident to eat. She informed the surveyor there were no notes on the back of the meal monitors. The medical record documented the resident voiced complaints of abdominal pain and constipation during his stay. Please refer to F309 as it relates to his problems with constipation and subsequent hospitalization for fecal impaction and dehydration. A Pressure Ulcer Risk Assessment Tool form, dated 12/6/10, and again on 12/16/10, documented nutrition as, "Probably inadequate." Resident #7's Speech Pathology-Dysphagia Discharge Summary, dated 1/6/11, documented the resident had been referred for evaluation due to failure to thrive and cognitive deficits limiting comprehension of effects of nutritional deficits on ability to maintain health/function. Noted in the progress summary, "A major barrier was perseveration on feelings of constipation which were addressed by nursing with bowel programming and eventually lead to evaluation in the acute setting and discharge from the facility." Also documented in a clinical summary, dated 12/20/10, "Resident was referred for speech language evaluation and treatment due to demonstrated evidence of failure to thrive with poor intake that will not support healing of wounds...Resident does demonstrate cognitive impairment that limits successful choices to promote health and visual deficits that limit food recognition...Resident is at high risk for [MEDICAL CONDITION] and dehydration and will benefit from short term intervention for environmental analysis, modification, implementation of changes and cognitive linguistic approaches for focused communication and comprehension of safety/needs for health." The Speech Therapist documented 17 meal therapies out of 54 meals, with the type of group noted as "Communication," from 12/20/10 to 1/6/11. Hospital records for Resident #7, dated 1/6/11, indicated he was admitted to the hospital with [REDACTED]. A Progress Note, dated 1/3/11, by the nurse practitioner, documented, "...In speaking with staff they report he's been constipated off and on, that he states that the constipation is affecting his appetite and that he's not been eating well..." Orders for a bedside x-ray of the resident's abdomen were received, as well as orders for [MEDICATION NAME] for anorexia and Senna-S twice daily for constipation. There was no documentation in this note that weight loss specifically had been addressed by medical supervision, only poor appetite. The facility's Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents documented the following: * Abdominal pain - Immediate (High Alert-within 1 hour) Abrupt onset severe pain or distention, OR With fever, vomiting * Abdominal pain - Non-Immediate (Medium Alert with 6-8 hours) Moderate diffuse or localized pain, unrelieved by antacids or laxatives * Abdominal Pain - Routine (Low Alert-one day to 72 hours) Persistent mild to moderate discomfort, without associated symptoms * Abdominal distention - Immediate (High Alert-within 1 hour) Rapid onset, OR Presence of marked tenderness, fever, vomiting, GI (gastrointestinal) bleeding * Abdominal distention - Non-Immediate (Medium Alert within 6-8 hours) Progressive or persistent distention not associated with other acute symptoms * Abdominal distention - Routine (Low Alert-one day to 72 hours) Gradual increase in abdominal girth not associated with acute symptoms * BUN, elevated - Immediate (High Alert - within 1 hour) BUN greater than 50% above usual in someone on diuretic or at high risk of dehydration * BUN, elevated - Non-Immediate (Medium Alert within 6-8 hours) Progressive rise in BUN in someone on antihypertensive therapy * BUN, elevated - Routine (Low Alert-one day to 72 hours) New onset elevated BUN, OR slowly progressive increase over time * Appetite, diminished - Immediate (High Alert - within 1 hour) N/A * Appetite, diminished - Non-Immediate (Medium Alert within 6-8 hours) Significant decline in food and fluid intake of someone with marginal hydration and nutritional status * Appetite, diminished - Routine (Low Alert - one day to 72 hours) Frequent or persistent poor appetite with gradual weight loss * Weight, change in - Immediate (High Alert - within 1 hour) (no information) * Weight, change in - Non-Immediate (Medium Alert within 6-8 hours) Weight loss of greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months According to the resident's medical record weight history, his weights were as follows: * 12/8/10 139.0 lbs - * 12/15/10 130.40 lbs - 6.18% loss since admission * 12/22/10 133.20 lbs - 4.17% loss since admission * 12/29/10 129.40 lbs - 6.90% loss since admission * 1/5/11 128.40 lbs - 7.63% loss since admission in one month According to Fundamentals of Nursing by Potter and Perry, 7th Edition, normal serum creatinine levels for men would be 0.6-1.5 mg/100 ml. This finding indicates renal function and an elevated level can indicate [MEDICAL CONDITION]. Additionally, blood urea nitrogen (BUN) levels should be 10-20 mg/100 ml. Again, this finding indicates renal function and BUN becomes elevated with dehydration. According to a hospital transfer note, dated 12/6/10, documented the resident had admission lab values on 11/30/10 of creatinine of 1.3 and BUN of 34, which indicated the resident was exhibiting clinical signs of dehydration on hospital admission. The facility Bladder Status Evaluation form for Resident #7 documented a creatinine of .98 and BUN of 18 on 12/1/10, which indicated the resident was not dehydrated on admission to the facility. Lab results for the resident, dated 1/5/11, documented a creatinine of 4.29 and BUN of 60. The resident had to be hosptalized on [DATE] for dehydration, acute [MEDICAL CONDITION], and fecal impaction. Lab values on 1/5/11 documented total protein of 4.8 whereas normal levels should have been between 6.3 to 8.0. [MEDICATION NAME] was documented as 2.3 where normal levels should have been 3.5 to 5.0. These abnormal low values are indicative of [MEDICAL CONDITION]. On 1/19/10 at 2:00 pm, the Registered Nurse Consultant, Acting DON and RD #11 were interviewed with regards to the care of Resident #7. The Registered Nurse Consultant stated the facility was concerned with the resident's constipation and felt his eating would improve after his bowel issues were addressed. When asked to supply the admission Care Plan for constipation for the resident, the Acting DON informed the surveyor there was not an admission Care Plan for constipation, even though the resident was admitted with the [DIAGNOSES REDACTED]. On 1/24/11, RD #9 and RD #12 were interviewed regarding the [MEDICAL CONDITION] and severe weight loss for Resident #7. RD #9 stated she did not feel they had a "weight loss issue but a weighing issue," meaning the weights were incorrect. The surveyor explained these were the weights in the medical record. Both RDs noted the hospital weight was lower than the facility admission weight. The surveyor noted these were different scales and it was not procedure to use weights from another facility. The RDs indicated the resident had received IV (intravenous) fluids prior to admission and his admission weight could have been exaggerated due to fluid overload. The surveyor asked the dietitians to supply the hospital records for IV fluid infusion and this information was supplied on 1/25/11 at 2:00 pm. Hospital records indicated Resident #7 received one thousand cc of fluid on 11/30/10 and 2,150 of fluid on 12/1/10. This fluid was administered to the resident 5-6 days prior to admission and would have been [MEDICATION NAME] by the time he was admitted to the facility. In addition, one thousand cubic centimeters of fluid weighs approximately 2.2 pounds and would have accounted for 4.75 pounds, if given just prior to admission. RD #9 and RD #12 also indicated the resident was admitted with 3-4 + [MEDICAL CONDITION]. The Resident Progress Notes documented 3-4+ [MEDICAL CONDITION] for the first time on 12/20/10. It was documented again on 12/23/10, 12/29/10, and 1/1/11. The dietitians indicated their interventions to the resident's rapid weight loss after his admission on 12/6/10 were as follows: * 12/7/10 Added fortified to regular meals * 12/9/10 Assisted dining * 12/16/10 Added health shakes twice daily, 120 milliliters each, 200 calories each * 1/3/11 MD ordered [MEDICATION NAME] for anorexia During the hospitalization that occurred 1/6/10-1/8/10, the resident was additionally diagnosed with [REDACTED]. This limited the resident from going to assisted dining and he was restricted to eating in his room and receiving any assistance with dining in his room under isolation. LN #7 was interviewed on 1/21/11 at 8:40 am. He was asked how many staff remained on the hallway during the meal and he stated one nurse and one CNA would be covering the hallway. LN #7 was asked who would be assisting Resident #7 to eat since he was in isolation. He stated it would be the CNA covering the hallway, as well as assisting any other residents on the hall. On 1/19/11, the breakfast tray for Resident #7 was observed sitting on his bedside table and no staff assisted him to dine. The resident lay in his bed asleep during this observation. On 1/21/11, CNA #13 was observed assisting the resident with his breakfast tray. She stayed at his bedside, providing encouragement and verbal cues. The meal monitor for that observation was noted to be blank so the amount consumed was unknown. The resident had voiced ongoing complaints of abdominal pain and was consuming less than 50 percent of his daily assessed fluid intake prior to being hospitalized for [REDACTED]. Even with classifying the resident's abdominal pain and constipation as "Routine," it is unclear the physician was aware of the chronic problem with constipation and its relation to the declining nutritional status and increased weight loss of the resident. There was no indication the facility or the physician were closely monitoring the fact this resident was not eating or drinking sufficient amounts before he became hospitalized . Although a nutrition Care Plan was devised, monitoring and evaluation of its efficacy was not implemented in a fastidious manner and the resident suffered severe weight loss as a result. 2. Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 9/30/10, documented the following: * Admission weight 166.2 lbs * Bowel sounds present, abdomen soft * Total dependence requiring two or more persons for physical assistance with transfers, toilet use, and dressing * Total dependence for eating * Extensive physical assistance required for fluid intake/eating * Upper and lower dentures, no chewing or swallowing problems, no mouth pain * No weight loss * No risk factors for dehydration, refusing liquids The Pressure Ulcer Risk Assessment Tool, dated 9/30/10, which was attached to this admission assessment, documented nutrition as "very poor". The quarterly Nursing Assessment, dated 1/6/11, documented the following: * Extensive assistance requiring one person for physical assistance for transfers, toilet use, and dressing * Supervision required for eating * Independent with fluid intake/eating * No weight loss Resident #13's Resident Care System Weight History documented the following weights: * 10/6/10 155.10 lbs * 10/13/10 150.40 lbs 4.7% loss since admission * 10/20/10 147.20 lbs 5.1% loss since admission * 10/27/10 145.50 lbs 6.2% loss since admission * 11/3/10 146.40 lbs 5.6% loss since admission - severe weight loss greater than 5% * 11/10/10 148.80 lbs 4.1% loss since admission * 12/5/10 148.20 lbs 4.4% loss since admission * 1/5/11 141.00 lbs 9.1% loss since admission - severe weight loss greater than 7.5% NOTE: The admission weight of 166.2 pounds was not used as the resident had been recently discharged from the hospital and this weight and subsequent loss could have been due to intravenous fluids received in the acute hospital setting. The resident's most recent quarterly MDS assessment, dated 12/31/10, documented the following: * Moderately impaired cognitive status * Extensive assistance requiring one person for physical assist for bed mobility, dressing, toilet use, and bathing * Independent requiring set up help only for eating * Frequently incontinent of bladder * Always continent of bowel * No weight loss of 5% or more in last month The resident's Triggered CAAS, dated 10/11/10, documented the following: * Nutritional Status - "No taking ensure supplement" (handwritten note) * Nutritional Status - "Intakes poor upon admit - refuses breakfast (historical preference). Intakes improving with [MEDICATION NAME] started 10/1/10." (handwritten note) Resident #13's Care Plan, dated 10/27/10, documented the problem, "Self-care deficit: eating r/t encourage fluid intake, r/t alteration in bowel function," with a problem date of 10/11/10. Approaches listed for these problems included: * "Allow ample time for tasks." * "Provide verbal cues as necessary" * "Report to charge nurse any declines in resident's ADL performance." * "Encourage fluids" * "Offer bowel care" * "Continue monitoring bowel status" Another problem documented in the same Care Plan, "Nutrition r/t leaves 25% or more uneaten," with a problem date of 10/7/10, included the following approaches: * "Diet as ordered: Regular" * "Monitor weight weekly x 4 (for 4 weeks), then monthly if stable." * "Administer as ordered: MVI (multivitamin) with minerals, iron supplement, calcium with Vit. (vitamin) D" * "Provide assistance as needed with meals to ensure adequate PO intake." * "Encourage PO intake and fluids-[MEDICATION NAME]" In a physician progress notes [REDACTED]. Staff has no issues at this time..." There was no notation as to the resident's weight loss. In a physician progress notes [REDACTED]. anything to eat but denies any pain or shortness of breath..." There was no notation as to the resident's weight loss. The Medical Nutrition Therapy Assessment form for Resident #13 documented the following: * "10/5/10 Resident recently admitted . Intakes from admit have been poor including refusal at breakfast, 40/30/40. Fluids 120-240..." * "10/7/10 Wt 10/6 = 155.1. PO intakes 0/32/56 with 126 cc/meal. PO intakes do not appear adequate to meet needs. Resident has had some confusion and pain which may be impacting intakes. Receiving Ensure which may aid in providing adequate nutrition." Nutrition Progress Notes for the resident, dated 1/6/11, documented, "...Wt with significant decline in 90 days. PO intakes are poor which may be r/t confusion and behaviors...Interventions here to attempt to stabilize include: [MEDICATION NAME], Ensure, encouragement to meals. Will bring through NAR to start fortified meals. Will monitor." Resident #13's Resident Progress Notes, a condition change form, dated 11/27/10, documented, "Resident continues to refuse Ensure between meals - Resident states, 'I don't like it.' Order received to DC (discontinue) Ensure." The November MAR for the resident documented she only accepted Ensure three times out of 79 offerings. Meal monitors and MARs documented the following fluid/meal intake and meal and bedtime snack refusals: October: Breakfast - Refused all but two times; Lunch - Refused six times, 25% or less eaten 11 times; Dinner - Refused twice, 25% or less eaten 10 times; Bedtime snack - Refused 17 times November: Breakfast - Refused all but one time; Lunch - Refused four times, 25% or less eaten eight times; Dinner - No refusals, 25% or less eaten six times; Bedtime snack - Refused one time NOTE: The meal monitor for Resident #13 for the month of December only documented 12/26-31. No other information was received. December: Breakfast - documented as refused one time, accepted one time out of six days; Lunch - documented as no refusals out of six days; Dinner - documented as received twice, 25% or less eaten one time Bedtime snack - no documentation received The physician's orders [REDACTED]. * Order date: 9/30/10 Diet Order: Regular/Regular * Order date: 11/4/10 Calcium w/vitamin D 600/200 mg PO BID (600 milligrams calcium with 200 milligrams vitamin D by mouth twice daily) with meals. Dx (diagnosis) Nutrition Deficiency * Order date: 9/30/10 Multivitamin w/minerals 1 tablet PO QD (daily). Dx: Nutrition Deficiency * Order date: 9/30/10 [MEDICATION NAME] sulfate - do not crush 325 mg PO QD at noon. Dx: Nutrition Deficiency * Order date: 11/7/10 [MEDICATION NAME] 5 mg PO BID. Dx: Dementia with psychotic features NOTE: This medication order was increased from 2.5 mg PO BID to 5 mg PO BID due to increase in behaviors. * Order date: 10/1/10 [MEDICATION NAME] 15 mg PO QHS (every night at bedtime). Dx: Depression/Appetite A prescription for [MEDICATION NAME], 250 mg, PO BID, dated 1/7/10, was also ordered with a Physician Telephone Order, dated 1/13/11, that documented a [DIAGNOSES REDACTED]. A Physician Telephone Order, dated 1/14/11, documented Health Shakes TID (three times daily) with meals as a nutrition supplement. On 1/21/11 at 1:10 PM, RD # 9 was interviewed regarding Resident #13's severe weight loss. RD #9 indicated Resident #13 dined in the assisted dining room but refused breakfast on a regular basis. She stated they did offer a continental breakfast to the resident if she slept in and refused breakfast, although there was no documentation of the continental breakfast being offered to the resident. RD #9 stated they had tried Ensure as a nutrition supplement but the resident refused and they were trying Health Shakes. NOTE: Ensure was discontinued on 11/17/10 and Health Shakes were not introduced until 1/14/11. RD #9 stated Speech Therapy had indicated the resident would not allow anyone to feed her or assist with cues. RD #9 also indicated the resident's behaviors interfered with her willingness to eat. Behavior Flow Sheets for November documented 5 days of verbal aggression with refusal of cares, with two instances where interventions were not effective. December Behavior Flow Sheets documented 8 days of verbal aggression with refusal of cares, with no documentation interventions were not effective. RD #9 also stated the resident was receiving [MEDICATION NAME], and [MEDICATION NAME] and indicated all three medications were appetite stimulants. According to Mosby's 2010 Nursing Drug Reference, the following side effects were listed for these medications: * [MEDICATION NAME] - increased appetite, nausea, vomiting * [MEDICATION NAME] - nausea, vomiting, appetite, dyspepsia, constipation, weight gain-common side effects, anorexia also listed as potential side effect * [MEDICATION NAME] - nausea, vomiting, diarrhea, dyspepsia-common side effects, anorexia and weight gain also listed as potential side effects (ordered 1/7/11) Resident #13 had been receiving [MEDICATION NAME] and [MEDICATION NAME] since admission and continued to lose weight. Lab values for Resident #13, dated 12/31/10, documented an [MEDICATION NAME] level of 3.0, compared to normal values of 3.5-5.0. In a handwritten note, in a column to the side, documented a date of 10/5/10, with 2.8 written to the side of the [MEDICATION NAME] level. RD #9 indicated this was Resident #13's [MEDICATION NAME] level after admission to the facility. Both of these abnormal low [MEDICATION NAME] levels were indicative of [MEDICAL CONDITION]. Resident #13 was harmed when the facility failed to evaluate the effectiveness of the resident's Care Plan and implement changes in a timely manner, resulting in severe weight loss for the resident and [MEDICAL CONDITION]. The Registered Nurse Consultant, Acting DON and the Administrator were informed of these issues on 1/25/11. No further information was received.

Based on observation, staff interview and record review, it was determined the facility failed to ensure sufficient fluid intake for 1 of 15 (# 7) sampled residents. Resident #7 was hospitalized for [REDACTED]. The facility documented the resident had a history of [REDACTED]. Findings included: Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 12/6/10, documented the following: * Bowel sounds present, abdomen distended * Experiencing pain, pain management prescriptions * Extensive assist requiring one person for assistance for toilet use * Supervision for eating * Disoriented occasionally * Regular diet type with regular consistency * Independent fluid and eating intake * No weight loss * No risk factors for dehydration, refusing fluids * Dehydration Risk Assessment Score of 3 -10 indicates high risk potential for dehydration On readmission after hospitalization , on 1/8/11, the resident was assessed as having a history of dehydration, with a Dehydration Risk Assessment Score of 10, which represented the resident was assessed as a high risk potential for dehydration. This was after the resident had been diagnosed with [REDACTED]. On 1/17/11, after his second readmission following a hospitalization for amputation of his left lower leg, the resident was assessed with [REDACTED]. The resident's admission MDS assessment, dated 12/13/10, documented the following: * Moderate difficulty with hearing * Moderately impaired vision * Severe cognitive impairment * Independent requiring set up help only for eating * Extensive assistance requiring one person for physical assistance for toilet use * Occasionally incontinent of bladder and bowel The resident's Triggered CAAs, dated 12/15/10, documented the following: * Behavioral Symptoms - "Resident had hx (history) of dehydration" (handwritten note) * Dehydration/Fluid Maintenance - Behavioral disturbance that interferes with intake * Dehydration/Fluid Maintenance - "Res is an (sic) 94 y old (year old) male, HOH (hard of hearing), legally blind, [MEDICAL CONDITIONS],[MEDICAL CONDITION](hypertension), atherosclorosis (sic) to LLE (left lower extremity), multiple ulcer, confused at times. Need to cont (continue) care plan to encourage and offer fluid to maintain good skin turgor and moist mucosa." (handwritten note) The resident's Care Plan, dated 1/3/11, documented the problem, "Nutrition, r/t leaves 25% or more uneaten, r/t weight loss/gain, r/t pressure wound, r/t refusal to eat at times, r/t at nutritional risk d/t hx prostate (cancer),[MEDICAL CONDITION](hypertension)", with a problem date of 12/14/10. Goals listed for these problems included, *"Resident will have no significant weight change-gradual repletion desired," * "Resident will consume >50-75% of meals," * "Labs will be within acceptable range," * "Resident will maintain nutrition/hydration on reg/thin with set up only." Approaches included: * "Monitor weight weekly x 4 (for four weeks), then monthly if stable." * "Monitor lab values as ordered" * "Review at IDT Nutrition at Risk Meeting" * "Encourage PO intake and fluids-ongoing" Resident Progress Notes for Nutrition as Risk documented the following: * 12/9/10 "Referred to mtg (meeting) d/t decrease wts (weights) and skin issues...Will start enhanced meals, consider assisted dining. Will monitor." * 12/16/10 "...Regular calorie enhanced. PO intakes 57 (percent eaten of breakfast)/62 (percent eaten of lunch)/65 (percent eaten of dinner) with 280 cc/meal. Show improvement...Wt with decline. Will start H shakes (health shakes) bid (twice daily) (illegible) meals and monitor." * 12/23/10 "...PO intakes 37/65/(illegible) with 240 cc/meal. H shakes started. Bowels working better. Will continue to monitor." * 1/6/11 "...PO intakes 12/25/29 (illegible)...Wt showing a decline. (illegible) Regular calorie enhanced H shakes BID (illegible) meals. Intakes remain poor and show a decline. Resident with hemoccult (positive). Pt to ER at this time for evaluation. Will await results and monitor." The Medical Nutrition Therapy Assessment for Resident #7, dated 12/14/10, documented estimated fluid needs of 1800 cc (cubic centimeters) intake daily. Meal monitors and MARs (health shakes ordered twice daily on 12/17/10) for Resident #7 documented the following fluid intake: 12/7/10 900 cc and 0 = 900 cc 12/8/10 750 cc and 0 = 750 cc 12/9/10 240 cc and 0 = 240 cc 12/10/10 660 cc and 0 = 660 cc 12/11/10 880 cc and 0 = 880 cc 12/12/10 540 cc and 0 = 540 cc 12/13/10 960 cc and 0 = 960 cc 12/14/10 840 cc and 0 = 840 cc 12/15/10 700 cc and 0 = 700 cc 12/16/10 480 cc and 0 = 480 cc 12/17/10 600 cc and 240 cc = 840 cc 12/18/10 960 cc and 240 cc = 1200 cc 12/19/10 720 cc and 240 cc = 960 cc 12/20/10 600 cc and 240 cc = 840 cc 12/21/10 680 cc and 240 cc = 920 cc 12/22/10 720 cc and 240 cc = 960 cc 12/23/10 740 cc and 240 cc = 980 cc 12/24/10 720 cc and 240 cc = 960 cc 12/25/10 600 cc and 240 cc = 840 cc 12/26/10 600 cc and 240 cc = 840 cc 12/27/10 480 cc and 240 cc = 720 cc 12/28/10 480 cc and 240 cc = 720 cc 12/29/10 640 cc and 240 cc = 880 cc 12/30/10 360 cc and 240 cc = 600 cc 12/31/10 360 cc and 240 cc = 600 cc 1/1/11 unknown cc and 180 cc = 180 cc 1/2/11 unknown cc and 60 cc = 60 cc 1/3/11 unknown cc and 90 cc = 90 cc 1/4/11 unknown cc and 60 cc = 60 cc 1/5/11 unknown cc and 0 cc = 0 cc 1/6/11 Transferred to hospital 1/7/11 In hospital 1/8/11 readmitted at 2:30 pm, Could not find documentation of health shakes on MAR given as ordered after readmission 1/8/11 unknown cc and 0 cc = 0 cc 1/9/11 unknown cc and 0 cc = 0 cc NOTE: The meal monitor information for 1/1/11-1/6/11 and 1/8/11-1/9/11 was requested three times from the facility and was not received. 1/10/11 Transferred to hospital at 11:30 am 1/10-1/17/11 readmitted to facility from hospital at 11:50 am 1/17/11 Documented refusals 1/18/11 360 cc and 0 cc = 360 cc 1/19/11 240 cc and 0 cc = 240 cc 1/20/11 600 cc and 0 cc = 600 cc 1/21/11 240 cc and 0 cc = 240 cc 1/22/11 480 cc and 0 cc = 480 cc 1/23/11 190 cc and 0 cc = 190 cc The physician's orders [REDACTED]. * [MEDICATION NAME] 25 mcg (micrograms) ER (extended release) topical patch, ordered 12/6/10 * [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg (milligrams) prn (as needed), ordered 12/6/10, common side effect [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg, was documented as given on 12/15, 12/20, 12/26, 12/29, and 1/1/11. The Resident Progress Notes, documented the following: * 12/10/10 6:00 am, "...at 0530 (5:30 am) this am, enema given 0530 due to constipation..." * 12/14/10 3:05 am, "...voided no bm (bowel movement) tonight..." * 12/15/10 Status change form "...Pt (patient) with constipation since admit. Not on anything for bowels routinely. Orders received for [MEDICATION NAME] for pain and [MEDICATION NAME] for bowels." * 12/20/10 11:00 pm "...has troubles with his bowels. Sometimes he 'just can't go.' Sometimes he 'has a little'..." * 12/31/10 10:00 pm "...Incontinent of stool while in bed..." * 1/3/11 Status change form "Res (resident) cont (continues) to state he has pain in his abdomen (illegible) hasn't had much of an appetite. Order received to x-ray abdomen on suggestion from ST (speech therapy)." NOTE: The bedside x-ray of the resident's abdomen documented moderate constipation on 1/3/11. * 1/3/11 Status change form "(nurse practitioner) here to see pt. New orders received for [MEDICATION NAME] 15 mg PO (by mouth) Q hs (every evening) for anorexia, Senna-S one (tablet) BID (twice daily) for constipation." * 1/5/11 Status change form "Pt with (positive) hemoccult. (Nurse practitioner) notified. Labs ordered..." * 1/6/11 2:30 am "...Pain? Indicated lower abd (abdomen)..." * 1/6/11 Late Entry Status change form "(Nurse practitioner) notified of labs. Rec (received) push PO fluids now...Pt noted to have small amt (amount) frank blood from rectum this AM. No discomfort. No external hemorrhoids noted..." * 1/6/11 Late Entry 12:30 am "Late Entry: Pt to (hospital) ER (emergency room ) via (ambulance company)..." Bowel records for the resident documented the following: No bowel movements on 12/6, 12/8, 12/11, 12/12, 12/14, 12/15, 12/20, 12/26, 1/17 In addition, the following were noted on days where a bowel movement occurred:12/17 2 small bowel movements 12/18 1 loose and 1 small bowel movement 12/19 1 small bowel movement 12/21 1 loose and 1 small bowel movement 12/27 1 small bowel movement 12/31 1 small and 1 loose bowel movement 1/1/11 1 small and loose bowel movement 1/2/11 2 small bowel movements 1/3/11 2 small bowel movements 1/8/11 1 medium loose bowel movement 1/9/11 3 small bowel movements 1/10/11 1 small bowel movement According to the Encyclopedia of Nursing and Allied Health, fecal impaction is the result of extreme constipation. It further states that the possibility that a "patient has a fecal impaction should be considered if he or she shows any or all of the following symptoms: * complaints of inability to have a bowel movement despite frequently feeling the urge to defecate * upon defecation, the stool appears to be either diarrheic or thin and pencil-like * abdominal pain * bloating and a swollen or hard abdomen * anorexia, or lack of appetite; nausea; and vomiting" The documented bowel movements described as "small" and/or "loose" should have been considered as possible indicators of fecal impaction, since in spite of having these bowel movements, the resident continued to report abdominal pain, anorexia, and constipation. Resident #7's Speech Pathology-Dysphagia Discharge Summary, dated 1/6/11, documented the resident had been referred for evaluation due to failure to thrive and cognitive deficits limiting comprehension of effects of nutritional deficits on ability to maintain health/function. Noted in the progress summary, "A major barrier was perseveration on feelings of constipation which were addressed by nursing with bowel programming and eventually lead to evaluation in the acute setting and discharge from the facility." Hospital records for Resident #7, dated 1/6/11, indicated he was admitted to the hospital with [REDACTED]. A Progress Note, dated 1/3/11, by the nurse practitioner, documented, "...In speaking with staff they report he's been constipated off and on, that he states that the constipation is affecting his appetite and that he's not been eating well..." Orders for a bedside x-ray of the resident's abdomen were received, as well as orders for [MEDICATION NAME] for anorexia and Senna-S twice daily for constipation. The facility's Guidelines for Physician Notification of Change of Condition/Clinical Problems in Center Residents documented the following: * Abdominal pain - Immediate (High Alert-within 1 hour) Abrupt onset severe pain or distention, OR With fever, vomiting * Abdominal pain - Non-Immediate (Medium Alert with 6-8 hours) Moderate diffuse or localized pain, unrelieved by antacids or laxatives * Abdominal Pain - Routine (Low Alert-one day to 72 hours) Persistent mild to moderate discomfort, without associated symptoms * Abdominal distention - Immediate (High Alert-within 1 hour) Rapid onset, OR Presence of marked tenderness, fever, vomiting, GI (gastrointestinal) bleeding * Abdominal distention - Non-Immediate (Medium Alert within 6-8 hours) Progressive or persistent distention not associated with other acute symptoms * Abdominal distention - Routine (Low Alert-one day to 72 hours) Gradual increase in abdominal girth not associated with acute symptoms * BUN, elevated - Immediate (High Alert - within 1 hour) BUN greater than 50% above usual in someone on diuretic or at high risk of dehydration * BUN, elevated - Non-Immediate (Medium Alert within 6-8 hours) Progressive rise in BUN in someone on antihypertensive therapy * BUN, elevated - Routine (Low Alert-one day to 72 hours) New onset elevated BUN, OR slowly progressive increase over time * Appetite, diminished - Immediate (High Alert - within 1 hour) N/A * Appetite, diminished - Non-Immediate (Medium Alert within 6-8 hours) Significant decline in food and fluid intake of someone with marginal hydration and nutritional status * Appetite, diminished - Routine (Low Alert - one day to 72 hours) Frequent or persistent poor appetite with gradual weight loss According to the resident's weight history, his weights were as follows: * 12/8/10 139.0 lbs - * 12/15/10 130.40 lbs - 6.18% loss since admission * 12/22/10 133.20 lbs - 4.17% loss since admission * 12/29/10 129.40 lbs - 6.90% loss since admission * 1/5/11 128.40 lbs - 7.63% loss since admission in one month According to Fundamentals of Nursing by Potter and Perry, 7th Edition, normal serum creatinine levels for men would be 0.6-1.5 mg/100 ml. This finding indicates renal function and an elevated level can indicate [MEDICAL CONDITION]. Additionally, blood urea nitrogen (BUN) levels should be 10-20 mg/100 ml. Again, this finding indicates renal function and BUN becomes elevated with dehydration. According to a hospital transfer note, dated 12/6/10, documented the resident had admission lab values on 11/30/10 of creatinine of 1.3 and BUN of 34, which indicated the resident was exhibiting clinical signs of dehydration on hospital admission. The facility Bladder Status Evaluation form for Resident #7 documented a creatinine of .98 and BUN of 18 on 12/1/10, which indicated the resident was not dehydrated on admission to the facility. Lab results for the resident, dated 1/5/11, documented a creatinine of 4.29 and BUN of 60. The resident had to be hosptalized on [DATE] for dehydration, acute [MEDICAL CONDITION], and fecal impaction. On 1/19/10 at 2:00 pm, the Registered Nurse Consultant, Acting DON and RD #11 were interviewed with regards to the care of Resident #7. The Acting DON informed the surveyor there was not an admission Care Plan for constipation, even though the resident was admitted with the [DIAGNOSES REDACTED]. The resident had voiced ongoing complaints of abdominal pain and was consuming less than 50 percent of his daily assessed fluid intake prior to being hospitalized for [REDACTED]. The Speech Pathology note indicated perseveration on feelings of constipation by the resident, and also in the Progress Note by the nurse practitioner on 1/3/11, where it indicated that staff had stated the resident was having problems with constipation and abdominal pain. The lack of an appropriate Care Plan for constipation on admission to the facility, coupled with the resident's lack of appropriate and sufficient hydration status, led to the resident having been harmed and subsequently, hospitalized . There was not evidence of a prompt response to the resident's ongoing concerns with insufficient fluid consumption and constipation. Even with classifying the resident's abdominal pain and constipation as "Routine," it is unclear the physician was aware of the chronic problem with constipation and its relation to the insufficient hydration status of the resident. There was no indication the facility or the physician were closely monitoring the fact this resident was becoming dehydrated before he was hospitalized . The Registered Nurse Consultant, Acting DON and the Administrator were informed of this issue on 1/25/11. No further information was received.