Every finding on record at Smoky Hill Rehabilitation Center

The facility identified a census of 65 residents, with three residents reviewed for lack of assessment and change of condition. Based on record review and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to assess a resident, (R)1 after she had a change in condition on 01/13/26 and 01/14/26, which included lethargy, weakness, inability to ambulate, inability to feed herself, and frequent urination. The facility failed to consider hyperglycemia or dehydration as a potential cause of R1's symptoms. On 01/14/26, R1 required transfer to the emergency room, and R1 had a blood glucose level of 1020 milligrams per deciliter (mg/dL) (an extremely high blood glucose level, which constitutes a severe life-threatening emergency) upon admission to the hospital emergency room. This deficient practice placed R1 in immediate jeopardy. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with other circulatory complications, dementia (progressive mental disorder characterized by failing memory, confusion), hyperlipidemia (condition of elevated blood lipid levels), and cognitive communication deficit. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had severely impaired cognition. The Brief Interview for Mental Status (BIMS) could not be completed. The MDS documented R1 as independent with ambulation and transfer and required supervision with eating. The Care Plan, dated 04/01/24, documented R1 was at risk for hyperglycemia (greater than normal amount of glucose in the blood). The care plan directed staff to observe/document/report to the doctor as needed for signs and symptoms of hyperglycemia (increased thirst and appetite, frequent urination, weight loss, fatigue, or dry skin). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/05/25, documented R1 had severe cognitive impairment and resided on a secure unit. The Psychosocial Well-Being CAA, dated 03/05/25, documented R1 enjoyed sitting on the couch or at the end of the hall in the secure unit to watch other peers or staff. R1's cognitive impairment hindered her ability to stay on task. The laboratory report, dated 05/15/25, documented R1 had a hemoglobin A1c (HbA1c, a blood test used to evaluate the level of glucose control over the past 90 days) of 5.8% (high), which indicated the resident was at risk for diabetes. R1's Medication Administration Record (MAR), dated January 2026, documented the facility performed blood glucose monitoring as needed related to type 2 diabetes. The staff were to notify the primary care provider if R1's blood sugar was lower than 70 mg/dL or higher than 400 mg/dL, with a start date of 01/07/25. R1's EMR Task Documentation, for 01/12/26, lacked documentation of the amount of food the resident ate for breakfast or lunch. The Task documentation documented R1 was able to eat with staff assistance and ate 26-50% of her supper meal. The transfer task documentation documented R1 did not transfer and/or the staff provided 100% care for R1 for transfers. The walk-in room and walk-in corridor task documentation noted R1 did not ambulate and/or staff provided 100% of care for R1 for ambulation. The task documentation failed to document milliliters of fluid intake. R1's EMR Task Documentation, for 01/13/26, lacked any documentation of the amount of food the resident ate for breakfast or lunch. The Task documentation noted R1 was able to eat with extensive staff assistance and ate 26-50% of her supper meal. The transfer task documentation documented R1 required extensive assistance from two staff members for transfer. The walk-in room and walk-in corridor task documentation documented R1 required extensive assistance from two staff members for ambulation. The task documentation failed to document milliliters of fluid intake. The Health Status Note, dated 01/13/26 at 03:42 AM, documented staff noted R1 had excessive weakness and the staff had to assist R1 from her chair to a wheelchair from the dining area to her room. R1 was unable to ambulate independently or with assistance. R1 was able to pivot with two staff assistance. The note documented R1's vital signs were within normal limits and R1 was in bed with her eyes closed. The EMR lacked documentation of a complete set of vital signs related to the 01/13/26 Health Status Note. The EMR documented R1's blood pressure was 110/90 millimeters of mercury (mmHg). The EMR lacked a blood glucose total for R1. The Fax Communication with Physician Form, dated 01/13/26 at 02:34 PM, documented R1 was having shakes, was more sleepy, and not awake as normal, with frequency of urine. Facility staff had tried several ways to obtain a urine specimen, including a straight catheterization (a sterile procedure to drain urine using a temporary, flexible tube inserted through the urethra (small tubular structure that drains urine from the bladder) into the bladder), with no luck. R1 also had discharge. Requested order for an antibiotic to treat a urinary tract infection (UTI) and noted Please advise. The EMR lacked documentation of the facility's attempt to obtain a urine specimen for R1. The Fax Communication from Physician, dated 01/13/26 at 03:03 PM, documented an order for Macrobid (an antibiotic) twice a day for ten days for R1. The Health Status Note, dated 01/13/26 at 05:26 PM, documented the first dose of Macrobid (an antibiotic) 100 milligrams (mg) pulled from the Cubex (an automated medication dispensing and inventory management system). The Health Status Note, dated 01/13/26 at 10:30 PM, documented R1 continued to have weakness and cognitive decline. R1 still did not ambulate independently as she did. R1 was non-verbal and staff had to feed her the evening meal. The note documented R1's vital signs were within normal limits and no adverse reaction from the first dose of Macrobid for R1's UTI. The EMR lacked a complete set of vital signs and lacked a blood glucose for R1. The Health Status Note, dated 01/14/26 at 04:20 AM, documented staff notified the nurse that R1's foot was cold and looked colorless. The nurse assessed and found R1's foot was pale, cold to the touch, and non-blanchable (when skin does not turn white or fade when pressed). The staff notified the on-call doctor of the situation, who advised the nurse to send R1 to the emergency department. Emergency Medical Technicians (EMTs) arrived at 03:55 AM and left with R1 at 04:03 AM. The Emergency Department Report, dated 01/14/26, documented R1 presented to the emergency department by ambulance from the nursing home. Staff reported R1 had a cold, pale, and pulseless right foot. The report documented R1 was confused and laid in bed all day. R1 had a history of dementia, type 2 diabetes, and a new prescription for Macrobid which started yesterday. On arrival, R1 was obtunded (decreased consciousness). Point of care (POC) glucose obtained, which read HI on the glucometer (instrument used to calculate blood glucose). Vital signs were as follows: temperature 97.8 degrees Fahrenheit (F), pulse 81 beats per minute, respirations 16 breaths per minute, blood pressure 127/116 mmHg, and pulse oximetry of 91% on room air. R1's laboratory glucose was 1020 mg/dL. Sodium level was 158 milliequivalents per liter (mEq/L), which indicated severe dehydration, a high salt diet, or diabetes. Urine specimen resulted in clear yellow urine, glucose level greater than 1000 (Hi), negative for bacteria, and negative for nitrites. After a two-liter bolus (medication administered over a short period of time), Lactated Ringer's (LR - an isotonic intravenous (IV) solution used for fluid resuscitation) along with ten milligrams of IV Humulin insulin (insulin used for rapid glucose control), R1's laboratory glucose was 861 mg/dL. At 05:50 AM, R1's guardian was given a review of problems: profound hyperglycemia, hypernatremia, hyperchloremia (excessive level of chloride in the blood), and acute kidney injury (sudden drop in kidney function). R1's guardian was made aware of R1's critical condition and decision was made to place R1 on hospice care and have R1 kept comfortable. The Health Status Note, dated 01/14/26 at 08:15 AM, documented R1 was to return to the facility on hospice for palliative care. The Health Status Note, dated 01/15/26 at 09:20 PM, documented R1's guardian told the nurse she believed R1 had cessation of vital signs. The nurse assessed R1 and was unable to obtain vital signs and documented cessation of vital signs at 09:23 PM. On 02/19/26 at 10:00 AM, Administrative Nurse E stated R1 had a decline in functioning, they thought R1 had a UTI, and R1 was placed on an antibiotic. Administrative Nurse D stated she did not know anything about R1 having blood sugar monitoring. On 02/19/26 at 11:30 AM, Certified Nurses Aid (CNA) M stated noticed R1 had a significant decline in functioning. CNA M stated he told the nurse R1 was not herself. CNA M stated he did not remember obtaining vital signs for R1, but if he had, he would have documented them in the EMR. CNA M stated he thought the nurse went back and assessed R1, but he could not remember. On 02/19/26 at 01:00 PM, Administrative Nurse D stated she really thought R1 had a UTI, and that is what they went with when they notified the doctor. Administrative Nurse D stated she did not know why the nurses had documented R1's vital signs as within normal limits, but no vital signs were documented and she further said if they weren't documented, they weren't done. On 02/19/26 at 01:30 PM, Licensed Nurse (LN) G stated R1 did have a decline and just was not herself. R1 was not able to walk like she normally did, was not really eating or drinking, and the staff thought, given her age, she probably had a UTI, so the staff contacted the doctor and asked for R1 to be started on an antibiotic. LN G stated they really could not obtain a urine specimen on R1 because she did not urinate in the hat. LN G stated she did not really try to get a straight catheterization because even though she could see the urinary meatus, it just was not in the right position. LN G stated R1 was exhibiting more frequent urination, but not to the extent it would have been her blood sugars, just more like a UTI. LN G stated she did not even know what R1 came back from the hospital with, if she was septic or had an infection. LN G stated they had never taken R1's blood sugar because there was no order to do so. On 02/19/26 at 03:24 PM, R1's Primary Care Physician (PCP) stated he had been treating R1 since 2024, and in that time, he had obtained her HGB A1C every three months, and it had never been above 6. He stated he thought R1 went through organ shutdown, and that was why her blood sugar was so high, as well as the other high labs. The physician stated if nursing had obtained labs and they had not been within normal limits within the first 36 hours of her change of condition, interventions could have been put in place to try to get R1 better before she got to organ shutdown. The facility's Acute Condition Changes Protocol, revised December 2012, documented that the nurse shall assess and document/report the following baseline information: VS's, neuro status, current level of pain, level of consciousness, cognitive status, onset, duration, and severity, recent labs, all active diagnoses, and all current medications. Before calling a physician about someone with an acute change in condition, nursing staff will make detailed observations and collect pertinent information to report to the physician. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. The nurse and physician shall discuss and evaluate the situation. The physician should ask questions to clarify the situation, for example, vital signs, physical findings, and description of symptoms. On 02/19/26 at 03:45 PM, Administrative Staff were provided the IJ template and notified the facility failure to ensure Resident (R) 1 remained free from neglect when the facility failed to assess a resident, (R)1 after she had a change in condition on 01/13/26 and 01/14/26, which included lethargy, weakness, inability to ambulate, inability to feed herself, and frequent urination. The facility identified and implemented immediate corrective actions, which were completed on 02/19/26 and included: Effective 2/19/2026 Upon change of condition of any resident Smoky Hill Nurses will: Complete Change of Condition Form and notify resident physician immediately. Any Resident with Diabetes Diagnosis will be assessed for hypo/hyper glycemia and labs as ordered by physician. Nursing Staff will be in-serviced on Hypo/Hyper Glycemia or any other conditions such as frequent urination, lethargy, weakness, inability to ambulate, and inability to feed self as associated with diabetes. All residents with Diabetes will be assessed for signs and symptoms of Dehydration or hypo/hyperglycemic or any other changes associated with Diabetes. Facility will monitor change in conditions 7 days a week and 5 days a week for 3 week. The immediate jeopardy was removed on 2/19/26 when the facility implemented their plan of removal and reviewed by the surveyor on-site. The scope and severity remained at a G.

The facility identified a census of 65 residents, with three residents sampled. Based on record review, observation, and interview, the facility failed to provide required respiratory care and equipment for Resident (R) 2 when the facility failed to provide a working Bi-Level Positive Airway Pressure (Bi-Pap-medical device which helps with breathing) for R2 upon release from the hospital, which contributed to R2 developing mucous plugs overnight and R2 becoming hypercapnic (a condition defined by abnormally high levels of carbon dioxide (CO2) with retention of CO2. Due to the failure, R2 was readmitted to the hospital the next day with a high CO2 level of 87 milliequivalents per liter (mEq/L), normal ranges of CO2 is 23 to 30 mEq/L. Findings included:- R2's Electronic Medical Record (EMR) documented R2 had diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), respiratory failure (occurs when the lungs cannot properly transfer oxygen to the blood or remove carbon dioxide), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heart beat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status score of 15 which indicated intact cognition. The MDS documented R2 required set-up/supervision assistance for eating, required two staff assistance for bathing, toileting, transfer, and dressing. The MDS documented R2 required continuous oxygen administration. The Functional Abilities Care Area Assessment (CAA), dated 09/05/25, documented R2's activities of daily living (ADLs) capabilities were impaired due to weakness, diagnoses, and comorbidities. The Care Plan dated 09/14/22, documented R2 had an ADL deficit and required assistance. R2 required two staff total assistance with transfer, bathing, toileting, and dressing (08/12/24). The care plan included R2 required oxygen at all times and to monitor R2 for signs and symptoms of respiratory distress and report to the primary care physician as needed: respirations, pulse, oximetry, increased heart rate, restlessness, sweating, headaches, lethargy, confusion, cough, accessory muscle usage, and skin color (09/14/24). The Discharge Instructions, dated 02/09/26, documented R2 was in the local hospital for hypercapnia and pneumonia (inflammation of the lungs). The instructions for R2 included 3 Liters (L) of oxygen at all times and to use a BiPap at night. The Follow-up Visit and Plan, dated 02/10/26, documented R2's primary care physician saw R2 following R2's dismissal from the local hospital. The assessment and plan documented that R2 reported he was doing fine, however R2 did not have the Bi-Pap he was supposed to have prior to leaving the hospital. R2 reported to the primary care physician the hospital told him the Bi-Pap would be at the nursing facility prior to his arrival there. R2's primary care physician documented in his plan: when R2 returned to the nursing facility, he was supposed to be on Bi-Pap, and the facility told the hospital they had a functioning Bi-Pap in the facility. At this time, the facility will need to see if they can acquire Bi-Pap. R2 was dismissed from the hospital on [DATE], and as of the time of this dictation, R2 had not been placed on the Bi-Pap. R2 needed an Arterial Blood Gas (ABG, a test that measures oxygen, carbon dioxide, and acidity levels in the blood) to evaluate R2's CO2 retention status to prevent any worsening of his mental status. If the facility could not get the Bi-Pap in a timely fashion and R2's CO2 continued to rise, he would likely need to go back to the emergency room. The 02/11/26 Health Status Note documented, per R2's primary care physician, R2 needed to go to the local emergency room due to his lab result. R2 had an ABG drawn that morning and the result was a CO2 of 85. The staff notified Emergency Medical Service and transported R2 to the hospital for further assessment. The Health Status Note, dated 02/16/26, documented R2 arrived to the facility via facility transport, and R2 was in good spirits and talked with staff. The Emergency Department Report, dated 02/11/26, documented R2 presented to the emergency department with elevated levels of CO2. R2 had an ABG drawn and showed CO2 of 82.6. The differential diagnosis was pneumonia, COPD exacerbation, mucous plug, hypoventilation syndrome, and viral respiratory illness. The note documented: will order a Bi-Pap to wash out the elevated CO2. The Hospital Health and Physical, dated 02/11/26, documented R2 readmitted for mucous plugging (occurs when thick retained mucous accumulates and blocks airways), left pleural effusion (abnormal accumulation of excess fluid in the space between the lungs and the chest wall), acute hypercapnic respiratory failure, and decreased responsiveness. R2 was dismissed two days ago with orders for Bi-Pap ventilation and the hospital kept R2 an extra day so the facility could arrange a Bi-Pap. R2, for some reason, did not have access to a Bi-Pap machine. The chest computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) showed near complete appearing collapse of the left upper lobe, small left pleural effusion, and potential mucous plugging in the left mainstem bronchus (a major airway in the respiratory system that conducts air to the lungs). The pulmonologist consulted and stated the CT scan showed likely mucous plugging. The Pulmonology Consult Note, dated 02/11/26, documented R2 came in with recurrent acute hypercapnic respiratory failure requiring Bi-Pap. R2 was recently seen in the hospital for hypercapnic respiratory failure and was discharged on Bi-Pap; however, R2 returned with similar symptoms. The note included they would run tests to determine if R2 was mucous plugging or if he had a pleural effusion. If there was mucous plugging, the Bi-Pap should help open up that area. If R2 had a pleural effusion, R2 would need a thoracentesis (removal of excess fluid from the air space between the lungs and the chest wall). The noted documented R2's mentation was already improving with Bi-Pap. On 02/19/26 at 12:45 PM, observation revealed R2 lay in his bed with a sheet covering his lower extremities and bare-chested. A fan cooled the room. R2 had oxygen on via nasal cannula. The Bi-Pap machine was on the right side of R2's bed and R2 had shortness of breath while speaking. On 02/19/26 at 12:45 PM, R2 stated he was upset because he was told the facility had the Bi-Pap machine, then the facility did not have one, and he had to go right back to the hospital. R2 said it was scary when he got so loopy, and he did not know what was going on. On 02/19/26 at 01:00 PM, Administrative Nurse D stated she talked to R2's physician and the physician said it was an unfortunate circumstance that led to R2 not having the Bi-Pap. Administrative Nurse D said nursing kind of dropped the ball a little bit, but what else could they do. Administrative Nurse D stated she did not know if the evening nurse had contacted anyone about R2 not having Bi-Pap overnight. On 02/19/26 at 01:30 PM, Licensed Nurse (LN) G stated the facility had told the hospital they had a Bi-Pap machine in-house they could use for R2. When she and the Administrative Nurse E went to set up the Bi-Pap with the appropriate settings, they could not get the settings put in the machine. They called the medical equipment company, and the medical equipment company told them the Bi-Pap was no longer functional. The medical equipment company told them they would send a new Bi-Pap machine to the facility, and it should be there by that evening. LN G stated she did not know until the next morning the Bi-Pap machine had not been delivered and R2 was without a Bi-Pap the previous night. The facility failed to provide a Respiratory Care Policy applicable to the deficient practice.

The facility identified a census of 67 residents. The sample included five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided bathing care per each resident's care plan/preference for Resident (R)1, R2, R3, and R4.Findings included:- During an observation on 12/09/25 at 09:05 AM, R4 laid in bed and watched television. R4's room had a distinct, bad odor in the room that was nauseating. The odor originated from R4 and R4's hair looked greasy and matted. During the observation, R4 stated he could not remember the last time he had a bath. R4 stated he was dependent on staff to assist him to bathe, and he did not feel like his hall had enough staff to take care of him. Review of bathing documentation from 11/01/25 through 12/09/25 (39 days) revealed the staff did not provide a bath for R4 during the 39 days. During an observation on 12/09/25 at 09:15 AM, R2 sat in the lobby area visiting with other residents. R2's hair looked greasy and matted. R2 had a distinct odor of urine about her. R2 stated she had received only two baths since she admitted to the facility, over a month ago. R2 stated bathing did not seem to be a priority in her care. R2 stated she felt gross and dirty, but what could she do, she was at the facility's mercy. Review of bathing documentation from 11/06/25 (date of admission) through 12/09/25 (34 days) revealed R2 received two baths in 34 days. During an observation on 12/09/25 at 09:20 AM, R1 sat in the hallway in his wheelchair. R1's t-shirt was soiled with what appeared to be food stains. The bottom of R1's t-shirt revealed R1's colostomy bag which had leaked a brown liquid substance that presented as bowel movement and soaked the shirt. R1's sweatpants were also stained with the appearance of brown food stains and liquid bowel movement. There was a foul odor to R1, which was notable just walking past. R1 sat in the hallway, unable to move himself to his room, while multiple staff members walked by him for over 45 minutes, at this observational time. R1 was unable to communicate how he felt about staff not bathing/showering him on a timely basis. During an observation on 12/09/25 at 09:30 AM, staff assisted R1 into the shower. Review of bathing documentation from 11/01/25 through 12/09/25 (39 days) revealed R1 received three baths in 39 days. During an observation on 12/09/25 at 09:20 AM, observation revealed R3 lay in bed and watched television. R3's hair looked matted and greasy. There was a distinct body odor to R3. R3 stated she rarely got baths at the facility and felt dirty and unclean most of the time. R3 stated she felt like she smelled. Review of bathing documentation from 11/01/25 through 12/09/25 (39 days) revealed R3 received two baths in 39 days. During an interview on 12/09/25 at 10:10 AM, Certified Nurse's Aide (CNA) M stated it was hard for staff to get all of the baths done the way the baths were scheduled to be done, and then the evening shift had their baths, and all of the baths that didn't get done on the day shift. CNA M stated she felt bad about residents not getting their baths. During an interview on 12/09/25 11:30 AM, Administrative Nurse D stated the facility was having problems with getting the bathing done on the evening shift because the evening shift was all agency staff, and agency staff felt like they were too good to give baths and would not perform bathing cares. During an interview on 12/09/25 at 11:45 AM, Administrative Staff A stated the facility was working on improving bathing on all shifts. The facility's Shower/Tub Bath Policy revised October 2010, documented the facility would provide bathing to residents to promote cleanliness, provide comfort, and observe the condition of the residents' skin.

The facility identified a census of 67 residents. The sample included five residents reviewed for activities of daily living (ADL) and dignity. Based on observation, record review, and interview, the facility failed to promote R1's dignity by the failure to recognize R1's colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) bag leaked through his shirt for approximately 45 minutes as he sat in the hallway unassisted. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following a cerebral infarct (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, major depressive disorder (major mood disorder which causes persistent feelings of sadness), and cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Quarterly Minimum Data Set (MDS) dated 11/06/25 documented R1 had a Brief Interview for Mental Status score of eight, which indicated moderate cognitive impairment. The MDS documented R1 required moderate staff assistance with bed mobility, transfer, and personal hygiene. The MDS documented R1 required maximum staff assistance with toileting, bathing, and dressing. The Functional Abilities Care Area Assessment (CAA) located in the EMR and dated 08/07/25 documented R1's functional abilities were impaired related to weakness and comorbidities. R1's Care Plan documented R1 had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and a colostomy. The care plan directed staff to provide care to R1's catheter and colostomy site every shift and as needed and to monitor R1 for signs and symptoms of infection (08/25/25). The care plan documented R1 suffered from hemiplegia and hemiparesis. The care plan documented R1 would be cleaned, well-groomed, and appropriately dressed. The care plan directed staff to use short sentences while showering to encourage R1 to do as much as he could during a shower to promote independence (08/31/25). During an observation on 12/09/25 at 09:20 AM, R1 sat in the hallway in his wheelchair. R1's t-shirt was soiled with what appeared to be food stains. The bottom of R1's t-shirt revealed R1's colostomy bag, which had leaked a brown liquid substance that presented as bowel movement and soaked the shirt. R1's sweatpants were also stained with the appearance of brown food stains and liquid bowel movement. There was a foul odor to R1, which was notable just walking past. R1 sat in the hallway, unable to move himself to his room, while multiple staff members walked by him for over 45 minutes at this observational time. R1 was unable to communicate how he felt about staff not bathing/showering him on a timely basis. On 12/09/25 at 10:10 AM, Certified Nurse's Aide (CNA) M stated she felt bad about residents not getting their baths. CNA M stated R1 was not on the list to lay down first after breakfast, so she and the other CNA working with R1 left the resident sitting in the hall to remind them to get him into bed after breakfast. On 12/09/25 at 11:30 AM, Administrative Nurse D stated she would have expected staff not to leave R1 in the hallway in the condition he was in and to take care of R1's needs and cares in a dignified manner. The facility's Quality of Life Policy, revised August 2009, documented residents would be provided a safe, clean, comfortable environment and receive treatments and supports for dignified daily living. Staff would provide person-centered care that emphasized the residents' comfort, independence, and personal needs while ensuring receipt of care and services.

The facility identified a census of 61 residents. Based on observation, interview, and record review, the facility failed to prepare, store, and serve meals under sanitary conditions for the 61 residents who received meals from the facility kitchen. This deficient practice placed all of the residents in the facility at risk for food-borne illnesses.Findings included:- On 09/03/25 at 08:45 AM, observation during the initial tour of the kitchen revealed the following:Dried dirt, dried food splatters, and debris were all over the tiled floor throughout the kitchen.The dishwashing area had dried brown, black, and red food splatter all over the back walls.The area off the dishwashing area where clean dishes were stored, the back wall had brown food splatter on the back wall. The carts that the clean dishes were on had brown, tan, black, and white food debris on them.The food serving area, where the hot table kept food warm, the back wall, stainless steel, had dried red crusty food platter. The back wall above the stainless-steel portion had more splattered food, which was black, brown, and tan in color.On the side of the food serving area on the carts, which kept the clean plates and plate covers, the carts were covered with brown, tan, and white food debris touching the clean plates and plate covers.The microwave had dried brown, tan, and red food debris on the inside of the microwave walls and ceiling.The Vulcan double-sided oven had black and brown old food spillover all over the bottom of the ovens. The oven grates were also covered with brown and black spillover. Aluminum foil pieces were lying on both sides at the bottom of the oven.The second oven with a stove top had a broken stove top grate. [NAME] and tan food debris covered the top of the stove. The inside of the oven had brown and black burned food debris.The side-by-side refrigerator revealed dried red juice in the bottom of both sides. There was dried food debris on the shelves and the bottom of the refrigerator.Two food scales sitting on the shelf were covered with brown and rust colored food debris.The bins holding the clean serving scoops, ladles, and serving utensils had dry brown, tan, and white food debris at the bottom of the bins. The bin tops were covered with grease and food debris and were sticky to the touch.The large commercial can opener with a large, pointed end to pierce the large cans was black with food debris and appeared to have never been cleaned.The ceilings above the food serving area, the food prep area, the dishwashing area, and the food storage area had brown and tan food splatter stains. The walk-in refrigerator had food debris all over the floor of the refrigerator, and it appeared to have been some time since it had been cleaned. The outside of the door had food debris on it.The three trash cans in the kitchen had thick grease on all of them and dried food particles. Two of the trash cans were uncovered.The dried food storage area had sugar and creamer packets all over the floor. The floor was dirty with dried onion skins and general dirt.There were three vents in the kitchen area, one above the clean dishes area, one above the food preparation area, and one above the handwashing sink that had no vent covers. The air filter was exposed to the air in the areas.On 09/03/25 at 09:00 AM, Dietary Staff BB stated it was not her job to clean the kitchen; it was the evening shift's job, and they did not do a good job of cleaning. Dietary Staff BB verified the uncleanliness of the kitchen.On 09/03/25 at 09:30 AM, Administrative Staff A and Administrative Nurse D went to the kitchen and verified the condition of the kitchen. Administrative Staff A stated he had only been at the facility for a week, and he was embarrassed at the condition of the kitchen. On 09/03/25 at 10:30 AM, Administrative Staff A stated he was an interim administrator brought into the facility to clean the facility up and make it a better place for residents to live. Administrative Staff A stated there had been some problems with the certified dietary manager, and he did not think she would be working at the facility for long. Administrative Staff A stated that the condition of the kitchen was unsanitary and unacceptable.The facility's Sanitation Policy, revised October 2008, documented the food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean and free from litter and rubbish and protected from rodents, roaches, flies, and other insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. All equipment, food contact areas, and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized with hot water and/or sanitizing equipment. Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers. The food service manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before moving on to the next assignment.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents who ate in the dining room. This placed the residents who ate in the main dining room at risk for unhomelike, unsanitary conditions. Findings included: - On 04/21/25 at 10:58 AM, approximately 2-3 feet of the mopboard located at the west end of the dining room was coming away from the wall. Approximately 6 inches (in) at the end of the mopboard was lying on the floor. On 04/23/25 at 08:28 AM, Maintenance Staff (MS) U verified the above finding and stated he was aware of the issue with the mopboard; he had placed a table in front of the mopboard, but someone had moved it. MS U stated the facility was changing all the mopboards throughout the facility. MS stated when staff had an environmental issue, they placed it in the telemonitoring system (TELS - refers to a telehealth or telemonitoring platform that uses technology to remotely monitor the health and well-being of residents) in the computer. On 04/23/25 at 08:45 AM, Administrative Nurse E stated she expected MS U to address an issue immediately when it was placed in the TELS system. The facility's Maintenance Service Policy, revised in December 2009, documented the maintenance supervisor was responsible for developing and maintaining a schedule of maintenance service to assure the buildings, grounds, and equipment were maintained in a safe and operable manner.

- R3's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), heart failure, obesity (excessive body fat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), chronic pain, tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R3's Annual Minimum Data Set (MDS), dated [DATE], documented that R3 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R3 required partial/moderate assistance with bed mobility, transfers, toileting hygiene, and upper and lower extremity dressing. The MDS further documented that R3 was frequently incontinent of urine and bowel, had pain, and had shortness of breath when lying flat, received oxygen therapy, and tracheostomy care. R3's Care Plan, dated 04/16/25, documented that R3 had a tracheostomy related to respiratory failure and was at high risk for infections and aspiration (inhaling liquid or food into the lungs). The care plan directed staff to ensure the tracheostomy ties were secured at all times, nursing staff were directed to complete cleaning of the tracheostomy, and check for signs of infection. R3's medical record documented he was hospitalized from [DATE] to 08/19/24. On 04/22/25 at 07:59 AM, R3 was sitting in his wheelchair in the dining room, appropriately dressed and groomed for the day, awaiting his breakfast. On 04/22/25 at 04:30 PM, SSD X verified the facility had not provided a Bed Hold Notice to R3 or his representative upon discharge to the hospital. He stated he only provided the Bed Hold Notice upon admission to the facility. On 04/22/25 at 04:50 PM, Administrative Staff A verified that the facility should have provided a Bed Hold Notice to the resident or their representative upon discharge or transfer to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility's Transfer or Discharge Notice policy, dated December 2016, stated the resident or their representative would be given the facility's Bed Hold policy upon impending transfer or discharge. - R38's Electronic Medical Record (EMR) recorded diagnoses of weakness, dependence on renal dialysis (a procedure where impurities or wastes are removed from the blood), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), amputation (surgical removal of a body part) of right index finger, chronic pain, and acquired absence of left leg below the knee. R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had intact cognition, required supervision or touch assistance with upper and lower body dressing, personal hygiene, transfers and bed mobility, and partial/moderate assistance with toileting hygiene, and bathing. R38's Care Plan, dated 02/19/25, documented that R38 required dialysis due to end-stage renal failure. The care plan directed staff to observe R38 for signs and symptoms of complications from dialysis, notify the medical doctor of any signs of infections, and ensure the resident went to dialysis on the scheduled days. R38's medical record documented he was hospitalized from [DATE] to 08/06/24, 08/23/24 to 08/27/24, and 04/18/25 to 04/21/25. On 04/22/25 at 04:30 PM, SSD X verified the facility had not provided a Bed Hold Notice to R38 or his representative upon discharge to the hospital. He stated he only provided the Bed Hold Notice upon admission to the facility. On 04/22/25 at 04:50 PM, Administrative Staff A verified that the facility should have provided a Bed Hold Notice to the resident or their representative upon discharge or transfer to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility's Transfer or Discharge Notice policy, dated December 2016, stated the resident or their representative would be given the facility's Bed Hold policy upon impending transfer or discharge. - R43's Electronic Medical Record (EMR) documented the resident had diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and acute (a condition characterized by a relatively sudden onset of symptoms that are usually severe) respiratory failure (a condition where the lungs can't adequately provide oxygen to the blood or remove carbon dioxide, leading to dangerously low oxygen levels or high carbon dioxide levels). R43's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented supervision with eating and oral hygiene, dependent toileting, showering, lower body dressing, taking off and putting on footwear, chair to bed, tub/shower transfers, wheel in wheelchair, substantial, maximal assist with upper body dressing, personal hygiene, bed mobility, and toilet transfer. R43's Care Plan, revised 03/13/25, documented R43 received nebulizer treatments related to COPD and acute respiratory failure with hypoxia. The plan instructed staff to administer medications as ordered, assist R43 in learning signs of respiratory compromise, elevate R43's head of bed when R43 allows to promote good breathing, and ensure the nebulizer machine was clean and mouth mouthpiece is bagged when not in use. The plan instructed staff to observe/document R43's changes in orientation, increased restlessness, anxiety, and air hunger. R43's Progress Notes, dated 01/17/25 at 04:28 AM, documented the resident was transferred and admitted to the hospital. Review of R43's clinical record lacked evidence that the resident or representative was provided the bed hold policy when transferred to the hospital. On 04/21/25 at 11:15 AM, R43 sat in a wheelchair in the commons area at the front of the facility without signs or symptoms of respiratory distress. On 04/22/25 at 04:30 PM, SSD X verified the facility had not provided a Bed Hold Notice upon discharge to the hospital. He only provided the Bed Hold Notice upon admission to the facility. On 04/22/25 at 04:50 PM, Administrative Staff A verified the facility should have provided a Bed Hold Notice to the resident or their representative upon discharge or transfer to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility's Transfer and Discharge Notice Policy, revised December 2016, documented the facility should provide a resident and/or representative, when an immediate transfer for urgent medical needs, with the bed hold policy. The facility had a census of 65 residents. The sample included 13 residents, with four reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide Resident (R) 46, R3, R38, and R43 a Bed Hold notice when the residents were hospitalized . This deficient practice placed the four residents at risk of not being permitted to return and resume residence in the nursing facility. Findings included: - R46's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). R46's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. R46's Care Plan, dated 02/12/25, directed staff to ensure the call light was within reach, encourage R46 to use it for assistance as needed, and respond promptly to all requests for assistance. R46's medical record documented he was hospitalized from [DATE] to 09/16/24 and again from 11/06/24 to 11/09/24. On 04/22/25 at 11:51 AM, Certified Medication Aide (CMA) R administered medication to R46. On 04/22/25 at 04:30 PM, SSD X verified the facility had not provided a Bed Hold Notice to R46 or his representative upon discharge to the hospital. He stated he only provided the Bed Hold Notice upon admission to the facility. On 04/22/25 at 4:50 PM, Administrative Staff A verified that the facility should have provided a Bed Hold Notice to the resident or their representative upon discharge or transfer to the hospital. The facility's Bed Hold Policy, undated, documented the facility would inform and give a written copy of this policy to the resident and/or representative upon admission and if transferred to a hospital or during therapeutic leave. The facility's Transfer or Discharge Notice policy, dated December 2016, stated the resident or their representative would be given the facility's Bed Hold policy upon impending transfer or discharge.

The facility had a census of 65 residents. Based on observation, interview, and record review, the facility failed to store medications securely and dispose of expired medications timely. This deficient practice placed residents of the facility at risk for ineffective medication and unsafe access to medications. Findings included: - On 04/21/25 at 08:25 AM, the facility's nurse treatment cart contained one bottle of aspirin (used for pain, fever, and inflammation), 325 milligrams (mg), with an expiration date of 08/2024 and one undated insulin (hormone that lowers the level of glucose in the blood) pen. The observation was verified by Licensed Nurse (LN) I. On 04/21/25 at 08:46 AM, the facility's 300 hall medication cart contained one bottle of biotin (a supplement) 5000 micrograms (mcg) with an expiration date of 03/2025. The expiration date was confirmed by Certified Medication Aide (CMA) R. On 04/22/25 at 02:15 PM, the facility's nurse treatment cart on the 300 hall was unlocked with warfarin (a blood thinner) and other pill medication cards, insulin pens, and breathing treatments accessible. No licensed staff were in sight of the cart for two minutes until the surveyor asked an aide whose cart it was. LN H came around the corner from the other hall and verified she should not have left the cart unlocked. On 04/23/25 at 10:10 AM, the facility's medication room had expired stock medications including: Magnesium chloride (a supplement) 64 mg, one bottle with an expiration date of 02/2025. Folic acid (a supplement) 400 mcg, 6 bottles with an expiration date of 03/2025. On 04/23/25 at 10:19 AM, LN G verified that the magnesium chloride and folic acid had expired dates. On 04/22/25 at 04:40 PM, Administrative Nurse D verified staff should have removed and disposed of the expired medications. Administrative Nurse D verified any cart holding medications should be locked when out of sight of licensed nursing staff. The facility's Storage of Medication policy, dated April 2007, stated that the facility shall not use discontinued or outdated drugs or biologicals, and all such drugs shall be destroyed or returned to the pharmacy. The policy stated that carts, rooms, and cabinets containing drugs and biologicals shall be locked when not in use and shall not be left unattended if open or otherwise potentially available to others.

The facility had a census of 65 residents. The sample included 13 residents, with four reviewed for hospitalization. Based on the record review and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of R43's discharge. This placed the residents at risk for uninformed care choices. Findings included: - R43's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and acute (a condition characterized by a relatively sudden onset of symptoms that are usually severe) respiratory failure (a condition where the lungs can't adequately provide oxygen to the blood or remove carbon dioxide, leading to dangerously low oxygen levels or high carbon dioxide levels). R43's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition. The MDS documented supervision with eating and oral hygiene, dependent toileting, showering, lower body dressing, taking off and putting on footwear, chair to bed, tub/shower transfers, wheel in wheelchair, substantial, maximal assist with upper body dressing, personal hygiene, bed mobility, and toilet transfer. R43's Care Plan, revised 03/13/25, documented R43 received nebulizer treatments related to COPD and acute respiratory failure with hypoxia. The plan instructed staff to administer medications as ordered, assist R43 in learning signs of respiratory compromise, elevate R43's head of bed when R43 allows to promote good breathing, and ensure the nebulizer machine was clean and mouth mouthpiece was bagged when not in use. The plan instructed staff to observe/document R43's changes in orientation, increased restlessness, anxiety, and air hunger. R43's Progress Notes, dated 01/17/25 at 04:28 AM, documented the resident was transferred and admitted to the hospital. R43's clinical record lacked evidence the LTCO was notified of R48's hospital transfer. On 04/22/25 at 12:20 PM, R43 rested in bed on his back, with no signs or symptoms of respiratory distress. On 04/22/25 at 04:30 PM, Social Service X verified it was his responsibility to notify the state LTCO of discharges from the facility, and he had not done that. On 04/22/25 at 04:50 PM, Administrative Staff A verified the facility should have notified the LTCO of the resident discharges each month. The facility's Transfer and Discharge Notice Policy, revised December 2016, documented a copy of R43's transfer to the hospital would be sent to the LTCO.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R) 48's care plan to include the physician-ordered fluid restriction. This placed the resident at risk of fluid overload and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R48 documented diagnoses of hypertension (HTN - elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, angina (chest pain) pectoris, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) recorded R48 had intact cognition, experienced no delirium, or exhibited behaviors. R48 required supervision or touch assistance with functional abilities and mobility. R48 was frequently incontinent of urine and bowel. The MDS further documented that R48 received no high-risk medications. The Functional Abilities Care Area Assessment (CAA) dated 03/04/25 recorded that R48 had impairment related to diagnosis, weakness, and comorbidities (several conditions simultaneously). R48's Care Plan dated 04/16/25, recorded R48 exhibited self-care performance deficit, the inability to control urination, and was frequently incontinent. The care plan directed staff R48 required supervision and set up assistance with eating, toileting, to provide an appropriate diet, and had a scheduled toileting program which consisted of taking R48 to the bathroom at 04:00 AM, at bedtime, 11:00 PM, as well as before and after meals, as R48 would allow. The care plan lacked the physician-ordered fluid restriction. The Physician Order dated 10/23/24, directed staff to implement a fluid restriction of three liters (3000 cubic centimeters - cc's) daily. The order directed the dietary department for the day shift to provide 1500 ccs, and nursing would provide 270 ccs. The evening shift dietary department provided 800 ccs, and nursing could provide 270 ccs, and the night shift nursing provided 160 ccs related to chronic kidney disease. The order for the dietary department would give a total of 2300 ccs, and nursing would provide 700 cc, which totaled 3000 ccs in 24 hours. The Nutritional Progress Note, dated 12/05/24, documented R48 remained on a regular diet with dysphagia (swallowing difficulty), advanced texture, and a fluid restriction of three liters daily. The Weight Change Progress Note dated 03/25/25, documented a decrease in weight trend possibly due to a current urinary tract infection and had a three-liter fluid restriction. The note further documented no edema, no diuretic order, and would see if the fluid restriction could be discontinued. On 04/22/25 at 09:33 AM, staff in R48's room, gathering urine-soiled clothing and bed linens. R48 had a 600-cc jug of ice water on the bedside table and was standing with the walker wearing only a blue incontinent brief, when staff exited the room and left the door open as R48 proceeded to walk to the dresser to obtain clothing, in which staff and visitors could observe R48 wearing only a brief as they passed in the hall. On 04/22/25 at 12:08 PM, Certified Nurse Aide (CNA) M reported she was not aware of a fluid restriction but would check on the restriction with the charge nurse. On 04/22/25 at 12:10 PM, Licensed Nurse (LN) G reported R48 had a fluid restriction but could not recall the amount, but stated the dietary department provided fluids with meals, and R48 should not have a 600-cc ice water mug at the bedside. LN G reported that the charge nurse and CNAs work together to determine the intake for the residents who had fluid restrictions, and the nurse should document the amount of intake on R48, but had not done so for R48. On 04/23/25 at 02:30 PM, Administrative Nurse E stated it was the responsibility of nursing staff to record and monitor the intake of residents on fluid restrictions, and expected the fluid restriction on R48's care plan. The facility's Care Planning-Interdisciplinary Team policy, dated 09/2013, documented the facility's Care Planning/Interdisciplinary Team were responsible for the development of an individualized comprehensive care plan for each resident.

The facility had a census of 65 residents. The sample included 13 residents, with three reviewed for Medicare Liability Notices. Based on the record review and interview, the facility failed to provide the resident (or their representative) a fully completed Advanced Beneficiary Notice (ABN) Centers for Medicare and Medicaid Services (CMS) Form 10055) for skilled services for Resident (R) 12 and R216, which included the estimated cost of services. This placed the residents at risk for uninformed care decisions. Findings included: - The facility provided a CMS Form 10124 to R12 instead of the CMS Form-10055 provided when the skilled services would end on 01/20/25, which informed the R12 that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) Receive the specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but could appeal Medicare. (2) Receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The facility provided a CMS Form 10124 to R216 instead of the Center of Medicare (CMS)-10055 form provided when the skilled services would end on 03/05/25, which informed the R216 that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included an option for the beneficiary to (1) Receive the specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but could appeal Medicare. (2) Receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. On 04/23/25 at 02:30 PM, Administrative Staff A reported the facility had stopped using CMS Form 10055, due to direction from corporate. Upon request, the facility failed to provide a Medicare beneficiary policy.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide assistance in privacy for Residents (R) 44 and R48 who wore incontinent briefs, which were visible from the hallway to visitors, staff, and other residents. This deficient practice placed R48 and 4 for impaired dignity and decreased psychosocial well-being. Finding included: - R44's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin(a hormone that lowers the level of glucose in the blood)), morbid obesity (excessive body fat), major depressive disorder (major mood disorder that causes persistent feelings of sadness), delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, restless leg syndrome, chronic pain, lymphedema (swelling caused by accumulation of lymph), and chronic respiratory failure The Admission Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition, had no delirium, no psychosis (any major mental disorder characterized by a gross impairment in reality perception), nor exhibited behaviors. R44 was dependent with rolling in bed and transfers. R44 was dependent on toileting hygiene, bathing, and upper and lower body dressing. The MDS further documented that R48 was frequently incontinent, had occasional pain which interfered with day-to-day activities, was short of breath with exertion or lying flat, used oxygen, and had falls before entering the facility. The MDS also recorded received insulin, antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), opioid (a class of medications used to treat pain), and hypoglycemic (greater than normal amount of glucose in the blood) medications. The Functional Abilities Care Area Assessment (CAA), dated 03/17/25, documented R44 with impaired abilities due to weakness and comorbidities (the presence of two or more diseases). R44's Interim Plan of Care dated 03/08/25, directed staff to encourage use of the call light due to fall risk, needed partial assistance from another person for functional cognition and setup or clean-up assistance with toileting hygiene, and upper and lower body dressing. The care plan further directed staff that R44 was dependent on bed mobility and personal hygiene. R44's Care Plan, dated 03/24/25, documented that R44 had a behavioral problem utilizing the call light appropriately related to difficulty adjusting to the new environment and had self-care performance deficit, required assistance with decision making, and limited mobility. The care plan directed staff to stop and talk with her as they passed by, but lacked specifics related to how much staff assistance was required for functional abilities. The Progress Note dated 03/08/25 at 05:34 AM documented R44 required a mechanical lift for transfers, two persons for turning, was incontinent of urine and bowel, wore pull-ups, to check every two hours, and change due to heavy wetting. R44 had high anxiety, used the call light to ask for help. The Progress Note dated 03/10/25 at 05:50 AM documented R44 had been very restless overnight, pulling on oxygen tubing, spilling drinks, kicking legs completely out of bed every 20 to 30 minutes, taking her oxygen off, and yelling out instead of using her call light. The Progress Note dated 03/28/25 at 09:48 AM documented speech and occupational therapy to see for mild confusion, cognition, and swallowing goals. The Progress Note dated 04/03/25 at 11:58 PM documented that the psychiatric practitioner recommended utilizing as-needed antianxiety medication for panic/breakthrough anxiety and would follow up in one month. On 04/21/25 at 02:33 PM, ongoing observations revealed R44 had coughing and gagging into a basin in the morning, placing her left leg off the bed, had the lower portion of her body uncovered with her brief and legs visible from the doorway and hall as staff and visitors walked by. No staff assistance until the midday meal was brought to her room. The resident was not assisted with positioning for the meal, the resident remained in bed with the head of the bed only raised 30 degrees. R44 plate and drinks were uncovered and left on the overbed table. R44 lacked assistance with positioning in bed, remained with the head of the bed lowered and ate a few bites, and coughed. On 04/21/25 at 03:01 PM, R44 continued with her left leg off the mattress and hanging, not touching the floor or covered from the waist down, exposing her incontinent brief, which was visualized from the hallway. Staff entered the room and told the resident her leg was hanging, and assisted the resident in putting her leg into the bed and covered the resident. On 04/21/25 at 03:45 PM, R44 had her left leg off the side of the bed and lower body, and an incontinent brief was exposed to staff, visitors, and other residents from the hallway. R44 called out for assistance. R44 stated she could not find her call light and needed her oxygen canula. Social Service Staff X entered the room, found R44's call light, which had been off to the right side of the bed, not within reach of the resident, and provided R44 with oxygen tubing. On 04/21/25 at 04:27 PM, R44 again observed from the hallway with left leg off the bed, lower body uncovered exposing her incontinent brief, and trying to drink with the head of bed at a 30-degree angle, with coughing following taking a drink from her cup. On 04/22/25 at 12:50 PM, staff brought R44's lunch and placed it on the overbed table. R44 was again positioned with the head of the bed at 30 degrees, and no offers to assist R44 into a sitting position for the meal. R44 then moved the plate off the tray and placed it on her abdomen, and tried to take a few bites, then removed the plate and placed it back onto the over-bed table. R44 then attempted to fill her drinking cup with soda from the overbed table while the head of the bed was not elevated. On 04/22/25 at 01:00 PM, R44 stated she relied on staff to adjust her bed, and that she had difficulty managing the bed controls. The bed controls on the right side of the bed, fastened on the bedrail, were not functioning when R44 tried adjusting the bed herself. R44 ' s call light was not within reach of the resident. Social Service Staff X entered the room and found the bed controls not working and placed the call light within reach of the resident. Social Service Staff X reported that he would see that the bed control would be fixed. On 04/22/25 at 03:44 PM, Certified Nurse Aide (CNA) N brought a pizza box into the room and left it on the overbed table. R44, again with the head of the bed lowered to a 30-degree angle, placed the pizza on her abdomen and started to eat it. On 04/22/25 at 03:51 PM, Administrative Staff A, while visualizing R44's head of the bed lowered and trying to eat the pizza, stated R44's position was not safe for eating or drinking and did not accommodate safe swallowing. On 04/23/25 at 01:30 PM, R44 sat in the recliner and called out for assistance. The call light was not within reach, and R44 reported staff had moved it earlier when picking up her meal tray. On 04/23/25 at 02:20 PM, Administrative Nurse E stated staff should assist residents as needed to protect the resident's privacy with closing doors and covering the residents. The facility's Quality of Life-Dignity policy, dated 08/2009, documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and treatment procedures. - R48's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN - elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, angina (chest pain) pectoris, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) recorded R48 had intact cognition, experienced no delirium, or exhibited behaviors. R48 required supervision or touching assistance with functional abilities and mobility. R48 was frequently incontinent of urine and bowel. The MDS further documented R48 received no high-risk medications. The Functional Abilities Care Area Assessment (CAA) dated 03/04/25 recorded that R48 had impairment related to diagnosis, weakness, and comorbidities (several conditions simultaneously). R48's Care Plan dated 04/16/25, recorded R48 exhibited self-care performance deficit, the inability to control urination, and was frequently incontinent. The care plan directed staff R48 required supervision and set up assistance with eating, toileting, to provide an appropriate diet, and had a scheduled toileting program which consisted of taking R48 to the bathroom at 04:00 AM, at bedtime, 11:00 PM, as well as before and after meals, as R48 would allow. On 04/22/25 at 07:50 AM, R48 remained in bed, covered with a blanket, clothing lying on the floor, and the room smelled of urine. On 04/22/25 at 09:33 AM, staff in R48's room gathered urine-soiled clothing and bed linens. R48 had a 600 cc jug of ice water on the bedside table and was standing with the walker wearing only a blue incontinent brief. When staff exited the room and left the door open as R48 proceeded to walk to the dresser to obtain clothing, in which staff and visitors could observe R48 wearing only a brief as they passed in the hall. On 04/23/25 at 02:20 PM, Administrative Nurse E stated staff should assist residents as needed to protect the resident's privacy with closing doors and covering the residents. The facility's Quality of Life-Dignity policy, dated 08/2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and treatment procedures.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide activities of daily living support for Resident (R) 44 and R48, who required assistance from staff. This placed the residents at risk for ongoing unmet needs and care. Findings included: - R44's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin(a hormone that lowers the level of glucose in the blood)), morbid obesity (excessive body fat), major depressive disorder (major mood disorder that causes persistent feelings of sadness), delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, restless leg syndrome, chronic pain, lymphedema (swelling caused by accumulation of lymph), and chronic respiratory failure The Admission Minimum Data Set (MDS), dated [DATE], documented R44 had intact cognition, had no delirium, psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors, was dependent with rolling in bed and transfers. R44 was dependent on toileting hygiene, bathing, and upper and lower body dressing. The MDS further documented that R48 was frequently incontinent, had occasional pain which interfered with day-to-day activities, was short of breath with exertion or lying flat, used oxygen, and had falls before entering the facility. The MDS also recorded received insulin, antianxiety (a class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), opioid (a class of medications used to treat pain), and hypoglycemic (greater than normal amount of glucose in the blood) medications. The Functional Abilities Care Area Assessment (CAA), dated 03/17/25, documented R44 with impaired abilities due to weakness and comorbidities (the presence of two or more diseases). R44's Interim Plan of Care, dated 03/08/25, directed staff to encourage use of the call light due to fall risk, needed partial assistance from another person for functional cognition and setup or clean-up assistance with toileting hygiene, and upper and lower body dressing. The care plan further directed staff that R48 was dependent on bed mobility and personal hygiene. R44's Care Plan, dated 03/24/25, documented that R44 had a behavioral problem utilizing the call light appropriately related to difficulty adjusting to the new environment and had self-care performance deficit, required assistance with decision making, and limited mobility. The care plan directed staff to stop and talk with her as they passed by, but lacked specifics related to how much staff assistance was required for functional abilities. The Progress Note dated 03/08/25 at 05:34 AM documented R44 required a mechanical lift for transfers, two persons for turning, was incontinent of urine and bowel, wore pull-ups, to check every two hours, and change due to heavy wetting. R48 had high anxiety, used the call light to ask for help. The Progress Note dated 03/10/25 at 05:50 AM documented R44 had been very restless overnight, pulling on cord/oxygen tubing, spilling drinks, kicking legs completely out of bed every 20 to 30 minutes, taking her oxygen off, and yelling out instead of using her call light. The Progress Note dated 03/28/25 at 09:48 AM documented speech and occupational therapy to see for mild confusion, cognition, and swallowing goals. The Progress Note dated 04/03/25 at 11:58 PM documented that the psychiatric practitioner recommended utilizing as-needed antianxiety medication for panic/breakthrough anxiety and would follow up in one month. On 04/21/25 at 02:33 PM, ongoing observations revealed R48 had coughing and gagging into a basin in the morning, placing her left leg off the bed, had the lower portion of her body uncovered with a brief, and legs visible from the doorway and hall as staff and visitors walked by. No staff assistance until the midday meal was brought to her room. The resident was not assisted with positioning for the meal, the resident remained with the head of the bed, and was only raised 30 degrees. R48 plate and drinks were uncovered and left on the overbed table. R44 lacked assistance with positioning in bed, remained with the head of the bed lowered, ate a few bites, and coughed. On 04/21/25 at 03:01 PM, R44 continued with her left leg off the mattress and hanging, not touching the floor or covered from the waist down, exposing her incontinent brief, which was visualized from the hallway. Staff entered the room and told the resident her leg was hanging, and assisted the resident in putting her leg into the bed and covered the resident. On 04/21/25 at 03:45 PM, R44 had her left leg off the side of the bed and lower body, and an incontinent brief was exposed to staff, visitors, and other residents from the hallway. R48 called out for assistance. R48 stated she could not find her call light and needed her oxygen canula. Social Service Staff X entered the room, found R44's call light, which had been off to the right side of the bed, not within reach of the resident, and provided R44 with oxygen tubing. On 04/21/25 at 04:27 PM, R44 again observed from the hallway with left leg off the bed, lower body uncovered exposing her incontinent brief, and trying to drink with the head of bed at a 30-degree angle, with coughing following taking a drink from her cup. On 04/22/25 at 12:50 PM, staff brought R44's lunch and placed it on the overbed table. R44 was again positioned with the head of the bed at 30 degrees, and no offers to assist R48 into a sitting position for the meal. R44 then moved the plate off the tray and placed it on her abdomen, and tried to take a few bites, then removed the plate and placed it back onto the over-bed table. R48 then attempted to fill her drinking cup with soda from the overbed table while the head of the bed was not elevated. On 04/22/25 at 01:00 PM, R44 stated she relied on staff to adjust her bed, and that she had difficulty managing the bed controls. The bed controls on the right side of the bed, fastened on the bedrail, were not functioning when R48 tried adjusting the bed herself. R44's call light was not within reach of the resident. Social Service Staff X entered the room and found the bed controls not working, and placed the call light within reach of the resident. Social Service Staff X reported that he would see that the bed control would be fixed. On 04/22/25 at 03:44 PM, Certified Nurse Aide (CNA) N brought a pizza box into the room and left it on the overbed table. R44, again with the head of the bed lowered to a 30-degree angle, placed the pizza on her abdomen and started to eat it. On 04/22/25 at 03:51 PM, Administrative Staff A, while visualizing R44's head of the bed lowered and trying to eat the pizza, stated R44's position was not safe for eating or drinking and did not accommodate safe swallowing. On 04/23/25 at 01:30 PM, R44, while sitting in the recliner, called out for assistance. The call light was not within reach, and R44 reported staff had moved it earlier when picking up her meal tray. The facility's Repositioning policy, dated 05/2013, documented the purpose of the procedure was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for al bed or chair-bound residents, to prevent skin breakdown, promote circulation, and provide pressure relief for residents. A turning/repositioning program includes a continuous, consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated. Upon request, the facility failed to provide a policy for activities of daily living support. - The Electronic Medical Record (EMR) for R48 documented diagnoses of hypertension (HTN - elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, angina (chest pain) pectoris, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) recorded R48 had intact cognition, experienced no delirium, or exhibited behaviors. R44 requires supervision or touching assistance with functional abilities and mobility. R48 was frequently incontinent of urine and bowel. The MDS further documented that R48 received no high-risk medications. The Functional Abilities Care Area Assessment (CAA) dated 03/04/25 recorded that R48 had impairment related to diagnosis, weakness, and comorbidities (several conditions simultaneously). R48's Care Plan dated 04/16/25, recorded R48 exhibited self-care performance deficit, the inability to control urination, and was frequently incontinent. The care plan directed staff R48 required supervision and set up assistance with eating, toileting, to provide an appropriate diet, and had a scheduled toileting program which consisted of taking R48 to the bathroom at 04:00 AM, at bedtime, 11:00 PM, as well as before and after meals, as R48 would allow. The care plan lacked the physician-ordered fluid restriction. The Weight Change progress note, dated 0/25/25, documented a decrease in weight trend possibly due to a current urinary tract infection and had a three-liter fluid restriction. The note further documented no edema, no diuretic order, and would see if the fluid restriction could be discontinued. On 04/22/25 at 07:50 AM, R48 remained in bed, covered with a blanket, clothing lying on the floor, and the room smelled of urine. On 04/22/25 at 09:33 AM, staff in R48's room gathered urine-soiled clothing and bed linens. R48 had a 600-cc jug of ice water on the bedside table and was standing with the walker wearing only a blue incontinent brief. The staff exited the room and left the door open. R48 proceeded to walk to the dresser to obtain clothing, in which staff and visitors could observe R48 wearing only a brief as they passed in the hall. On 04/23/25 at 02:20 PM, Administrative Nurse E stated staff should assist the residents as needed and to protect their privacy by ensuring the residents are dressed, covered, or have their doors closed. Upon request, the facility failed to provide a policy for activities of daily living support.

The facility had a census of 65 residents. The sample included 13 residents, with four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine into a collection bag) or urinary tract infection (UTI - an infection in any part of the urinary system). Based on observation, interview, and record review, the facility failed to provide urinary catheter care in a manner to prevent urinary tract infections for Resident (R) 12. This deficient practice placed R12 at risk for infections and catheter-related complications. Findings included: - R12's Electronic Medical Record documented diagnoses of cerebral infarction (stroke), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and infection due to an indwelling urinary catheter. R12's Annual Minimum Data Set (MDS), dated [DATE], documented R12 had severely impaired cognition. The MDS documented R12 required moderate assistance for toileting, had a urinary catheter, and received antibiotic and diuretic (medication to promote the formation and excretion of urine) medications. R12's Care Plan, dated 03/27/25, directed staff to change the 18 French catheter as ordered, check for patency and urinary output every shift, and observe for pain or discomfort due to the catheter. Staff were to check the catheter tubing for kinks, position the catheter bag and tubing below the level of the bladder, and obtain and document the output every shift. On 04/21/25 at 03:14 PM, R12 was seated in her wheelchair in the dining room. The catheter bag was in a privacy bag hung to dependent drainage under the wheelchair. Approximately four inches of catheter tubing rested on the floor when her foot was on the floor. On 04/23/25 at 07:45 AM, R12 was seated in her wheelchair in the dining room. The catheter bag was in a privacy bag hung to dependent drainage under the wheelchair. Approximately one inch of catheter tubing rested on the floor. On 04/22/25 at 01:13 PM, Administrative Nurse D verified she expected staff to be aware and not allow the tubing to rest or drag on the floor. The facility's Urinary Catheter Care policy, dated September 2014, directed staff to be sure the catheter tubing and drainage bag were kept off the floor.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to monitor Resident (R) 48's physician order for fluid restriction. This placed R48 at risk of complications related to hydration status due to the resident's cardiac status. Findings included: - The Electronic Medical Record (EMR) for R48 documented diagnoses of hypertension (HTN-elevated blood pressure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, angina (chest pain) pectoris, delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Annual Minimum Data Set (MDS) recorded R48 had intact cognition, experienced no delirium, or exhibited behaviors. R44 requires supervision or touching assistance with functional abilities and mobility. R48 was frequently incontinent of urine and bowel. The MDS further documented that R48 received no high-risk medications. The Functional Abilities Care Area Assessment (CAA) dated 03/04/25 recorded that R48 had impairment related to diagnosis, weakness, and comorbidities (several conditions simultaneously). R48's Care Plan dated 04/16/25, recorded R48 exhibited self-care performance deficit, the inability to control urination, and was frequently incontinent. The care plan directed staff R48 required supervision and set up assistance with eating, toileting, to provide an appropriate diet, and had a scheduled toileting program which consisted of taking R48 to the bathroom at 04:00 AM, at bedtime, 11:00 PM, as well as before and after meals, as R48 would allow. The care plan lacked the physician-ordered fluid restriction. The Physician Order dated 10/23/24, directed staff to implement a fluid restriction of three liters (3000 cubic centimeters (cc)) daily. The order directed the dietary department for the day shift to provide 1500 cc, and nursing would provide 270 cc. The evening shift dietary department provides 800 cc, and nursing could provide 270 cc, and the night shift nursing provides 160 cc related to chronic kidney disease. The order for the dietary department would give a total of 2300 cc, and nursing would provide 700 cc, which totaled 3000 cc in 24 hours. The Nutritional Progress Note, dated 12/05/24, documented R48 remained on a regular diet with dysphagia (swallowing difficulty), advanced texture, and a fluid restriction of three liters daily. The Weight Change progress note, dated 0/25/25, documented a decrease in weight trend possibly due to a current urinary tract infection and had a three-liter fluid restriction. The note further documented no edema, no diuretic order, and would see if the fluid restriction could be discontinued. On 04/22/25 at 07:50 AM, R48 remained in bed, covered with a blanket, clothing lying on the floor, and the room smelled of urine. On 04/22/25 at 09:33 AM, staff in R48's room gathered urine-soiled clothing and bed linens. R48 had a 600-cc jug of ice water on the bedside table and was standing with the walker wearing only a blue incontinent brief. When staff exited the room and left the door open as R48 proceeded to walk to the dresser to obtain clothing, in which staff and visitors could observe R48 wearing only a brief as they passed in the hall. On 04/22/25 at 12:08 PM, Certified Nurse Aide (CNA) M reported she was not aware of a fluid restriction but would check on the restriction with the charge nurse. On 04/22/25 at 12:10 PM, Licensed Nurse (LN) G reported R48 had a fluid restriction but could not recall the amount, but stated the dietary department provided fluids with meals, and R48 should not have a 600 cc ice water mug at the bedside. LN G reported that the charge nurse and CNAs work together to determine the intake for the residents who had fluid restrictions, and the nurse should document the amount of intake on R48, but had not done so for R48. On 04/23/25 at 02:30 PM, Administrative Nurse E stated it was the responsibility of nursing staff to record and monitor the intake of residents on fluid restrictions, and expected the fluid restriction on R48's care plan. The facility's Encouraging and Restricting Fluids policy, dated 10/2010, documents that the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. General guidelines direct staff to follow specific instructions concerning food intake or restriction. The general guidelines documented the instructions concerning fluid intake or restriction. Record intake of fluids. When a resident has been placed on fluids, remove the water pitcher and cup from the room. If the resident refuses to have a water pitcher and cup from the room.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to obtain an appropriate indication or the required physician documentation for the continued use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication for R42. This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and potential adverse effects. Findings included: - R42's Electronic Medical Record documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and generalized anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear). R42's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS documented R42 displayed physical, verbal, wandering, and rejection of care behaviors. The MDS documented R42 required maximum staff assistance for all activities of daily living. R42 received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and opioid (narcotic) medications routinely. R42's Care Plan, dated 02/20/25, directed staff to assess R42 for the need to reside in a secure unit upon admission, quarterly, and as needed or appropriate. The care plan further instructed staff to promote an environment conducive to social interaction and provide opportunities for expression of feelings, thoughts, and stressors to assist with coping. R42's Physician Order, dated 03/09/25, directed staff to administer Zyprexa (antipsychotic medication), 5 milligrams (mg) at bedtime for a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). On 04/22/25 at 11:51 AM, Certified Medication Aide (CMA) R administered medication in pudding to R42, who took the pills whole without problems. On 04/23/25 at 11:06 AM, Consultant Nurse GG verified Zyprexa was not approved by the Center for Medicare and Medicaid Services (CMS) for a diagnosis of depression. The facility's Antipsychotic Medication Use policy, dated April 2007, stated that antipsychotic medication therapy would only be used when necessary to treat a specific condition for which they are indicated and effective.

The facility had a census of 65 residents. The sample included 13 residents, with one reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R) 18, who admitted to hospice on 02/25/25, which included a plan of care and a description of the services provided, such as contact information, visit frequency, medications, and medical equipment. This placed the resident at risk of not receiving needed care. Findings included: - R18's Electronic Health Record (EHR) revealed diagnoses of sarcopenia (a condition characterized by the progressive decline of skeletal muscle mass, strength, and function) and transient ischemic attack (TIA - temporary episode of inadequate blood supply to the brain). R18's Significant Change Minimum Data Set (MDS), dated [DATE], documented R18 had a Brief Interview of Mental Status (BIMS) of 12, which indicated moderately impaired cognition. The MDS documented R18 required staff supervision with eating, oral hygiene, rolling left to right in bed, wheeling in a wheelchair, partial, moderate staff assistance with toileting, showering, upper and lower body dressing, sit to lying and lying to sitting in bed, and transfers. The MDS documented R18 received hospice services. R18's Care Plan, dated 03/20/25, documented R18 required extensive assistance with most activities of daily living (ADL) care. The plan documented R18 had a terminal prognosis related to diagnoses of sarcopenia and TIA and was admitted to hospice services on 02/25/25. The plan instructed staff to adjust provision of ADLs to compensate for residents' changing abilities, encourage R18 to participate to the extent the resident wishes to participate, assess R18 for coping strategies and respect resident wishes, encourage resident to express her feelings, and listen with non-judgment. The plan instructed staff to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. The plan lacked instructions on the services provided by hospice, including the frequency and type of support visits, supplies, and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of R18's clinical record revealed the resident was admitted to hospice care on 02/25/25. The Hospice Skilled Nursing Facility Contract dated December 2022, documented the nursing facility plan of care shall mean a written care plan established, maintained, reviewed, and modified, if necessary, by the nursing facility's interdisciplinary team (IDT) with the participation of the hospice patient. The nursing facility plan of care shall be consistent with the hospice plan of care for the hospice patient. On 04/21/25 at 02:40 PM, R18 sat quietly in a recliner in her room without signs and symptoms of pain. On 04/23/25 at 10:26 AM, Administrative Nurse F stated she oversaw updating care plans and verified R18's care plan lacked hospice contact information, medications provided by hospice, supplies, and equipment hospice would provide, visitations, and care they would provide. Administrative Nurse F stated she did not put that information on a hospice resident's care plan. On 04/23/25 at 10:50 AM, Consultant Staff GG verified R18's care plan lacked the services provided by hospice, including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. Consultant Staff GG stated that staff had not placed this information on the facility care plan; they could get it from the hospice care plan kept at the nurse's station. The facility's Hospice Program Policy, updated August 2010, documented that when a resident participated in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family would be developed and should include directives for managing pain and other uncomfortable symptoms.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to ensure R43's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) tubing and uncovered bag off the floor. Findings included: - R43's Electronic Medical Record (EMR) documented that R43 had diagnoses of obstructive and reflux uropathy (a condition where the normal flow of urine through the urinary tract is blocked, while reflux uropathy (vesicoureteral reflux or VUR) is when urine flows backward from the bladder to the ureters (small tubular structure that drains urine from the bladder) and kidneys (a pair of organs in the abdomen which remove waste and extra water from the blood (as urine) and help keep chemicals (such as sodium, potassium, and calcium) balanced in the body) instead of flowing forward). R43's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R43 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R43 had a urinary catheter, occasional incontinence of urine, and no urinary tract infection (UTI - infection in any part of the urinary system). R43's Care Plan, revised 03/13/25, instructed staff to provide R43 assistance with toileting. The plan documented the resident had a urinary catheter and instructed staff to change the catheter as ordered, check for patency and urinary output every shift, and check the tubing for kinks The plan instructed staff to observe, report to the physician any signs or symptoms of UTI, and position R43's catheter bag and tubing below the level of the bladder On 04/21/25 at 11:15 AM, R43 sat in a wheelchair in the commons area at the front of the facility. Certified Nurse Aide (CNA) M turned the resident's wheelchair around, the wheelchair wheel caught on the urinary catheter tubing, the catheter drainage bag came out of the privacy bag, and landed on the floor. CNA M placed the catheter drainage bag back in the privacy bag on the wheelchair and propelled the resident to the dining room table, with the catheter tubing touching the floor. On 04/22/25 at 01:40 PM, Administrative Nurse E stated she would expect staff to change out R43's urinary catheter drainage bag and tubing if they touched the floor. The facility's Catheter Care, Urinary Policy, revised September 2014, instructed staff to ensure the catheter tubing and drainage bag were kept off the floor.

The facility had a census of 65 residents. The sample included 13 residents. Based on the interview and record review, the facility failed to offer pneumococcal (type of bacterial infection) PCV20 immunizations for Residents (R)3, R18, and R39, per the guidance from the Centers for Disease Control and Prevention (CDC). This placed the resident at risk for pneumococcal infection. Findings included: - R3's Electronic Medical Record (EMR) documented R3 received one Prevnar 13 dose on 04/30/15. The facility lacked documentation of whether R3 was offered or refused any further pneumococcal vaccinations. R18's EMR documented R18 received one Prevnar 13 dose on 03/12/15. The facility lacked documentation of whether R18 was offered or refused any further pneumococcal vaccinations. R39's EMR lacked pneumococcal information, whether R29 was offered, or refused any pneumococcal vaccinations. On 04/23/25 at 02:06 PM, Administrative Nurse E stated she was not aware of the CDC guidance related to the PCV 20 immunization. The facility's Pneumococcal Vaccine policy, dated 08/2016, documents all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The administration of the pneumococcal vaccines or revaccinations will be made following the current CDC recommendations at the time of the vaccination.

The facility identified a census of 63 residents, with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to obtain the as needed (PRN) pain medicine prescribed to Resident (R) 1 after a total hip replacement. The facility further failed to follow R1's discharge orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's Electronic Medical Record as needed, requiring R1 to ask for the pain medication. On 02/11/25, R1 admitted to the facility for skilled care for rehabilitation after a total hip replacement. The orders from the surgical center documented R1 was to receive 5 milligrams (mg) of oxycodone (pain medication) as needed every six hours, acetaminophen 1000 mg every six hours scheduled, and an order to discontinue the Norco (pain medication) 5/325 mg. The facility failed to try to obtain the oxycodone 5 mg medication until the following day, Saturday, 02/12/25. The local pharmacy did not have any oxycodone. Instead of checking with twelve other pharmacies in town to see if they had oxycodone 5 mg, they had the medical director prescribe Norco 5/325 mg every six hours as needed. R1 told nursing staff multiple times over the weekend she was taking oxycodone 5 mg as needed and Norco 5/325 mg as needed at home before her hip replacement, and the Norco 5/325 mg did not help her pain. Staff did nothing to help alleviate R1's pain over the weekend after a Friday admission. This deficient practice placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment. Findings included: - R1's EMR documented R1 had diagnoses of aftercare following a joint replacement surgery, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R1's Entry Tracking Record Minimum Data Set (MDS), dated [DATE], documented R1 admitted from a short-term hospital and was in the facility for a Medicare-covered stay. R1's Care Plan, dated 02/18/25, documented R1 had acute pain related to postoperative right hip discomfort. The care plan directed facility staff to administer pain medication per physician orders, anticipate R1's need for pain relief, and respond immediately to any complaint of pain, notify R1's physician if interventions were not successful, or if R1's current pain was a significant change from her past experience of pain. The care plan documented R1 required setup/supervision assistance for all activities of daily living (ADL). The Surgical Discharge Instruction, dated 02/14/25, documented R1 could walk as tolerated, use a walker as instructed for four to six weeks following surgery, and use a walker as long as R1 felt unsteady. R1 could use stairs as instructed by physical therapy. R1 was not to flex her right hip more than a right angle or ninety degrees for six weeks, avoid low chairs or sofas, and R1 could sit in a recliner or hard chair. R1 may need to use a high-rise toilet seat; R1 was not to cross her legs for six weeks after surgery. R1's discharge instructions documented R1 was to take acetaminophen 1000 mg by mouth every six hours scheduled, and the last time R1 took the medication was 02/14/25 at 10:00 AM, oxycodone 5 mg by mouth every six hours as needed for pain. The discharge instructions documented R1 was to discontinue Norco 5mg/325mg every four hours as needed for pain. R1's Medication Administration Record (MAR) for February 2025 documented Norco 5/325 mg, give one tablet every six hours as needed for pain with a start date of 02/14/25 and a discontinued date of 02/16/25. R1 received Norco 5/325 mg twice on 02/15/25 once at midnight and once at 08:32 PM. The MAR documented oxycodone 5 mg every four hours by mouth as needed for pain with a start date of 02/14/25. The oxycodone 5 mg was not given until 02/17/25 at 09:33 PM and again on 02/18/25 at 10:39 PM. The MAR documented acetaminophen 1000 mg by mouth every six hours as needed for pain with a start date of 02/14/25. The acetaminophen was given one time on 02/14/25 at 07:38 PM. The Health Status Note, dated 02/14/25 at 12:00 PM, documented R1 arrived at the facility at 11:00 AM from the surgical hospital after having a right hip replacement. The Social Service Note, dated 02/14/25 at 12:27 PM, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The note documented R1 did not have any signs of depression, and discharge planning had begun for R1 to go home with home health services. The Daily Skilled Note, dated 02/14/25 at 11:46 PM, documented R1 was alert and oriented, able to make needs known, had as needed Norco for pain control, and R1 was resting with her call light in reach. The Health Status Note, dated 02/15/25 at 12:16 AM, documented per Administrative Nurse D to continue Norco 5/325mg one tab every six hours as needed. The Daily Skilled Note, dated 02/15/25 at 09:55 AM, documented R1 was upset the way her pain was being handled because she did not feel Norco would hold her pain like the oxycodone did. The Health Status Note, dated 02/15/25 at 01:27 PM, documented the facility nurse was told in report R1 had oxycodone 5 mg at a local pharmacy which needed picked up. Facility staff went to the local pharmacy and the pharmacy did not have a prescription for oxycodone as it had been discontinued due to being on a different pain medication. The note documented staff would continued to use Norco as needed. The note documented there was an order in R1's MAR for oxycodone that came from the hospital. R1 told the nurse she took both pain medications at home. The medical director sent over a prescription for Norco which was available in the facility in the Cubex (medication dispensing machine). R1 stated Norco does not work as well as the oxycodone. The note documented facility staff would continue to use as needed Norco until clarification was obtained on oxycodone versus Norco, but R1's pain was being taken care of. The Daily Skilled Note, dated 02/15/25 at 07:33 PM, documented R1 was upset about her pain medication orders. R1 stated she was almost crying due to hurting so bad. Staff utilized as needed Norco at the time of assessment, and R1 was encouraged to ask for a pain pill at the onset of pain. The Daily Skilled Note, dated 02/16/25 at 08:53 AM, documented R1 was upset with the way her pain was being handled because she did not feel the Norco held her pain like oxycodone. The nurse had to educate R1 on asking for the pain medication as it was not scheduled. The night nurse reported R1 was in tears last night due to being in pain. R1 verbalized understanding. The Health Status Note, dated 02/16/25, documented the medical director reached out to facility staff about R1's pain medication. The medical director discontinued the as needed Norco and directed staff to just do as needed oxycodone. The medical director sent the prescription to Pharm Script for the oxycodone. R1 was told of the order. The Facility Medication Review Report, signed by the facility's medical director on 02/17/25, documented R1 had acetaminophen 1000 mg every six hours as needed for pain, Norco 5/325 mg every six hours as needed for pain, and oxycodone 5 mg every four hours as needed for pain. On 02/19/25 at 10:30 AM, observation revealed R1 sat in a hard-backed chair, legs at a ninety-degree angle, and reading a book. R1 had her call light and water within reach. R1's lights were off, the window shades were open, and the television was off. On 02/19/25 at 10:30 AM, R1 stated she was very upset with the facility for how her pain was managed the first three days at the facility. R1 stated she had Norco and oxycodone prescribed for her to take at home for pain, and Norco never worked to help alleviate her pain. R1 stated oxycodone helped her pain. R1 stated she tried repeatedly to tell the nurses Norco did not work for her, but they would not listen. R1 stated the first three nights she was in the facility, she was in tears every night and could not sleep due to the pain. R1 stated she did not understand how the staff expected her to participate in rehabilitation when her pain was not under control. R1 stated the only reason she was at the facility was for rehabilitation. R1 stated she just wanted to go home with home health and not be in the facility anymore. On 02/19/25 at 11:00 AM, Administrative Nurse D stated she was not aware R1's pain was not relieved over the weekend. Administrative Nurse D stated she knew there had been a problem getting the oxycodone from the local pharmacy as the pharmacy was out of oxycodone. Administrative Nurse D verified there were numerous other pharmacies in town, and staff did not reach out to any other pharmacy to get R1's oxycodone filled but instead had the medical director order Norco. Administrative Nurse D verified R1's acetaminophen 1000 mg every six hours had been ordered scheduled for R1 from the surgical hospital, and the facility staff had input the order in the MAR incorrectly. Administrative Nurse D stated she expected facility staff to help alleviate residents' pain and if residents' pain was not under control, to call and get different orders. On 02/19/25 at 11:30 AM, Administrative Staff A stated R1 admitted to the facility on a Friday, late in the afternoon. Administrative Staff A stated the facility got their medication from a pharmacy company out of another town a couple of hours away, and facility staff had reached out to one of the local pharmacies to obtain R1's medications otherwise, R1's medications would not have been delivered to the facility until 03:00 AM Sunday, 02/16/25. The facility's Pain - Clinical Protocol, revised April 2009, documented the physician and staff will identify individuals who have pain or who are at risk for pain. The nursing staff will assess each individual for pain upon admission, at the quarterly review, upon a change of condition, new or worsening of existing pain. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. The staff will discuss significant changes in the level of comfort with the attending physician, who will consider adjusting interventions accordingly. With input from the resident, the physician and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, or sleep. The facility failed to obtain the as needed pain medicine R1 was prescribed after a total hip replacement. The facility further failed to follow R1's dismissal orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's EMR for as needed, requiring R1 to ask for the pain medication without her knowledge. This deficient practice placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment.

The facility identified a census of 63 residents, with three residents reviewed for pain. Based on record review, observation, and interview, the facility failed to obtain the as-needed (PRN) pain medicine prescribed to Resident (R) 1 after a total hip replacement. The facility further failed to follow R1's discharge orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's Electronic Medical Record (EMR) as needed, requiring R1 to ask for the pain medication. These significant medication errors placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment. Findings included: - R1's EMR documented R1 had diagnoses of aftercare following a joint replacement surgery, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R1's Entry Tracking Record Minimum Data Set (MDS) dated [DATE], documented R1 admitted from a short-term hospital and was in the facility for a Medicare-covered stay. R1's Care Plan, dated 02/18/25, documented R1 had acute pain related to postoperative right hip discomfort. The care plan directed facility staff to administer pain medication per physician orders, anticipate R1's need for pain relief, respond immediately to any complaint of pain, notify R1's physician if interventions were not successful, or if R1's current pain was a significant change from her past experience of pain. The care plan documented R1 required setup/supervision assistance for all activities of daily living (ADL). The Surgical Discharge Instruction, dated 02/14/25, documented R1 could walk as tolerated, use a walker as instructed for four to six weeks following surgery, and use a walker as long as R1 felt unsteady. R1 could use stairs as instructed by physical therapy. R1 was not to flex her right hip more than a right angle or ninety degrees for six weeks, avoid low chairs or sofas, and R1 could sit in a recliner or hard chair. R1 may need to use a high-rise toilet seat; R1 was not to cross her legs for six weeks after surgery. R1's discharge instructions documented R1 was to take acetaminophen 1000 mg by mouth every six hours scheduled, and the last time R1 took the medication was 02/14/25 at 10:00 AM, oxycodone 5 mg by mouth every six hours as needed for pain. The discharge instructions documented R1 was to discontinue Norco 5 mg/325 mg every four hours as needed for pain. R1's Medication Administration Record (MAR) for February 2025 documented Norco 5/325 mg, give one tablet every six hours as needed for pain with a start date of 02/14/25 and a discontinued date of 02/16/25. R1 received Norco 5/325 mg twice on 02/15/25 once at midnight and once at 08:32 PM. The MAR documented oxycodone 5 mg every four hours by mouth as needed for pain with a start date of 02/14/25. The oxycodone 5 mg was not given until 02/17/25 at 09:33 PM and again on 02/18/25 at 10:39 PM. The MAR documented acetaminophen 1000 mg by mouth every six hours as needed for pain with a start date of 02/14/25. The acetaminophen was given one time on 02/14/25 at 07:38 PM. The Health Status Note, dated 02/14/25 at 12:00 PM, documented R1 arrived at the facility at 11:00 AM from the surgical hospital after having a right hip replacement. The Social Service Note, dated 02/14/25 at 12:27 PM, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The note documented R1 did not have any signs of depression, and discharge planning had begun for R1 to go home with home health services. The Daily Skilled Note, dated 02/14/25 at 11:46 PM, documented R1 was alert and oriented, able to make needs known, had as-needed Norco for pain control, and R1 was resting with her call light in reach. The Health Status Note, dated 02/15/25 at 12:16 AM, documented per Administrative Nurse D to continue Norco 5/325mg one tab every six hours as needed. The Daily Skilled Note, dated 02/15/25 at 09:55 AM, documented R1 was upset with the way her pain was being handled because she did not feel Norco would hold her pain like the oxycodone did. The Health Status Note, dated 02/15/25 at 01:27 PM, documented the facility nurse was told in report R1 had oxycodone 5 mg at a local pharmacy, which needed to be picked up. Facility staff went to the local pharmacy and the pharmacy did not have a prescription for oxycodone as it had been discontinued due to being on a different pain medication. The note documented staff continued to use Norco as needed. The note documented there was an order in R1's MAR for oxycodone that came from the hospital. R1 told the nurse she took both pain medications at home. The medical director sent over a prescription for Norco which was available in the facility in the Cubex (medication dispensing machine). R1 stated Norco did not work as well as the oxycodone. The note documented facility staff would continue to use as-needed Norco until clarification was obtained on oxycodone versus Norco, but R1's pain was being taken care of. The Daily Skilled Note, dated 02/15/25 at 07:33 PM, documented R1 was upset about her pain medication orders. R1 stated she was almost crying due to hurting so bad. Staff utilized as-needed Norco at the time of assessment, and R1 was encouraged to ask for a pain pill at the onset of pain. The Daily Skilled Note, dated 02/16/25 at 08:53 AM, documented R1 was upset with the way her pain was being handled because she did not feel the Norco held her pain like oxycodone. The nurse had to educate R1 on asking for the pain medication as it was not scheduled. The night nurse reported R1 was in tears the prior night due to being in pain. R1 verbalized understanding. The Health Status Note, dated 02/16/25, documented the medical director reached out to facility staff about R1's pain medication. The medical director discontinued the as-needed Norco and directed staff to just do as needed oxycodone. The medical director sent the prescription to Pharm Script for the oxycodone. R1 was told of the order. The Facility Medication Review Report, signed by the facility's medical director on 02/17/25, documented R1 had acetaminophen 1000 mg every six hours as needed for pain, Norco 5/325 mg every six hours as needed for pain, and oxycodone 5 mg every four hours as needed for pain. On 02/19/25 at 10:30 AM, observation revealed R1 sat in a hard-backed chair, legs at a ninety-degree angle, and reading a book. R1 had her call light and water within reach. R1's lights were off, the window shades were open, and the television was off. On 02/19/25 at 10:30 AM, R1 stated she was very upset with the facility for how her pain was managed the first three days at the facility. R1 stated she had Norco and oxycodone prescribed for her to take at home for pain, and Norco never worked to help alleviate her pain. R1 stated oxycodone helped her pain. R1 stated she tried repeatedly to tell the nurses Norco did not work for her, but they would not listen. R1 stated the first three nights she was in the facility; she was in tears every night and could not sleep due to the pain. R1 stated she did not understand how the staff expected her to participate in rehabilitation when her pain was not under control. R1 stated the only reason she was at the facility was for rehabilitation. R1 stated she just wanted to go home with home health and not be in the facility anymore. On 02/19/25 at 11:00 AM, Administrative Nurse D stated she was not aware R1's pain was not relieved over the weekend. Administrative Nurse D stated she knew there had been a problem getting the oxycodone from the local pharmacy as the pharmacy was out of oxycodone. Administrative Nurse D verified there were numerous other pharmacies in town, and staff did not reach out to any other pharmacy to get R1's oxycodone filled but instead had the medical director order Norco. Administrative Nurse D verified that R1's acetaminophen of 1000 mg every six hours had been ordered to be scheduled for R1 from the surgical hospital, and the facility staff had input the order in the MAR incorrectly. Administrative Nurse D stated she expected facility staff to help alleviate residents' pain and if residents' pain was not under control, to call and get different orders. On 02/19/25 at 11:30 AM, Administrative Staff A stated R1 was admitted to the facility on a Friday, late in the afternoon. Administrative Staff A stated the facility got their medication from a pharmacy company out of another town, a couple of hours away, and facility staff had reached out to one of the local pharmacies to obtain R1's medications otherwise, R1's medications would not have been delivered to the facility until 03:00 AM Sunday, 02/16/25. The facility's Medication Monitoring and Management Policy, dated 10/01/2007, documented in order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medication and non-pharmacological intervention, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. The facility failed to obtain the as-needed pain medicine R1 was prescribed after a total hip replacement. The facility further failed to follow R1's dismissal orders regarding acetaminophen (pain medication) being given four times a day on a scheduled basis and instead put the order into R1's EMR for as-needed, requiring R1 to ask for the pain medication without her knowledge. This deficient practice placed R1 at risk for unalleviated pain, decreased ability to participate in rehabilitation, inability to sleep, and psychosocial impairment.

The facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect. On 08/16/24 at 07:00 AM Certified Nurse Aide (CNA) M entered R1's room, asked if he wanted to get up and when R1 did not answer, CNA M lifted the covers, patted the front of R1's brief, and left the room without ensuring R1 had his call light in reach. At 08:32 AM, CNA M entered R1's room and placed his food tray on the bedside table but did not raise the head of the bed or unwrap R1's silverware. R1 proceeded to eat breakfast lying flat, using his left hand, and dropping food all over the front of his shirt. At 09:18 AM R1 reached into his brief and pulled out feces. R1 still did not have a call light in reach to call for staff assistance. At 09:28 AM R1 removed a large ball of feces from his brief and placed it on the bedside table. At 09:39 AM, R1 pulled himself to a seated position on the side of the bed, and at 09:41 AM Certified Medication Aid (CMA) R entered the room and gave R1, who sat on the side of the bed, his medications. R1 picked up the ball of feces from the table and showed it to the CMA. CMA R walked out of the room without assisting the resident, leaving R1 sitting on the side of the bed, with no call light in reach, and the wheelchair pushed to R1's far right, out of his reach. Four minutes later, at 09:45 AM, R1 tried to pull the bed pad, which was covered with feces, out from underneath him using his left hand. During this action, R1 fell to the right side but due to his hemiplegia was unable to break his fall and fell to the right, hitting his head on the floor. R1 lay on the floor yelling and staff entered the room at 09:48 AM. Licensed Nurse (LN) G assessed his blood pressure, and then all staff left the room to get linens, leaving R1 on the floor yelling. The staff did not place a pillow or padding underneath R1's head. Staff returned and began cleaning the area and removing the soiled linens from R1's bed. When staff removed the bed pad, there was a soiled, soaked area under the bed pad as well. During this cleanup procedure, R1 remained on the floor, moaning and yelling. Staff did not close the privacy curtain until the cleanup was done and they assisted R1 from the floor. The facility failed to ensure R1 received the care and service he required when staff failed to ensure R1 had a call light in his reach to call for staff assistance and failed to provide assistance after R1 gestured and communicated the need for help by showing staff a ball of feces. The facility further failed to provide basic toileting and incontinent care when staff failed to thoroughly check the resident for incontinence early in the morning, also evidenced by the bed pad and linens soaked and covered with feces. The facility failed to ensure the resident's dignity was protected and failed to provide comfort measures when staff left the resident on the floor, stepping around and over him without providing padding or a pillow. This series of failures resulted in R1 falling from the bed, hitting his head, and having an acute hemorrhagic brain bleed (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain). The facility's neglect placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of right-sided hemiplegia (paralysis of one side of the body), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), aphasia (condition with disordered or absent language function), dysphagia (swallowing difficulty), and repeated falls. The Quarterly Minimum Data Set [MDS], dated 07/25/24, documented R1 was rarely/never understood, had short-term and long-term memory loss; R1 was able to recall the location of his room, staff names, and faces, and that he resided in a nursing home. The MDS documented R1 had impairment on one side of his upper and lower extremities and required a wheelchair for locomotion. The MDS documented R1 required substantial/maximum assistance from staff for toileting, bathing, dressing, bed mobility, and transfers. The MDS documented R1 was always incontinent of bowel and bladder. The MDS documented R1 had one non-injury fall during the lookback period. The Activity of Daily Living Care Area Assessment (CAA), dated 05/13/24, documented R1 required assistance with self-care and mobility due to weakness, limited range of motion, poor coordination, and poor balance. The Fall CAA, dated 05/13/24, documented R1 required assistance with stabilization when moving from surface to surface and took antidepressants that increased his risk for falls. R1's Care Plan documented directed staff to ensure frequently used items were within easy reach (05/16/22) and document and report to the physician as needed post-fall for seventy-two hours of pain, bruises, change in mental status, sleepiness, inability to maintain posture, or agitation (05/18/22). The plan documented R1 needed to be up in his wheelchair for all meals (09/29/22). R1's Care Plan documented R1 was on antiplatelet therapy related to a CVA and staff were to observe, document, and report to the physician any signs and symptoms of anticoagulant complications including blood-tinged or obvious blood in the urine, black tarry stools, dark or bright blood in stools, sudden severe headaches, nausea, vomiting, lethargy, bruising, sudden changes in mental status, or significant changes in vital signs (02/06/23). A soft touch call light was to be placed on the left side of the bed (06/16/23). Staff were to offer R1 toileting between meals and rounding between meals to check for incontinence (11/28/23). R1's Fall Risk Assessment, dated 07/21/24, documented a score of 18, which indicated R1 was a high fall risk. R1's EMR contained a Late Entry Health Status Note, dated 08/16/24 at 09:45 AM but entered in R1's EMR on 08/17/24 at 08:20 PM, documented LN G was called to R1's room for a report of R1 being on the floor. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel, and he had placed his bowel movement on his side table. R1 was yelling, Saw, you saw, and was hand motioning to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading up to the fall due to a language barrier. R1 responded No when asked if he was in any pain. Once R1 was assisted back into bed and cleaned up, R1 began laughing about the situation with the staff. LN G documented she assessed R1's vital signs and neurological status. R1 was assisted to a sitting position and then assisted off the floor and into bed by three staff and a gait belt. LN G documented R1 had an abrasion noted on his right knee; the abrasion was not actively bleeding and there were no other skin concerns observed. The note recorded that staff notified Administrative Nurse D, R1's primary care physician, and R1's responsible party. LN G documented R1's responsible party reviewed camera footage and reported R1 had attempted to pull the bed pad out from underneath him which caused him to slip off the edge of the bed and fall to the floor. The Health Status Note, dated 08/16/24 at 05:21 PM, documented R1 was having emesis (vomiting) and had some bruising to the right side of his face to mid-ear, was answering to his name, and his grips were at baseline. R1's blood pressure was 176/89 millimeters of mercury (mmHg), pulse was 106 beats per minute, temperature was 97.2 degrees Fahrenheit (F), respirations were 18 breaths per minute, and oxygen saturation was at 93 percent (%). Staff notified R1's responsible party and she wanted R1 to go to the emergency room for evaluation. The on-call doctor for R1's primary care physician gave the order to send R1 to the emergency room . R1's EMR documented a Health Status Note, dated 08/16/24 at 05:37 PM, which documented Emergency Medical Services (EMS) was called at 05:35 PM and arrived at the facility at 05:45 PM. EMS left with R1 at 05:49 PM. Staff notified R1's responsible party that R1 was on his way to the emergency room . The EMS Exam and Summary, dated 08/16/24 at 06:00 PM, documented EMS was dispatched to the facility for a resident who experienced an altered level of consciousness for the last five hours. The facility reported R1 was non-ambulatory, did not speak, and had slid out of his low-standing bed onto the ground earlier that morning. Upon arrival, EMS personnel found R1 to be experiencing an altered mental status. The summary documented facility staff reported R1's current condition could be his baseline, but the nurse was not sure. R1 was transported to the local hospital. The Emergency Physician Report, dated 08/16/24 at 07:48 PM, documented R1 arrived at the hospital via EMS secondary to a fall; R1 was sitting at the side of the bed and had a mechanical fall onto his right side at approximately 09:30 AM. R1 had a history of a previous CVA and was non-verbal. R1 was on clopidogrel (medication used to prevent blood from clotting) and was activated as a head alert. A computed tomography (CT scan- test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) of the head demonstrated a large subdural hemorrhage ( bleeding between the skull and surface of the brain) on the right side extending from the frontal region (the front part of the brain) along the temporal (the part of the brain that helps you use your senses to understand and respond to the world around you) parietal (region of the brain above the temporal region) region and up over the right convexity (curvature on the skin side) leading to a 1.6-millimeter (mm) shift (deformation of the brain that can occur after a traumatic brain injury) from right to left with compression of the right lateral ventricle (area of the brain that produces and distributes cerebrospinal fluid). The Neurosurgical Consult Note, dated 08/16/24 at 07:50 PM, documented R1 lived in a nursing home. About two years ago R1 had a left-sided stroke which left him aphasic (without the ability for speech), hemiparetic (partial paralysis), and dependent living. The note documented that day, R1 had a ground-level video-recorded fall striking his head. R1 was brought to the emergency room and found to have an acute subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). R1's Glasgow Coma Scale (GCS-a system to measure how conscious someone is) score was four which indicated a severe traumatic brain injury. R1 had unequal pupil size and an episode of vomiting. R1 had an intracerebral hemorrhage score (ICH - a prognostic model that predicts the risk of death for patients) of four which indicated a 97% risk of death within the next thirty days. The note documented the neurosurgeon talked with R1's family and indicated R1's prognosis was poor, and the family elected to proceed with comfort care for R1. R1's EMR contained a Health Status Note, dated 08/16/24 at 08:00 PM, which documented the facility received a notification from R1's responsible party that R1 had a major traumatic brain injury (TBI) and brain bleed, and the family was deciding between surgery and comfort care. CMA R's Witness Statement, dated 08/19/24, documented CMA R gave R1 his pills around 09:22 AM. R1 was sitting on the edge of the bed eating breakfast. A short time later, CNA N came from R1's room requesting a nurse because R1 was on the floor. LN H's Witness Statement, dated 08/19/24, documented LN H was the charge nurse of R1's hall and was in a nurse's meeting at the time of the fall. LN H stated the last time she laid eyes on R1 was about 08:30 AM and R1 rested in bed at that time. CNA M's Witness Statement, dated 08/19/24, documented CNA M checked on R1 at 08:00 AM and tried to get R1 up but R1 refused. CNA M stated he checked R1's brief and R1 was dry. CNA M stated he was not aware of the fall when it happened. LN G's Witness Statement, dated 08/19/24, documented that LN G was called to R1's room for a report of R1 being on the floor at 09:45 AM. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel and had placed part of his bowel movement on his side table. R1 was hand motioning that he wanted to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading to his fall. R1 did respond No when asked if he was in any pain. LN G stated she checked R1's vital signs, neurological status, and range of motion. R1 was assisted to a sitting position and then assisted off the floor by three staff. An abrasion was noted on R1's right knee that was not actively bleeding; there were no other skin concerns. LN G stated she notified R1's responsible party, who reviewed the camera footage and stated that R1 had attempted to pull the bed pad from underneath himself which caused the fall because R1 got too close to the edge of the bed. R1's responsible party stated she could not tell if R1 had hit his head or not. CNA O's Witness Statement, dated 09/20/24, documented that CNA O responded to a call on the walkie involving a resident down. CNA O went to R1's room. LN G was already in the room when he got there. R1 was lying on his chest, his feet by the bed, and his head was toward the end of his roommate's bed. CNA O stated he assisted R1 to a comfortable position. CNA O stated LN G did an assessment and staff got R1 cleaned up and comfortable in bed. The Facility Incident Report, dated 08/23/24, documented the morning of 08/16/24 at approximately 09:30 AM R1 fell from his bed, unwitnessed by staff. R1's family utilized a camera in his room. LN G gave report of the fall. R1's family reviewed the footage and observed R1 pulling on his bed pad which resulted in the fall. Neurological exams were initiated at the time of the fall at 09:30 AM and remained within normal limits until approximately 05:30 PM when R1's blood pressure increased and R1 began vomiting. Once vital signs were outside of normal parameters, staff notified R1's primary care physician and obtained orders for R1 to be evaluated in the ER. The staff notified R1's family as well. R1 was sent via EMS to the local hospital around 06:00 PM. Upon evaluation, R1 was found to have a brain bleed at approximately 08:20 PM. R1 was last checked prior to the fall at 08:30 AM. R1 refused to get out of bed; CNA M stated that R1 was dry, and the bedding was clean at that time. Corrective actions taken were to place a bedside commode, as R1 refused staff assistance with toileting. A review of the motion-activated video footage which also recorded audio and date and time stamps revealed the following series of events that occurred on 08/16/24: At 07:01 AM, CNA M entered R1's room and asked R1 if he wanted to get up for breakfast. R1 did not answer. CNA M said, Okay you want to stay in bed. CNA M lifted R1's blankets off him, patted R1's incontinence brief with his ungloved hand, covered R1 up, turned off the light, and left the room. R1's call light and/or cord was not visible on his bed, or anywhere in the footage. At 08:32 AM a staff member entered R1's area for the first since 07:01 AM. CNA M brought in R1's breakfast tray and placed it on the bedside table. CNA M did not raise R1's head of the bed, did not set up R1's tray by unwrapping the silverware, and did not cut up R1's sausage patties. CNA M moved the tray table over R1 as R1 laid flat in bed and left the room. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1 proceeded to pick up the scrambled eggs and sausage and eat it with his left finger. R1 dropped multiple pieces of food on his shirt. R1 manipulated his coffee cup until he could pick it up, then raised his head slightly off the pillow and attempted to drink the coffee while lying in bed. At 09:18 AM, R1 reached down into his brief with his left hand. R1 brought his left hand out of his brief, looked at his hand, which appeared to have feces on it, and cleaned his hands off on the sheets. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:28 AM, R1 removed his covers with his left hand and left leg. He reached down into his brief removed a large ball of what appeared to be feces and placed it on his bedside table. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:39 AM, R1 used the repositioning rail on the left side of his bed and struggled to pull himself up and position himself on the edge of the bed. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1's wheelchair was visible to R1's far right, past the end of the bed, and out of reach. The cushion in the wheelchair was partially hanging off the seat. At 09:41 AM, staff entered the area again for the first time since 08:32 AM. CMA R came into R1's room and gave R1 his medications in a small pill cup. CMA R opened an Ensure (nutritional drink) and placed it on the tray table. R1 pointed at the ball of feces on his bedside table. CMA R said, Okay, okay. R1 then picked up the ball of feces from the bedside table and held it out towards CMA R. CMA R then walked out of R1's room. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:43 AM, R1 sat on the side of his bed with his left elbow on his left knee, leaning forward. His feet were not visible, but his legs were bent at a 90-degree angle, and he appeared to have his feet on the floor. R1's wheelchair was visible in the background and R1's bed appeared to be at the same height or slightly higher than the seat of the wheelchair. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:45 AM R1 sat on the side of the bed. R1 tried to pull the bed pad out from underneath him with his left hand. R1 then repositioned himself using his left hand to move a little to his right, then again attempted to pull the bed pad out from underneath him. R1 leaned a bit to the right and then fell off the bed, to his right. R1's right arm remained flaccid, and he fell on to the floor. The right side of R1's face struck the floor, and his back bumped into his wheelchair, which was seen to move backward with the impact. There was a large amount of feces visible on the bed pad, sheet, brief, and on R1's left buttock. There was light brownish-yellow soiling or discoloration on the area of the sheet that was previously under the bed pad that became visible after the bed pad was folded and pulled away from the area. R1 moaned as he struck the floor. At 09:47 AM, R1 lay on the floor yelling out loudly in pain. Staff can be heard outside the door saying, We're coming and asking an unknown person, not visible in the footage, if someone had a walkie. At 09:48 AM, LN G assessed R1's blood pressure using a wrist monitor on R1's left wrist. R1 remained lying on his left side. A staff member partially visible from the waist down repositioned R1's wheelchair and then pushed the chair from the room. LN G removed the wrist cuff from R1's left wrist and told R1 that staff were going to get him up and cleaned up. LN G stood up, placed the wrist cuff on the bedside table, and left the room. R1 continued to moan and yell Oh, oh, [expletive], oh [expletive]. At 09:49 AM, R1 continued to lay on his right side, his right arm was not visible. He continued to call out though all staff had exited the room. Thirty seconds later, three staff members reentered the room. R1 continued to cry out and yell. One staff member, visible from the waist down and identifiable by the attire as LN G, carried in a trash can and set it on the floor between R1 and the bedside table. LN G removed the ball of feces from the bedside and tossed it in the trash. Two staff visible from the legs down stood towards the entryway of R1's area. LN G then wiped the side of the tray table and moved the trash can farther away from the bed. R1 continued to lie on the floor repeating the same Oh [expletive] oh over and over. LN G approached the bed and told R1 to hang on as staff had to get things cleaned up so they could get him up. LN began to remove the soiled linens from R1's bed. When LN G pulled the bed pad completely, a large oval-shaped area on the sheet appeared damp and with discoloration. Another staff stood at the foot of the bed and assisted LN G in removing the soiled linens. R1 continued to call out and became louder and louder in his cries. Without speaking to R1, LN G bent down and unfastened the tape on R1's incontinence brief, then stood, and pulled the privacy curtain between R1's side of the room and his roommates and the entryway. The privacy curtain was visible floating above R1's head and lightly touching his left shoulder. LN G exits the footage viewing area towards the door, then is seen coming back and picking up the soiled linens and again moving towards the door. CNA O stood on the right side of R1's bed and proceeded to clean the mattress with wipes. LN G stood towards the foot of the bed, and CNA O pulled back the privacy curtain momentarily and reentered the area, standing in front of R1, who continued to lie on the floor on his right side crying out, and yelling. At 09:51 AM, CNA O stood in front of R1, who remained on the floor on his right side. LN G stood behind R1, and CNA N remained on the right side of R1's bed. The staff discussed how they would get R1 off the floor while R1 continued to groan and cry out. CNA moved the bedside table and trashcan towards the wall, and then bent down and attempted to bend R1's legs and pull them towards CNA O. LN G informed R1 the staff were going to bed his legs. As CNA O bent and pulled on R1's legs, R1 screamed out and there was feces visible on R1's left hip/buttock area. CNA O let go of R1's legs and stood up. CNA N moved to the foot of the bed. LN G placed her left hand on R1's left upper arm and used her right hand to push him upward. LN G then supported R1's back as CNA O straddled R1's legs and CNA N used both hands to lift R1 from under his left arm/ armpit area. LN G moved to R1's far right and told R1 they were going to get him up. CNA O wrapped his arms around R1's torso and the three staff lifted R1 to a semi-standing position and then pivoted R1 to a seated position on the left side of the bed. The video revealed no gait belt was in use during the transfer from the floor, and no assessment was completed regarding range of motion or attempts to identify any latent injury. No pupil assessment (or hand grips) were assessed. At 09:55 AM, R1 lay in bed while LN G and CNO O provided incontinent care. At 09:57 AM, the two staff completed care and covered R1 with his blankets. At 09:58 AM, R1 lay in bed, covered by his blankets. His flat call light was visible on top of the blue blanket and the cord going off the left side of the bed. LN G stood on the right side of R1's bed and LN G took R1's blood pressure on his left wrist with a wrist monitor. The video revealed no other assessments, including pupil assessment or hand grips were conducted. At 10:00 AM, CNA N brought R1's wheelchair into the room and parked it parallel to the left lower end of the bed. CNA N left the room. At 10:28 AM, R1 lay in bed and tried to reach his water pitcher with his left hand, but the water pitcher on the bedside table was just out of reach for R1 to grab. After multiple attempts, R1 was able to push his water cup into a position that allowed him to pick up the cup. He lifted his head up off the pillow as he lay flat in the bed to take a drink through a straw. At 11:52 AM, CNA M entered R1's room and asked R1 if he was ready to get up for lunch. R1 took his covers off with his left hand. CNA M put sweatpants on R1. During the activity, an abrasion or reddened area was visible on R1's right knee. CNA M placed R1's shoes on his feet. Using a gait belt, CNA M transferred R1 to the wheelchair using a stand pivot transfer. CNA M propelled R1 out of the room. At 12:26 PM, R1 propelled himself in his wheelchair back into his room using his left hand and left leg. R1 used the repositioning rail on the left side of his bed and transferred himself into bed. R1 used his left arm and leg to get his covers up and over himself. R1 did not have his call light. At 12:52 PM, CNA M steps just inside of R1's room, and then immediately left the room without speaking or providing care. R1 did not have his call light. This was the last time staff entered R1's room until 05:21 PM. Review of all the video footage revealed no staff went into R1's room or assessed him from 12:52 PM until 05:21 PM. On 09/18/24 at 01:30 PM, CNA O stated he was in R1's room after the fall. CNA O stated R1 was yelling out in pain. CNA O stated he followed LN G's direction about getting R1 off the floor. CNA O stated staff cleaned up R1's room and bed before providing care to R1. CNA O stated there had been feces on R1's bed pad and when the bed pad was removed it revealed the sheets were urine-soaked. CNA O stated he should have given R1 a pillow and comforted R1. CNA O went on to say the staff should have obtained a lift to get R1 up off the floor instead of just lifting him up underneath his arms. CNA O stated LN G had not checked R1's pupillary response. In an interview on 09/18/24 at 10:30 AM, Administrative Nurse D stated she expected she could trust the two administrative nurses on duty on 08/16/24 to follow the facility's unwitnessed fall policy and neurological check policy. Administrative Nurse D stated the family did not bring the video clips of the events until 10 days after she had submitted the report of the fall with injury to the state. Administrative Nurse D stated they had concerns about how the two nurses and CMA R, CNA M, and CNA N handled the fall even before they saw the videos. She further stated the facility took disciplinary actions for all staff involved in the incident that day and ended up terminating LN G and LN H. Administrative Nurse D also stated the facility provided education to all staff on falls and neurological assessments, completed after she and Administrative Staff A saw the videos the family brought to them. Administrative Nurse D stated she assumed since the neurological checks were documented in R1's chart that they had been performed. Administrative Nurse D stated she expected staff to provide residents comfort after a fall and take care of their needs. Administrative Nurse D stated R1 should have been checked on more frequently and provided with incontinent care more frequently than what had been provided to him. On 09/18/24 at 10:45 AM, Administrative Staff A stated that a lot of things had been missed the day R1 fell . Administrative Staff A said there was no way for the facility staff to know the neurological assessments were not completed when the assessment results were charted in R1's EMR. Administrative Staff A stated she wished the family would have shown the facility the video footage sooner than ten days after the incident. Administrative Staff A stated the facility staff were completely invested in making sure all the residents of the facility were given the care they deserved. The facility's policy Abuse Prevention Program, revised December 2016, documented the residents have the right to be from abuse and neglect. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. The facility and staff should protect all residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The facility will develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment of our residents. The facility will require staff training/orientation programs that include abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations. Identify and assess all possible incidents of abuse, investigate, and report any allegations of abuse within time frames as required by federal requirements, establish, and implement a QAPI review and analysis of abuse incidents, and implement changes to prevent future occurrences of abuse. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. The facility's policy Assessing Falls and Their Causes Policy, revised December 2007, documented that if a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injury to the head, neck, spine, and extremities. Once an assessment rules out significant injury, the nursing staff will help the resident to a comfortable lying, sitting, or standing position and then document relevant details. Nursing will notify the attending physician and family in an appropriate time frame. When a fall results in significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or condition change nursing staff will notify the practitioner routinely by phone. Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness or consciousness and overall function. It will note the presence or absence of significant findings. The facility's Neurological Assessment Policy, revised October 2010, documented that staff were to familiarize themselves with any existing physical, mental, and or neurological deficits or disorders the resident may have before the assessment. Assess vital signs (temperature, pulse, respirations, blood pressure). Check the resident's motor abilities and mental ability to follow simple commands by asking the resident to move extremities. Use a penlight to check pupil response by turning off room and over bed lights, moving the penlight from the outer to the inner aspect of both eyes noting pupil constriction when the light beam crosses the pupil and pupil dilation when light is removed. Check pupil size to ascertain if they are equal in size. Ask the resident to grip and squeeze your hands to assess and compare strength bilaterally. Ask the resident if he or she is experiencing any numbness, pain and or tingling in any extremity. The frequency of neurological checks will be every 15 minutes for one hour, every thirty minutes for one hour, every 60 minutes for two hours, every four hours for 16 hours, and every eight hours for 48 hours. Neurological checks will be documented in the resident's electronic medical record. The physician will be notified of the resident's change of condition and any deterioration in neurological status will be reported to the physician immediately. On 09/18/24 at 02:32 PM Administrative Staff A received copies of the Immediate Jeopardy [IJ] Templates and was informed the facility failed to prevent the neglect of R1 and ensure he received the care and service he required, when staff failed to ensure R1 had a call light in his reach to call for staff assistance and failed to provide assistance after R1 gestured and communicated the need for help by showing staff a ball of feces. The facility further failed to provide basic toileting and incontinent care when staff failed to thoroughly check the resident for incontinence early in the morning, also evidenced by the bed pad and linens

The facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 received adequate post-fall treatment consistent with the standards of practice. On [DATE] at 09:45 AM R1 fell from a seated position out of bed, onto the floor. R1 fell to the right, hitting his head on the floor. R1 remained on the floor, yelling until staff entered the room at 09:48 AM. Licensed Nurse (LN) G entered the room, assessed his blood pressure with a wrist cuff then all staff left the room to get linens, leaving R1 on the floor yelling. Staff returned and began cleaning the area and preparing R1's bed. During this time, R1 remained on the floor, moaning and yelling. Certified Nurse's Aide M and Licensed Nurse (LN) G started to assist R1 off the floor. Without LN G assessing for fractures or other injuries, CNA M tried to bend R1's legs and R1 yelled out in obvious pain. LN G, CNA M, and Certified Nurse Aide (CNA) N picked R1 up using an underarm method, not using a gait belt, and placed R1 back in bed. LN G wiped the right side of R1's face but made no other assessment of his face or head though R1 had visible redness on the right side of his face and received Plavix (medication used to prevent blood from clotting) daily. LN G assessed a wrist blood pressure but did not perform a neurological assessment on R1. LN G asked R1 if he was in pain but R1 did not answer, and LN G took no further action at that time. At 10:36 AM, LN G entered R1's room again and assessed wrist blood pressure but did not perform a neurological exam. At 11:52 AM CNA M assisted R1 out to lunch and at 12:26 PM R1 self-propelled into his room and transferred himself back to bed. Staff did not reenter R1's room until 05:21 PM when staff found R1 lethargic and with vomit on his bed. R1 was transferred emergently to the acute hospital where he was diagnosed with an acute hemorrhagic brain bleed and subsequently died on [DATE]. The facility's failure to ensure R1 received adequate care consistent with the standards of care after a fall for a resident taking blood thinners placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of right-sided hemiplegia (paralysis of one side of the body), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), aphasia (condition with disordered or absent language function), dysphagia (swallowing difficulty), and repeated falls. The Quarterly Minimum Data Set [MDS], dated [DATE], documented R1 was rarely/never understood, had short-term and long-term memory loss; R1 was able to recall the location of his room, staff names, and faces, and that he resided in a nursing home. The MDS documented R1 had impairment on one side of his upper and lower extremities and required a wheelchair for locomotion. The MDS documented R1 required substantial/maximum assistance from staff for toileting, bathing, dressing, bed mobility, and transfers. The MDS documented R1 was always incontinent of bowel and bladder. The MDS documented R1 had one non-injury fall during the lookback period. The Activity of Daily Living Care Area Assessment (CAA), dated [DATE], documented R1 required assistance with self-care and mobility due to weakness, limited range of motion, poor coordination, and poor balance. The Fall CAA, dated [DATE], documented R1 required assistance with stabilization when moving from surface to surface and took antidepressants that increased his risk for falls. R1's Care Plan documented directed staff to ensure frequently used items were within easy reach ([DATE]) and document and report to the physician as needed post-fall for seventy-two hours of pain, bruises, change in mental status, sleepiness, inability to maintain posture, or agitation ([DATE]). The plan documented R1 needed to be up in his wheelchair for all meals ([DATE]). R1's Care Plan documented R1 was on antiplatelet therapy related to a CVA and staff were to observe, document, and report to the physician any signs and symptoms of anticoagulant complications including blood-tinged or obvious blood in the urine, black tarry stools, dark or bright blood in stools, sudden severe headaches, nausea, vomiting, lethargy, bruising, sudden changes in mental status, or significant changes in vital signs ([DATE]). A soft touch call light was to be placed on the left side of the bed ([DATE]). Staff were to offer R1 toileting between meals and rounding between meals to check for incontinence ([DATE]). R1's Fall Risk Assessment, dated [DATE], documented a score of 18, which indicated R1 was a high fall risk. R1's EMR contained a Late Entry Health Status Note, dated [DATE] at 09:45 AM but entered in R1's EMR on [DATE] at 08:20 PM, documented LN G was called to R1's room for a report of R1 being on the floor. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel, and he had placed his bowel movement on his side table. R1 was yelling, Saw, you saw, and was hand motioning to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading up to the fall due to a language barrier. R1 responded No when asked if he was in any pain. Once R1 was assisted back into bed and cleaned up, R1 began laughing about the situation with the staff. LN G documented she assessed R1's vital signs and neurological status. R1 was assisted to a sitting position and then assisted off the floor and into bed by three staff and a gait belt. LN G documented R1 had an abrasion noted on his right knee; the abrasion was not actively bleeding and there were no other skin concerns observed. The note recorded that staff notified Administrative Nurse D, R1's primary care physician, and R1's responsible party. LN G documented R1's responsible party reviewed camera footage and reported R1 had attempted to pull the bed pad out from underneath him which caused him to slip off the edge of the bed and fall to the floor. The Health Status Note, dated [DATE] at 05:21 PM, documented R1 was having emesis (vomiting) and had some bruising to the right side of his face to mid-ear, was answering to his name, and his grips were at baseline. R1's blood pressure was ,d+[DATE] millimeters of mercury (mmHg), pulse was 106 beats per minute, temperature was 97.2 degrees Fahrenheit (F), respirations were 18 breaths per minute, and oxygen saturation was at 93 percent (%). Staff notified R1's responsible party and she wanted R1 to go to the emergency room for evaluation. The on-call doctor for R1's primary care physician gave the order to send R1 to the emergency room . R1's EMR documented a Health Status Note, dated [DATE] at 05:37 PM, which documented Emergency Medical Services (EMS) was called at 05:35 PM and arrived at the facility at 05:45 PM. EMS left with R1 at 05:49 PM. Staff notified R1's responsible party that R1 was on his way to the emergency room . The EMS Exam and Summary, dated [DATE] at 06:00 PM, documented EMS was dispatched to the facility for a resident who experienced an altered level of consciousness for the last five hours. The facility reported R1 was non-ambulatory, did not speak, and had slid out of his low-standing bed onto the ground earlier that morning. Upon arrival, EMS personnel found R1 to be experiencing an altered mental status. The summary documented facility staff reported R1's current condition could be his baseline, but the nurse was not sure. R1 was transported to the local hospital. The Emergency Physician Report, dated [DATE] at 07:48 PM, documented R1 arrived at the hospital via EMS secondary to a fall; R1 was sitting at the side of the bed and had a mechanical fall onto his right side at approximately 09:30 AM. R1 had a history of a previous CVA and was non-verbal. R1 was on clopidogrel (medication used to prevent blood from clotting) and was activated as a head alert. A computed tomography (CT scan- test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) of the head demonstrated a large subdural hemorrhage ( bleeding between the skull and surface of the brain) on the right side extending from the frontal region (the front part of the brain) along the temporal (the part of the brain that helps you use your senses to understand and respond to the world around you) parietal (region of the brain above the temporal region) region and up over the right convexity (curvature on the skin side) leading to a 1.6-millimeter (mm) shift (deformation of the brain that can occur after a traumatic brain injury) from right to left with compression of the right lateral ventricle (area of the brain that produces and distributes cerebrospinal fluid). The Neurosurgical Consult Note, dated [DATE] at 07:50 PM, documented R1 lived in a nursing home. About two years ago R1 had a left-sided stroke which left him aphasic (without the ability for speech), hemiparetic (partial paralysis), and dependent living. The note documented that day, R1 had a ground-level video-recorded fall striking his head. R1 was brought to the emergency room and found to have an acute subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). R1's Glasgow Coma Scale (GCS-a system to measure how conscious someone is) score was four which indicated a severe traumatic brain injury. R1 had unequal pupil size and an episode of vomiting. R1 had an intracerebral hemorrhage score (ICH - a prognostic model that predicts the risk of death for patients) of four which indicated a 97% risk of death within the next thirty days. The note documented the neurosurgeon talked with R1's family and indicated R1's prognosis was poor, and the family elected to proceed with comfort care for R1. R1's EMR contained a Health Status Note, dated [DATE] at 08:00 PM, which documented the facility received a notification from R1's responsible party that R1 had a major traumatic brain injury (TBI) and brain bleed, and the family was deciding between surgery and comfort care. CMA R's Witness Statement, dated [DATE], documented CMA R gave R1 his pills around 09:22 AM. R1 was sitting on the edge of the bed eating breakfast. A short time later, CNA N came from R1's room requesting a nurse because R1 was on the floor. LN H's Witness Statement, dated [DATE], documented LN H was the charge nurse of R1's hall and was in a nurse's meeting at the time of the fall. LN H stated the last time she laid eyes on R1 was about 08:30 AM and R1 rested in bed at that time. CNA M's Witness Statement, dated [DATE], documented CNA M checked on R1 at 08:00 AM and tried to get R1 up but R1 refused. CNA M stated he checked R1's brief and R1 was dry. CNA M stated he was not aware of the fall when it happened. LN G's Witness Statement, dated [DATE], documented that LN G was called to R1's room for a report of R1 being on the floor at 09:45 AM. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel and had placed part of his bowel movement on his side table. R1 was hand motioning that he wanted to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading to his fall. R1 did respond No when asked if he was in any pain. LN G stated she checked R1's vital signs, neurological status, and range of motion. R1 was assisted to a sitting position and then assisted off the floor by three staff. An abrasion was noted on R1's right knee that was not actively bleeding; there were no other skin concerns. LN G stated she notified R1's responsible party, who reviewed the camera footage and stated that R1 had attempted to pull the bed pad from underneath himself which caused the fall because R1 got too close to the edge of the bed. R1's responsible party stated she could not tell if R1 had hit his head or not. CNA O's Witness Statement, dated [DATE], documented that CNA O responded to a call on the walkie involving a resident down. CNA O went to R1's room. LN G was already in the room when he got there. R1 was lying on his chest, his feet by the bed, and his head was toward the end of his roommate's bed. CNA O stated he assisted R1 to a comfortable position. CNA O stated LN G did an assessment and staff got R1 cleaned up and comfortable in bed. The Facility Incident Report, dated [DATE], documented the morning of [DATE] at approximately 09:30 AM R1 fell from his bed, unwitnessed by staff. R1's family utilized a camera in his room. LN G gave report of the fall. R1's family reviewed the footage and observed R1 pulling on his bed pad which resulted in the fall. Neurological exams were initiated at the time of the fall at 09:30 AM and remained within normal limits until approximately 05:30 PM when R1's blood pressure increased and R1 began vomiting. Once vital signs were outside of normal parameters, staff notified R1's primary care physician and obtained orders for R1 to be evaluated in the ER. The staff notified R1's family as well. R1 was sent via EMS to the local hospital around 06:00 PM. Upon evaluation, R1 was found to have a brain bleed at approximately 08:20 PM. R1 was last checked prior to the fall at 08:30 AM. R1 refused to get out of bed; CNA M stated that R1 was dry, and the bedding was clean at that time. Corrective actions taken were to place a bedside commode, as R1 refused staff assistance with toileting. A review of the motion-activated video footage which also recorded audio and date and time stamps revealed the following series of events that occurred on [DATE]: At 07:01 AM, CNA M entered R1's room and asked R1 if he wanted to get up for breakfast. R1 did not answer. CNA M said, Okay you want to stay in bed. CNA M lifted R1's blankets off him, patted R1's incontinence brief with his ungloved hand, covered R1 up, turned off the light, and left the room. R1's call light and/or cord was not visible on his bed, or anywhere in the footage. At 08:32 AM a staff member entered R1's area for the first since 07:01 AM. CNA M brought in R1's breakfast tray and placed it on the bedside table. CNA M did not raise R1's head of the bed, did not set up R1's tray by unwrapping the silverware, and did not cut up R1's sausage patties. CNA M moved the tray table over R1 as R1 laid flat in bed and left the room. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1 proceeded to pick up the scrambled eggs and sausage and eat it with his left finger. R1 dropped multiple pieces of food on his shirt. R1 manipulated his coffee cup until he could pick it up, then raised his head slightly off the pillow and attempted to drink the coffee while lying in bed. At 09:18 AM, R1 reached down into his brief with his left hand. R1 brought his left hand out of his brief, looked at his hand, which appeared to have feces on it, and cleaned his hands off on the sheets. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:28 AM, R1 removed his covers with his left hand and left leg. He reached down into his brief removed a large ball of what appeared to be feces and placed it on his bedside table. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:39 AM, R1 used the repositioning rail on the left side of his bed and struggled to pull himself up and position himself on the edge of the bed. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1's wheelchair was visible to R1's far right, past the end of the bed, and out of reach. The cushion in the wheelchair was partially hanging off the seat. At 09:41 AM, staff entered the area again for the first time since 08:32 AM. CMA R came into R1's room and gave R1 his medications in a small pill cup. CMA R opened an Ensure (nutritional drink) and placed it on the tray table. R1 pointed at the ball of feces on his bedside table. CMA R said, Okay, okay. R1 then picked up the ball of feces from the bedside table and held it out towards CMA R. CMA R then walked out of R1's room. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:43 AM, R1 sat on the side of his bed with his left elbow on his left knee, leaning forward. His feet were not visible, but his legs were bent at a 90-degree angle, and he appeared to have his feet on the floor. R1's wheelchair was visible in the background and R1's bed appeared to be at the same height or slightly higher than the seat of the wheelchair. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:45 AM R1 sat on the side of the bed. R1 tried to pull the bed pad out from underneath him with his left hand. R1 then repositioned himself using his left hand to move a little to his right, then again attempted to pull the bed pad out from underneath him. R1 leaned a bit to the right and then fell off the bed, to his right. R1's right arm remained flaccid, and he fell on to the floor. The right side of R1's face struck the floor, and his back bumped into his wheelchair, which was seen to move backward with the impact. There was a large amount of feces visible on the bed pad, sheet, brief, and on R1's left buttock. There was light brownish-yellow soiling or discoloration on the area of the sheet that was previously under the bed pad that became visible after the bed pad was folded and pulled away from the area. R1 moaned as he struck the floor. At 09:47 AM, R1 lay on the floor yelling out loudly in pain. Staff can be heard outside the door saying, We're coming and asking an unknown person, not visible in the footage, if someone had a walkie. At 09:48 AM, LN G assessed R1's blood pressure using a wrist monitor on R1's left wrist. R1 remained lying on his left side. A staff member partially visible from the waist down repositioned R1's wheelchair and then pushed the chair from the room. LN G removed the wrist cuff from R1's left wrist and told R1 that staff were going to get him up and cleaned up. LN G stood up, placed the wrist cuff on the bedside table, and left the room. R1 continued to moan and yell Oh, oh, [expletive], oh [expletive]. At 09:49 AM, R1 continued to lay on his right side, his right arm was not visible. He continued to call out though all staff had exited the room. Thirty seconds later, three staff members reentered the room. R1 continued to cry out and yell. One staff member, visible from the waist down and identifiable by the attire as LN G, carried in a trash can and set it on the floor between R1 and the bedside table. LN G removed the ball of feces from the bedside and tossed it in the trash. Two staff visible from the legs down stood towards the entryway of R1's area. LN G then wiped the side of the tray table and moved the trash can farther away from the bed. R1 continued to lie on the floor repeating the same Oh [expletive] oh over and over. LN G approached the bed and told R1 to hang on as staff had to get things cleaned up so they could get him up. LN began to remove the soiled linens from R1's bed. When LN G pulled the bed pad completely, a large oval-shaped area on the sheet appeared damp and with discoloration. Another staff stood at the foot of the bed and assisted LN G in removing the soiled linens. R1 continued to call out and became louder and louder in his cries. Without speaking to R1, LN G bent down and unfastened the tape on R1's incontinence brief, then stood, and pulled the privacy curtain between R1's side of the room and his roommates and the entryway. The privacy curtain was visible floating above R1's head and lightly touching his left shoulder. LN G exits the footage viewing area towards the door, then is seen coming back and picking up the soiled linens and again moving towards the door. CNA O stood on the right side of R1's bed and proceeded to clean the mattress with wipes. LN G stood towards the foot of the bed, and CNA O pulled back the privacy curtain momentarily and reentered the area, standing in front of R1, who continued to lie on the floor on his right side crying out, and yelling. At 09:51 AM, CNA O stood in front of R1, who remained on the floor on his right side. LN G stood behind R1, and CNA N remained on the right side of R1's bed. The staff discussed how they would get R1 off the floor while R1 continued to groan and cry out. CNA moved the bedside table and trashcan towards the wall, and then bent down and attempted to bend R1's legs and pull them towards CNA O. LN G informed R1 the staff were going to bed his legs. As CNA O bent and pulled on R1's legs, R1 screamed out and there was feces visible on R1's left hip/buttock area. CNA O let go of R1's legs and stood up. CNA N moved to the foot of the bed. LN G placed her left hand on R1's left upper arm and used her right hand to push him upward. LN G then supported R1's back as CNA O straddled R1's legs and CNA N used both hands to lift R1 from under his left arm/ armpit area. LN G moved to R1's far right and told R1 they were going to get him up. CNA O wrapped his arms around R1's torso and the three staff lifted R1 to a semi-standing position and then pivoted R1 to a seated position on the left side of the bed. The video revealed no gait belt was in use during the transfer from the floor, and no assessment was completed regarding range of motion or attempts to identify any latent injury. No pupil assessment (or hand grips) was assessed. At 09:55 AM, R1 lay in bed while LN G and CNO O provided incontinent care. At 09:57 AM, the two staff completed care and covered R1 with his blankets. At 09:58 AM, R1 lay in bed, covered by his blankets. His flat call light was visible on top of the blue blanket and the cord going off the left side of the bed. LN G stood on the right side of R1's bed and LN G took R1's blood pressure on his left wrist with a wrist monitor. The video revealed no other assessments, including pupil assessment or hand grips were conducted. At 10:00 AM, CNA N brought R1's wheelchair into the room and parked it parallel to the left lower end of the bed. CNA N left the room. At 10:28 AM, R1 lay in bed and tried to reach his water pitcher with his left hand, but the water pitcher on the bedside table was just out of reach for R1 to grab. After multiple attempts, R1 was able to push his water cup into a position that allowed him to pick up the cup. He lifted his head up off the pillow as he lay flat in the bed to take a drink through a straw. At 11:52 AM, CNA M entered R1's room and asked R1 if he was ready to get up for lunch. R1 took his covers off with his left hand. CNA M put sweatpants on R1. During the activity, an abrasion or reddened area was visible on R1's right knee. CNA M placed R1's shoes on his feet. Using a gait belt, CNA M transferred R1 to the wheelchair using a stand pivot transfer. CNA M propelled R1 out of the room. At 12:26 PM, R1 propelled himself in his wheelchair back into his room using his left hand and left leg. R1 used the repositioning rail on the left side of his bed and transferred himself into bed. R1 used his left arm and leg to get his covers up and over himself. R1 did not have his call light. At 12:52 PM, CNA M steps just inside of R1's room, and then immediately left the room without speaking or providing care. R1 did not have his call light. This was the last time staff entered R1's room until 05:21 PM. At 01:41 PM R1 was restless in bed. R1 did not have his call light. R1's bed was not in the lowest position. At 03:10 PM, R1 was restless in bed and held his head with his left hand. At 03:25 PM, R1 rubbed his head and the right side of his face. R1 continued to move around. At 03:30 PM, R1 held his head with his left hand. At 03:45 PM, R1 rolled to his left side and vomited yellow emesis on the sheet. R1 did not have his call light. At 03:58 PM, R1 sat up using his left hand and left leg. R1 positioned himself on the left edge of the bed in a seated position, leaning forward with his head over his knee. At 04:02 PM, R1 sat on the edge of the bed and rocked back and forth and side to side. At 04:13 PM, R1 laid back in bed on his left side, on the emesis. R1 yelled out but did not have a call light. R1 held his head with his left hand. At 05:20 PM staff entered R1's room, noted the emesis and left. Review of all the video footage revealed no staff went into R1's room or assessed him from 12:52 PM until 05:21 PM. R1's EMR recorded the following neurological assessments on [DATE] although the video footage revealed R1's temperature, bilateral hand grips, pupillary function and range of motion were not assessed while R1 was in his room: The Neurological Assessment, dated [DATE] at 09:45 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 87 beats per minute, respirations of 20 breaths per minute, and a temperature of 97.8. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:00 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 83 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.6. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:15 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 73 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.6. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:30 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 75 beats per minute, respirations of 19 breaths per minute, and a temperature of 98.4. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 11:00 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 78 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.8. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 11:30 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 83 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.9. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 01:30 PM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 68 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.5. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. On [DATE] at 01:30 PM, CNA O stated he was in R1's room after the fall. CNA O stated R1 was yelling out in pain. CNA O stated he followed LN G's direction about getting R1 off the floor. CNA O stated staff cleaned up R1's room and bed before providing care to R1. CNA O stated there had been feces on R1's bed pad and when the bed pad was removed it revealed the sheets were urine-soaked. CNA O stated he should have given R1 a pillow and comforted R1. CNA O went on to say the staff should have obtained a lift to get R1 up off the floor instead of just lifting him up underneath his arms. CNA O stated LN G had not checked R1's pupillary response. In an interview on [DATE] at 10:30 AM, Administrative Nurse D stated she expected she could trust the two administrative nurses on duty on [DATE] to follow the facility's unwitnessed fall policy and neurological check policy. Administrative Nurse D stated the family did not bring the video clips of the events until 10 days after she had submitted the report of the fall with injury to the state. Administrative Nurse D stated they had concerns about how the two nurses and CMA R, CNA M, and CNA N handled the fall even before they saw the videos. She further stated the facility took disciplinary actions for all staff involved in the incident that day and ended up terminating LN G and LN H. Administrative Nurse D also stated the facility provided education to all staff on falls and neurological assessments, completed after she and Administrative Staff A saw the videos the family brought to them. Administrative Nurse D stated she assumed since the neurological checks were documented in R1's chart that they had been performed. Administrative Nurse D stated she expected staff to provide residents comfort after a fall and take care of their needs. Administrative Nurse D stated R1 should have been checked on more frequently and provided with incontinent care more frequently than what had been provided to him. On [DATE] at 10:45 AM, Administrative Staff A stated that a lot of things had been missed the day R1 fell . Administrative Staff A said there was no way for the facility staff to know the neurological assessments were not completed when the assessment results were charted in R1's EMR. Administrative Staff A stated she wished the family would have shown the facility the video footage sooner than ten days after the incident. Administrative Staff A stated the facility staff were completely invested in making sure all the residents of the facility were given the care they deserved. The facility's policy Assessing Falls and Their Causes Policy, revised [DATE], documented that if a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injury to the head, neck, spine, and extremities. Once an assessment rules out significant injury, the nursing staff will help the resident to a comfortable lying, sitting, or standing position and then document relevant details. Nursing will notify the attending physician and family in an appropriate time frame. When a fall results in significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or condition change nursing staff will notify the practitioner routinely by phone. Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness or consciousness and overall function. It will note the presence or absence of significant findings. The facility's Neurological Assessment Policy, revised [DATE], documented that staff were to familiarize themselves with any existing physical, mental, and or neurological deficits or disorders the resident may have before the assessment. Assess vital signs (temperature, pulse, respirations, blood pressure). Check the resident's motor abilities and mental ability to follow simple commands by asking the resident to move extremities. Use a penlight to check pupil response by turning off room and over bed lights, moving the penlight from the outer to the inner aspect of both eyes noting pupil constriction when the light beam crosses the pupil and pupil dilation when light is removed. Check pupil size to ascertain if they are equal in size. Ask the resident to grip and squeeze your hands to assess and compare strength bilaterally. Ask the resident if[TRUNCATED]

The facility identified a census of 70 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed the facility failed to implement safety interventions to ensure Resident (R) 1 remained free from falls. On [DATE], R1, laid flat in his bed around 07:00 AM. The bed was not in the lowest position and R1 did not have his call light within reach. Certified Nurse Aide (CNA) M entered R1's room, asked if R1 wanted to get up and when R1 did not answer, CNA M lifted the covers, patted the front of R1's brief and left the room without ensuring R1 had his flat call light in reach. At 08:32 AM, another staff entered R1's room, placed a food tray on the bedside table but did not ensure R1 had his call light. At 09:39 AM, R1 pulled himself to a seated position on the side of the bed. At 09:41 AM Certified Medication Aid (CMA) R entered the room and gave R1, who sat on the side of the bed, his medications. CMA R walked out of the room leaving R1 sitting on the side of the bed, with no call light in reach. Four minutes later, at 09:45 AM, R1 pulled the bed pad, which was covered with feces out from underneath him using his left hand. During this action, R1 fell to the right side but due to his hemiplegia was unable to break his fall. R1 fell to the floor from a seated position, hitting his head on the floor. As a result of the fall, R1 suffered a hemorrhagic brain bleed and subsequently died . The facility's failure to identify the resident's risks and implement immediate basic safety interventions and staff assistance to prevent a fall placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of right-sided hemiplegia (paralysis of one side of the body), cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), aphasia (condition with disordered or absent language function), dysphagia (swallowing difficulty), and repeated falls. The Quarterly Minimum Data Set [MDS], dated [DATE], documented R1 was rarely/never understood, had short-term and long-term memory loss; R1 was able to recall the location of his room, staff names, and faces, and that he resided in a nursing home. The MDS documented R1 had impairment on one side of his upper and lower extremities and required a wheelchair for locomotion. The MDS documented R1 required substantial/maximum assistance from staff for toileting, bathing, dressing, bed mobility, and transfers. The MDS documented R1 was always incontinent of bowel and bladder. The MDS documented R1 had one non-injury fall during the lookback period. The Activity of Daily Living Care Area Assessment (CAA), dated [DATE], documented R1 required assistance with self-care and mobility due to weakness, limited range of motion, poor coordination, and poor balance. The Fall CAA, dated [DATE], documented R1 required assistance with stabilization when moving from surface to surface and took antidepressants that increased his risk for falls. R1's Care Plan documented directed staff to ensure frequently used items were within easy reach ([DATE]) and document and report to the physician as needed post-fall for seventy-two hours of pain, bruises, change in mental status, sleepiness, inability to maintain posture, or agitation ([DATE]). The plan documented R1 needed to be up in his wheelchair for all meals ([DATE]). R1's Care Plan documented R1 was on antiplatelet therapy related to a CVA and staff were to observe, document, and report to the physician any signs and symptoms of anticoagulant complications including blood-tinged or obvious blood in the urine, black tarry stools, dark or bright blood in stools, sudden severe headaches, nausea, vomiting, lethargy, bruising, sudden changes in mental status, or significant changes in vital signs ([DATE]). A soft touch call light was to be placed on the left side of the bed ([DATE]). Staff were to offer R1 toileting between meals and rounding between meals to check for incontinence ([DATE]). R1's Fall Risk Assessment, dated [DATE], documented a score of 18, which indicated R1 was a high fall risk. R1's EMR contained a Late Entry Health Status Note, dated [DATE] at 09:45 AM but entered in R1's EMR on [DATE] at 08:20 PM, documented LN G was called to R1's room for a report of R1 being on the floor. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel, and he had placed his bowel movement on his side table. R1 was yelling, Saw, you saw, and was hand motioning to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading up to the fall due to a language barrier. R1 responded No when asked if he was in any pain. Once R1 was assisted back into bed and cleaned up, R1 began laughing about the situation with the staff. LN G documented she assessed R1's vital signs and neurological status. R1 was assisted to a sitting position and then assisted off the floor and into bed by three staff and a gait belt. LN G documented R1 had an abrasion noted on his right knee; the abrasion was not actively bleeding and there were no other skin concerns observed. The note recorded that staff notified Administrative Nurse D, R1's primary care physician, and R1's responsible party. LN G documented R1's responsible party reviewed camera footage and reported R1 had attempted to pull the bed pad out from underneath him which caused him to slip off the edge of the bed and fall to the floor. The Health Status Note, dated [DATE] at 05:21 PM, documented R1 was having emesis (vomiting) and had some bruising to the right side of his face to mid-ear, was answering to his name, and his grips were at baseline. R1's blood pressure was ,d+[DATE] millimeters of mercury (mmHg), pulse was 106 beats per minute, temperature was 97.2 degrees Fahrenheit (F), respirations were 18 breaths per minute, and oxygen saturation was at 93 percent (%). Staff notified R1's responsible party and she wanted R1 to go to the emergency room for evaluation. The on-call doctor for R1's primary care physician gave the order to send R1 to the emergency room . R1's EMR documented a Health Status Note, dated [DATE] at 05:37 PM, which documented Emergency Medical Services (EMS) was called at 05:35 PM and arrived at the facility at 05:45 PM. EMS left with R1 at 05:49 PM. Staff notified R1's responsible party that R1 was on his way to the emergency room . The EMS Exam and Summary, dated [DATE] at 06:00 PM, documented EMS was dispatched to the facility for a resident who experienced an altered level of consciousness for the last five hours. The facility reported R1 was non-ambulatory, did not speak, and had slid out of his low-standing bed onto the ground earlier that morning. Upon arrival, EMS personnel found R1 to be experiencing an altered mental status. The summary documented facility staff reported R1's current condition could be his baseline, but the nurse was not sure. R1 was transported to the local hospital. The Emergency Physician Report, dated [DATE] at 07:48 PM, documented R1 arrived at the hospital via EMS secondary to a fall; R1 was sitting at the side of the bed and had a mechanical fall onto his right side at approximately 09:30 AM. R1 had a history of a previous CVA and was non-verbal. R1 was on clopidogrel (medication used to prevent blood from clotting) and was activated as a head alert. A computed tomography (CT scan- test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) of the head demonstrated a large subdural hemorrhage ( bleeding between the skull and surface of the brain) on the right side extending from the frontal region (the front part of the brain) along the temporal (the part of the brain that helps you use your senses to understand and respond to the world around you) parietal (region of the brain above the temporal region) region and up over the right convexity (curvature on the skin side) leading to a 1.6-millimeter (mm) shift (deformation of the brain that can occur after a traumatic brain injury) from right to left with compression of the right lateral ventricle (area of the brain that produces and distributes cerebrospinal fluid). The Neurosurgical Consult Note, dated [DATE] at 07:50 PM, documented R1 lived in a nursing home. About two years ago R1 had a left-sided stroke which left him aphasic (without the ability for speech), hemiparetic (partial paralysis), and dependent living. The note documented that day, R1 had a ground-level video-recorded fall striking his head. R1 was brought to the emergency room and found to have an acute subdural hematoma (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain). R1's Glasgow Coma Scale (GCS-a system to measure how conscious someone is) score was four which indicated a severe traumatic brain injury. R1 had unequal pupil size and an episode of vomiting. R1 had an intracerebral hemorrhage score (ICH - a prognostic model that predicts the risk of death for patients) of four which indicated a 97% risk of death within the next thirty days. The note documented the neurosurgeon talked with R1's family and indicated R1's prognosis was poor, and the family elected to proceed with comfort care for R1. R1's EMR contained a Health Status Note, dated [DATE] at 08:00 PM, which documented the facility received a notification from R1's responsible party that R1 had a major traumatic brain injury (TBI) and brain bleed, and the family was deciding between surgery and comfort care. CMA R's Witness Statement, dated [DATE], documented CMA R gave R1 his pills around 09:22 AM. R1 was sitting on the edge of the bed eating breakfast. A short time later, CNA N came from R1's room requesting a nurse because R1 was on the floor. LN H's Witness Statement, dated [DATE], documented LN H was the charge nurse of R1's hall and was in a nurse's meeting at the time of the fall. LN H stated the last time she laid eyes on R1 was about 08:30 AM and R1 rested in bed at that time. CNA M's Witness Statement, dated [DATE], documented CNA M checked on R1 at 08:00 AM and tried to get R1 up but R1 refused. CNA M stated he checked R1's brief and R1 was dry. CNA M stated he was not aware of the fall when it happened. LN G's Witness Statement, dated [DATE], documented that LN G was called to R1's room for a report of R1 being on the floor at 09:45 AM. R1 was lying on his left side wearing a t-shirt and a brief. R1 was incontinent of bowel and had placed part of his bowel movement on his side table. R1 was hand motioning that he wanted to get up off the floor. R1's call light was not engaged. R1 was unable to give a description of what happened leading to his fall. R1 did respond No when asked if he was in any pain. LN G stated she checked R1's vital signs, neurological status, and range of motion. R1 was assisted to a sitting position and then assisted off the floor by three staff. An abrasion was noted on R1's right knee that was not actively bleeding; there were no other skin concerns. LN G stated she notified R1's responsible party, who reviewed the camera footage and stated that R1 had attempted to pull the bed pad from underneath himself which caused the fall because R1 got too close to the edge of the bed. R1's responsible party stated she could not tell if R1 had hit his head or not. CNA O's Witness Statement, dated [DATE], documented that CNA O responded to a call on the walkie involving a resident down. CNA O went to R1's room. LN G was already in the room when he got there. R1 was lying on his chest, his feet by the bed, and his head was toward the end of his roommate's bed. CNA O stated he assisted R1 to a comfortable position. CNA O stated LN G did an assessment and staff got R1 cleaned up and comfortable in bed. The Facility Incident Report, dated [DATE], documented the morning of [DATE] at approximately 09:30 AM R1 fell from his bed, unwitnessed by staff. R1's family utilized a camera in his room. LN G gave report of the fall. R1's family reviewed the footage and observed R1 pulling on his bed pad which resulted in the fall. Neurological exams were initiated at the time of the fall at 09:30 AM and remained within normal limits until approximately 05:30 PM when R1's blood pressure increased and R1 began vomiting. Once vital signs were outside of normal parameters, staff notified R1's primary care physician and obtained orders for R1 to be evaluated in the ER. The staff notified R1's family as well. R1 was sent via EMS to the local hospital around 06:00 PM. Upon evaluation, R1 was found to have a brain bleed at approximately 08:20 PM. R1 was last checked prior to the fall at 08:30 AM. R1 refused to get out of bed; CNA M stated that R1 was dry, and the bedding was clean at that time. Corrective actions taken were to place a bedside commode, as R1 refused staff assistance with toileting. A review of the motion-activated video footage which also recorded audio and date and time stamps revealed the following series of events that occurred on [DATE]: At 07:01 AM, CNA M entered R1's room and asked R1 if he wanted to get up for breakfast. R1 did not answer. CNA M said, Okay you want to stay in bed. CNA M lifted R1's blankets off him, patted R1's incontinence brief with his ungloved hand, covered R1 up, turned off the light, and left the room. R1's call light and/or cord was not visible on his bed, or anywhere in the footage. At 08:32 AM a staff member entered R1's area for the first since 07:01 AM. CNA M brought in R1's breakfast tray and placed it on the bedside table. CNA M did not raise R1's head of the bed, did not set up R1's tray by unwrapping the silverware, and did not cut up R1's sausage patties. CNA M moved the tray table over R1 as R1 laid flat in bed and left the room. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1 proceeded to pick up the scrambled eggs and sausage and eat it with his left finger. R1 dropped multiple pieces of food on his shirt. R1 manipulated his coffee cup until he could pick it up, then raised his head slightly off the pillow and attempted to drink the coffee while lying in bed. At 09:18 AM, R1 reached down into his brief with his left hand. R1 brought his left hand out of his brief, looked at his hand, which appeared to have feces on it, and cleaned his hands off on the sheets. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:28 AM, R1 removed his covers with his left hand and left leg. He reached down into his brief removed a large ball of what appeared to be feces and placed it on his bedside table. R1's call light and/or cord were not visible on the bed or anywhere in the footage. At 09:39 AM, R1 used the repositioning rail on the left side of his bed and struggled to pull himself up and position himself on the edge of the bed. R1's call light and/or cord were not visible on the bed or anywhere in the footage. R1's wheelchair was visible to R1's far right, past the end of the bed, and out of reach. The cushion in the wheelchair was partially hanging off the seat. At 09:41 AM, staff entered the area again for the first time since 08:32 AM. CMA R came into R1's room and gave R1 his medications in a small pill cup. CMA R opened an Ensure (nutritional drink) and placed it on the tray table. R1 pointed at the ball of feces on his bedside table. CMA R said, Okay, okay. R1 then picked up the ball of feces from the bedside table and held it out towards CMA R. CMA R then walked out of R1's room. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:43 AM, R1 sat on the side of his bed with his left elbow on his left knee, leaning forward. His feet were not visible, but his legs were bent at a 90-degree angle, and he appeared to have his feet on the floor. R1's wheelchair was visible in the background and R1's bed appeared to be at the same height or slightly higher than the seat of the wheelchair. R1's call light and/or cord were not visible on the bed or anywhere in the recorded footage. At 09:45 AM R1 sat on the side of the bed. R1 tried to pull the bed pad out from underneath him with his left hand. R1 then repositioned himself using his left hand to move a little to his right, then again attempted to pull the bed pad out from underneath him. R1 leaned a bit to the right and then fell off the bed, to his right. R1's right arm remained flaccid, and he fell on to the floor. The right side of R1's face struck the floor, and his back bumped into his wheelchair, which was seen to move backward with the impact. There was a large amount of feces visible on the bed pad, sheet, brief, and on R1's left buttock. There was light brownish-yellow soiling or discoloration on the area of the sheet that was previously under the bed pad that became visible after the bed pad was folded and pulled away from the area. R1 moaned as he struck the floor. At 09:47 AM, R1 lay on the floor yelling out loudly in pain. Staff can be heard outside the door saying, We're coming and asking an unknown person, not visible in the footage, if someone had a walkie. At 09:48 AM, LN G assessed R1's blood pressure using a wrist monitor on R1's left wrist. R1 remained lying on his left side. A staff member partially visible from the waist down repositioned R1's wheelchair and then pushed the chair from the room. LN G removed the wrist cuff from R1's left wrist and told R1 that staff were going to get him up and cleaned up. LN G stood up, placed the wrist cuff on the bedside table, and left the room. R1 continued to moan and yell Oh, oh, [expletive], oh [expletive]. At 09:49 AM, R1 continued to lay on his right side, his right arm was not visible. He continued to call out though all staff had exited the room. Thirty seconds later, three staff members reentered the room. R1 continued to cry out and yell. One staff member, visible from the waist down and identifiable by the attire as LN G, carried in a trash can and set it on the floor between R1 and the bedside table. LN G removed the ball of feces from the bedside and tossed it in the trash. Two staff visible from the legs down stood towards the entryway of R1's area. LN G then wiped the side of the tray table and moved the trash can farther away from the bed. R1 continued to lie on the floor repeating the same Oh [expletive] oh over and over. LN G approached the bed and told R1 to hang on as staff had to get things cleaned up so they could get him up. LN began to remove the soiled linens from R1's bed. When LN G pulled the bed pad completely, a large oval-shaped area on the sheet appeared damp and with discoloration. Another staff stood at the foot of the bed and assisted LN G in removing the soiled linens. R1 continued to call out and became louder and louder in his cries. Without speaking to R1, LN G bent down and unfastened the tape on R1's incontinence brief, then stood, and pulled the privacy curtain between R1's side of the room and his roommates and the entryway. The privacy curtain was visible floating above R1's head and lightly touching his left shoulder. LN G exits the footage viewing area towards the door, then is seen coming back and picking up the soiled linens and again moving towards the door. CNA O stood on the right side of R1's bed and proceeded to clean the mattress with wipes. LN G stood towards the foot of the bed, and CNA O pulled back the privacy curtain momentarily and reentered the area, standing in front of R1, who continued to lie on the floor on his right side crying out, and yelling. At 09:51 AM, CNA O stood in front of R1, who remained on the floor on his right side. LN G stood behind R1, and CNA N remained on the right side of R1's bed. The staff discussed how they would get R1 off the floor while R1 continued to groan and cry out. CNA moved the bedside table and trashcan towards the wall, and then bent down and attempted to bend R1's legs and pull them towards CNA O. LN G informed R1 the staff were going to bed his legs. As CNA O bent and pulled on R1's legs, R1 screamed out and there was feces visible on R1's left hip/buttock area. CNA O let go of R1's legs and stood up. CNA N moved to the foot of the bed. LN G placed her left hand on R1's left upper arm and used her right hand to push him upward. LN G then supported R1's back as CNA O straddled R1's legs and CNA N used both hands to lift R1 from under his left arm/ armpit area. LN G moved to R1's far right and told R1 they were going to get him up. CNA O wrapped his arms around R1's torso and the three staff lifted R1 to a semi-standing position and then pivoted R1 to a seated position on the left side of the bed. The video revealed no gait belt was in use during the transfer from the floor, and no assessment was completed regarding range of motion or attempts to identify any latent injury. No pupil assessment (or hand grips) was assessed. At 09:55 AM, R1 lay in bed while LN G and CNO O provided incontinent care. At 09:57 AM, the two staff completed care and covered R1 with his blankets. At 09:58 AM, R1 lay in bed, covered by his blankets. His flat call light was visible on top of the blue blanket and the cord going off the left side of the bed. LN G stood on the right side of R1's bed and LN G took R1's blood pressure on his left wrist with a wrist monitor. The video revealed no other assessments, including pupil assessment or hand grips were conducted. At 10:00 AM, CNA N brought R1's wheelchair into the room and parked it parallel to the left lower end of the bed. CNA N left the room. At 10:28 AM, R1 lay in bed and tried to reach his water pitcher with his left hand, but the water pitcher on the bedside table was just out of reach for R1 to grab. After multiple attempts, R1 was able to push his water cup into a position that allowed him to pick up the cup. He lifted his head up off the pillow as he lay flat in the bed to take a drink through a straw. At 11:52 AM, CNA M entered R1's room and asked R1 if he was ready to get up for lunch. R1 took his covers off with his left hand. CNA M put sweatpants on R1. During the activity, an abrasion or reddened area was visible on R1's right knee. CNA M placed R1's shoes on his feet. Using a gait belt, CNA M transferred R1 to the wheelchair using a stand pivot transfer. CNA M propelled R1 out of the room. At 12:26 PM, R1 propelled himself in his wheelchair back into his room using his left hand and left leg. R1 used the repositioning rail on the left side of his bed and transferred himself into bed. R1 used his left arm and leg to get his covers up and over himself. R1 did not have his call light. At 12:52 PM, CNA M steps just inside of R1's room, and then immediately left the room without speaking or providing care. R1 did not have his call light. This was the last time staff entered R1's room until 05:21 PM. At 01:41 PM R1 was restless in bed. R1 did not have his call light. R1's bed was not in the lowest position. At 03:10 PM, R1 was restless in bed and held his head with his left hand. At 03:25 PM, R1 rubbed his head and the right side of his face. R1 continued to move around. At 03:30 PM, R1 held his head with his left hand. At 03:45 PM, R1 rolled to his left side and vomited yellow emesis on the sheet. R1 did not have his call light. At 03:58 PM, R1 sat up using his left hand and left leg. R1 positioned himself on the left edge of the bed in a seated position, leaning forward with his head over his knee. At 04:02 PM, R1 sat on the edge of the bed and rocked back and forth and side to side. At 04:13 PM, R1 laid back in bed on his left side, on the emesis. R1 yelled out but did not have a call light. R1 held his head with his left hand. At 05:20 PM staff entered R1's room, noted the emesis and left. Review of all the video footage revealed no staff went into R1's room or assessed him from 12:52 PM until 05:21 PM. R1's EMR recorded the following neurological assessments on [DATE] although the video footage revealed R1's temperature, bilateral hand grips, pupillary function and range of motion were not assessed while R1 was in his room: The Neurological Assessment, dated [DATE] at 09:45 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 87 beats per minute, respirations of 20 breaths per minute, and a temperature of 97.8. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:00 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 83 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.6. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:15 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 73 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.6. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 10:30 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 75 beats per minute, respirations of 19 breaths per minute, and a temperature of 98.4. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 11:00 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 78 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.8. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 11:30 AM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 83 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.9. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. The Neurological Assessment, dated [DATE] at 01:30 PM, documented R1 had a blood pressure of ,d+[DATE] mm/Hg, pulse of 68 beats per minute, respirations of 18 breaths per minute, and a temperature of 97.5. R1 was documented as being alert, hand grasps were greater on the left then the right (normal finding), moved all extremities, and pupils were reactive to light. On [DATE] at 01:30 PM, CNA O stated he was in R1's room after the fall. CNA O stated R1 was yelling out in pain. CNA O stated he followed LN G's direction about getting R1 off the floor. CNA O stated staff cleaned up R1's room and bed before providing care to R1. CNA O stated there had been feces on R1's bed pad and when the bed pad was removed it revealed the sheets were urine-soaked. CNA O stated he should have given R1 a pillow and comforted R1. CNA O went on to say the staff should have obtained a lift to get R1 up off the floor instead of just lifting him up underneath his arms. CNA O stated LN G had not checked R1's pupillary response. In an interview on [DATE] at 10:30 AM, Administrative Nurse D stated she expected she could trust the two administrative nurses on duty on [DATE] to follow the facility's unwitnessed fall policy and neurological check policy. Administrative Nurse D stated the family did not bring the video clips of the events until 10 days after she had submitted the report of the fall with injury to the state. Administrative Nurse D stated they had concerns about how the two nurses and CMA R, CNA M, and CNA N handled the fall even before they saw the videos. She further stated the facility took disciplinary actions for all staff involved in the incident that day and ended up terminating LN G and LN H. Administrative Nurse D also stated the facility provided education to all staff on falls and neurological assessments, completed after she and Administrative Staff A saw the videos the family brought to them. Administrative Nurse D stated she assumed since the neurological checks were documented in R1's chart that they had been performed. Administrative Nurse D stated she expected staff to provide residents comfort after a fall and take care of their needs. Administrative Nurse D stated R1 should have been checked on more frequently and provided with incontinent care more frequently than what had been provided to him. On [DATE] at 10:45 AM, Administrative Staff A stated that a lot of things had been missed the day R1 fell . Administrative Staff A said there was no way for the facility staff to know the neurological assessments were not completed when the assessment results were charted in R1's EMR. Administrative Staff A stated she wished the family would have shown the facility the video footage sooner than ten days after the incident. Administrative Staff A stated the facility staff were completely invested in making sure all the residents of the facility were given the care they deserved. The facility's policy Assessing Falls and Their Causes Policy, revised [DATE], documented that if a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injury to the head, neck, spine, and extremities. Once an assessment rules out significant injury, the nursing staff will help the resident to a comfortable lying, sitting, or standing position and then document relevant details. Nursing will notify the attending physician and family in an appropriate time frame. When a fall results in significant injury or condition change, nursing staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or condition change nursing staff will notify the practitioner routinely by phone. Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness or consciousness and overall function. It will note the presence or absence of significant findings. On [DATE] at 02:32 PM Administrative Staff A received copies of the Immediate Jeopardy [IJ] Templates and was informed that the facility's failure to identify the resident's risks and implement immediate basic safety interventions and staff assistance to prevent a fall placed R1 in immediate jeopardy. The facility identified and implemented immediate corrective actions, which were completed on [DATE] that included the following: All nursing staff were re-educated on policies including Quality Care Documentation, Notifying Primary Care Physician (PCP) and Family, Neurological Assessments and Vital Signs, Change in Condition, Gait Belt Use, Falls, Using a Lift, Abuse, Neglect, and Exploitation] Recognition and reporting. The facility implemented a Quality Assurance and Performance Improvement (QAPI) review of the incidents. The facility conducted one-on-one disciplinary counseling with direct care staff on duty. The involved nurses were terminated. Audits were completed to identify residents at risk and to ensure all appropriate actions/interventions were implemented. The corrective actions were completed prior to the onsite survey therefore the deficient practice was determined to be past noncompliance and remained at the scope and severity of a J.

The facility identified a census of 75 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to provide adequate supervision and intervene during Resident (R) 1's unsafe behaviors to prevent injury. On 06/15/24, R1 repeatedly leaned forward in his wheelchair and then leaned forward too far, fell headfirst to the floor, and sustained a broken nose and a head laceration (cut). This deficient practice also placed R1 at risk for falls, injuries, and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS documented R1 required moderate to maximum staff assistance for all activities of daily living (ADLs) except eating, which required supervision. The MDS documented R1 had no behaviors during the look-back period. The MDS documented R1 had no falls during the observation period. The Significant Change MDS, dated [DATE], documented the BIMS interview could not be completed due to R1 was rarely/never understood. The MDS documented R1 had short-term and long-term memory problems and did not have the ability to recall the current season, the location of his own room, staff names and faces, or that he was in a nursing home. The MDS documented R1 required maximum assistance from staff for all his ADLs except for eating for which required supervision. The MDS documented R1 had physical and verbal behaviors directed toward others for one to three days during the observation period. The MDS documented R1 had two or more falls with major injuries (bone fractures, joint dislocations, closed head injuries with altered level of consciousness, or subdural hematoma). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 06/20/24, documented R1 had periods of confusion and yelled at others. The Falls CAA, dated 06/20/24, documented R1 was a fall risk due to his cognitive impairment and his need for assistance with transfers. R1's Care Plan documented R1 had impaired safety awareness and required assistance from two staff for transfers with a full lift. The plan documented R1 was at high risk for falls due to his confusion and history of falls. The plan directed staff to anticipate and meet R1's needs, avoid repositioning furniture, be sure R1's call light was within reach, and encourage R1 to use the call light. The plan directed staff to ensure a safe environment for R1. The staff were to provide R1 with as-needed medication when he became agitated, and a bolster on his bed. The intervention for the fall on 06/15/24 directed staff to continue fall interventions already in place. The Fall Risk Assessment, dated 06/04/24, documented R1 had a fall risk score of 17 and was a high fall risk. The Fall Risk Assessment on 07/05/24, documented R1 had a fall risk score of 27 and was a high fall risk. The Health Status Note, dated 06/15/24, documented the nurse was notified R1 had a fall and hit his nose. Licensed Nurse (LN) G assessed R1 and put R1 in his bed. Staff called Emergency Medical Service (EMS) upon R1's responsible party's request for further evaluation at the hospital. The fall occurred at 01:18 PM and R1 left the facility at 01:50 PM. The Health Status Note, dated 06/15/24, documented R1 had a broken nose and a laceration to his forehead with no acute issues. The Emergency Department Report, dated 06/15/24, documented R1 was seen in the emergency department for a head injury after a fall. The face computed tomography scan (CT scan- a test that uses X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) showed an acute comminuted fracture (break or splinter of the bone into more than two fragments) of R1's right and left nasal bone with rightward deviation of the bony nasal septum. There was also a potential chip fracture from the maxillary (upper jawbone) spine. R1's left forehead stellate (radiating from the center in a star-like pattern) laceration was approximated (pulled together) and glued shut. R1's discharge instructions included an instruction that R1 was to see an ear, nose, and throat (ENT) doctor for further evaluation and treatment of the nose fracture. The Health Status Note, dated 06/15/24, documented R1 returned to the facility via the transport van. R1 was awake and alert with confusion. R1 stated, I feel like hell. Certified Nurse Aide (CNA) M's Witness Statement, dated 06/15/24, documented that around 01:30 PM, CNA M was cleaning the dining hall and R1 fell directly on his face. CNA M noted a gash to R1's face, right elbow, and a fractured nose. R1 was assessed by LN G. After R1's vital signs were obtained, the CNA staff lifted R1 with a full lift and placed him back in bed until emergency medical assistance arrived. LN G's Witness Statement, dated 06/15/24, documented LN G was outside getting a soda and was alerted R1 had fallen. LN G approached the situation, and the staff were getting R1 up. LN G called R1's responsible party and she requested R1 be sent to the hospital for further evaluation. LN G then collected R1's paperwork and called 911 and informed them of the situation. LN G then called hospice and left a message regarding the situation. The Health Status Note, dated 06/16/24, documented R1 continued on fall follow-up. R1 had been very restless at times since returning from the ER. R1 was given routine Ativan and as needed morphine for pain. R1 was agitated when redirected. The Ear, Nose and Throat Assessment and Plan of Care Document, dated 06/19/24, documented R1 was seen after sustaining a nasal fracture from a fall from his wheelchair four days ago. The physical exam showed a marked deviation of the nasal dorsum to the left with a collapse of the right lateral wall of the nose and airway obstruction internally on that side. Marked external deviation was apparent on examination and a CT scan obtained in the emergency room confirmed the same. R1 had an airway obstruction on the right side. R1 needed to be scheduled for a closed nasal reduction within a few days. The Health Status Note, dated 06/20/24, documented R1 would have surgery to his nose. R1 was to be at the hospital at 09:30 AM for surgery. R1 would be NPO (nothing by mouth) after midnight. The Facility Incident Report, dated 06/20/24, documented on 06/15/24 R1 propelled himself in his wheelchair around the memory care unit. R1 leaned forward in his wheelchair and staff re-directed him multiple times that he needed to sit back in his chair. CNA M was cleaning up the dining room area and turned around to wipe off the table. CNA M heard a sound and turned back around and saw R1 was on the floor. It appeared that R1 fell out of his wheelchair and R1 was bleeding from his nose. CNA M notified LN G and staff notified hospice. Staff notified hospice and EMS and R1's responsible party. R1's responsible party wanted R1 taken to the hospital for evaluation. R1 was evaluated and found to have a broken nose. R1 returned to the facility with an appointment to see an ENT doctor. Education was provided to the staff that R1 should be monitored closely to help mitigate falls. R1 lived in the memory care unit and was monitored closely. R1's Discharge Instructions, dated 06/21/24, documented R1 had surgery for a nasal fracture. R1 was to keep the nasal splint dry, keep the nasal splint on, and not to blow his nose. The Health Status Note, dated 06/21/24, documented the hospital nurse called and reported R1 was on his way back to the facility and had a nose splint in place that needed to be left on for a week, until his next appointment. On 07/08/24 at 10:30 AM, observation revealed R1 sat in his wheelchair self-propelling around the memory care unit. R1's nose appeared healed and there were no signs of bruising. On 07/08/24 at 10:35 AM, CNA M stated when R1 fell she had turned around for just a second and heard R1 fall. CNA M stated R1 had been leaning forward in his wheelchair off and on all morning. On 07/08/24 at 12:45 PM, Administrative Nurse D stated she did not understand what staff were expected to do to keep R1 from falling. Administrative Nurse D stated CNA M had just turned her back on R1 for a moment and he fell . Administrative Nurse D confirmed R1 had been leaning forward in his wheelchair off and on that morning and staff had redirected him verbally. The facility's Managing Falls and Fall Risk Policy, dated December 2007, documented based on previous evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. Staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions the staff may choose to prioritize interventions. The facility failed to provide adequate supervision to intervene during R1's unsafe behaviors to prevent injury when R1 repeatedly leaned forward in his wheelchair, then fell , which resulted in a broken nose and a head laceration. This deficient practice also placed R1 at risk for falls, injuries, and pain.

The facility identified a census of 77 residents with three residents reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 for his activities of daily living, personal health, hygiene, nourishment, and hydration, as well as a sanitary and homelike environment. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for ongoing neglect. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 was rarely/never understood and had severely impaired cognition for making daily decisions. The MDS documented R1 was always incontinent of urine and bowel. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/04/23, documented R1 was at the facility for aftercare following a stroke. R1 had disorganized thinking and had trouble communicating. The ADL Functional/Rehabilitation Potential CAA, was not triggered. The Urinary Incontinence/Indwelling Catheter CAA, dated 05/04/23, documented R1 was incontinent of urine and bowel and required extensive assistance. R1's Care Plan, documented R1 had a self-care performance deficit due to a stroke. The Plan directed staff to keep R1's call light within reach (05/13/22). The plan documented R1 was a two-person squat-pivot transfer to R1's left side from the bed to the wheelchair, and wheelchair to the bed (11/08/22). R1 required an arm-trough on the right side of his wheelchair (11/08/23). R1's Care Plan directed staff to check R1 for incontinence during rounds; wash, rinse, and dry his perineum, and change clothing as needed after incontinence episodes (11/28/23). R1's Care Plan, directed staff to offer R1 toileting between meals and rounding between meals to check his incontinence (11/28/23). On 02/19/24 at 05:30 PM, observation revealed video files from the video camera in R1's room. The video footage included a date of 02/02/24 and a time clock starting at 06:22 PM. The video showed R1 lying in bed. He struggled to take off an incontinence brief which appeared to be soiled. R1's flat soft-touch call light was tied around the left bed rail at the level of R1's shoulder. R1 was able to remove the brief and toss it to the end of the bed. R1 struggled to sit up in bed and attempted to push himself into a seated position using only his left hand. After several attempts, he was able to sit upright on the left side of the bed. R1 obtained a clean brief. R1 then laid back in bed and tried to open the brief using only his left hand and his teeth. R1 then called out Yo, yo and an unidentified female voice responded, Whatcha need? R1 again yelled out something incomprehensible and the female voice answered, Do what?. At 07:02 PM a female staff wearing nursing scrubs walked over to R1, leaned on his bedside table, and asked him if he needed to be changed. R1 held the open incontinence brief in his left hand and said, Yeah. The staff member left the room and did not return. Between 07:03 PM and 07:05 PM, an unidentified staff member delivered R1's dinner tray to his room and placed it on the bedside table. The staff did not open any cartons or provide any set-up assistance. R1 continued to lay on his bed, with the open brief in his left hand. A continued review of the video revealed R1 continued to struggle to open the brief and used his teeth to release the tabs. R1 called out incomprehensibly. R1 struggled for another 17 minutes to get the brief under his bottom and to cover his front genital area. At 07:22 PM R1 laid back on his bed sighed heavily, and said Oh, oh. Continued footage revealed at 07:42 PM, R1 still rolled and squirmed in bed with the brief under him and over his genitals, but the brief remained unfastened. R1 had spasm like movements observed and verbal expressions of moaning and groaning while he continued to fidget with the brief. The video footage showed R1's supper tray remained untouched on his bedside table. On 02/20/24 at 08:45 AM, R1's room had a strong smell of old urine. R1 laid in bed. When asked R1 how things were going for him, R1 looked down and away and shook his head no. Observation revealed R1 wore a completely saturated incontinence brief, and his bed was saturated with urine. R1's clothes were also saturated with urine. R1's soft touch call light hung at the head of the bed on R1's bed rail, out of his reach. R1's water pitcher was empty. On 02/20/24 at 08:50 AM, Certified Nurse's Aide (CNA) M and CNA N entered R1's room to provide him care. CNA M and CNA N applied gloves without washing their hands. CNA M took R1's urine-soaked pants down his legs and then removed the urine-soaked briefs. CNA M asked CNA N to get the wipes out of R1's drawer. R1 did not have any wipes in his room. CNA N left the room to get more wipes. CNA M continued to undress R1's upper body. R1's shirt was soaked with urine from the bottom of the shirt up to the neck of the shirt. CNA M put R1's dirty clothing in a sack. CNA N came back into the room with wipes, placed gloves on without washing her hands, and proceeded to provide peri care to R1's front side. R1's peri-area was very red and irritated and R1 yelled out when CNA N cleaned the area. CNA N did not change her gloves after providing peri-care to R1. R1 rolled over to his right side and CNA M proceeded to provide peri-care to R1's backside. R1 had dried feces around his anus and surrounding buttock area. CNA M had to use multiple wipes and several attempts to remove the dried feces. CNA M and CNA N applied R1's clean brief and then put on his sweatpants and shoes while wearing the same soiled gloves. CNA M and CNA N assisted R1 to a sitting position. CNA N noted R1's clean sweatpants were wet from the bed being soaked with urine. CNA M and CNA N applied a gait belt while wearing the same soiled gloves and assisted R1 up to his wheelchair, pulling R1'ssweatpants down in preparation to remove before letting R1 sit. On 02/20/24 at 09:19 AM, R1 sat at the breakfast table and drank coffee. R1 had not touched his breakfast tray. On 02/20/24 at 08:55 AM, CNA M stated that he had been in R1's room before when it smelled of urine, but it had never been as bad as it was that day. CNA M stated it was the first time (around 08:55 AM) that staff had entered R1's room that morning. CNA M stated that R1's incontinence brief, clothing, and bedding were all urine-soaked. CNA M stated R1 should receive better care. CNA M stated he did not think the night shift CNA had done anything with R1 all night. On 02/20/24 at 09:10 AM, CNA N stated she should have changed her gloves after providing R1 peri care before touching his clean clothing and gait belt. CNA N stated she had not been in R1's room that morning before now. CNA N verified R1's brief, clothes, and bedding were urine-soaked. On 02/20/24 at 09:19 AM, when asked if he felt safe at the facility, R1 stared at the surveyor with wide eyes and stated, No. You saw. When asked if he received good care at the facility, R1 stated, No. You saw. On 02/20/24 at 10:30 AM, Administrative Staff A expressed disbelief about the condition R1 was in. Administrative Staff A agreed R1 had not received adequate care. The Abuse Prevention Program, revised in December 2016, documented the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy documented the facility would develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment and would require staff training or orientation programs that included such topics as abuse prevention and identification. The policy lacked identification and description of the types of abuse and how staff would recognize abuse. The Quality of Life Policy, revised August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed. Residents are provided with a safe, clean, comfortable and homelike environment. Staff shall provide person-centered care that emphasizes the residents' comfort, independence, personal needs, and preferences. The facility failed to ensure R1 remained free from neglect when staff failed to assist R1 with his basic care needs including incontinence management and assistance with ADL. The facility neglected to ensure R1 had adequate water for hydration and neglected to ensure R1's environment remained clean, sanitary, and comfortable. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for ongoing neglect. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's impaired cognitive status and communication deficit resulting in the inability to fully express his feelings.

The facility identified a census of 77 residents with three residents reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from neglect when the facility failed to provide the necessary care and services required by R1 for his activities of daily living, personal health, hygiene, nourishment, and hydration, as well as a sanitary and homelike environment. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for ongoing neglect. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), hemiplegia (paralysis of one side of the body), and hemiparesis (muscular weakness of one half of the body). The Quarterly Minimum Data Set (MDS), dated 02/01/24, documented R1 was rarely/never understood and had severely impaired cognition for making daily decisions. The MDS documented R1 was always incontinent of urine and bowel. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/04/23, documented R1 was at the facility for aftercare following a stroke. R1 had disorganized thinking and had trouble communicating. The ADL Functional/Rehabilitation Potential CAA, was not triggered. The Urinary Incontinence/Indwelling Catheter CAA, dated 05/04/23, documented R1 was incontinent of urine and bowel and required extensive assistance. R1's Care Plan, documented R1 had a self-care performance deficit due to a stroke. The Plan directed staff to keep R1's call light within reach (05/13/22). The plan documented R1 was a two-person squat-pivot transfer to R1's left side from the bed to the wheelchair, and wheelchair to the bed (11/08/22). R1 required an arm-trough on the right side of his wheelchair (11/08/23). R1's Care Plan directed staff to check R1 for incontinence during rounds; wash, rinse, and dry his perineum, and change clothing as needed after incontinence episodes (11/28/23). R1's Care Plan, directed staff to offer R1 toileting between meals and rounding between meals to check his incontinence (11/28/23). On 02/19/24 at 05:30 PM, observation revealed video files from the video camera in R1's room. The video footage included a date of 02/02/24 and a time clock starting at 06:22 PM. The video showed R1 lying in bed. He struggled to take off an incontinence brief which appeared to be soiled. R1's flat soft-touch call light was tied around the left bed rail at the level of R1's shoulder. R1 was able to remove the brief and toss it to the end of the bed. R1 struggled to sit up in bed and attempted to push himself into a seated position using only his left hand. After several attempts, he was able to sit upright on the left side of the bed. R1 obtained a clean brief. R1 then laid back in bed and tried to open the brief using only his left hand and his teeth. R1 then called out Yo, yo and an unidentified female voice responded, Whatcha need? R1 again yelled out something incomprehensible and the female voice answered, Do what?. At 07:02 PM a female staff wearing nursing scrubs walked over to R1, leaned on his bedside table, and asked him if he needed to be changed. R1 held the open incontinence brief in his left hand and said, Yeah. The staff member left the room and did not return. Between 07:03 PM and 07:05 PM, an unidentified staff member delivered R1's dinner tray to his room and placed it on the bedside table. The staff did not open any cartons or provide any set-up assistance. R1 continued to lay on his bed, with the open brief in his left hand. A continued review of the video revealed R1 continued to struggle to open the brief and used his teeth to release the tabs. R1 called out incomprehensibly. R1 struggled for another 17 minutes to get the brief under his bottom and to cover his front genital area. At 07:22 PM R1 laid back on his bed sighed heavily, and said Oh, oh. Continued footage revealed at 07:42 PM, R1 still rolled and squirmed in bed with the brief under him and over his genitals, but the brief remained unfastened. R1 had spasm like movements observed and verbal expressions of moaning and groaning while he continued to fidget with the brief. The video footage showed R1's supper tray remained untouched on his bedside table. On 02/20/24 at 08:45 AM, R1's room had a strong smell of old urine. R1 laid in bed. When asked R1 how things were going for him, R1 looked down and away and shook his head no. Observation revealed R1 wore a completely saturated incontinence brief, and his bed was saturated with urine. R1's clothes were also saturated with urine. R1's soft touch call light hung at the head of the bed on R1's bed rail, out of his reach. R1's water pitcher was empty. On 02/20/24 at 08:50 AM, Certified Nurse's Aide (CNA) M and CNA N entered R1's room to provide him care. CNA M and CNA N applied gloves without washing their hands. CNA M took R1's urine-soaked pants down his legs and then removed the urine-soaked briefs. CNA M asked CNA N to get the wipes out of R1's drawer. R1 did not have any wipes in his room. CNA N left the room to get more wipes. CNA M continued to undress R1's upper body. R1's shirt was soaked with urine from the bottom of the shirt up to the neck of the shirt. CNA M put R1's dirty clothing in a sack. CNA N came back into the room with wipes, placed gloves on without washing her hands, and proceeded to provide peri care to R1's front side. R1's peri-area was very red and irritated and R1 yelled out when CNA N cleaned the area. CNA N did not change her gloves after providing peri-care to R1. R1 rolled over to his right side and CNA M proceeded to provide peri-care to R1's backside. R1 had dried feces around his anus and surrounding buttock area. CNA M had to use multiple wipes and several attempts to remove the dried feces. CNA M and CNA N applied R1's clean brief and then put on his sweatpants and shoes while wearing the same soiled gloves. CNA M and CNA N assisted R1 to a sitting position. CNA N noted R1's clean sweatpants were wet from the bed being soaked with urine. CNA M and CNA N applied a gait belt while wearing the same soiled gloves and assisted R1 up to his wheelchair, pulling R1'ssweatpants down in preparation to remove before letting R1 sit. On 02/20/24 at 09:19 AM, R1 sat at the breakfast table and drank coffee. R1 had not touched his breakfast tray. On 02/20/24 at 08:55 AM, CNA M stated that he had been in R1's room before when it smelled of urine, but it had never been as bad as it was that day. CNA M stated it was the first time (around 08:55 AM) that staff had entered R1's room that morning. CNA M stated that R1's incontinence brief, clothing, and bedding were all urine-soaked. CNA M stated R1 should receive better care. CNA M stated he did not think the night shift CNA had done anything with R1 all night. On 02/20/24 at 09:10 AM, CNA N stated she should have changed her gloves after providing R1 peri care before touching his clean clothing and gait belt. CNA N stated she had not been in R1's room that morning before now. CNA N verified R1's brief, clothes, and bedding were urine-soaked. On 02/20/24 at 09:19 AM, when asked if he felt safe at the facility, R1 stared at the surveyor with wide eyes and stated, No. You saw. When asked if he received good care at the facility, R1 stated, No. You saw. On 02/20/24 at 10:30 AM, Administrative Staff A expressed disbelief about the condition R1 was in. Administrative Staff A agreed R1 had not received adequate care. The Abuse Prevention Program, revised in December 2016, documented the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy documented the facility would develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment and would require staff training or orientation programs that included such topics as abuse prevention and identification. The policy lacked identification and description of the types of abuse and how staff would recognize abuse. The Quality of Life Policy, revised August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed. Residents are provided with a safe, clean, comfortable and homelike environment. Staff shall provide person-centered care that emphasizes the residents' comfort, independence, personal needs, and preferences. The facility failed to ensure R1 remained free from neglect when staff failed to assist R1 with his basic care needs including incontinence management and assistance with ADL. The facility neglected to ensure R1 had adequate water for hydration and neglected to ensure R1's environment remained clean, sanitary, and comfortable. This deficient practice resulted in impaired psychosocial well-being and placed R1 at risk for ongoing neglect. The scope and severity were determined to be actual harm based on the reasonable person concept due to the circumstances of R1's impaired cognitive status and communication deficit resulting in the inability to fully express his feelings.

The facility identified a census of 76 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review and interview, the facility failed to prevent Resident (R) 1 from acquiring two Stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcers on R1's bilateral posterior (back) upper thighs. R1 sustained shearing (the separation of skin layers caused by friction or trauma) and friction (the mechanical force exerted on skin that is dragged across any surface) injuries to the back of his bilateral thighs. The facility failed to implement pressure ulcer prevention interventions after the shearing and friction injuries, which subsequently progressed to Stage 3 pressure injuries. This deficient practice placed R1 at risk for further pressure ulcers, pain, and related complications. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), morbid obesity (excessive body fat) due to excess calories, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R1 was dependent on staff for toileting, bathing, lower body dressing, putting on and taking off footwear, and moving from a seated position to a standing position. The MDS documented R1 was not at risk for pressure ulcer development and had entered the facility without any skin alterations. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 12/10/23, documented R1 was at risk for developing pressure ulcers due to incontinence and cognitive loss. The CAA documented R1 needed a special mattress or seat cushion to reduce or relieve pressure. R1's Interim Care Plan, dated 12/11/23, documented R1 had various healing scabs due to scabies and bed bug bites. R1 had redness under his pannus (extra skin and fat deposits hang from the stomach or belly area on the abdomen), redness to his perineum (the area between the anus and the genitalia), and an abrasion to his midline back. The only intervention for pressure ulcer prevention listed on this care plan was to inspect R1's skin according to facility protocol. The plan lacked mention of a pressure reduction device in R1's recliner. R1's Care Plan, which was initiated on 12/28/23 (22 days after R1 was admitted ), directed staff R1 required extensive help with bathing, toileting, and transfer (12/28/23). The Care Plan documented R1 slept in his recliner (12/28/23). The Care Plan documented R1 had shearing to his bilateral posterior thighs and directed staff to assist R1 with turning/repositioning during rounds, check R1 for incontinence, and provide care as needed (12/28/23). The Care Plan directed nursing staff to administer treatments as ordered monitor for effectiveness and document R1's wound appearance, color, wound healing, signs and symptoms of infection, and wound size, and to report any changes to R1's physician (12/28/23). The Care Plan documented R1 had a Roho cushion (pressure relief cushion that is made of soft, flexible air cells) in his wheelchair (01/02/24) R1's Admission Screener, dated 12/06/23, documented R1 required extensive assistance with bed mobility, and transfer, and was totally dependent on staff for toileting. R1's Admission Screener, documented R1 had scattered scabs throughout his entire body due to previous bedbugs and scabies and a large lesion on his midline back; R1 was red and moist in his groin area. The Braden Scale for Predicting Pressure Ulcers, dated 12/06/23, documented R1 had no sensory impairment, was occasionally moist, walked occasionally, and made frequent though slight changes in body or extremity position independently. His food intake was adequate, and there was no apparent problem with friction and shearing. He had a Braden score of 19, which indicated low risk. The Daily Skilled Note, dated 12/12/23, documented R1 preferred to sleep in his recliner. The Weekly Skin Integrity Review, dated 12/13/23, documented R1 had various healing scabs all over body related to scabies/bedbug bites, redness under his pannus with treatment in place for washing and applying nystatin powder three times a day, redness to his perineum with treatment in place to cleanse and apply barrier cream daily and post toileting/incontinent episodes, and an abrasion midline back with treatment in place for daily dressing changes. R1's Skin/Wound Note, dated 12/19/23, documented the nurse was notified by the charge nurse R1 had some skin issues on his bilateral legs. Upon assessment, it was noted R1 had shearing and friction to his bilateral posterior (backside) thighs. The right posterior upper thigh measured 6.0 centimeters (cm) by 5.0 cm with a depth of 0.2 cm. The area was cleansed with wound cleanser and patted dry, and calcium alginate (highly absorbent dressing) was applied and covered with a bordered foam dressing. The dressing was changed daily and as needed. R1's left posterior upper thigh measured 4.0 cm by 5.0 cm with a depth of 0.2 cm. The area was cleansed with wound cleanser, patted dry, calcium alginate was applied, and covered with a bordered foam dressing to be changed daily and as needed. R1 had a cushion in his wheelchair. R1's responsible party and primary care physician were notified. R1's Weekly Skin Integrity Review, dated 12/20/23, documented R1 had an open area to his left posterior upper thigh (friction). The area was red with serosanguineous (semi-thick blood-tinged drainage) and measured 4.0 cm by 5.0 cm with a depth of 0.2 cm. The review documented R1 had an open area to his right posterior upper thigh (friction) that was red with serosanguineous drainage and measured 6.0 cm by 5.0 cm with a depth of 0.2 cm. The Health Status Note, dated 12/20/23, documented R's primary care physician called the facility and told the facility R1's sodium level from his blood draw was critically low and requested R1 go to the emergency room for evaluation. R1 was admitted to the intensive care unit for low sodium level. R1's hospital Discharge Instructions, dated 12/28/23, documented R1's wounds, which were present on admission were progressing towards healing and had greatly decreased since last week on admission. The treatment plan for R1's Stage 3 pressure injuries to his bilateral posterior medial (inner) thighs directed to wash the wounds daily with wound cleanser and pat dry, apply Cavilon (barrier film) wipes to the peri-wound to prevent maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods), apply a thick coat of SensiCare (protective skin barrier cream) to the wound three times a day and after bowel movements. The orders directed nursing to send TAP's system (strap lifting and turning/repositioning system which minimizes the risk of pressure ulcers), and Prevalon boots (special pressure-reducing heel protectors). The orders directed for a pressure-relieving mattress, friction-reducing surfaces, and turning regimen should be continued at dismissal to prevent pressure-related injuries. The orders noted to call the physician if the wounds started to deteriorate, had increased drainage, and for any other questions or problems. R1's Weekly Skin Integrity Review, dated 12/28/23 and performed at the facility upon readmission documented that R1 had an area of shearing to his right rear thigh but lacked measurements or wound description. The review documented R1 had an area of shearing to his left rear thigh that lacked measurements or description. R1's Interim Care Plan, dated 12/28/23, documented R1 required pressure relieving devices, skin inspection according to facility protocol, incontinent care, and a cushion in his wheelchair and recliner. R1's Weekly Skin Integrity Review, dated 01/04/24, documented R1 had an old open area to his right rear thigh (shearing) which measured 5.0 cm by 2.5 cm with a depth of 0.3 cm. The review documented R1 had an old open area to his left rear thigh (shearing) which measured 2.5 cm by 1.5 cm with a depth of 0.2 cm. The Health Status Note, dated 01/08/24, documented R1 was admitted to the hospital with low potassium. The Health Status Note, dated 01/09/24, documented R1 to start a multivitamin and liquid protein to aid in wound healing upon return from the hospital. The Health Status Note, dated 01/18/24 documented R1 readmitted to the facility on hospice care. The Health Status Note, dated 01/21/24, documented R1 was found without heart or lung sounds verified by two nurses. Hospice was notified, and orders were obtained for the release of the body. On 01/24/24 at 11:00 AM, Certified Nurse's Aide (CNA) M stated she remembered R1, and she did not remember him being on a turning/repositioning schedule until after he returned from the hospital. CNA M did not remember R1 having a cushion for his wheelchair or recliner. On 01/24/24 at 11:15 AM, Licensed Nurse (LN) G agreed shearing and friction could lead to pressure ulcer formation and pressure ulcer prevention should be addressed on new admissions. On 01/24/24 at 01:30 PM, Administrative Nurse D stated staff wanted to do whatever they could to prevent pressure ulcer prevention. Administrative Nurse D did not agree the facility had not done anything to prevent pressure ulcer formation regarding R1. Administrative Nurse D did not agree shearing and friction were related to pressure ulcer formation. The facility's Prevention of Pressure Ulcers/Injuries, revised in July 2017, documented the purpose of the policy was to provide information regarding the identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Keep the skin clean and free of exposure to urine and fecal matter. Monitor the resident for weight loss and intake of food and fluids. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preference. Reposition every two hours for residents who are reclining and dependent on staff for repositioning. Teach residents who can change position independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture, body size, weight, and overall risk factors. The facility failed to implement pressure ulcer prevention interventions for R1 when he developed shearing and friction-related wounds which subsequently progressed to Stage 3 pressure ulcers. This deficient practice also placed R1 at risk for the development of more pressure ulcers, pain, and other related complications.

The facility had a census of 69 residents. The sample included 18 residents with six reviewed for falls. Based on observation, record review, and interview the facility failed to provide adequate supervision and appropriate assessment for the safe use of reclining chairs to prevent falls and hospitalization s for Resident (R)123 who had multiple recliner related falls, one of which resulted in a hip fracture, for R123. Findings Included: - The Medical Diagnosis section within R123's Electronic Medical Records (EMR) included diagnoses of cerebrovascular accident (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic kidney disease, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, psychosis (any major mental disorder characterized by a gross impairment in reality testing), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and history of femur fracture (broken large bone of the leg). R123's Admission Minimum Data Set (MDS) completed 12/24/22 noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated he required extensive assistance from two staff for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated he had a history of falls but none since his admission. R123's Quarterly MDS completed 04/19/23 noted BIMS score of zero. The MDS indicated he required extensive assistance from two staff for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated he was frequently incontinent of bladder, but occasionally incontinent of bowel with no toileting program implemented. The MDS indicated the resident had no falls since the last assessment. R123's Dementia Care Area Assessment (CAA) completed 12/27/22 indicated he had severe cognitive impairment and resided on the memory care unit. The CAA noted he had observable characteristics of confusion, disorientation, and forgetfulness. R123's Falls CAA completed 12/27/23 indicated he had difficulty maintaining balance during transitions and sitting. The CAA indicated his medical diagnoses of bowel/bladder incontinence, and cognitive decline put him at risk for falls. R123's Care Plan created 12/28/23 indicated the resident exhibited a self-care performance deficit for his activities of daily living (ADLs). The plan noted he had actual falls related to poor balance and unrealistic sense of his physical abilities (01/03/23). The care plan instructed staff to anticipate and meet his needs and continue interventions on his plan (01/03/23). The plan instructed staff to keep frequently used items within reach (01/03/23). The plan noted R123 should only use a stationary chair when in the dining room (01/03/23). The plan noted on 03/11/23 a soft touch call light was placed in his room. The plan indicated R123 required assistance from two staff, his walker, and a gait belt for walking, transferring, and toileting (02/17/23). On 06/07/23 R123's plan indicated staff were educated on the importance of easy visualization of him at all times. On 06/15/23 staff were reeducated that R123 was not to be in the recliner in the dining room. R123's Fall Investigation report completed 01/25/23 documented R123 had a non-injury fall. The note indicated he tipped the chair attempting to get out of a recliner in the dining room. The note indicated he was restless and confused during the incident. The report recorded an intervention that R123 would only use stationary chair while in the dining room and indicated he had difficulty with reclining chairs. R123's Fall Investigation on 02/22/23 documented he had an unwitnessed major injury fall in his room when staff found him on the floor in front of his recliner. There report noted staff saw him seated in his recliner three minutes before the fall. The report indicated R123 was sent to an acute care facility for emergency treatment. The report indicated he was treated for a right hip fracture. R123's Fall Investigation on 04/04/23 documented staff witnessed R123 using the recliner and attempted to exit the chair. The report indicated R123 fell backwards out of the chair and landed on his back. The note indicated R123 was moved to the dining area by staff due to his need for monitoring. A review of a Fall Investigation report completed 05/01/23 indicated R123 had an unwitnessed non-injury fall in the dining room while attempting to exit the recliner he sat in. On 08/14/23 at 11:41AM R123's representative stated R123 received two broken hips while at the facility. She stated she felt the facility was not ensuring R123's safety by not checking in on him enough. She stated R123 struggled during transitions between chairs and should not have been allowed back in the recliner after his first hip fracture. On 08/17/23 at 02:10PM Licensed Nurse (LN) H stated indicated staff had difficulty managing R123's falls due to him constantly moving and walking. She stated R123 would constantly wander when staff were not watching him and go into other resident's room or use the recliner. She stated he was easily redirectable when kept in sight. On 08/17/23 at 02:10PM Administrative Nurse D stated the facility tried multiple interventions related to R123's falls. She stated the facility put reminders in place for call light use, alarms, staff assisted walks, adjusting his bed height, and having staff sit outside his room. She stated the facility assessed him after his fall on 06/24/24 and R123 reported no pain or injuries. She further stated he did not exhibit signs of injury, until two days later and was sent out for treatment. A review of the facility's Fall and Fall Risk policy revised 12/2007 indicated the facility will provide continual and interventions to manage residents with high risks related to falls and injuries. The policy indicated the facility will identify risks associated with medical diagnoses, environmental, physical, and medications to minimize or prevent falls. The facility failed to provide adequate supervision and assessment to ensure safe use of recliners for R123. R123 subsequently had a recliner related fall which resulted in a hip fracture. These deficient practices resulted to R123 having a hip fractures.

The facility identified a census of 68 residents with three residents reviewed for quality of care. Based on record review, observations, and interview, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to respond to Resident (R)1's acute change in condition and staff administered oral medications to R1 despite R1's decreased level of consciousness and delayed contacting the physician or Emergency Medical Services (EMS) for a dangerously low blood glucose level and abnormal respiration patterns. On 02/16/23 at approximately 07:30 PM, after staff reported R1 was unresponsive, Administrative Nurse D arrived to R1's room and assessed R1 who was sweating, cool to the touch, and had [NAME]-Stoke (abnormal pattern of breathing, characterized by periods of not breathing and deep, rapid breathing) respirations though R1 received oxygen at 2 liters per minute (l/min) per nasal cannula. R1's blood sugar was assessed and measured 44 milligrams per deciliter (mg/dl) with an oxygen saturation between 65-72%. R1's blood pressure was 228/110 millimeters of mercury (mmHg) and she had a severe non-productive cough. Administrative Nurse D then administered glucose gel in the corner of R1's mouth, which R1 did not tolerate well. Administrative Nurse D called R1's Durable Power of Attorney (DPOA), but did not notify the physician. Administrative Nurse D continued to delay any physician notification until R1's representatives made the request for R1 to go the emergency room . EMS was notified at 08:40 PM and R1 was transported to the ER at 08:54 PM. The facility failure to ensure staff provided adequate nursing care for R1 placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had Brief Interview for Mental Status (BIMS) score of two, indicating severe cognitive impairment. The MDS documented R1 required limited to extensive assistance of one to two staff for all activities of daily living. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/28/23, documented R1 had severe cognitive impairment, resided on the memory care unit, and sometimes recognized staff. The Nutritional Status CAA, dated 01/28/23, documented R1 was on consistent carbohydrate diet and had no problems with chewing or swallowing. The Nutritional Care Plan, dated 02/21/23, directed staff to know that R1 was on a consistent carbohydrate diet, mechanical soft consistency with nectar thickened liquids. The care plan lacked direction related to diabetic cares. The undated Standing Orders directed staff to notify the primary care physician when the resident's systolic blood pressure (SBP-maximum level of blood pressure measured related to contraction of the heart during heartbeat; top number of a BP reading) was greater than 180 millimeter of mercury (mmHg) and diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; bottom number of a BP reading) was greater than 110 mmHg , blood sugar was less than 80 milligrams per deciliter (mg/dL), and if oxygen saturation was less than 90 percent (%) despite application of oxygen. The facility Electronic Treatment Administration Record (TAR), lacked any intervention to monitor R1's blood sugars. The TAR directed nursing staff to administer Humalog 75/25 (long and short acting insulin), 100 units per 1 milliliter (ml), give 13 units subcutaneously (under the skin) twice a day, one in the morning and at supper. The Health Status Note, dated 02/16/23, documented Administrative Nurse D went to R1's room after care staff reported R1 was unresponsive that evening and did not eat any supper. Administrative Nurse D noted R1 was diaphoretic (sweaty) and cool to the touch. R1 had [NAME]-Stokes respirations with oxygen on at 2 liters per minute (l/min) per nasal canula. R1's blood sugar was 44 mg/dl and oxygen saturation measured between 65-72%, blood pressure was 228/110 mmHg. R1 had a severe cough that was unproductive. R1's head of the bed was elevated. Administrative Nurse D administered 5 cubic centimeters (cc) of glucose gel at the corner of R1's mouth and R1 did not tolerate the administration well. Administrative Nurse D called R1's Durable Power of Attorney (DPOA) and updated her on R1's status. R1's DPOA stated she would come to the facility. Upon the DPOA's arrival to the facility, R1's status was unchanged except R1's blood sugar was 50 mg/dL. The DPOA called R1's son and daughter to tell them to come to the facility. Administrative Nurse D notified the on-call primary care physician at 08:23 PM. As Administrative Nurse D was on the phone with the on-call primary care physician, R1's DPOA told Administrative Nurse D she wanted to keep R1 at the facility until his family arrived as R1's condition remained unchanged. R1 remained unresponsive with [NAME]-Stokes respirations and low oxygen saturation. R1's family arrived at the facility at 08:30 PM and the family decided to send R1 to the emergency room . Emergency medical staff was notified at 08:40 PM, arrived at the facility, and transferred R1 out at 08:54 PM. The Hospital History and Physical, dated 02/16/23 documented staff found R1unresponsive at the nursing facility and the receiving nurse in the emergency room stated, according to the nursing home nurse, there was an hour delay after staff found R1 unresponsive before facility staff called EMS. R1's daughter was at the bedside and confirmed the delay in care and stated nursing home staff told her Maybe it was time to let him go. When EMS arrived, R1's blood glucoses measured in the 40's. R1 was given dextrose (glucose solution) and R1 was hypoxic (inadequate oxygen levels) in route to the hospital. R1 admitted to the hospital with a diagnosis of aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit). On 02/27/23 at 01:00 PM, observation revealed R1 sat in a recliner watching TV. R1 had on a cap and was dressed for the day. On 02/27/23 at 01:00 PM, R1 stated he had problems with his blood sugars staying normal. R1 denied any difficulty eating or swallowing. On 02/28/23 at 12:30 PM, R1's DPOA stated R1 should have been sent to the emergency room immediately instead of over an hour later. On 02/27/23 at 02:00 PM, CNA M stated she thought it was odd R1 was not making comments to her as she went up and down the hall. CNA M went into R1's room and he was unresponsive and pretty out of it. CNA M stated CMA R assisted in placing R1 into bed with his oxygen on because R1 was supposed to have oxygen on when he was in bed. CNA M said CMA R told her she though he was okay because she thought R1 had been given a pain pill before they came on shift, and he was probably out of it from the pain pill. CNA M stated she had CMA R finish rounds on the other residents and then CMA R notified the nurse that R1 was still unresponsive. On 02/27/23 at 10:30 AM, Administrative Nurse D stated she was the nurse on the evening of 02/16/23. Administrative Nurse D stated the CNA reported R1 had been unresponsive for their shift and reportedly did not eat supper. Administrative Nurse D stated when she got to his room R1 was cold and clammy and had [NAME]-stokes respirations. She obtained a blood sugar, and it was 44 mg/dL, so she tried to administer glucose gel into the corner of his buccal (mouth) cavity and it just drooled back out of his mouth. Administrative Nurse D stated R1 was on oxygen at 2 l/min per nasal canula and she kept bumping his oxygen up to see if his oxygen saturations would improve. Administrative Nurse D stated she raised his oxygen up to 5 l/min per nasal canula. Administrative Nurse D stated she called R1's DPOA first because it was inferred that R1's DPOA wanted to lay eyes on R1, before she transported to the hospital. Administrative Nurse D stated she called the on-call physician at probably 07:55 PM and left a message for him to call her back. The on-call physician called her back at 08:23 PM. The DPOA went back and forth between sending R1 to the emergency room or keeping R1 at the facility for comfort care. Administrative Nurse D stated she told the on-call physician what was going on and he told her that it was fine per family's choice to either leave R1 at the facility or transfer him to the emergency room . Administrative Nurse D stated R1's DPOA inferred to her she wanted to see R1 before he was sent to the emergency room because she did not trust the facility staff to make appropriate decisions regarding transfers, but there was never anything like that in writing or in R1's care plan. The facility's Change in a Resident's Condition or Status policy, revised December of 2016, documented the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan. The facility's Nursing Care of the Resident with Diabetes Mellitus, policy, revised December 2015, documented for symptomatic unresponsive residents with hypoglycemia (low blood sugar) less than 70 mg/dL or less than physician ordered parameter: immediately administer oral glucose paste to the buccal mucosa, intramuscular glucagon or intravenous (administered through the vein) 50% dextrose per facility protocol and notify the physician for further orders. If the resident remains unresponsive, call 911, remain with the resident, monitor vital signs, and hold all diabetic medications. The facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to respond to R1's acute change in condition, staff administered oral medications to R1, despite R1's decreased level of consciousness and delay contacting the physician or EMS for dangerously low blood glucose level and abnormal respiration patterns. This deficient practice placed R1 in immediate jeopardy. The facility completed the following corrective actions to remove the immediacy: An in-service was conducted on 02/27/23 on hypoglycemic (low blood glucose) protocol, identifying signs and symptoms of acute changes of condition, and timely notifying the physician of changes of condition by the Clinical Serviced Director with the Director of Nursing. An in-service was initiated by the DON and ADON on 02/27/23 on Hypoglycemic protocol, identifying signs and symptoms of acute changes of condition, timely notifying the physician of changes of condition to licensed nursing staff. After the surveyor verified onsite the immediacy was removed, the scope and severity remained at a G (isolated, actual harm).

The facility identified a census of 66 residents with three residents reviewed for medication errors. Based on record review and interview, the facility failed to prevent a significant medication error when facility staff wrongly transcribed Resident (R) 1's admission order for [MEDICATION(S)], an antipsychotic medication (medication used to treat [CONDITION(S)] and other severe mental disorders), at a dose 10 times the ordered amount. On [DATE] Licensed Nurse (LN) G transcribed R1's admission order for [MEDICATION(S)] 2.5 milligrams (mg) into R1's Electronic Medical Record as 25 mg. The facility nurses failed to perform the facility protocol for chart audits and R1 received 10 administrations at the incorrect dose. On [DATE] at 03:11 PM staff noted R1 had decreased responsiveness, a protruding tongue, and slurred speech; R1 was transferred to the acute care hospital. On the night of [DATE] in the hospital R1 aspirated and he died on the morning of [DATE] at the hospital. The deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS) was in progress, but not yet completed. The [CONDITION(S)] [medication which alters mood or thought] Medication Care Plan, dated [DATE], documented R1 would be free of complications including movement disorder, discomfort, [CONDITION(S)], gait disturbance, or cognitive/behavioral disturbance. The care plan directed staff to administer medications as ordered, monitor/document for side effects and effectiveness and to alert the primary care physician with new onset of adverse reactions/side effects from medication. The Activity of Daily Living (ADL) Care Plan, dated [DATE], documented R1 had a self-care performance deficit due to dementia. The care plan directed staff R1 required extensive assistance of one staff for bathing, eating, toileting, and transfer. The Fall Care Plan, dated [DATE], documented R1 had three falls since his admission on [DATE]. The care plan documented staff should perform 72-hour bowel and bladder monitoring, keep bed in the lowest position, frequent checks to assess for safety and offer ADL assistance. Staff should offer assist with toileting before meals, after meals, before bedtime and as needed, and a medication review. The Hospital Health and Physical (H&P), dated [DATE], documented R1 was an [AGE] year old male admitted to the hospital with escalating behavior, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) and olfactory (sense of smell) hallucinations (sensing things while awake that appear to be real, but the mind created). The H&P documented R1 was confused, moved all extremities well and was in no acute distress. The H&P documented R1's current active medications included [MEDICATION(S)] 2.5 mg by mouth twice a day. The Hospital Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Hospital Discharge Instructions, dated [DATE], directed the receiving facility staff to continue to administer [MEDICATION(S)] 2.5 mg by mouth twice a day. R1's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the Hospital Discharge Orders were signed and noted by Administrative Nurse D that she had reviewed R1's orders. The Admission Checklist, dated [DATE], directed the admitting nurse to begin the Admission Checklist and check off items as they were completed, and any areas not completed during the admitting shift would be continued onto the following shift and so forth until the admission was completed. The Administrative Nurse was to complete a verification check to ensure all areas were addressed (verified that the areas were addressed in the medical record and not just checked off as completed on the checklist. The Admission Checklist included for medications to be entered in the EMR. The Admission Checklist tasks were initialed and signed completed on [DATE] by Administrative Nurse D. The EMR lacked an Admission Note on [DATE] regarding R1's admission. The Daily Skilled Note, dated [DATE] at 03:19 AM, documented R1 was on skilled care for physical and occupational therapy, had taken his medications as ordered, and ate supper poorly. The Daily Skilled Note, dated [DATE] at 09:45 PM, documented R1 was on skilled care for physical and occupational therapy, took his medications as ordered, and had no complaints of pain. The Health Status Note, dated [DATE] at 06:54 AM, documented R1 had an unwitnessed fall at 04:00 AM and then again at 04:30 AM. R1 required an increase in visual checks throughout the rest of the night shift due to R1 wandering in the halls, going into other residents' rooms, not using his call light, and falls. Staff attempted to educate R1 on using his call light, but R1 was unable to recall instructions. The Health Status Note, dated [DATE] at 07:03 AM, documented R1 was found at 05:05 AM lying on his left side on the floor next to his bed. When staff asked R1 what had happened R1 stated, I had buckets of water. R1 was unable to further elaborate about the fall. R1 had no shoes on, was wearing his own underwear, and was incontinent of urine. The Health Status Note, dated [DATE] at 05:14 PM, documented R1 was observed lying on the floor in his room outside the bathroom door by the sink at 10:58 AM. Vital signs were obtained and were within normal limits for R1. R1 was alert and oriented to person and date but was confused on situation and place. The Interdisciplinary Team [IDT] Note, dated [DATE] at 11:19 AM, documented R1's wife was expressing concern regarding R1's decline in status. The Health Status Note, dated [DATE] at 02:02 PM, documented R1's wife was called regarding R1's continued declining status. The Health Status Note, dated [DATE] at 02:50 PM, documented R1's wife was informed that R1's primary care physician ordered to send R1 to the emergency room . R1's wife did not want to send R1 to the emergency room , but wanted to keep R1 as comfortable as possible and pursue hospice services. R1's primary care physician did not want to order hospice until R1 could be evaluated and rule out any other reason for R1's decline. R1's wife agreed to have R1 evaluated at the emergency room . The Health Status Note, dated [DATE] at 03:11 PM, documented R1's tongue was protruding from his mouth and he was not able to put his tongue all the way back in his mouth. R1's speech was slurred, and he was very hard to understand. New orders were received to transfer R1 to the emergency room to be evaluated and treated. The emergency room H&P, dated [DATE], documented R1 was oriented to his name but was unable to have a conversation with the emergency room doctor as R1's words were unintelligible. The H&P documented that R1's wife reported R1 had a severe decline in his mental and functional status. R1's wife stated on Thursday, [DATE], R1 was able to talk to her and stand with some assistance, but over the weekend his mental status and physical abilities declined. R1's wife reported R1 had not been able to communicate with her for two days. The emergency room doctor contacted R1's primary care physician and R1's primary care physician reported he had evaluated R1 on Friday and R1 was confused but talking and able to walk to the bathroom. The emergency room Report, dated [DATE], documented R1's workup showed no evidence of pneumonia, stroke, urinary tract infection, and lab work was unremarkable. The note documented Administrative Nurse D from the facility called and informed the emergency room doctor that there had been a discrepancy with the medication R1 had been receiving since Friday. Administrative Nurse D reported R1 had been prescribed [MEDICATION(S)] 2.5 mg by mouth twice a day, but had received [MEDICATION(S)] 25 mg by mouth twice a day. The emergency room doctor documented the overdose of [MEDICATION(S)] explained R1's decline in mental status and functional status and was going to admit him to the hospital to monitor R1 while he metabolized the [MEDICATION(S)] from his system. On [DATE] Consultant JJ reported R1 admitted to the hospital due to an overdose of [MEDICATION(S)] at the facility. R1 aspirated on the night of [DATE] in the hospital and R1 died the following morning on [DATE] at 09:14 AM with his wife at his bedside. On [DATE] at 10:30 AM, Administrative Nurse D stated that on admission to the facility the admitting nurse was supposed to check the medication that were ordered from the admitting facility and place the orders into the EMR for administration; the following nurse coming on the next shift was supposed to double check all the orders. Administrative Nurse D said the administrative nurses were supposed to then re-check the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse D stated the admitting nurse was an agency nurse and was not to return to work at the facility. Administrative Nurse D stated she had not checked the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon request, the facility could not provide a policy for checking orders. The facility failed to prevent a significant medication error when facility staff wrongly transcribed R1's admission order for [MEDICATION(S)], at a dose 10 times the ordered amount. As a result, on [DATE] R1 had decreased responsiveness, a protruding tongue and slurred speech, and required acute hospital care. R1 died at the hospital the following morning. The deficient practice placed R1 in immediate jeopardy. On [DATE] the facility identified the error, performed a root cause analysis to determine causative factors. The facility audited all new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The corrective actions were completed prior to the survey event so the deficient practice was deemed past noncompliance, and existed at a J (isolated, immediate jeopardy to resident health or safety) scope and severity.

The facility identified a census of 59 residents with two residents identified as at risk for elopement in the sample. The facility failed to provide a safe environment and adequate supervision to prevent elopement for Resident (R) 1, who was independently mobile and cognitively impaired. R1 had a history of wandering and wore a Wander guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort). On 06/06/22 at 04:00 PM nursing staff provided cares to R1. At 05:35 PM facility staff identified R1 was missing from the facility. Sometime after 04:00 PM, R1 exited the facility without staff knowledge or supervision through the unalarmed back door, into the smoking area. R1 then exited the smoking area through a gate which was secured with a baby lock. R1 walked three blocks from the facility. He was found by staff and returned to the facility at 05:48 PM. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (muscular weakness of one half of the body) following a nontraumatic intracerebral hemorrhage (a condition in which a ruptured blood vessel causes bleeding inside the brain) affecting the right non-dominant side, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and malignant neoplasm (spreading cancer) of the tonsils. R1's Annual Minimum Data Set, dated dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four which indicated R1 was severely cognitively impaired. The MDS further documented R1 required supervision with set-up help for ambulation, locomotion, bed mobility, eating, toileting, and transfer. The MDS recorded R1 had no wandering behaviors in the look back period. The Cognitive Function Care Area Assessment (CAA), dated 04/21/22, documented R1 was cognitively impaired. The Communication CAA, dated 04/21/22, documented R1 had difficulty with communication and speech. The Fall CAA, dated 04/21/22, documented R1 was at risk for falls. The Elopement Risk Care Plan, revised 04/26/22, documented R1 would not leave the facility unattended, and his safety would be maintained. The care plan directed staff to monitor R1's whereabouts on rounds, distract R1 from wandering with activities, document wandering behavior, provide reality orientation and structured activities, and provide R1 with a Wander guard (a bracelet that triggers alarms and locks monitored doors to prevent wander prone residents from leaving unattended) to his right ankle. The Elopement Risk Assessment, dated 04/16/22, documented R1 was cognitively impaired with poor decision-making skills, was able to ambulate independently, had communication problems, and was not at risk for elopement/wandering. A Health Status Note under the Notes tab in R1's EMR dated 06/06/22 art 06:44 PM recorded unidentified staff alerted LN G staff had not visualized R1 in a while. LN G documented R1 was more anxious throughout that shift asked several times to go outside and smoke. R1 checked time frequently on the hall kiosks. LN G dispatched two unidentified staff to look for R1outside and the other staff conducted a room-to-room search. Staff contacted Administrative nurse D and Administrative Staff A. LN G asked when R1 was last seen and R2 reported she saw R1 exit through the back gate. The note recorded an unidentified resident stated he saw R1 walking outside by the dining room window. The note further recorded Certified Medication Aid (CMA) r found the resident outside approximately three blocks away. R1 told CMA R he was 'going for a walk. LN G assessed R1 and found no injuries. R1 was placed on 15-minute checks. On 06/09/22 at 08:25 AM, observation revealed the corner of Penn Avenue and Ash Street was in an [NAME] area, heavily trafficked, with multiple lanes of traffic. R1 crossed three intersections to arrive at that location where he was found by staff, three blocks from the facility. On 06/09/22 at 09:00 AM observation revealed R1 unable to answer questions regarding the day that he eloped and walking with a short-shuffled gait in his room. On 06/09/22 at 10:00 AM, observations revealed the exit code to the smoker's area in the back yard was well displayed by the keypad. Observation also revealed the north and south gates from the smoking area were locked with a plastic adjustable U-shaped cabinet latch that could be easily unlatched. On 06/09/22 at 10:10 AM, R2 stated R1 came out to the smoking area a lot and walked around. R2 stated that he would come out and not even smoke, but just wander around. R2 stated it did not surprise her that R1 got out of the gate because he was always tinkering around with things. R2 stated it was amazing that R1 did not get hurt because of how he walks. On 06/09/22 at 10:15 AM, Licensed Nurse (LN) G, stated R1 was very anxious the day that he eloped. R1 had been wandering up and down the halls, checking the time, and asking if it was time to smoke. LN G stated she did not think anything about it until at approximately 05:35 staff came to her and told her that they had not seen R1 in a while and she directed staff to start looking for R1. She stated a resident told staff that he had seen R1 walking outside by his window. LN G stated R1 knew the code to get out to the smoking area but could not smoke without supervision. On 06/09/22 at 10:30 AM, Administrative Nurse D, stated R1 was a risk for wandering and elopement and that he had a Wander guard on his right ankle. Administrative Nurse D could not say when the smoking times were at the facility, but if R1 knew the code to get out the smoker's door then the Wander guard would not alarm. On 06/09/22 at 10:45 AM, Certified Medication Aide (CMA) R stated she had noticed R1 was more anxious the day that he eloped. CMA R stated R1 kept coming up to her and asking her if it was time to smoke and checking the time. CMA R stated she wasn't exactly what time it was when staff were made aware that R1 had left the facility, but another resident said he saw R1 outside of his window and staff started checking everywhere. Another staff wentout the smoker's door and found that the gate lock had been removed and was laying on the outside of the gate. That staff member called CMA R and when and got in her car and started looking for R1 and found him three blocks away at the corner of Penn Avenue and Ash Street. CMA R stated R1 loved to go outside and would go outside just to walk around and not smoke. She stated he was always tinkering with things because he used to be a plumber. On 06/09/22 at 11:00 AM, Certified Nurse's Aide (CNA) M stated that when he heard that R1 was missing he immediately started looking for R1. Then another resident, R3, told him that he had seen R1 walking outside by his window. CNA M stated that he looked out the dining room windows and could see R1 standing at the corner but by the time he got to the door R1 was gone and he didn't know which way he had gone. On 06/09/22 at 11:15 AM, CNA N stated that she did not see R1 for probably two hours prior to her discovering that R1 had left the building. CNA N stated when she received word that R1 was missing she ran to the smoker's door and went out and checked the baby lock on the gate. The baby lock was missing and when she opened the gate, she saw the lock laying on the ground re-engaged. She called the other staff to tell them R1 was out of the building and went and got in her car to go start searching for R1. On 06/09/22 at 12:00 PM, Administrative Staff A verified the facility did not provide a safe environment for R1. He expressed concern he was directed to replace the padlocks that had previously been on the gates with baby locks. Administrative Staff A verbalized if the pad locks would have still been in place, the event would not have happened. The facility's Wandering, Unsafe Resident policy dated December 2007, documented the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Staff will identify residents who are at risk for harm because of unsafe wandering including elopement. Staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. Staff will notify the Administrator and Director of Nursing immediately and will institute appropriate measure (including searching) for any resident who is discovered to be missing from the unit or facility. The facility failed to provide a safe environment and adequate supervision to prevent elopement for R1, who was independently mobile and cognitively impaired which presented the likelihood of serious harm or impairment occurring. The facility completed the following actions to remove the immediacy: On 6/6/22 R1 was put on 15-minute checks to be completed and documented by staff. Exit code to the door was changed so that other residents were not aware of the code and staff were in-serviced on new code so that they can supervise residents who go out into the courtyard. An alternative lock was placed on the gate to secure the courtyard area. An in-service was completed with all staff on how to release the lock in case of an emergency An audit was completed on 6/9/22 on all wander risks to determine their appropriateness for placement in the general population. No other residents at risk were identified. The scope and severity remained at a D

The facility had a census of 60 residents. The sample included three residents, with three reviewed for pharmaceutical services. Based on observation, record review, and interview, the facility failed to correctly transcribe admission MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administered 20 milligrams (mg) of [MEDICATION(S)] (immune system suppressant and [CONDITION(S)] agent) daily instead of the prescribed 20 mg one time a week. The resident displayed bleeding from her mouth, admitted to the hospital, and later died . This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The MDS documented the resident received five days of insulin (medication that regulates the amount of glucose (sugar) in the blood), antidepressant (medication used to treat mood disorders and relieve symptoms of depression), anticoagulant (medication that prevents and treats blood clots), and opioid (medication used to treat moderate to severe pain) medication. The Baseline Care Plan, dated [DATE], documented the resident required extensive staff assistance for all activities of daily living (ADLs) except eating, which required supervision and set up help. The care plan documented the resident as a moderate risk for falls and cognitively intact. The Patient Transfer Orders, dated [DATE], directed staff to administer [MEDICATION(S)] Sodium, 20 mg by mouth, every Friday for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Note, dated [DATE] at 10:48 AM, documented the resident had sores in her right check that appeared to be open with some white areas and some redness to the top palate (the bony front portion of the roof of the mouth) in the back of her mouth. The note further stated the resident did not want to eat because it was too painful to swallow. The Nurse's Note, dated [DATE] at 09:02 AM, documented the resident was confused about where she was and had dried blood around her mouth. The resident attempted to swallow two of her pills but immediately vomited. The nurse noticed blood in the resident's emesis (vomit). The note further documented the resident's family member stated the resident had been having dark black diarrhea and had been unable to keep food or fluids down. The note documented staff contacted the physician who ordered staff to send the resident to the hospital for evaluation and treatment. The resident left by Emergency Medical Services (EMS) at 08:00 AM. The Facility's Investigation, dated [DATE], documented on [DATE] at approximately 08:00 AM, staff sent the resident to the local hospital via EMS for dried blood around her mouth and black colored diarrhea as reported by her family member. The local hospital admitted the resident on [DATE]. On [DATE] at approximately 02:00 PM, the local hospital contacted the facility to inform them the resident had a [CONDITION(S)] (bleeding into the stomach and/or digestive tract) that was the result of a medication error of [MEDICATION(S)]. Facility staff entered the order for frequency as daily medication instead of weekly as prescribed. On [DATE] at 10:31 AM, Physician GG stated the resident had received too much [MEDICATION(S)] while at the facility and passed away while in the hospital. The resident received the medication daily instead of weekly, which was too much medication. On [DATE] at 11:17 AM, Administrative Staff A stated the facility became aware of the medication error from the hospital on [DATE] and immediately started an investigation. The facility completed audits on all new admission paperwork from [DATE] to the present and in-serviced all nurses on reconciliation of medications on admission. On [DATE] at 11:38 AM, Licensed Nurse (LN) G stated she went to the resident's room to administer her morning medications and stated the resident was very pale and did not look well. LN G further stated she administered two pills to the resident and the resident immediately vomited. The resident's breath smelled metallic like a [MEDICATION(S)] penny. LN G stated the resident vomited and had diarrhea all weekend and LN G called the physician to see what he recommended. The resident went to the hospital and received a blood transfusion for a GI bleed, but the hospital was not sure where the blood originated from. On [DATE] at 11:47 AM, LN I stated she entered the resident's admission medication orders into the computer and gave them to another nurse to check for discrepancies and did not hear anything back from the other nurse, so she assumed all the information was entered correctly. On [DATE] at 12:29 PM, LN H stated she looked over the admission medications that had been entered into the computer and did not see the error. The facility's Reconciliation of Medications on Admission policy dated, [DATE], documented the policy was to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. The policy further documented medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission or readmission process. The facility failed to correctly transcribe R1's admission medication orders who received 20 mg of [MEDICATION(S)] daily instead of the prescribed 20 mg one time a week, admitted to the hospital, and later died . The facility's failure placed R1 in immediate jeopardy The facility implemented in-service education for all nurses regarding Reconciliation of Medication on Admission on [DATE]. This deficient practice was identified as past non-compliance and corrected on [DATE].

The facility had a census of 58 residents. The sample included three residents reviewed for abuse. Based on observation, record review, and interview the facility failed to prevent an incident of abuse for Resident (R) 1, when Certified Nurse Aide (CNA) M posted a video of the resident to a social media site, which exposed the resident in only a brief and bare skin, while the resident yelled out at staff. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, with a Brief Interview for Mental Status (BIMS) score of 13. The resident required two-person physical assistance with transfers, bed mobility, and toileting. The resident did not have any delusions or hallucinations. The Care Plan, dated 10/21/20, directed staff to monitor R1's behaviors, document the number of episodes, and try to redirect undesirable behavior. The staff were also directed to provide opportunities for expression of feelings related to situational stressors. On 02/01/21 at 10:47 AM, CNA N stated on 01/17/21 around 02:38 PM he looked at his Facebook account and saw a Facebook Story (a short user-generated photo or video that can be uploaded to the user's Facebook page) posted by CNA M, which contained a video of R1 in bed, with only a brief on. A staff member kneeled beside R1's bed and talked to him due to R1's confusion and he was yelling at the staff. CNA N stated he saved the video to his cellular telephone so he would have proof that the video was there, but did not notify facility management staff of the video until 01/18/21, when he showed the video to Social Services (SS) X and she directed him to delete the video from his phone. On 02/01/21 at 11:09 AM, CNA N reviewed his cellular telephone's recently deleted files and found the video CNA M posted of R1. The video showed R1 in the bed on his back with only a brief on and no bed linen covered his body. The resident's face was identifiable in the video. The resident stated, come here and help me for God sake, they are going to kill me, I said stop. Licensed Nurse (LN) G kneeled at R1's bedside talking to the resident in a calm but stern voice and stated, the FBI is not even in the building, yelling is not going to get them here. The resident stated again, make her stop for God sakes, make her stop. On 02/01/21 at 09:47 AM, Administrative Nurse D stated on 01/18/21 she was made aware CNA M made a video of R1 and posted the video on Facebook. She suspended CNA M until they talked via telephone on 01/19/21. CNA M admitted to videotaping the interaction between LN G and R1 because she felt LN G was gruff with the resident and was going to show the video to Administrative Nurse D. CNA M stated while she was asleep her two year old child played with her cellular telephone and must have posted the video on her Facebook account. CNA M took the video off her Facebook account after a friend called and told her it was on her account. Administrative Nurse D terminated CNA M after their conversation. On 02/01/21 at 11:33 AM, LN G stated on 01/17/21, R1 had confusion and thought the FBI was trying to kill him. She knelt beside R1's bed to talk to him and reassured him they were safe. She was not aware CNA N recorded the interaction on her cellular telephone. On 02/01/21 at 04:30 PM, Administrative Staff A stated staff were trained on the facility's social media and abuse policy and the staff should follow those policies. The facility's Confidentiality and Non-Disclosure Agreement Policy, dated 10/08/20, documented any public comments on Social Media sites, regardless if they are written on facility time or personal time, may not impact the facility, its residents, staff, and/or stakeholders in a negative manner. Not to make any photographs, videos or other images of residents or their families with personal device. No images taken in the course and scope of employment may be maintained, used, printed, copied, scanned, emailed, posted, shared, or distributed in any manner, including posting photos on personal websites and any Social Media sites. The facility failed to protect R1 from abuse when CNA M made a video and posted the inappropriate video of the resident to a social media site, placing the resident at risk for humiliation and embarrassment. The facility terminated CNA M on 01/19/21 and implemented in-service education for all staff regarding the Abuse, Neglect, and Exploitation policy, Social media policy, and employee cell phone use policy on 01/18/21. This deficient practice was identified as past non-compliance and was corrected on 01/18/21. This deficient practice remained at a scope and severity of a J.

The facility had a census of 72 residents. The sample included three residents. Based on interview and record review, the facility failed to administer Resident (R) 1's physician ordered medication from 11/15/19 through 01/19/2020, which caused R1 altered mental status, a critical low [MEDICAL CONDITION] level and hospitalization . This deficient practice placed R1 in immediate jeopardy. The deficient practice had the potential to affect other new admissions to the facility. Findings included: - R1's Physician order [REDACTED]. R1's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and received anticoagulant (medication used to prevent formation of blood clots), diuretic (medication to promote the formation and excretion of urine), and pain medications. The Medication Care Plan, dated 12/02/2019, directed staff to administer the resident's medications as ordered. The Hospital Patient Transfer Form, dated 11/15/19, directed staff to administer [MEDICATION NAME] (medication for high blood pressure) 2.5 milligrams (mg) by mouth daily, Aspirin 81 mg by mouth daily, atorvastatin (medication for high cholesterol) 80 mg by mouth at bedtime, [MEDICATION NAME] (medication for [MEDICAL CONDITION]) 150 micrograms (mcg) by mouth 60 minutes prior to breakfast, and Omega 3 fish oil 1000 mg by mouth daily. The (MONTH) 2019, (MONTH) 2019, and (MONTH) 1-20, 2020 Medication Administration Records (MAR) did not list [MEDICATION NAME], Aspirin, Atorvastatin, [MEDICATION NAME], and Omega 3 fish oil. The Nurse's Note, dated 01/19/2020 at 08:30 AM, documented the resident stated the Certified Nurse Aides (CNAs) took his cell phone, staff informed the resident the cellphone was on his bed and the CNAs placed it in his pocket. The resident removed the phone and started talking on it while closed and upside down. The resident then stated someone was on top of his legs, was being tied down and he could not breathe. When staff attempted to talk to the resident, he continued yelling and screaming. Staff notified the on-call physician and received an order to send the resident to the emergency room (ER) for altered mental status. The Emergency Department Report, dated 01/19/2020, documented the resident presented with altered mental status, upon investigation the patient's [MEDICAL CONDITION] medication had been stopped at some point within last year, and unsure as to why it was not given. Laboratory test results revealed the resident's TSH ([MEDICAL CONDITION] Stimulating Hormone - blood test to determine [MEDICAL CONDITION] functioning) was high 41.263 (normal range 0.5 - 3.0), Free T4 ([MEDICAL CONDITION] blood test) was undetectable, and potassium level was low 2.7 (normal range 3.5 - 5.0). The report documented hospital staff administered intravenous (administered into a vein) [MEDICATION NAME] and oral potassium while the resident was in the ER. The Nurse's Note, dated 01/19/2020 at 03:40 PM, documented the resident returned from the ER and indicated the resident had abnormal lab values and needed to be rechecked in two weeks. The resident's potassium levels needed to be rechecked in two to three days. The Nurse's Note, dated 01/20/2020 at 08:01 AM, documented therapy came to Licensed Nurse (LN) G and stated the resident would not wake up and when he was in his chair, his oxygen saturation would drop to the 80's (normal range 95 to 100). LN G went to the resident's room and checked his blood pressure (B/P) 86/40 millimeters of Mercury (mmHg) (normal range 90/60 - 120/80). Staff notified Consultant (C) GG and obtained an order to send the resident to the ER. The Nurse's Note, dated 01/20/2020 at 12:52 PM, documented ER staff called the facility and stated the resident admitted to the hospital Intensive Care Unit (ICU) for [MEDICAL CONDITION] coma (severe [MEDICAL CONDITION] leading to decreased mental status, and hypothermia, a condition of having abnormally low body temperature) and other symptoms related to slowing of function in multiple organs. The facility's Corrective Action Paperwork, dated 01/21/2020 documented the facility suspended LN G while investigating the medication error, educated all licensed nurses on the new procedure for new admission medication verification and a licensed nurse monitored LN G's first new admission upon return to the facility. On 02/03/2020 at 10:33 AM, LN G stated on 11/15/19 R1 was her second new admission after working at the facility for approximately one month. LN G stated R1's admission packet sent with the resident from the hospital was given to Administrative Nurse D to input the resident's medication orders into the computer. On 01/19/2020 the resident had hallucinations, was sent to the ER, and upon return to the facility, hospital staff notified facility staff the resident's potassium and [MEDICAL CONDITION] levels were very low. LN G stated on 01/19/2020, she discovered the resident had a [DIAGNOSES REDACTED]. LN G stated she discovered a medication card for [MEDICATION NAME] in the overflow medication area in the bottom draw of the medication cart and no order in the computer for this medication. On 02/03/2020 at 12:52 PM, Consulting Pharmacist HH stated the facility faxed the pharmacy a medication sheet with the resident's medications for them to fill that included [MEDICATION NAME], Atorvastatin and [MEDICATION NAME]. Consulting Pharmacist HH stated the pharmacy delivered the following medications to the facility on [DATE] at 12:32 PM and signed for by LN H : [MEDICATION NAME] 2.5 mg, Atorvastatin 80 mg and [MEDICATION NAME] 150 mcg. On 02/03/2020 at 01:08 PM, Administrative Nurse D verified she entered R1's admission medication orders into the computer on 11/15/19 and the admission orders [REDACTED]. Administrative Nurse D stated the next day, Administrative Nurse E, Assistant Director of Nursing (ADON) did not compare the admission orders [REDACTED]. Administrative Nurse H verified the medication card for [MEDICATION NAME] should not have been placed into the overflow medication area in the medication cart. On 02/03/2020 at 01:15 PM, LN H stated when the pharmacy delivered medications to the facility, the nurses checked the computer to see which time slot the medication cards should be placed. LN H stated if she checked the computer and there was not an order for [REDACTED]. LN H stated if she received a medication card and did not have an order in the computer or on admission papers, she would call the pharmacy and ask how they filled the order and have the day shift nurse call to clarify the medication order. LN H verified the only medication cards placed in the overflow area of the medication cart were extra cards of same medications. On 02/03/20 at 01:36 PM, C GG stated if a resident was not given their prescribed [MEDICATION NAME] they could hallucinate and go into a [MEDICAL CONDITION] coma. C GG stated usually one of the first signs was decreased mental status. C GG stated she expected two nurses to double check all of the resident's admission medications. The facility's Reconciliation of Medication on Admission policy, dated (MONTH) (YEAR) documented using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. List the dose, route, and frequency for all medications. Review the list carefully to determine if there are discrepancies or conflicts. If there was a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: contact nurse from referring facility, contact the physician from referring facility, contact resident's primary physician, or contact community pharmacy used by resident. Document findings and actions. The facility's Medication Orders and Receipt Record policy, dated (MONTH) 2007, documented the receiving nurse shall record medication orders received on the receipt record. The receiving nurse shall verify each delivered med and check off the order form. Noted discrepancies shall be reported to the dispensing pharmacy. The facility failed to administer R1 physician ordered [MEDICATION NAME] from 11/15/19 through 01/19/2020 which caused altered mental status, a critical low [MEDICAL CONDITION] level, and hospitalization , placing R1 in immediate jeopardy. The facility removed the immediate jeopardy on 01/21/2020 when the facility suspended LN G, educated all licensed nurses on the new procedure for new admission medication verification and a licensed nurse monitored LN G's first new admission upon return to the facility. The deficient practice remained at a scope and severity of a [NAME]

The facility had a census of 77 residents. The sample included 18 residents, of which 7 residents were reviewed for nutrition. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status for 3 of 7 sampled residents. The facility failed to address resident #47's low [MEDICATION NAME] level (laboratory test to measure protein levels in the blood) and not receiving physician ordered protein supplements. The facility failed to accurately monitor meal, snack and nutritional supplement intake for resident #13, who had a significant weight loss. The facility failed to accurately monitor meal, snack and nutritional supplement intake for resident #29, who had severe weight loss. Findings included: - Resident #29's quarterly (MDS) Minimum Data Set assessment, dated 07/20/17, recorded the resident weighed 143 pounds, had a problem of losing liquids and solids from his/her mouth when eating or drinking, received a mechanically altered diet (finely chopped or shredded), and had a recent weight loss. Resident #29's annual (MDS) Minimum Data Set assessment, dated 10/04/17, recorded the resident had severe cognitive impairment with short and long term memory problems. The MDS also recorded the resident weighed 144 pounds, required extensive assistance with eating and drinking, and received a mechanically altered therapeutic diet. The 10/04/17 annual (CAA) Care Area Assessment Summary for nutrition recorded the resident received a mechanical altered diet with thickened liquids, ate his/her meals in the dining room, and required extensive staff assistance and cueing with eating and drinking. The 10/04/17 care plan recorded the resident had a nutrition/hydration deficit related to dysphagia (swallowing difficulty), and directed staff to provide a mechanical soft diet with thickened liquids and assist the resident as needed with eating/drinking. The care plan directed staff to provide house shake nutritional supplements at lunch and supper and record food intake at every meal. The care plan directed staff to notify the (RD) Registered Dietician, if the resident had significant weight loss and to implement the RD recommendations for nutritional interventions. The facility's weight report recorded the following weights for the resident: 05/02/17 - 147.8 06/01/17 - 148.0 07/05/17 - 143.0 08/01/17 - 143.0 09/08/17 - 144.2 10/04/17 - 148.6 11/08/17 - 131.8 (12.75% weight loss in 1 month and 10.13% weight loss in 6 months since 05/02/17) 11/21/17 - 134.2 12/01/17 - 135.0 The 07/10/17 Nutrition Progress Note recorded the resident had gradual non-significant weight loss related to a downward trend in health status. The note recorded the resident received a mechanical soft diet and started a House Shake supplement with lunch and supper to increase calories and stabilize weight. The 10/30/17 Nutrition Assessment recorded the resident weighed 148 pounds, had a mechanical soft diet with thickened liquids related to swallowing difficulties, and received nutritional supplement shakes 2 times a day. The assessment recorded the resident was at risk for weight loss, and directed staff to monitor the resident's weight to prevent significant weight loss. The 11/12/17 Nutrition Assessment recorded the resident had a current weight of 131.8 pounds, which was a 16.8 pound or 11.3% severe weight loss (surveyor's computer software calculation resulted in 12.75% weight loss) since 10/04/17 (the last time the facility recorded the resident's weight). The RD recommended staff provide the resident Ensure nutritional supplement 3 times a day to increase calories and stabilize the resident's weight, assist the resident at meals, and weigh the resident every week. The resident's Meal Consumption Log, dated (MONTH) (YEAR), lacked documentation of meal intakes for 21 out of 93 possible meals. The meal consumption log recorded the resident's average meal intake was 76-100%, but lacked documentation for supplement or snack intakes. The resident's Meal Consumption Log, dated (MONTH) (YEAR), lacked documentation of meal intakes for 23 out of 90 possible meals. The meal consumption log recorded the resident's average meal intake was 76-100%, but lacked documentation for supplement or snack intakes. The resident's Meal Consumption Log, dated (MONTH) (YEAR), lacked documentation of meal intakes for 8 out of 12 possible meals. The meal consumption log recorded the resident's average meal intake was 76-100%, but lacked documentation for supplement or snack intakes. The (MONTH) (YEAR) and (MONTH) (YEAR) (MAR) Medication Administration Record recorded the order for a Health Shake supplement 2 times a day and an Ensure supplement 3 times a day. The MAR lacked documentation for the supplement intakes. On 11/28/17 at 12:04 PM, observation revealed the resident, seated in a wheelchair, at the dining room table, and staff provided the resident with extensive assistance to eat and drink. Continued observation revealed the resident made no attempts to eat or drink independently. Continued observation revealed the resident consumed less than 50% of the supplement served with his/her meal and staff did not offer other foods or supplements. On 11/30/17 at 11:21 AM, observation revealed the resident, seated in a wheelchair, in his/her room. Continued observation revealed an unopened Health Shake supplement on the resident's nightstand. At 11:52 AM, continued observation revealed the resident, seated in a wheelchair, in the hall, and the unopened Health Shake remained on the resident's nightstand. At 11:57 AM, Nurse Aide G stated staff offered the resident the Health Shake several times and the resident refused. On 11/30/17 at 10:16 AM, direct care staff G stated the resident required extensive staff assistance with food and drink and received supplements with his/her meals. Staff G stated staff recorded the resident's meal and fluid intake, but did not record supplement or snack intake. On 12/04/17 at 8:40 AM, licensed nurse E stated the cognitively impaired resident required extensive staff assistance with food and drink, and the resident received Ensure supplement with meals and House Shake supplement between meals. Licensed nurse E stated staff recorded the supplement administration or refusal on the MAR, but the supplement intake was not recorded or monitored. On 12/04/17 at 8:55 AM, dietary staff K stated nursing staff recorded and monitored supplement and snack intake. On 12/04/17 1:21 PM, direct care staff M stated the resident required extensive assistance with eating and drinking, and received a mechanical soft diet with thickened liquids. Staff M stated the resident received a Health Shake supplement with meals, staff did not record supplement intakes and he/she was not aware when the resident received Ensure supplement. On 12/05/17 at 8:37 AM, dietary staff K stated dietary provided the resident with House Shake supplements at lunch and supper and thickened milk at breakfast . On 12/05/17 at 8:47 AM, licensed nurse J stated the resident received Ensure supplement at meals and a Health Shake supplement between meals and in the evening. Licensed nurse J stated staff documented supplement administration on the MAR and the (CNA) Certified Nurse aides recorded the supplement intake on the resident's meal consumption log. On 12/05/17 at 8:57 AM, direct care staff H stated the resident required extensive assistance with food and drink, had a mechanical soft diet with thickened liquids, and received a House Shake supplement with lunch and supper. Staff H stated staff do not document snack or supplement intake and he/she did not know when the resident received the Ensure supplements. On 12/05/17 at 9:45 AM, Administrative Nurse A stated the facility had not developed a care plan to direct staff to administer the resident's supplements and nurses were not aware of supplement administration and intake due to (CMA) Certified Medication Aides usually administered the supplements. Administrative Nurse A stated nursing staff recorded supplement administration on the MAR when the supplement intake was more than 50%, but the facility has no documentation or policy to support this practice. Administrative Nurse A stated the facility had no system to document snack and supplement intakes and staff should record the resident's meal intake. On 12/05/17 at 10:43 AM, (RD) Registered Dietician L stated the facility notified him/her the resident had a significant weight loss the previous month (no weights noted on the resident's medical record from 10/04/17 to 11/08/17). RD L stated he/she recommended the resident receive Ensure supplement 3 times a day because of the resident's swallowing problems. Registered Dietician L stated the facility should monitor meal, snack and supplement intakes for residents with significant weight loss. The facility's Nutrition/Unplanned Weight Loss Policy, dated 12/2008, directed staff to monitor weight and all dietary intake for residents with weight loss. The policy directed staff to accurately monitor nutritional interventions to determine if the interventions were effective to meet the resident's nutritional needs. The facility's Snack Policy, dated 12/2008, directed staff to document the date and time snacks were served and record the snack intake to include with the resident's dietary intake. The facility failed to implement care interventions to accurately monitor meal, snack and nutritional supplement intake for cognitively impaired dependent resident #29, identified at risk for nutrition deficit who experienced severe weight loss. - Resident #47's significant change (MDS) Minimum Data Set assessment, dated 11/17/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS also recorded the resident weighed 466 pounds, received a therapeutic diet, had an unstageable pressure ulcer and was on [MEDICAL TREATMENT] (process of removing waste products and excess fluids from the body). The 11/17/17 significant change (CAA) Care Area Assessment for nutrition recorded the resident received a diabetic/renal diet and his/her average meal intake was 76-100%. The 11/17/17 care plan recorded the resident was diabetic (body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) received [MEDICAL TREATMENT], and had an unstageable pressure ulcer (not able to assess the wound bed due to coverage by slough (dead tissue) and eschar (dried dead tissue). The care plan directed staff to report medical changes requiring nutritional interventions, to the (RD) Registered Dietician and follow the recommendations to ensure the nutritional interventions were effective. The 10/03/17 Nutrition Progress note recorded the resident had a pressure ulcer and received [MEDICATION NAME] ( a nutritional supplement to promote wound healing) 2 times a day and 30 (ml) milliliter liquid protein 4 times a day to promote wound healing. The note directed staff to encourage the resident to be compliant with his/her diet and nutritional interventions. The 10/18/17 laboratory test recorded the resident had a low [MEDICATION NAME] level (laboratory test to measure protein levels in the blood) of 3.2 (normal 3.5 - 5.0). The 11/07/17 Nutrition Progress Note recorded the resident received [MEDICAL TREATMENT] 3 times a week and the resident was not always compliant with his/her renal diet and nutritional interventions. The note recorded the resident had a pressure ulcer with a [DEVICE] (medical device to promote healing of acute or chronic wounds, by removing drainage and tissues that impair healing), and received [MEDICATION NAME] 2 times a day and 30 ml protein supplement 4 times a day. The 11/14/17 [MEDICAL TREATMENT] Report recorded the resident had an [MEDICATION NAME] level of 3.3 (below the [MEDICAL TREATMENT] goal of 4.0). The report recorded protein in the blood helps fight infection and aids in wound healing. The report also recorded the resident had a low nPCR level (laboratory test to assess dietary protein intake in [MEDICAL TREATMENT] patients to detect malnutrition) of 0.8 (below the [MEDICAL TREATMENT] goal of 1.1). The report recorded the low nPCR level suggests the resident was not eating enough fish, meat, eggs or other protein sources. The facility's (MONTH) (YEAR) Meal Consumption Log lacked documentation for snack and supplement intake. The (MONTH) (YEAR) (MAR) Medication Administration Record recorded the resident refused or was absent from the facility 24 out of 52 times for the [MEDICATION NAME] supplement administration and 66 out of 105 times for the 30 ml protein supplement administration. The facility's (MONTH) (YEAR) Meal Consumption Log lacked documentation for snack and supplement intake. The (MONTH) (YEAR) MAR recorded the resident refused or was absent from the facility 16 out of 60 times for the [MEDICATION NAME] supplement administration and 62 out of 120 times for the 30 ml protein supplement administration. On 11/30/17 at 5:44 PM, observation revealed the resident, sat in his/her wheelchair, at a bedside table in his/her room. Continued observation revealed the resident ate his/her meal without staff assistance. On 12/04/17 at 8:28 AM, Nurse E stated the resident received scheduled protein supplements, but often refused or was gone to [MEDICAL TREATMENT] or medical appointments. Nurse E stated nursing staff record the refusal or absence from the building on the MAR. Nurse E further stated the supplement intake was not monitored and he/she was not aware of snack intake documentation. On 12/04/17 at 8:44 AM, Dietary Manager K stated the resident should receive snacks and nursing staff administer the snack and monitor the intake. On 12/04/17 at 1:21 PM, Nurse Aide M stated nursing staff deliver snacks to the residents, but do not monitor the intake. On 12/05/17 at 9:45 AM, Administrative Nurse A stated he/she was not aware, if staff notified the (RD) Registered Dietician about the resident frequently not receiving his/her scheduled protein supplements. Administrative Nurse A stated staff did not document snack or supplement intake. On 12/05/17 at 10:47 AM, RD L stated the resident received scheduled protein supplements to promote wound healing and for [MEDICAL TREATMENT] needs. RD L stated he/she was not aware the resident was not receiving the scheduled protein supplements approximately 50% of the time, and other scheduling or supplement options were available. RD L stated the resident's snack and supplement intake should be recorded. The facility's Nutrition/Unplanned Weight Loss Policy, dated 12/2008, directed staff to monitor weight and all dietary intake for residents with weight loss. The policy directed staff to accurately monitor nutritional interventions to determine if the interventions were effective to meet the resident's nutritional needs. The facility's Snack Policy, dated 12/2008, directed staff to document the date and time snacks were served and record the snack intake to include with the resident's dietary intake. The facility failed to address Resident #47 not receiving physician ordered, scheduled protein and nutritional supplements, placing the resident at risk for continued low protein levels needed for wound healing and [MEDICAL TREATMENT]. - Resident #13's (POS) physician order [REDACTED]. the blood), dysphagia (swallowing difficulty) [MEDICAL CONDITION] phase (the tube food travels to the stomach), muscle weakness, constipation, [DIAGNOSES REDACTED] (low levels of potassium in the blood), pain and gastro-[MEDICAL CONDITION] reflux disease (backflow of stomach contents to the esophagus) without esophagitis (inflammation or irritation of the esophagus). The annual (MDS) Minimum Data Set assessment, dated 9/14/17, documented the resident had a (BIMS) Brief Interview for Mental Status score 5, which indicated severely impaired cognition, and he/she required supervision and cueing for activities of daily living. The MDS recorded the resident had no dental issues, no swallowing disorders, no weight loss or gain, received a therapeutic diet, was 62 inches tall, weighed 106 pounds, and received an antidepressant medication. The Nutritional (CAA) Care Area Assessment, dated 9/19/17, recorded the resident received a no added salt diet, regular texture and consistency, made food choices off the menu with some assistance, received liquid protein 30 (ml) milliliters twice a day, consumed 51 to 76% of meals, and ate his/her meals in the common area due to resident preference of not wanting to go in the dining room. The care plan, dated 9/20/17, directed staff to assist the resident with meal set up as needed, allow the resident to eat in the commons area per his/her choice, honor likes/dislikes, administer liquid protein 30 ml twice a day, notify care provider of any weight changes +/- 5% in 30 days, +/- 7.5% in 90 days and +/- 10% in 180 days, provide a no added salt diet with regular texture and thin liquids. The 11/14/17 the care plan update directed staff to provide house shakes twice a day. On 10/24/16 physician order [REDACTED]. The medical record revealed the following resident weights: 11/7/17 - 103.0 pounds 11/16/17 - 98.0 pounds 11/21/17 - 96.2 pounds 12/1/17 - 93.8 pounds (8.93% weight loss in 1 month) The 11/19/17 nutritional progress note recorded the resident's current weight was 98 pounds which was a -4.9% loss since 11/7, (BMI) Body Mass Index = 17.9, considered underweight, shakes started 2 times a day on 11/14, oral intake remains poor at that time. [MEDICATION NAME] (a medication used to treat depression and stimulate appetite) was started on 11/16/17 to try to increase appetite. Monitor weight trends with goal for weight maintenance/gradual weight gain. Review of the (MONTH) (YEAR) meal intake tracking, revealed no documentation of the breakfast meal intake for 19 days, refused breakfast 7 days, and ate 25 to 75% intake the remaining 4 days. The midday meal lacked intake documentation for 21 days, he/she refusal of meal 1 day, and ate 0 to 75% meal consumption for 8 days. The evening meal lacked documentation for intake on 13 days, refusal of meal 1 day, and 25 to 100% meal intake for 16 days. The meal consumption log lacked documentation for supplements or snacks. Review of the (MONTH) (YEAR) (MAR) Medication Administrative Record revealed the resident received a house supplement 2 times a day in the morning and evening, and 30 ml of protein liquid 2 times a day, in the morning and evening. The record had no documentation of amounts consumed. Review of meal tracking record revealed lack of documentation for the potential of 12 meals, for the month of (MONTH) (YEAR). On 11/30/17 at 1:00 PM, observation revealed the resident sat in his/her room, in his/her recliner, had a meal tray, on his/her lap. At 1:05 PM, the resident asked a staff member to take away the meal tray which he/she placed on his/her bed. No food was consumed from the tray, so the staff member left a bowl of mixed fruit on the bedside table and encouraged the resident to eat it. On 12/4/17 at 12:45 PM observation revealed staff entered the resident's room with a meal tray that consisted of chicken spaghetti, mixed vegetables, ½ slice of garlic bread and a cup of pudding. At 1:45 PM, observation revealed the meal tray sat on the bed, with only the pudding dish empty. On 12/5/17 at 1:20 PM, Nurse Aide S reported the resident has had a change in condition and does not want to come out of his/her room as often and was more anxious. Nurse Aide S further reported the resident's preference at meal time was a cookie and coffee, and he/she was not aware if the resident received a supplement, or who was to provide it for the resident. Nurse Aide S stated aides were to document the meal intake daily on the day and evening shifts if the resident ate in their room. On 12/5/17 at 8:42 AM, Nurse R stated he/she was aware of the resident's weight loss and decline, and numerous staff have tried to get him/her to eat, but will often complain of having difficulty of swallowing when he/she does not want to eat. Nurse R stated the resident received a house supplement 2 times a day and was offered donuts, but the resident became tired of them and quit eating them also. Nurse R reported occupational therapy was working with the resident related to the change in condition, and speech therapy had not seen the resident. On 12/5/17 at 10:25 AM, Registered Dietician L stated Administrative Nurse A emailed weekly and monthly weight of the residents to him/her prior to his/her weekly visit. He/she was aware of the resident's weight loss, house shakes, liquid protein and antidepressant medication was being used to treat the resident's weight loss. Registered Dietician L stated his/her expectation of staff was to document meal intake of residents, as he/she used it to evaluate Resident #13. On 12/5/17 at 8:00 AM, Administrative Nurse A, stated his/her expectation of the staff was to document meal intake of the residents, the certified nurse aides documented on the residents who had room trays, and the facility had no system in place to document or policy to support this practice. Administrative Nurse A stated he/she was not aware of the lack of documentation of meal intake for Resident #13. The facility's Resident Nutrition Services policy, dated 4/2010, directed nursing staff to assess and document the amount eaten as indicated for individuals with or at risk for, impaired nutrition, and significant variations from the usual or intake patterns must be recorded in the resident's medical record. The facility failed to accurately monitor meals and nutritional supplement intake for Resident #13, placing the resident at risk for further weight loss and nutritional problems.

The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to administer medications in accordance with professional standards of practice for 1 of 6 residents reviewed for hospitalization , when Resident #273 received another resident's medication, which caused adverse reactions and side effects, and resulted in 2 hospital emergency room visits. Findings included: - Review of Resident #273's [DIAGNOSES REDACTED]. - Resident #273's admission (MDS) Minimum Data Set assessment, dated 11/22/17, documented the resident had a (BIMS) Brief Interview of Mental Status score 15, which indicated the resident was cognitively intact. The MDS documented the resident required extensive staff assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene, and supervision with eating. The MDS documented the resident used a wheelchair for mobility. The MDS documented the resident received hypnotic (a class of medications used to induce sleep and treat [MEDICAL CONDITION]) and opioid (a medication used to treat moderate to severe pain) medications during the 7 look back days The 11/16/17 [MEDICAL CONDITION] drug use (CAA) Care Area Assessment documented the resident receives [MEDICATION NAME] (antidepressant medication), [MEDICATION NAME] (antidepressant medication) for Major [MEDICAL CONDITION] (major mood disorder), nurse had awareness of the side effects and monitored them daily. The CAA documented a pharmacy consult would be completed monthly, he/she would review the resident's chart, make any recommendations, and MAR along with daily skilled nurses notes. The 11/17/17 care plan instructed staff to administer his/her medications as ordered. The 10/9/17 facility report documented on 11/23/17 Medication Aide P administered Resident #53's medications to Resident #273, which included: [MEDICATION NAME], 10 (mg) milligrams, [MEDICATION NAME], 20 mg, and [MEDICATION NAME], 50 mg (medications used to treat high blood pressure (the pressure of the blood in the circulatory system). Aspirin (a medication used to treat fever, pain, and inflammation in the body. It also prevents blood clots, stroke, chest pain, and [MEDICAL CONDITION]) 81 mg. Calcium [MEDICATION NAME] (dietary supplement) Vitamin D (a dietary supplement) 600-40 mg. [MEDICATION NAME] (medication used to treat heart failure and irregular heartbeat. It slows down and strengthens the heart beat ), 250 (mcg) micrograms. [MEDICATION NAME] (medication used to relieve the symptoms of cough and loosen mucus in the chest) 400 mg. Iron (a medication used for [MEDICAL CONDITION], (decrease in the total amount of red blood cells) 325 mg. [MEDICATION NAME] (a synthetic [MEDICAL CONDITION] hormone) 88 mcg. Multivitamin (a dietary supplement). [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] and nerve pain) 100 mg. [MEDICATION NAME] (a medication used for the short-term treatment in the healing and relief of symptoms of acid-related damage to the esophagus (a tube that connects the throat and the stomach)) 40 mg. The Nursing (YEAR) Drug Handbook documented the following side effects of some of the above medications as follows: [MEDICATION NAME]- fatigue (extreme tiredness), [MEDICAL CONDITION], and [MEDICAL CONDITION] (slow heart rate). [MEDICATION NAME]-may increase the severity of heart failure, cause [MEDICAL CONDITION] and excessively slow pulse rate. [MEDICATION NAME]-[MEDICAL CONDITION] and chest pain. [MEDICATION NAME]-[MEDICAL CONDITION], heartburn, and may cause [MEDICAL CONDITION]. [MEDICATION NAME]- dyspnea (diffucltly breathing). The report documented Medication Aide P looked at the picture posted in the resident's medical record, felt he/she recognized the resident and approached Resident #273 and stated he/she had the resident's morning medications and administered them to the resident. The report documented Nurse J was the charge nurse that morning, gathered Resident #273's medications, went to administer them to him/her and the resident stated he/she already received his/her medications. Nurse J notified the physician and he/she instructed staff to monitor the resident's vital signs and assess the resident for 6-8 hours, and if the resident's blood pressure was less than 100/60 or pulse less then 60 to transfer the resident to the emergency room for evaluation. The physician ordered the nurse to administer the resident's normal scheduled medications except [MEDICATION NAME] (a prescription medication used to treat [MEDICAL CONDITION], (tissue swelling) and also used for high blood pressure) and [MEDICATION NAME] (a medication used to decrease the amount of acid produced in the stomach), only administer 200 mg of [MEDICATION NAME], and keep the resident in the facility. The report documented Medication Aide P was immediately suspended pending the investigation. The facility's notarized witness statement, dated 11/27/17, documented Medication Aide P came to work on or about 11/24/17 (even though the incident occurred 11/23/17), received report that Resident #53 moved from the 300 hall to the 400 hall. The statement documented Medication Aide P, during his/her morning medication pass, observed a resident (resident #273) sitting in the dining room, working with therapy, eating his/her breakfast and he/she looked like the picture of the Resident #53 on the (MAR) Medication Administration Record, who had moved to the 400 hall, so he/she administered Resident #53's medication to him/her. The statement documented the resident took the pills and drank the [MEDICATION NAME] but refused the protein liquid and [MEDICATION NAME] because it tasted nasty. The statement documented, a little while later Medication Aide P was in the dining room, when he/she overheard therapy staff state, (Resident #273) has more pills? Nurse J asked Medication Aide P if he/she gave the resident his/her pills already and Medication Aide P stated yes, that is Resident #53 isn't it?, Nurse J stated no. The statement documented normally Medication Aide P would ask if the person was the resident or ask them to tell him/her their name but the resident was already eating, working with therapy, and there was so much going on. The statement documented Medication Aide P should have asked the resident his/her name to be sure but he/she looked at the picture on the MAR and just thought for sure he/she had the right resident. The facility's undated witness statement documented on or about 11/23/17 Speech Language Pathologist Q was working with Resident #273 for speech therapy services during breakfast in the dining room when Medication Aide P presented medication to the resident and said, Hi and stated the resident's name and the resident commented the liquid medications were unfamiliar to him/her and Medication Aide P said they were recommended but not required. Resident #273 declined the liquid medications since he/she did not like the taste, but swallowed all the pills. Within 10 minutes, Nurse J approached Resident #273 with more pills, Speech Language Pathologist Q told Nurse J Medication Aide P already administered medications a few minutes ago, at this point Nurse J withheld the pills and proceeded to investigate the error and contact the resident's physician for further instructions. The 11/23/17 at 11:30 AM nurse's note documented the charge nurse called the physician related to the resident's blood pressure 102/54 and pulse 60. The physician instructed staff to keep monitoring the resident and if he/she became symptomatic to send the resident to the emergency room for evaluation. The note at 12:00 PM documented the nurse assessed the resident and his/her blood pressure was 98/50, pulse 59, respiration 16 and oxygen saturation 93% on room air and the resident was having shortness of breath and light chest pain. The note documented staff transferred the resident to the hospital. The note documented the resident returned to the facility at 5:17 PM with paperwork stating he/she was seen today for overdose and [MEDICAL CONDITION] (low blood pressure), and instructed the resident to return immediately if he/she became worse, or developed any concerning symptoms, and to follow up with his/her primary physician. The 11/23/17 hospital emergency department report documented the resident presented to the emergency department after staff accidentally gave the wrong medications around 9:00 AM that morning. The resident was given 10 mg [MEDICATION NAME], 81 mg of aspirin, calcium and vitamin D, 250 [MEDICATION NAME], 400 mg [MEDICATION NAME], iron, 80 mcg of [MEDICATION NAME], 20 mg [MEDICATION NAME], 50 mg of [MEDICATION NAME], 100 mg [MEDICATION NAME], and 40 mg [MEDICATION NAME]. The resident had his/her aspirin, vitamin D, [MEDICATION NAME], and [MEDICATION NAME] held. Patient was given 200 extra milligrams [MEDICATION NAME]. The report documented the resident had some left sided, sharp chest pain with a deep breath, that lasted for about 30 seconds 2 hours ago, went away, and never came back. The report documented at 1:30 PM the resident's blood pressure was 74/59 and pulse 64, at 1:31 PM blood pressure 71/37 and pulse 48, at 1:32 PM blood pressure 78/42 and pulse 48. The resident received fluids intravenously. At 4:57 PM his/her blood pressure was 107/49 pulse 97 and the resident discharged at 5:00 PM with instructions to please return immediately if he/she became worse, did not get better, developed any new concerning symptoms, or if he/she had any concerns. The National Heart, Lung, and Blood Institute (NHLBI) guidelines now define normal blood pressure as follows: * Less than 120 mm Hg systolic(top number) pressure and * Less than 80 mm Hg diastolic (bottom number) pressure The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The 11/24/17 at 11:09 AM nurse's note documented the resident complained of dull/quivering pain/hurt, or heaviness on left side of his/her chest, only every once in a while, the nurse asked the resident if he/she felt short of breath and the resident responded it feels like a cold or sinus feeling in my chest, but only when I'm up stirring around or trying to get out of bed. The note documented the nurse assessed the resident, checked the resident's vitals and they were within normal limits. The nurse asked the resident if there were any other things he/she felt like needed to be addressed and the resident responded he/she had the dropsies for a week or so and has been feeling like his/her body was jumpy. The note documented the nurse notified the physician and received orders to administer [MEDICATION NAME] 600 mg to the resident, and call back if complaints do not subside. The note documented the nurse administered the [MEDICATION NAME] 600 mg to the resident, reassessed the resident at 12:30 PM and the resident had chest pain rated 5 on pain scale of 10 (a numerical pain level scale used to rate pain, 0 (zero) means no pain at all and 10 means the greatest pain humanly possible), which was in his/her back and the resident stated feels like I've been shot straight through here (pointed to his/her heart). The note documented the nurse notified the physician and received orders to send the resident to the emergency room for evaluation. The note documented the resident was sent to the emergency room at 1:35 PM. The 11/24/17 hospital emergency department report documented the resident was seen yesterday after he/she was given multiple hypertension medicines by accident at the facility. The resident had chest pain yesterday for several minutes before coming, had negative workups, and stated he/she has had pain since leaving the emergency department yesterday, which he/she described as left sided, sharp, hurts to push and move. The resident reported no shortness of breath, nausea, vomiting, or diaphoresis (sweating) with the pain. The report documented the resident's blood pressure at 2:30 PM was 102/51 and pulse 68, and the resident received fluids intravenously. At 5:24 PM the resident's blood pressure was 113/58 and pulse 76. The report documented the resident was discharged from the emergency room with instructions to return immediately if he/she became worse, did not get better, developed any new concerning symptoms, or if he/she had any concerns. The report instructed the resident to followup with his/her primary physician on Monday and return for increasing chest pain, shortness of breath, or any concern. On 12/4/17 at 12:09 PM, observation revealed during medication administration, Nurse E with Nurse R overseeing him/her, went to the medication cart, pulled up Resident #273's MAR on the laptop computer, closed the laptop, opened the drawer of the cart, took out Aspirin 81 mg, took the lid off, and was about to dispense a tablet into a med cup, when Nurse R intervened and directed Nurse E to pull up the resident's MAR again on the laptop because he/she had the wrong medication. Nurse E stated the right medication was Aspirin 325 mg. Observation revealed Nurse E pulled up the resident's MAR on the laptop computer, looked at the order and placed the Aspirin 81 mg back in the drawer, took out the correct Aspirin 325 mg and placed one tab into a medication cup. On 12/4/17 at 12:15 PM, observation revealed the resident seated in a wheelchair, in his/her room, visiting with a family member. On 12/4/17 at 2:43 PM Nurse J stated the resident recently went to the emergency department at the hospital for medication overdose, but was not admitted to the hospital. On 12/5/17 at 9:23 AM, Administrative Nurse A stated he/she expected staff to ask the residents their name before administrating medications to them if they can answer, if a resident was unable to state their name, staff should ask another member of staff who knows that resident. The facility's (MONTH) 2007 Administering Oral Medications policy documented the guidelines for the safe administration of oral medications place are the following: place the MAR within easy viewing distance, unlock the medication cart, select the drug from the unit dose drawer or stock supply, check the label on the medication and confirm the medication name and dose with the MAR, check the expiration date on the medication, check the medication dose, recheck the to confirm the proper dose and confirm the identity of the resident. The facility failed to ensure residents were free of significant medication errors, when Resident #273 was administered another resident's medication, which caused adverse reactions and side effects from the medications, and 2 trips to the hospital emergency department, placing him/her at risk for adverse reactions and side effects to medications. Resident #273 experienced low blood pressure and required 2 hospital emergency room visits. He/she needed intravenous fluids to correct the low blood pressure.

The facility had a census of 74 residents, and the sample included 3 residents. The facility identified 28 residents who were full code (when an individual has cardiac or respiratory arrest, the facility is ethically and legally obligated to perform life-saving measures). Based on observation, record review, and interview, the facility failed to initiate (CPR) cardiopulmonary resuscitation (emergency medical procedures for restoring normal heartbeat and breathing to victims of heart or [MEDICAL CONDITION]), for 1 of the 3 sampled residents (#1). Resident #1 was found unresponsive and without a pulse or respirations, and ultimately died . This deficient practice placed resident #1 in immediate jeopardy. Findings included: - Resident #1's 14 day Medicare (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 9, which indicated the resident had moderately impaired cognition. The MDS indicated the resident had clear speech, could make himself/herself understood, and he/she was able to understand others. The [DATE] care plan indicated the resident was a full code, directed staff to keep his/her advanced directives in the resident's chart, and to mark the chart appropriately The [DATE] signed physician orders [REDACTED]. The [DATE] at 12:29 PM, nurse's note stated staff received a call from the hospital with a discharge report indicating the resident was a full code. The [DATE] at 8:52 AM, nurse's note stated on [DATE] at 11:45 PM, staff in the memory care unit went to the resident's room when the resident called out help me, help me. I can't breathe. The staff assisted the resident to the dining room, positioned him/her in a recliner, and applied his/her oxygen. The note stated within a few minutes, staff noted the resident was not breathing. One of the nurse aides ran to get the nurse, and the other nurse aide stayed with the resident. The note stated two licensed nurse's came to the memory care unit and found the resident unresponsive, no pulse, no respirations, and limp. The noted stated the resident's skin tone on the top half of his/her face was ashen and pale, and the bottom half was pink, and the resident's mouth was open with oral secretions drooling down his/her chin and chest. The note stated the four staff transferred the resident into a wheelchair, took the resident to his/her room, and placed him/her in bed. The note stated staff notified the physician and the director of nursing, and attempted to contact the resident's durable power of attorney without success. The clinical record lacked evidence the facility staff implemented CPR per this resident's wishes. The [DATE] at 12:30 AM, physician orders [REDACTED]. On [DATE] at 9:00 AM, Nurse A stated when he/she came to work at 5:10 AM on [DATE], he/she talked to Nurse C and was told he/she checked the resident's chart and the resident was a full code. Nurse C stated he/she did not start CPR because Nurse E was the charge nurse and he/she said the resident was deceased . Nurse A stated the code status for residents is in the medical chart, on the profile page in the computer chart, and in the (ADL) activities of daily living located at the nurse's station. On [DATE] at 9:25 AM, Nurse Aide B stated the resident called out for help and said he/she couldn't breathe. Nurse Aide B stated he/she assisted the resident to the dining room, and placed him/her in a recliner to make him/her more comfortable. Nurse Aide B stated a few minutes later, Nurse Aide D said he/she did not think the resident was breathing. Nurse Aide B stayed with the resident, while Nurse Aide D ran to get a nurse. Nurse Aide B stated the nurses did not call a code or start CPR, and Nurse E said the resident was gone. Nurse Aide B stated the 4 staff members transferred the resident to a wheelchair, took him/her to his/her room, and placed him/her in bed. Nurse Aide B stated Nurse C or Nurse E did not direct him/her to call 911. Nurse Aide B stated the code status is located in the residents chart, on the computer, and in the ADL book at the nurse's station. On [DATE] at 10:30 AM, Nurse Aide D stated Nurse Aide B brought the resident to the dining room and positioned him/her in a recliner. Nurse Aide D stated he/she and Nurse Aide B were seated at a dining room table, not far from the resident, when he/she noticed the resident was not breathing, and his/her color was pale. Nurse Aide D stated he/she ran to get the nurse. Nurse Aide D stated Nurse C and Nurse E did not start CPR and and Nurse E stated the resident was gone. Nurse Aide D stated Nurse C and Nurse E did not ask him/her to call 911. On [DATE] at 1:50 PM, Nurse E stated at approximately 11:45 PM on [DATE], a nurse aide came to get him/her and said a resident was not breathing. Nurse E stated upon his/her assessment of the resident, the resident was not breathing, his/her body was limp, and his/her skin tone was ashen gray. Nurse E stated the resident's mouth was open and oral secretions were running down his/her chin, chest, and onto his/her clothing. Nurse E stated he/she did not start CPR or ask the staff to call 911. Nurse E stated he/she did not know the code status of the resident, and he/she had never been educated on where to find the code status for any of the residents. On [DATE] at 3:00 PM, Nurse Consultant F stated Nurse C and Nurse E made a poor decision, and this situation is an unfortunate incident where 2 nurses made a huge, devastating error in judgement when they failed to start CPR on a resident who was a full code. On [DATE] at 4:20 PM, Administrative Nurse G stated he/she would have expected the staff to initiate CPR on the resident, who was a full code. The facility policy for Cardiopulmonary Resuscitation/Basic Life Support, dated [DATE], stated if a resident was found unresponsive, and without a pulse, a licensed staff person certified in CPR/BLS shall initiate CPR, unless it was known that a (DNR) Do Not Resuscitate that specifically prohibited CPR and/or external defibrillation existed for that resident, or have obvious signs of irreversible death (rigor mortis (the stiffening of the joints and muscles of a body after death). The policy further stated the charge nurse from each shift was the designated CPR team in case of an actual [MEDICAL CONDITION]. The policy stated the procedure would be to check the resident for pulse and respiration, and if they are absent, attempt to arouse the resident. If the resident was unresponsive (no movement or response to stimuli), and no return of pulse and/or respirations, activate the emergency response team and initiate CPR, call a code as designated by the facility protocol, designate a staff person to call 911, and contact the resident's physician and family. The policy stated the staff should open the resident's airway, check breathing, administer rescue breaths, check for a pulse and give chest compressions. The facility failed to identify and facilitate Resident #1's right to formulate an advanced directive and follow the facility policy, when Resident #1 was found unresponsive, without a pulse and respirations, and the staff did not initiate CPR, and the resident died . This deficient practice placed Resident #1, in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when the facility completed in-service training for the staff regarding how to respond appropriately to a full code event. This deficient practice remains at a scope and severity of a G.

The facility had a census of 74 residents. The sample included 5 residents, of which 3 were reviewed for urinary tract infections. Based on observation, interview and record review the facility failed to provide appropriate care and services to 4 of 4 residents reviewed for [MEDICAL CONDITION] urinary tract infections. The staff failed to obtain a physician's orders [REDACTED].#1, who developed urosepsis (a life-threatening bacterial infection of the blood; urosepsis [MEDICAL CONDITION] that complicates a urinary tract infection) a systemic (spread throughout the body) infection and required hospitalization , where he/she later died . This failure placed the resident in Immediate Jeopardy for extensive harm from a wide spread infection. The facility further failed to prevent urinary tract infections by not performing appropriate peri-care for 2 dependent residents after toileting and incontinence (#2, #3), and failed to provide assessment and direction to staff for the decline in urinary status for a resident. (#4) Findings included: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status score of 15, displayed verbal behavior toward others, and rejected care. The MDS further indicated the resident required extensive assistance of 2 staff with toilet use and transfers, and was dependent on staff for personal hygiene. The MDS further indicated the resident was continent of bowel and bladder, and received antianxiety, antidepressant, and diuretic (medication to eliminate excess water through the kidneys) medications. The [DATE] urinary (CAA) Care Area Assessment indicated the resident required assistance with toileting, the resident was independent with using his/her urinal, and staff would empty it. The [DATE] care plan informed staff the resident was continent of bowel and bladder and could ask for assistance with toileting needs when he/she felt the need. The [DATE] (UA) Urinalysis indicated the resident had 3 + bacteria present (the presence of bacteria in urinalysis is a signal to a physician of the possibility of a UTI) in his/her urine. The medical record lacked the results from the physician ordered urine culture. The [DATE] physician's orders [REDACTED]. The [DATE] UA indicated blood and leukocytes (white blood cells, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) present. The urine culture indicated no UTI was identified. The [DATE] bowel and bladder assessment indicated the resident was currently incontinent of bowel and bladder, and demonstrated symptoms of stress incontinence (loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder). The assessment further indicated the resident could participate in an incontinence program but failed to mention interventions. The [DATE] UA indicated trace bacteria present in the urine. The [DATE] urine culture indicated mixed organisms (combination of organisms). The [DATE] physician's orders [REDACTED]. The physician directed staff to discontinue the Bactrim on [DATE]. The [DATE] (ER) emergency room report indicated the resident was diagnosed with [REDACTED]. The [DATE] at 10:17 PM, nurse's note indicated the resident was lethargic (sluggish, limp) and refused to eat the evening meal. The note indicated staff offered the resident a candy bar and he/she ate it. The note further indicated the resident complained of burning with urination. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 12:50 PM, nurse's note indicated the resident had straw colored urine and complained of burning with urination and lower back pain. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 10:12 AM, nurse's note indicated staff had to use a full mechanical lift to transfer the resident from the bed to his/her wheelchair. The note further indicated staff notified the physician by fax. The [DATE] at 4:29 PM, nurse's note indicated staff observed the resident with confusion and lethargy, was slow to respond to questions, and unable to remember his/her name. The note further indicated related to the confusion and lethargy the physician ordered a (CBC) Complete Blood Count (blood labortory test), (CMP) Comprehensive Metabolic Profile (blood labortory test), and a UA. The [DATE] physician progress notes [REDACTED]. The note instructed staff to promptly notify the physician with any change in condition. The [DATE] UA was negative for UTI. The [DATE] physician's orders [REDACTED]. The [DATE] at 11:25 PM, nurse's note indicated the resident had straw colored urine and complained of burning with urination. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 12:30 PM, nurse's note indicated the resident complained of burning with urination, and had straw colored urine. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 11:36 PM, nurse's note indicated the resident continued to complain of burning with urination and low back pain. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] physician progress notes [REDACTED]. The progress note instructed staff to obtain a UA in 2 days, and to encourage and advise the resident the importance of getting out of bed. The [DATE] at 3:05 AM, nurse's note indicated the resident had a hallucination (sensing things while awake that appear to be real, but the mind created) he/she was on a bus after walking at night. The note further indicated the resident remained agitated until staff reoriented him/her. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 4:48 PM, nurse's note indicated the resident had an elevated (WBC) white blood cell count of 14.6 (normal 4XXX,[DATE].0), the resident received his/her last dose of [MEDICATION NAME] today, and staff notified the director of nursing who was to notify the resident's physician. The [DATE] physician's orders [REDACTED]. The [DATE] at 4:07 AM, nurse's note indicated staff received a fax in regards to the resident's laboratory results and forwarded the information to the physician by fax. The [DATE] at 11:12 PM, nurse's note indicated the resident was incontinent of bladder and continued to complain of burning upon urination. The note indicated staff encouraged the resident to drink, and he/she consumed more than 1000 (mls) milliliters of water that shift. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 1:57 AM, nurse's note indicated the resident had multiple delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and was unsure where he/she was. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 9:59 AM, nurse's note indicated the resident continued to complain of lower back pain, and his/her urine was straw colored with a slight foul odor. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 1:38 AM, nurse's note indicated the resident called out at times with delusions, and continued to complain of burning with urination, and low back pain. The note further indicated the resident was incontinent at times and no foul odor noted by staff. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 4:50 AM, nurse's note indicated staff attempted to obtain a UA twice, once by straight cath, but the resident had no urine output. The nurse's note further indicated staff gave the resident multiple sips of water, and the resident's brief was wet with light straw colored urine. (The clinical record lacked evidence that staff notified the resident's physician.) The medical record revealed no documentation the staff notified the physician of the resident's decrease in urine output. The [DATE] at 10:19 PM, nurse's note indicated the resident continued to call out. The [DATE] at 2:34 PM, nurse's note indicated the resident requested assistance with his/her meals. The note further indicated staff assisted the resident with fluids and food. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 12:13 AM, nurse's note indicated the resident was very drowsy and called out at times. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] at 5:02 AM, nurse's note indicated the resident had peach colored, cloudy, foul smelling urine, and a UA was sent to the laboratory. (The physician ordered the UA to be obtained on [DATE], 5 days earlier. The clinimal record lacked evidence that staff notified the resident's physician when unable to obtain the UA.) The [DATE] at 5:03 AM, nurse's note indicated staff observed the resident was delusional stating a physician was in his/her room, and going to perform an abdominal procedure on him/her. (The clinical record lacked evidence that staff notified the resident's physician.) The [DATE] UA indicated positive blood and bacteria. The [DATE] urine culture indicated (e coli) escherichia coli (bacteria found in the intestines) >100,000 was in the urine. The [DATE] at 9:16 AM, nurse's note indicated staff notified the nurse the resident was mumbling, non coherent, was pale, lethargic, and his/her eyes were fixed without tracking. The note further indicated the resident's blood pressure was ,[DATE] (normal ,[DATE]). The nurse notified the physician who directed the resident be transferred to the (ER) emergency room for evaluation and treatment. The [DATE] hospital discharge summary indicated the resident's cause of death was (ESBL) Extended Spectrum Beta Lactmase e coli infection that caused septic shock (a serious medical condition that occurs [MEDICAL CONDITION], which is a body-wide [MEDICAL CONDITION] response to infection, leads to dangerously low blood pressure, and most commonly caused by bacteria) and kidney failure. On [DATE] at 1:51 PM, Nurse E verified the physician had treated the resident with 2 rounds of antibiotics for his/her UTI. On [DATE] at 2:44 PM, Nurse Aide D stated a week before the resident went to the hospital he/she had to transfer the resident with use of a full mechanical lift, which was a change for him/her. Nurse Aide D stated the Sunday before the resident went to the hospital the resident had a big change and was not able to feed him/herself. On [DATE] at 2:35 PM, Administrative Nurse B verified a lack of peri care could contribute to the resident's UTI. On [DATE] at 5:25 PM, Administrative Nurse B verified staff obtained the physician ordered [DATE] UA on [DATE] related to difficulty obtaining the urine sample due to the resident's incontinence and no output with straight cath (a tube-shaped medical device that is used to remove urine from a person's bladder if he or she is having trouble voiding naturally) at times. On [DATE] at 8:45 AM, Physician N verified he/she was not informed in a timely manner of the resident's decline, and when he/she had been sent to the hospital, the resident was already septic. Physician N verified staff should have notified him/her when they were unable to obtain a UA as ordered on [DATE]. Physician N stated although he/she anticipated it would be difficult to keep the resident's urine clear, he/she was not notified timely of the resident's decline, until after he/she was septic. On [DATE] at 2:00 PM, Administrative Nurse B, verified the resident had experienced a change in condition including requirement of a mechanical lift for transfers, delusions, lethargy, requested feeding assistance, and had continued to complain of burning with urination and back pain. Administrative Nurse B stated he/she expected staff to notify the physician as the changes occurred and were identified. Administrative Nurse B further stated staff had obtained a straight cath order back in November, and that is what they used when they could not obtain the UA. Administrative Nurse B verified he/she expected staff to notify the physician they were unable to obtain the UA related to incontinence and straight cath due to no urine output. Administrative Nurse B further verified staff received the results from the [DATE] UA on [DATE] at 11:22 AM, and faxed the results to the physician's office at that time, but the resident was already transferred to the hospital earlier in the morning. On [DATE] at 12:55 PM, Physician P stated if the resident had displayed symptoms when the UA was ordered, and if staff had collected the UA when ordered both could have affected the resident's outcome, and he/she may not have developed urosepsis with earlier treatment. Physician P verified back pain, burning with urination, hallucinations, confusion, and a physical & cognitive decline would be considered symptoms and a UA would had been beneficial to identify the infection [MEDICAL CONDITION] had occurred. The facility failed to obtain a physician's orders [REDACTED].#1, who developed a systemic infection, required hospitalization , and died at the hospital. This deficient practice placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy on [DATE], when the facility provided an in-service on the facility's lab monitoring system, including reconciliation of lab orders, requisition, results and physician notification. The facility in serviced the nursing staff on notifying the physician of changes in condition, and on providing per-care with required return demonstration. The facility will monitor all lab orders written in the last 30 days to verify they were completed and the staff notified the physician of results. Nursing Administration will monitor lab orders, and peri care for 4 weeks, or until resolved. The deficient practice remains at a scope and severity of a G. - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident was cognitively intact with a (BIMS) Brief Interview for Mental Status of 14, and required extensive assistance from 1 staff for his/her (ADLs) Activities of Daily Living including toileting. The MDS further indicated the resident had a [MEDICAL CONDITION] Urinary Tract Infection in the last 30 days, and received antidepressant, diuretic, and antibiotic medications. The [DATE] urinary incontinence (CAA) Care Area Assessment indicated the resident required assistance with toileting and was continent. The [DATE] care plan informed staff the resident required assistance for toileting, had periods of incontinence, and a history of UTI. The [DATE] care plan update instructed staff to report concerns related to urinary problems, and the [DATE] care plan update instructed staff to encourage fluids and observe for signs/ symptoms of UTIs. The [DATE] physician's progress note indicated the resident had problems with urinary control and incontinence. The [DATE] (POS) Physician order [REDACTED]. (initiated on [DATE]) The [DATE] (UA) urinalysis report indicated the resident's urine had 3+ leukocytes (white blood cells, are the cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders), with too numerous to count white blood cells with large clumps. The Urine Culture indicated >100,000 (e coli) escherichia coli (bacteria found in the intestines) was isolated in his/her urine. The [DATE] physician's orders [REDACTED]. The [DATE] physician's orders [REDACTED]. The [DATE] UA indicated the resident had positive 3+ leukocytes, had white blood cells, and numerous bacteria in his/her urine. The [DATE] Urine Culture indicated > 100,000 e coli isolated in his/her urine. The [DATE] physician's orders [REDACTED]. The [DATE] physician's orders [REDACTED]. The [DATE] and [DATE] UA revealed they were negative for UTI. The [DATE] UA indicated 4+ bacteria present and no documentation of a urine culture in the medical record. The [DATE] physician progress notes [REDACTED]. (not added to the resident's care plan) The [DATE] physician's orders [REDACTED]. The [DATE] UA revealed it was negative. The [DATE] at 4:16 PM, nurse's note indicated the resident returned from a physician's office visit with orders for a UA with a urine culture, and was collected in the physician's office. On [DATE] at 3:35 PM, observation revealed Nurse Aide F and Nurse Aide G assisted the resident to toilet. Nurse Aide F assisted the resident with a pivot transfer with a gait belt, from his/her wheelchair to the toilet. Nurse Aide F pulled down the resident's dry brief, the resident sat on the toilet, and urinated. Observation revealed the resident did not cleanse or wipe his/her peri area, and Nurse Aide F assisted the resident to stand and pulled up his/her brief, without cleansing or wiping his/her peri area. On [DATE] at 7:11 PM, observation revealed Nurse Aide H assisted the resident to toilet. Nurse Aide H assisted the resident with a pivot transfer with a gait belt from his/her wheelchair to the toilet. Nurse Aide H pulled down the resident's brief, verified it was damp, and the resident sat on the toilet, and urinated. Observation revealed Nurse Aide H asked if he/she wanted assistance with peri care, and the resident stated yes. Further observation revealed Nurse Aide H, grabbed some toilet paper, and quickly wiped the resident's peri rectal area. On [DATE] at 3:35 PM, Nurse Aide F stated staff provide peri care to the residents with wipes or peri spray after incontinence, and he/she had not cleansed the resident after toileting because the resident had not had a bowel movement. On [DATE] at 1:51 PM, Nurse E verified he/she expected staff to cleanse a resident after a resident is toileted or is incontinent. Nurse E further verified the infection control nurse does spot checks with the staff to observe peri care. On [DATE] at 7:11 PM, Nurse Aide F verified when a resident is incontinent, staff should provide peri care with personal cleansing wipes, and he/she had not done that. On [DATE] at 7:30 PM, Nurse I verified he/she observes staff to monitor for proper peri care. Nurse I stated he/she had not identified concerns with staff performing peri care, but identified they may not have all their supplies together before hand. Nurse I stated he/she has not monitored the night/evening shift. On [DATE] at 2:35 PM, Administrative Nurse B verified he/she expected staff to cleanse a resident after toileting or an incontinent episode from front to back, be certain bowel is not in other areas, and to cleanse with more then 1 wipe. Administrative Nurse B further verified the lack of incontinence care and cleansing after toileting could have contributed to the resident's frequent UTIs. The facility's undated Incontinence Care Policy and Procedure instructed staff to provide incontinence care with peri foam and to apply barrier cream. The facility failed to provide peri care after incontinence and toileting for dependent Resident #3 who had a history of [REDACTED]. - Resident #2's (POS) Physician order [REDACTED]. The significant change (MDS) Minimum Data Set assessment, dated [DATE], indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview of Mental Status score of 6, and required extensive assistance from 1 staff with his/her (ADLs) Activities of Daily Living, including toileting. The MDS further indicated the resident was frequently incontinent of urine, and received antianxiety, antidepressant, and insulin medications. The [DATE] care plan informed staff the resident was incontinent of urine, required assistance from staff for incontinent care, and had a history of [REDACTED]. The [DATE] (UA) Urinalysis revealed numerous bacteria in the resident's urine, and had no documentation of a urine culture in the medical record. The [DATE] physician's orders [REDACTED]. The [DATE] physician's orders [REDACTED]. The [DATE] UA revealed 4+ bacteria in the resident's urine. The [DATE] Urine Culture indicated >100,000 (e coli) escherichia coli (bacteria found in the intestines) was isolated in his/her urine. The [DATE] physician's orders [REDACTED]. The medical record revealed the physician discontinued [MEDICATION NAME] [DATE]. The [DATE] physician's orders [REDACTED]. The [DATE] UA revealed numerous bacteria in the resident's urine. The [DATE] preliminary Urine Culture indicated a gram negative bacteria (a group of bacteria) >100,000. The [DATE] physician's orders [REDACTED]. On [DATE] at 10:19 AM, observation reveled Nurse Aide J and Nurse Aide K assisted the resident a mechanical lift to transfer him/her to the toilet. Nurse Aide K removed the resident's brief and verified it was soaked with urine. Further observation revealed the resident had a bowel movement while seated on the toilet, and staff raised the resident with the mechanical lift, cleaned his/her backside with 1 wipe, applied barrier cream, and a new brief. Observation revealed Nurse Aide K did not cleanse the resident's peri area after he/she was incontinent with urine. On [DATE] at 10:25 AM, Nurse Aide J stated staff cleansed the resident in the morning with peri wash, and staff use a wipe for cleansing after a bowel movement. On [DATE] at 7:30 PM, Nurse I verified he/she observes staff to monitor for proper peri care. Nurse I stated he/she had not identified concerns with staff performing peri care, but identified they may not have all their supplies together before hand. Nurse I stated he/she has not monitored the night/evening shift. On [DATE] at 2:35 PM, Administrative Nurse B verified he/she expected staff to cleanse a resident after toileting, or after an incontinent episode, from front to back, be certain bowel is not in other areas, and to cleanse with more than 1 wipe. Administrative Nurse B further verified the lack of incontinence care and cleansing after toileting could have contributed to the resident's frequent UTIs. The facility's undated Incontinence Care Policy and Procedure instructed staff to provide incontinence care with peri foam and to apply barrier cream. The facility failed to provide peri-care after incontinence and toileting to dependent Resident #2, who had a history of [REDACTED]. - Resident #4's annual (MDS) Minimum Data Set assessment, dated [DATE] indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for metal status score of 12, and required extensive assistance of 1 staff for toilet use, dressing and personal hygiene. The MDS indicated the resident was always continent of bowel and bladder, and received insulin, antipsychotic (drug used to treat [MEDICAL CONDITION]), antidepressant, and diuretic (medication used to elimnate excess water through the kidneys) medications. The [DATE] urinary (CAA) Care Area Assessment indicated the resident would toilet independently and required assistance with cleansing after a bowel movement. The [DATE] care plan informed staff the resident toilets independently, and he/she is at risk for incontinence related to diuretic use. The care plan had no direction regarding incontinence briefs, a toileting plan, or assistance with peri-care. Review of the medical record revealed no bowel or bladder assessment completed by staff. Review of the [DATE] (ADL) Activities of Daily Living record revealed no documentation by staff the resident had been incontinent. On [DATE] at 6:58 PM, observation revealed the resident, seated in the commons area, of the facility, on a cushioned bench, in a slumped forward posture, and eyes closed. On [DATE] at 9:20 AM, Resident #4 stated he/she sometimes urinates unintentionally in his/her clothing, and staff asked him/her not to sit in the chairs in the commons area. Resident #4 stated he/she was in the commons area because he/she wanted to visit with the group of residents who were there. On [DATE] at 10:44 AM, Nurse Aide L stated the resident is not incontinent too often, and staff encourage him/her to change his/her brief. On [DATE] at 2:20 PM, interview with Resident #6 revealed he/she observed staff ask Resident #4 to go to his/her room so he/she did not urinate on the new chairs. Resident #6 further verified 2 days prior, Resident #4 had urinated on the couch. On [DATE] at 2:26 PM, interview with Resident #7 revealed he/she observed staff tell Resident #4 he/she could not sit on the furniture unless he/she went to the restroom because Resident #4 will pee when he/she falls asleep. On [DATE] at 3:10 PM, Nurse M verified the resident is incontinent. On [DATE] at 3:25 PM, Nurse Aide H verified the resident is mostly incontinent when he/she is in a deep sleep. Nurse Aide H verified a couple days prior, the resident was incontinent on the couch. On [DATE] at 2:26 PM, Administrative Nurse B verified the resident had not had a bowel or bladder assessment completed by the staff, and verified staff reported a decline in urinary status. The facility failed to provide direction to staff for appropriate care for Resident #4, who had a decline in urinary status.

The facility had a census of 74 residents. The sample included 8 residents. Based on record review and interview the facility failed to evaluate Resident #4' s change in behavior to maintain his/her mental or psychosocial functioning, who had started isolating himself /herself to his/her bedroom. Findings included: - The 9/9/14 physician's orders [REDACTED]. The Admission (MDS) Minimum Data Set assessment, dated 9/15/14, indicated the resident cognitively intact, felt tired or had little energy 12-14 days during the look back time and required supervision with (ADLs) Activities of Daily Living. The resident displayed no other mood or behavior symptoms. The 9/15/14 care plan instructed the staff to observe the resident for nonverbal signs/symptoms of pain, anxiety, and increased confusion. The care plan instructed the staff to provide opportunities for the resident to vent his/her feelings, and to observe him/her for signs/symptoms of depression and anxiety. The care plan instructed the staff to observe for signs/symptoms of sadness, crying, withdrawal, loss of interest in usual activities, appetite changes and to redirect mood and behavior by giving praise and reassurance to the resident. The 9/9/14 at 6:46 PM admission nurse's note indicated the resident ambulated with oxygen at 4 liters per nasal cannula. (nose piece) The 9/14/14 at 5:11 PM nurse's note indicted the resident had increased respirations during any form of exertion and stayed in his/her room between meals. The clinical record lacked evidence the resident received psychosocial related social services after he/she began staying in his/her room more. The 9/15/14 at 2:39 AM nurse's note indicated the resident self-propelled about the facility, ate supper well in the dining room, and rested in his/her room, in the recliner, watching television or using his/her computer, throughout the evening. The 9/16/14 at 4:16 AM nurse's note indicated the resident self-propelled ad lib about the facility and ate supper in the dining room. The 9/21/14 at 10:47 AM nurse's note indicated the resident sat and talked with the nurse about not fearing death. The 9/23/14 at 2:41 AM nurse's note indicated the resident was very pleasant, talkative and visited with staff, residents and visitors. The 10/7/14 at 3:21 PM nurse's note indicated the resident received a new dose of [MEDICATION NAME] and the nurse had applied the patch on the resident this morning. The note indicated the resident stated he/she had pain 10 out of 10 on the pain scale to his/her chest and rib area that " comes and goes " . The note indicated the resident was short of breath this shift, and the resident had oxygen on at 2-3 liters per nasal cannula when he/she came to the cart this morning. The note indicated the resident came out to the dining room for breakfast and lunch. The 10/10/14 at 6:00 PM nurse's note indicated the resident asked for meals in his/her room today. The clinical record lacked evidence the resident received psychosocial related social services after he/she began staying in his/her room more. Review of the medical record revealed the resident had a change of status from 9/26/14 to 10/12/14, during which time he/she started to spend increased time in his/her room. The 10/12/14 at 3:08 PM nurse ' s note indicated the resident continued to stay in his/her room for meals, had a poor appetite, had oxygen up to 4 liters per nasal cannula, and requested [MEDICATION NAME] (a medication used in treatment of [REDACTED]. The clinical record lacked evidence the resident received psychosocial related social services after he/she began staying in his/her room more. The 10/12/14 at 10:11 PM nurse's note indicated the resident stayed in his/her room for supper this evening, ate well, had frequent visitors, and received [MEDICATION NAME], 0.5(ml) milliliter, (IM)intramuscular) at 9:45 PM. The clinical record lacked evidence the resident received psychosocial related social services after he/she began staying in his/her room more. The 10/13/14 at 7:55 AM nurse's note indicated the resident had stayed in his/her room last evening, came out of his/her room at 9:49 PM, and requested a shot for feeling anxious. The note indicated the nurse administered [MEDICATION NAME], 0.5 ml, IM to the resident, and described the resident as bright eyed and talkative. The note indicated at 1:00 AM the resident was working on his/her computer, denied pain, smiled and was talkative. The note indicated at 1:30 AM the resident was outside his/her room and stated " just getting some air, need to take a drive I think " and the nurse reminded the resident he/she had received [MEDICATION NAME] at 9:45 PM, and driving was dangerous as it was raining pretty hard outside. The note indicated at 1:45 AM, the resident was visiting with staff for about 15-20 minutes and reminiscing about the old days in 1969, then stated " I'm going on a drive around the block " . The note indicated the nurse followed the resident to his/her vehicle, parked in the facility parking lot, and brought the resident's wheelchair back into the facility. The note indicated the resident drove off the facility parking lot at 2:10 AM. The note indicated at 2:35 AM, the nurse received a phone call from the resident's family member who asked the nurse if the resident was still in the facility. The family member reported the resident had called him/her and stated he/she was going to kill himself/herself. The note indicated the nurse told the family member the resident had gone for a drive in his/her pickup, then staff checked the facility parking lot and the vehicle was not there. The note indicated the resident's family member called back and told the nurse the resident would not answer his/her cell phone, gave the nurse the make, model and license plate number of the resident's truck, and at 2:55 AM, the nurse notified 911 of the resident ' s statement and vehicle information. The note indicated at 3:00 AM the nurse notified the director of nursing, and at 3:10 AM the nurse notified the physician, and during the phone call with the physician the family member called and stated " you can stop looking he/she did it. " The nurse notified the family member that the resident was alert and oriented x 4, able to make his/her own decisions, not an elopement risk and had made it very clear to staff that we were not changing his/her mind about going on a drive. The 10/13/14 incident report indicated the resident reported to Social Service staff, on 9/10/14, that he/she was worried about insurance not covering his/her stay in facility, and if he/she had to pay privately, he/she would go home. The report indicated the resident told the social service staff he/she wanted to leave money to his/her family member. The 10/13/14 witness statement from Social Service Staff E stated the facility admitted the resident for end of life care due to last stage of [MEDICAL CONDITION], and the resident had only one functioning lung. The note stated the resident had not taken home medications for over a month, but only told his/her primary doctor that it was only the last 1-2 weeks. The statement indicated the resident talked about watching his/her spouse die and stated he/she would never let anybody put an expiration date on him/her. The 10/16/14 witness statement by Nurse A stated on 10/13/14 at 1:50 AM the nurse had reminded the resident he/she had not only taken [MEDICATION NAME], but it was also raining pretty hard and the resident said he/she had his/her truck, keys and own free will. The 10/16/14 witness statement by Nurse F stated the resident sat at the front door of the facility, in his/her wheelchair, watching the rain and said he/she wanted to go outside because he/she liked the rain and wanted to get wet. Nurse F stated once the resident was at his/her pickup, he/she took his/her keys out of his/her pocket, walked from the bumper to driver's door with his/her portable oxygen concentrator in a bag and Nurse F asked if the resident had everything, and he/she got into his/her pickup, adjusted the oxygen and cane, and closed the pickup door. Nurse F stated he/she took the resident's wheelchair back into the facility and around 2:10 AM, the aide checked to see if the resident had left, and he/she was gone. On 10/16/14 at 1:45 PM Nurse A stated the resident had his/her own vehicle and was able to come and go as desired and the facility did not have a sign out sheet for residents who leave the facility. On 10/15/14 at 2:16 PM, Nurse Aide G stated he/she never saw the resident leave the facility and the facility did not have a sign out sheet for the residents when they leave the building. On 10/15/14 at 2:45 PM Nurse I stated the facility does not have a sign out sheet for residents that leave the building. On 10/15/14 at 3:09 PM, Nurse Aide H stated he/she never saw the resident leave the building. On 10/16/14 at 1:45 PM, Nurse A stated the facility does not have a sign out sheet for residents to sign before leaving the building. On 10/16/14 at 1:45 PM Nurse A stated the facility does not have a sign out sheet for residents to sign before leaving the building. On 10/16/14 at 5:30 PM, Nurse J stated the facility did not have a sign out sheet for residents to sign before leaving the building. On 10/16/14 at 9:16 AM, Administrative Nurse B stated he/she did not know the resident had been leaving the facility driving his/her pickup until 10/13/14 after the incident. Administrative Nurse B stated he/she would expect the staff to call him/her if the resident wanted to leave the facility at 2:30 AM, in the rain, before allowing them to leave. Administrative Nurse B verified there was no documentation the resident had left the building on earlier occasions. On 10/16/14 at 9:16 AM, Social Service staff E stated he/she talked to the resident about his/her insurance not covering his/her stay in the facility but did not document the conversation. Social Service staff E stated he/she was unaware of the resident ' s emotional/psychosocial needs. On 10/21/14 at 9:20 AM, Physician C stated he/she would have expected the staff to call the on call physician if the resident requested to leave the facility at 2:30 AM, in the rain. Physician C stated it was not reasonable for the resident to drive a vehicle. The facility ' s revised 2006 signing Resident Out policy stated each resident leaving the premises (excluding transfers/discharges) must be signed out. Inquiries concerning the signing out of residents should be referred to the Director of Nursing Services or to the Administrator. The facility's Psychosocial Well-being policy, dated September 2005, intent waas to determine the resident's emotional adjustment to the nursing facility. The facility failed to evaluate Resident #4 ' s behavior to maintain his/her mental or psychosocial functioning.

The facility had a census of 76 residents. The sample included 3 residents. Based on observation, interview and record review the facility failed to provide adequate supervision as planned, to prevent accidents for 1 of 3 residents who had two unattended falls in the dementia unit dining room, and sustained injuries (head laceration requiring sutures after one fall and a hip fracture and subdural hematoma (collection of blood on the surface of the brain) after a repeated fall. (#1) Findings included: - Resident #1 ' s quarterly (MDS) Minimum Data Set 3.0 assessment, dated 6/6/13, indicated the resident had cognitive impairment with short and long term memory problems and severely impaired decision making skills. The MDS indicated the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and totally dependant of staff for hygiene and eating. The MDS indicated the resident had an unsteady balance, was only able to stabilize with assistance from the staff, used a wheelchair for mobility and had 1 injury fall since admission. The 6/12/13 care plan instructed the staff to ensure the resident had a low bed with a blue mat at the bedside and to keep the bed in the lowest position. The care plan further instructed the staff to provide the resident activities and to sit with him/her when he/she was is in the dining room. The care plan directed the staff to frequently check on the resident. The 7/30/13 care plan update indicated the resident had a fall on 7/30/13 and instructed the staff not to leave the resident unattended while he/she was in his/her wheelchair. This intervention was in place on the 6/12/13 care plan. The 7/30/13 at 3:04 PM, nurse's note indicated the resident had been seated in his/her wheelchair in the dining room and when the staff had returned to the dining room the resident was lying on the floor with a bleeding laceration to the left side of the resident's head which measured 6.5 (cm) centimeters by 3.0 cm. The note further indicated the staff sent the resident to the emergency room for further treatment and evaluation. On 7/30/13 at 6:18 PM, nurse's note indicated the staff removed gauze from the resident's top left forehead and cleansed it. The note further indicated the resident had 9 visible sutures without drainage. On 9/13/13 at 4:35 PM, nurse's note indicated the staff reported the resident had been found on the floor in the dining room with a large protruding hematoma (a collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to the resident ' s right eye. The nurse ' s notes revealed the (EMS) Emergency Medical Service transported the resident to the emergency room for further evaluation and treatment. The 9/13/13 hospital x ray report indicated the resident had a possible right hip fracture with an acute right subcapital femoral neck fracture (long bone running through the thigh near the hip). The 9/13/13 hospital (CT) Computerized Tomography report revealed the resident had a 2.1 (cm) centimeter x 2.1 cm acute hemorrhage (bleeding) in the right frontal lobe of his/her head with surrounding edema (swelling). The CT report further revealed the resident had a small right front acute subdural hematoma (collection of blood on the surface of the brain) and right frontal subarachnoid hemorrhage (when blood leaks into the space between two membranes that surround the brain). The 9/14/13 follow up CT of the resident ' s head revealed an increase of the acute hematoma of the right frontal lobe now measuring 5.1 cm x 4.3 cm with an increase of surrounding edema. On 9/15/13 at 4:52 PM, nurse's note indicated the resident readmitted to the facility from the hospital with a right femoral fracture and 2 intraparenchymal hemorrhages (bleeding in the brain). The 9/16/13 care plan update instructed the staff to use a full lift sling and 4 staff members for all transfers and to use a geri chair for the resident's mobility. On 11/14/13 at 11:00 AM, observation revealed the resident lying in his/her bed, in low position to the floor, with a fall mat in place and the call light within the resident ' s reach. On 11/13/13 at 4:50 PM, Nurse Aide A verified the dementia care unit always had at least 3 staff at all times. On 11/14/13 at 11:55 AM, Administrative Nurse C reported the dementia care unit staff were to call the nursing unit when there was a need for coverage and or help in the memory care unit. Administrative Nurse C verified the day the resident fell on [DATE], there were 3 aides in the unit as scheduled, but one left and went home sick. Administrative Nurse C verified he/she had no witness statements about the details of the incidents. Administrative Nurse C further verified there was a resident in the dementia care unit who required 2 staff members to use the mechanical lift, so there is always a 3rd staff member in the dementia unit to observe the residents in the hall and the dining area at all times. Administrative Nurse C verified when the resident fell , there were only 2 staff in the dementia care unit, leaving the resident unattended and the resident had a second injury fall. On 11/18/13 at 9:00 AM, Nurse Aide D verified he/she had been called in to work on 9/13/13,the day of the resident's fall, and had stated he/she could only work until 2:00 PM on that day. Nurse Aide D further stated he/she did not know if the facility had found a replacement for the remainder of the shift. On 11/18/13 at 9:36 AM, Nurse Aide B verified there were only 2 staff members at the time the resident fell in the dementia unit on 9/13/13 due to the 3rd staff member leaving the unit. He/She further verified the staff left the resident unattended in the dining room, while seated in his/her wheelchair to assist another resident. On 11/18/13 at 10:39 AM, Administrative Nurse C verified he/she verbally informed the staff not to leave the resident unattended in the dining room after the fall in July. Administrative Nurse C verified there was no documentation the staff were educated after the incident on 7/30/13, when the resident was unattended in his/her wheelchair, in the dining room and fell , requiring an emergency room visit and sutures to his/her forehead. Nurse C further verified the resident had another fall on 9/13/13, when staff left him/her in his/her wheelchair, unattended in the dining room, resulting in serious injuries. The facility failed to provide adequate supervision for Resident #1 as outlined in the plan of care, which resulted in the resident having 2 falls which resulted in injury.

The facility had a census of 80 residents. The sample included 6 residents of which 3 were reviewed for pain. Based on observation, interview and record review the facility failed to provide effective pain management interventions for 1 of the 3 residents reviewed for pain. Cognitively impaired Resident # 2, on comfort care, had not received effective pain management and the facility failed to adequately assess and seek physician intervention concerning the resident's lack of effective pain control. This failure placed the resident in immediate jeopardy. Findings included: - Resident # 2's significant change (MDS) Minimum Data Set 3.0 assessment, dated 5/25/13, indicated the resident rarely was understood, rarely understands others, had short term and long term memory problems, and severely impaired decision making skills. The MDS indicated the resident required assistance from 2 staff for bed mobility, transfers, toilet use, personal hygiene and bathing, and had a range of motion limitation impairment on 1 side upper and lower extremities. The MDS further indicated the resident had a stage 4 pressure ulcer measuring 6.0 (cm) centimeters by 5.5 cm. The resident received sceduled pain medication with indicators of pain observed. The 5/25/13 (CAAs) Care Area Assessment, stated the resident experienced pain when the dressing to his/her foot was touched, and screamed during wound care. The CAA indicated the staff, who work closely with the resident, stated he/she yelled if the staff touched his/her foot lightly, so it was difficult to say for certain if it caused pain and the resident received routine pain medication. The 5/29/13 care plan instructed the staff the resident received scheduled [MEDICATION NAME] (an [MEDICATION NAME]) and as needed [MEDICATION NAME] and Tylenol (an [MEDICATION NAME]) and staff were to notify the physician if not effective. The care plan further instructed the staff to monitor for non verbal signs of pain such as crying, frowning or being tense. The care plan instructed the staff to encourage non pharmalogical interventions for pain, such as soothing music and therapeutic touch, as the resident would allow. Review of the 5/9/13 physician's orders [REDACTED]. - Tylenol, 650 (mg) milligrams, as needed every 4 hours, for pain or temperature, (intiated on 1/2/13). - [MEDICATION NAME], 5/500 mg, daily, for pain, (initiated on 1/2/13). - [MEDICATION NAME], 5/500 mg, 1-2 tablets, as needed every 4-6 hours, for pain, (initated on 1/2/13). - [MEDICATION NAME] (an [MEDICATION NAME]) 12.5 (mcg) micrograms, [MEDICATION NAME], every 72 hours, for pain, (initiated on 1/2/13) discontinued on 3/15/13. - [MEDICATION NAME], 10 mg, every 4 hours as needed, for pain, (initiated on 1/2/13) discontinued 3/1/13. - [MEDICATION NAME] 25 mcg, [MEDICATION NAME], every 72 hours, for pain, (initiated on 3/15/13), discontinued on 5/20/13. - [MEDICATION NAME] (an antianxiety medication), 0.25 - 0.5 mg, daily as needed, prior to foot care, (initiated on 4/2/13) - 5/20/13 discontinue the [MEDICATION NAME] related to the resident sleeping all the time. Review of the monthly (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - April 2013, Staff had not administered, [MEDICATION NAME], as needed, [MEDICATION NAME] or Tylenol as ordered although the staff documented the resident had crying out behaviors on the day shift 4/9, 4/13, 4/14, 4/15, 4/22 and 4/29. - May 2013, Staff had not administered as needed [MEDICATION NAME] prior to foot care, as ordered by the physician, Staff had administered 1 as needed [MEDICATION NAME], on 5/19 for a pain level of 8, decreasing the level to a 3, and the as needed Tylenol had not been administered. - June 2013, Staff had not administered as needed [MEDICATION NAME] prior to foot care, as ordered by the physician, and no [MEDICATION NAME] or Tylenol had been administered as needed, although the staff documented the resident had crying out behaviors on the night shift on 6/1, 6/2, 6/6, 6/9, 6/10 and 6/11. Review of the nurse's notes revealed the following: - 5/6/13 at 2:30 PM, the resident screams and yells with each dressing change - 5/20/13 at 4:30 PM, the resident screams with all cares. On 6/12/13 at 9:30 AM, observation revealed Nurse Aide A and Nurse Aide B assisted the resident to the bed, from the wheelchair, using the mechanical lift. The staff informed the resident what they were going to do. The resident is lifted by the mechanical lift and began to scream, when he/she is touched. The resident continued to scream as the staff positioned his/her feet as he/she is lowered to the bed. The resident stated "I do not like this". The resident continued to scream and holler with a fearful (clenched mouth, wide opened eyes) look on his/her face with every movement and adjustment by the staff. The resident screamed as the staff rolled him/her from side to side and he/she yelled at the staff when the staff attempted to console her.The staff positioned the resident up in bed and the resident stated he/she did not feel better, when asked by the staff. The staff did not ask the resident if he/she was in pain, although the resident displayed verbal and nonverbal signs of pain, as outlined in the plan of care. On 6/12/13 at 11:54 AM, observation revealed Nurse C and Nurse Aide A changed the dressing on the resident's right foot. Nurse C verified the wound on the resident's right heel measured 8 cm x 5.5 cm and the wound bed was yellow and black, and extended to the back of his/her heel. Observation revealed the resident screamed every time he/she was touched and the resident loudly counted, "91, 92, 93 Ahhhhh, 17, 18, 19 Ahhhhh", and continued to scream throughout the entire dressing change. Nurse C stated to the resident, "I know it hurts but we have some medicine on it now". On 6/12/13 at 8:38 AM, Nurse C stated he/she has a hard time doing the dressing changes for the resident because he/she knows the resident hurts bad during the procedure. On 6/12/13 at 2:27 PM, Nurse E verified the resident had not received the as needed [MEDICATION NAME] medication as ordered by the physician prior to dressing changes. Nurse E further verified the staff had not requested the pharmacy fill the medication and the facility did not have any [MEDICATION NAME] on hand to administer to the resident. On 6/12/13 at 2:33 PM, Nurse F verified the staff should have administered the [MEDICATION NAME], as ordered by the physician, prior to the wound care. Nurse F further verified the resident did not appear to be comfortable and comfort care had not been achieved. On 6/12/13 at 4:00 PM, Nurse D stated he/she would monitor the effectiveness of pain medication for a cognitively impaired resident by monitoring for facial grimacing, how the residentheld him/herself and verbal cues. Nurse D further stated, if after administration of pain medication, a cognitively impaired resident were to receive a dressing change and screamed during the duration but afterward were resting, he/she would consider the scenario effective pain management. On 6/13/13 at 12:09 PM, Nurse F verified staff had not administered the [MEDICATION NAME] as perscribed by the physician on 1/2/13, for pain, and it had been discontinued. Nurse F further verified the resident's pain was not effectively managed with his/her pharmalogical interventions. On 6/13/13 at 4:44 PM, Physician G verified the resident would experience pain during dressing changes and verified he/she was aware he/she was in pain. Physician G further verified he/she expected the facility to administer the [MEDICATION NAME] to the resident as ordered. The facility's Comfort Care policy, dated 2/20/12, instructed the staff to provide palliative and or comfort care by relieving a patient's pain and other symptoms with good medical treatment, comfort, and support for the patient. The facility failed to adequately provide treatment to Resident # 2 for effective pain management, follow physician orders [REDACTED]. This failure placed Resident # 2 in immediate jeopardy for not providing effective pain management. The immediate jeopardy was abated on June 13, 2013, when the facility inserviced all nursing staff on new policies related to how to assess a resident for pain, to provide effective pain management, and when to notify the physician if the resident continued to display non verbal signs of pain. The deficient practice remains at a scope and severity of a G.

The facility had a census of 80 residents. The sample included 6 residents of which 3 were reviewed for nutrition. Based on observation, interview and record review the facility failed to reassess and provide nutritional supplements as recommended by the registered dietician for 1 of 3 sampled residents who continued to have a significant weight loss. (#2) Findings included: - Resident # 2's significant change (MDS) Minimum Data Set 3.0 assessment, dated 5/25/13, indicated the resident had short term and long term memory problems with severely impaired decision making skills. The MDS indicated the resident required assistance from 2 staff for bed mobility, transfers, toilet use, personal hygiene and bathing and assistance from 1 staff for eating. The MDS further indicated the resident had a swallowing disorder, was 64 inches tall, weighed 158 pounds, and had a significant weight loss. The 5/25/13 (CAAs) Care Area Assessment, stated the resident had a significant weight loss in the past 6 months, was routinely weighed and received supplements. The CAAs stated the resident received a pureed diet, assistance with meals and provided the resident supplements as scheduled. The 5/29/13 care plan instructed the staff to document the percentage the resident eats at meals and he/she will sometimes need prompted to drink. The care plan further instructed the staff to weigh the resident monthly and notify the physician of loss or gain of 5% in 30 days or 10% in 180 days. The registered dietician reviews the weights and labs then will notify the staff if any changes are needed. The care plan further notified the staff the resident had a stage 4 pressure ulcer on his/her right heel. Review of the resident's medial record revealed the following weights: - 1/2/13 - 190 - 2/6/13 - 175 - 3/2/13 - 167 - 4/2/13 - 159 (31 pounds or 16.3% in 3 months) - 5/4/13 - 158 - 6/2/13 - 155 (4 pound weight loss in 2 months) (A total of 35 pound weight loss or 18.4% in 5 months) Review of the (RDLD) Registered Licensed Dietician notes revealed the following: On 2/25/13, the resident's current weight was 175 pounds, down 7.89% in 1 month and 11.62% in 6 months. The resident's intake had been poor and he/she is on a pureed diet with Med Pass 2.0 supplement at 60 (ml) milliliters, 4 times daily, and Active supplement 30 ml, twice daily. The resident received a treatment on his/her right heel and the registered dietician had requested to increase the Med Pass supplement to 120 ml, 4 times daily to the resident. On 3/27/13, the resident's current weight is 167 pounds, down 8 pounds in 1 month and 30 pounds in 6 months. The registered dietician recommended to increase Med Pass to 120 ml, 4 times daily, as the 2/25/13 had not been implemented by the staff although the resident had lost another 8 pounds. On 4/28/13, the resident's current weight is 159 pounds, down 4.7% in 1 month and down 16% in 90 days. RDLD requested to increase the Active supplement to 30 ml three times daily. Review of the physician's orders [REDACTED]. On 4/29/13, administer Med Pass 2.0 supplement 120cc, four times daily, to the resident for wound healing. (63 days after the initial registered dietician's request) On 6/3/13, administer Med Pass 2.0 supplement 240cc, four times daily, to the resident for wound healing. Review of the the meal percentages recorded by the facility revealed the resident refused meals on several days for the past 5 months and the facility failed to document several meals as outlined in the plan of care. Review of faxes sent to the physician revealed the following: - On 4/2/13 the facility notified the physician of an 8 pound weight loss in 1 week and requested to increase the Med Pass supplement to 120 ml, four times daily, by fax, the physician approved the request on 5/6/13 - On 4/29/13 the facility notified the physician of a 8 pound weight loss and requested the Med Pass supplement to be increased to 120 ml, 4 times daily, by fax, the physician approved the request on 4/29/13. Review of both the 4/2/13 and 4/29/13 faxes to the physician included the same 2/25/13 registered dietician's request to increase the Med Pass supplement. The physician signed and returned the faxes 1 week apart. On 6/12/13 at 12:26 PM, observation revealed the resident eating his/her noon meal with the assistance of the staff, after the resident had received an as needed pain medication. The resident had to be prompted and woke up to eat, chew and swallow. The resident ate 70% of his/her noon meal that consisted of pureed BBQ beef, rice and cole slaw with ice cream and 75% of his/her fluids that consisted of cranberry juice, milk and a supplement. On 6/13/13 at 12:25 PM, observation revealed the resident eating his/her noon meal with the assistance of the staff, the resident had not received any as needed pain medication. The resident received a pureed meal of egg salad, pasta salad and apple crisp. The resident had to be prompted to eat and drink. The resident cried and whimpered when his/her clothing protector was placed on him/her and whined when the nurse lifted the resident's head to assist him/her to drink the supplement and only ate bites of his/her meal. On 6/12/13 at 2:33 PM, Nurse F verified the facility failed to notify the physician of the the registered dietician's recommendations on 2/25/13 and further verified the registered dietician's recommendation on 3/27/13 were not implemented until 4/29/13 due to the facility failing to recognize the physician had not responded to the fax. Nurse F further verified the facility had not tried to use pain medicine before meals to increase his/her intake but thought pain medicine could help the resident eat better. The facility failed to maintain acceptable nutritional status and to implement registered dietician recommendations for Resident # 2 with a significant weight loss, who also had a pressure ulcer.

The facility had a census of 68 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 15 sampled residents. The staff assessed Resident #94 with a high level of pain but failed to implement an effective pain management plan and the resident had a significant decline in their activities of daily living. Findings included: - Resident #94's medical record revealed [DIAGNOSES REDACTED]. On 02/07/11 at 8:00 AM, observation revealed the resident resting quietly in bed with the head of bed elevated and a pillow under the resident's knees. Continued observation revealed Staff B and Staff C assisted the resident with repositioning and dressing. Continued observation revealed the resident complained several times of bilateral knee pain, when the staff moved the resident's legs during cares. Continued observation revealed the resident grimaced and anxiously called out, " Don't turn me too much, my knees hurt a lot", while the staff assisted the resident to pivot during the transfer from the bed to the resident's wheelchair. Continued observation revealed the resident requested the staff to propel the resident's wheelchair to the dining room due to the resident's increased bilateral knee pain. On 02/07/11 at 10:34 AM, Staff B indicated the resident's mobility had recently declined and the resident required extensive assistance with most (ADLs) activities of daily living. Staff B also indicated the resident usually complained of bilateral knee pain during cares. Staff B further indicated the nursing staff had been notified of the resident's bilateral knee pain. review of the resident's medical record revealed [REDACTED]. The admission (MDS) Minimum Data Set 2.0 assessment, dated 09/09/10, indicated the resident had no memory problems and moderate independent decision making skills. The MDS also indicated the resident independent with all ADLs except supervision with bathing. The MDS further indicated the resident had no pain. The quarterly MDS 3.0 assessment, dated 11/10/10, indicated the resident's (BIMS) Brief Interview for Mental Status score was 13, which indicated the resident cognitively intact. The MDS also indicated the resident independent of all ADLs except for limited assistance with bathing. The MDS further indicated the resident had almost constant pain and received non-medication pain interventions. The significant change MDS 3.0 assessment, dated 1/18/11, indicated the resident's BIMS score was 13, which indicated the resident cognitively intact. The MDS also indicated the resident required extensive assistance with bed mobility, transfers, dressing, toilet use and bathing. The MDS further indicated the resident had occasional severe pain and responded yes to "has pain made it hard for you to sleep at night?" and "have you limited your day-to-day activities because of pain?". The 1/18/11 (CAA) Care Area Assessment for ADL function indicated the resident had a significant decline in bed mobility, transfers, dressing and ambulation. The CAA also indicated the resident required extensive assistance with toilet use and had become incontinent. The CAA further indicated the resident's bilateral knee pain was a contributing factor and the resident received Medicare Part B therapy for the bilateral knee pain. The 1/18/11 CAA for pain indicated the resident experienced significant bilateral knee pain and had a decreased level of function/mobility related to the knee pain. The CAA also indicated the resident had received multiple modalities for pain relief including cortisone injection therapy, diathermy and heat and results had not been satisfactory for the resident to resume ambulation. The CAA indicated the resident's bilateral knee pain had led to falls, caused the resident to use a wheelchair for mobility and made the resident reluctant to get out of bed. The 02/02/11 care plan directed the staff to provide extensive assistance with the resident's transfers. The care plan also directed the staff to encourage the resident to self propel their wheelchair. Further review of the resident's care plan revealed no documentation to address the resident's chronic bilateral knee pain. The 11/30/10 Physical Therapy progress notes indicated the resident received services due to the resident's bilateral knee pain limiting the resident's gait/ambulation skills The 12/13/10 Physical Therapy progress notes indicated the nurses had placed the resident in a wheelchair due to the resident's increased bilateral knee pain. The progress notes indicated physical therapy requested the nurses make the resident an appointment with an orthopedic surgeon. The 01/07/11 Physical Therapy progress note indicated the resident refused therapy due to increased bilateral knee pain. The progress notes indicated the resident rated their pain an 8 on the 1 to 10 scale ( 1 = mild pain and 10 = severe pain). The 1/14/11 Physical Therapy progress note indicated the resident refused therapy due to bilateral knee pain. The progress notes indicated the resident rated their knee pain at a 10 (severe pain). The progress notes also indicated the resident discharged from therapy due to the resident's increased bilateral knee pain and activity intolerance. The progress notes further indicated physical therapy suggested the nurses make the resident another appointment with the orthopedic surgeon. The 01/18/11 facility pain assessment indicated the resident had intermittent, shooting bilateral knee pain. The pain assessment indicated the resident's current pain level for their bilateral knees was 4 (moderate) and 8 (severe) on the 1-10 pain scale. The 01/19/11 physician's orders [REDACTED]. Review of the January and February 2011 (MAR) Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the resident's MAR indicated [REDACTED]. The 02/07/11 care plan revision directed the staff to provide a Broda chair (tilt and recline wheelchair for comfort and positioning) for the resident's primary mode of mobility. The care plan revision also directed the staff to provide complete assistance with the resident's mobility in the Broda chair. On 02/08/11 at 8:05 AM, observation revealed the resident seated in a Broda chair (tilt and recline wheelchair for comfort and postioning) and the staff propelled the resident to the dining room. On 02/08/11 at 7:42 AM, Nurse D verified the resident had been assessed and treated for [REDACTED]. The facility failed to provide scheduled pain medications for Resident #94, who had a significant decline in mobility related to chronic bilateral knee pain.