Every finding on record at Snyder Village

Based on observation, interview, and record review, the facility failed to store controlled medications safely to prevent potential unauthorized access and failed to store medications under verified proper temperature controls. This failure has the potential to affect all 70 residents currently residing in the facility. The facility policy, Medication Storage, dated (revised) 01/30/2024 directs staff that it is the policy of the facility to ensure all medications housed (in the facility) will be stored in medication rooms according to manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Narcotics and Controlled Substances such as Schedule II drugs and back up Schedule III, IV and V medications are stored under double-lock and key.On 4/29/2026, at 10:47AM, an observation of the facility Central Nurses Station Medication Room, with V13/Registered Nurse present, a white medication refrigerator was present. No medication temperature log was present. At that time, V13/RN stated she did not know whose responsibility it was to obtain and document the daily required temperature check. Upon opening the unlocked medication refrigerator, a thick buildup of residue was noted on the door seal and covering the bottom of the refrigerator. An unsecured, removable locked red metal box and a plastic tackle box were present on the bottom shelf. With V2/Director of Nurses present, upon opening the red container, a 30 ML (milliliter) bottle of Lorazepam (schedule IV-controlled substance) 2 MG (milligrams)/ML bottle was present. The plastic tackle box contained two bottles of Lorazepam 30 ML, 2MG/ML. At that time, V2 stated the third shift staff were responsible for checking the facility medication refrigerator temperatures and had not been doing so for the past few months. V2/DON confirmed the dirty medication storage refrigerator and the lack of the medication being stored in a locked permanently affixed container. The Centers for Medicare and Medicaid Services form 671, dated 4/30/2026 and signed by V3/Executive Director, documents 70 residents currently reside in the facility.

Based on interview and record review, the facility failed to offer bedtime snacks to all residents. This has the potential to affect all 70 who reside within the facility.Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 671, dated 4/30/26 and signed by V3/Executive Direct (Administrator), documents 70 residents reside within the facility.The facility's Health Center Snack Policy, dated 3/1/25, documents, Policy: The facility shall provide an organized snack program to ensure residents have access to nutritious food between the evening meal and breakfast. Snacks will be of nourishing quality, consistent with individual dietary needs, and offered in a manner that promotes resident choice, dignity, and adequate nutritional intake.The facility's Resident Council Minutes, dated 12/16/25, documents, New Business: 6) Feedback for Departments: b. Dietary: The last meal is finished early so dietary ask Certified Nursing Assistants to get resident to dining room early so they can leave early. This leaves too many hours between lunch and breakfast, and the snacks are not passed, only for those who can ask for it.R8, R15, R29, R35, and R72's electronic health records do not contain documentation of R8, R15, R29, R35, and R72 being offered or receiving bedtime snacks.On 4/28/26 at 1:36 PM, R8, R15, R29, R35, and R72 all stated they never get offered snacks at bedtime. R15 stated the facility did away with going around and offering all residents a snack at bedtime that could have one around a year ago. R8, R15, R29, R35, and R72 all denied being told they must ask for a snack and stated they would like snacks to be offered at bedtime again.On 4/28/26 at 2:00 PM, V2/Director of Nursing stated snacks are not routinely offered at bedtime and the residents know snacks are available upon request and the residents must hit their call light to request one.On 4/28/26 at 10:45 PM, V3/Executive Director verified bedtime snacks are not automatically provided to all residents. Instead, snacks are available upon request, requiring residents to proactively ask if they would like one.

Based on observation, interview and record review, the facility failed to ensure proper hair restraints were worn in the kitchen and while preparing food, repackaged frozen food items were labeled, the quaternary sanitation bucket contained an adequate level of chemical to sanitize the kitchen, cool down temperatures were monitored and recorded for foods cooked then refrigerated, and ensure the dish machine testing strips monitored the required level of heat sanitation during the dishwashing cycle for a high temperature dishwasher. These failures have the potential to affect all 70 residents residing in the facility.Findings include:The facility's Dining Service Hair Restraint policy, dated 4/4/25, documents, Staff members entering food preparation, dishwashing, or service areas must wear effective hair restraints to prevent hair from contaminating food, food-contact surfaces, and equipment. All individuals working in or entering food preparation, dishwashing, or services areas must wear appropriate hair restraints at all times. Acceptable hair restraints include: Hairnets, [NAME] nets (for individuals with facial hair), Caps or hats that fully contain the hair. Hair restraints must effectively cover and restrain all head hair, including bangs and loose strands. Staff members with beards, mustaches, or other facial hair must wear beard restraints when working with exposed food or clean equipment and utensils.The facility's Dining Service Cold Storage policy, dated 4/4/25, documents, To ensure all food is stored under safe temperature conditions to prevent foodborne illness and comply with (state) regulations governing long-term care facilities and food sanitization. This policy also documents Ready to eat foods held over 24 hours must be clearly marked. Used or discard within seven days at less than or equal to 41 degrees Fahrenheit (F). Cooked foods must be cooled from 135 degrees F to 70 degrees F within two hours and from 70 degrees F to 41 degrees F within four additional hours.The facility's Cooling Monitoring Form policy, dated 3/25/19, documents, Using the cooling monitoring form record temperature of food every hour. The food should be cooled from 140 degrees F to 70 degrees F within two hours and cooled from 70 degrees F to 41 degrees F within four additional hours. If the temperature does not reach 70 degrees F in two hours, or 41 degrees F in an additional four hours, reheat to 165 degrees F and start the cooling process again or discard the product. Reheating could compromise the quality of the food.The facility's Dining Service Sanitation policy, dated 4/4/25, documents, To ensure proper cleaning and sanitizing of food-contact surfaces in accordance (state agency) and FDA (Food and Drug Administration) Food Code requirements. Verify concentration using quat (quaternary ammonium) test strips. Acceptable concentration range: 200-400 ppm (parts per million) or per manufacturer label.The facility's Dining Service Dishwashing policy, dated 4/4/25, documents, All dishes, utensils, and kitchen equipment shall be washed, rinsed, and sanitized using approved methods and equipment. This policy also documents Machines must reach required temperatures: High-temp machines; wash 150-165 degrees F; final rinse at least 180 degrees F. Temperatures and sanitizer levels must be checked and recorded daily.On 4/27/26 at 9:30 AM V4 (Dietary Manager), V6 (Cook), and V5 (Dietary Server) were in the facility's kitchen. V4 was wearing a hat with approximately four inches of hair sticking out the back of her hat, unrestrained. V6 was wearing a baseball style hat with a ponytail of hair sticking out from under the back of the hat, unrestrained. V6 was also wearing a paper mask over his facial beard with facial hair sticking out from both sides of the mask. V5 was wearing a baseball style hat with about two to three inches sticking out from under the back of the hat, unrestrained. At this time, V4 stated, Staff can either wear a hairnet or a hat while in the kitchen.On 4/27/26 at 9:40 AM, during the kitchen tour, the facility's walk-in cooler contained a metal pan of cooked chicken tenders, dated 4/24. V4 (Dietary Manager) stated, These were cooked, cooled, and then will be placed on buns for a grab and go option. The walk-in freezer contained a metal pan with several snack size zipper plastic bags of diced meat. These bags and the pan did not contain a label, date, or date of expiration. V4 stated, This is diced ham for residents on feeding programs. V4 confirmed they should be labeled and dated. The kitchen sink near a food preparation counter contained a red bucket with water and rags. V6 (Cook) confirmed this bucket contained a quat solution and is used to wipe food services. V4 took a testing strip and checked the level of quat in the bucket. V4 and V6 confirmed with two strips that the quat level testing strip did not change color, indicating the sanitation solution chemical level was zero and not high enough for sanitation. V6 stated he just filled the sanitation bucket approximately an hour prior and that he usually changes the solution about every two or three hours. On 4/27/26 at 10:05 AM, the kitchen's April 2026 cool down log was reviewed, and the most recent entry was made on 4/21/26 for cooling of gravy. V4 confirmed the chicken tenders in the walk-in cooler that were dated 4/24, are not on the cool down log. V4 stated, I don't see a cool down for the chicken strips that are in the cooler and those will need to be discarded.On 4/27/26 at 10:10 AM, V9 (Dishwasher/ Server) stated the dish machine used in the kitchen is a high temp dishwasher and the temperature testing strips turn black when water reaches 160 degrees F. V4 (Dietary Manager) confirmed the rinse cycle internal temperature is checked with the dish-machine testing strips. V4 stated the strip will turn to black with a temperature of 160 degrees F and that there is no other thermometer or tests completed to ensure the dish machine's rinse cycle reaches 180 degrees F.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671, dated 4/30/26 and signed by V3 (Executive Director), documents 70 residents reside within the facility.

Based on interview and record review, the facility failed to ensure residents and resident representatives were explained arbitration agreements accurately prior to signing upon admission to the facility. This failure has the potential to affect all 70 residents residing in the facility.Findings include:The facility's Binding Arbitration Agreements policy, dated 1/30/24, documents, This facility asks all residents to enter in an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at this facility. Binding Arbitration is a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds. This policy also documents When explaining the arbitration agreement, the facility shall: Explain to the resident and his or her representative in a form and manner that her or she understands, including in a language the resident and his or her representative understands. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.The facility's admission contact (undated) Arbitration section, documents, Should the parties fail to reach a resolution of any claim, dispute, or controversy described by way of mediation, the dispute shall be arbitrated in accordance with the American Arbitration Association (AAA). By agreeing to arbitration of all disputes, the resident and/or resident's representative and the facility are waiving a jury trial for all claims, disputes, and controversies referenced in this paragraph. The parties agree that this agreement to arbitrate shall survive and not otherwise be revoked by the death or incompetency of the resident. The award cost of the arbitration shall be determined by the arbitrator in accordance with state law.On 4/29/26 at 2:20 PM, V3 (Executive Director) stated, We do not have arbitration agreements, but everyone has signed the arbitration section in the contract. All of the residents here have signed an admission contract and initialed arbitration portion. I don't believe anyone has refused.On 4/29/26 at 2:45 PM, V17 (Social Service Coordinator) confirmed she is the person who goes over the admission contracts with all residents and families. V17 stated, I am more versed on the contract than other staff and have been doing them since November 2025. There is a dispute resolution in the contract that speaks mostly to non-payment and steps include mediation and then arbitration. I explain to them that if there is an issue with non-payment then that can be settled first with mediation and then arbitration. I am not aware of the arbitration agreement having anything to do with a resident's ability to sue the facility or that is has anything to do with a care or injury dispute. I do not tell them that they are giving up their rights to a jury trial or the ability to independently sue the facility. That is not something I am aware of. V17 confirmed she was trained on admission contracts and is completing them the same as they have always been when someone is admitted to the facility. V17 confirmed everyone in the facility has a signed admission contract which includes an arbitration agreement portion.On 4/30/26 at 10:15 AM, V18 (R50's family member) stated he is the one who signed paperwork for R50's admission in March 2026. V18 stated it was V17 who went over the admission contract and he does not recall anything about mediation or arbitration being explained or discussed with them.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671, dated 4/30/26 and signed by V3 (Executive Director), documents 70 residents reside within the facility.

Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of medication administration for one of ten residents (R65) reviewed for medication oversight in a sample of 36.Findings include:The facility's Resident Self-Administration of Medication Policy, dated 1/30/24, documents, Policy: The facility supports each resident's right to self-administer medication. A resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely and physician order is obtained. Policy Explanation and Compliance Guidelines: 1. Each resident may be considered for self-administration of medication, if requested and deemed capable and appropriate with physician order. 2. Resident's preference will be documented on the care plan and placed in the medical record.R65's admission Record documents R65 is an [AGE] year-old female who was admitted to the facility on [DATE], with the following diagnoses: Essential Hypertension, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Retention of Urine, and Chronic Respiratory Failure.R65's MDS (Minimum Data Set) Assessment, dated 4/6/26, documents R65 is cognitively intact.R65's Order Summary Report, dated 4/28/26, documents the following Physician Order Order Date: 3/31/26- Lasix 80 milligrams give one tablet by mouth three times a day related to Essential Hypertension.R65's Electronic Medical Record lacked documentation of any orders, care plan, or assessments for self-administration of medications, or any orders for R65's medications to be left at her bedside.On 4/27/26 at 10:18 AM, R65 was observed in her room with a bedside table positioned in front of her. A clear medicine cup containing a single round white pill was on the table. R65 explained the nurse typically leaves her Lasix in the cup in the morning for her to take at a later time.On 4/29/26 at 11:03 AM, V15/Licensed Practical Nurse verified she left R65's Lasix unattended in a medication cup in R65's room. V15 explained R65 often prefers to delay the dose until after therapy. V15 noted while she occasionally waits to administer the medication herself to R65, she also leaves it in R65's room for R65 to self-administer later.On 4/29/26 at 12:44 PM, V2/Director of Nursing verified R65 does not have an assessment for self-administering her own medications or a care plan/order to self-administer medications. V2 stated she was not aware R65's Lasix was being left in her room to take on her own, and stated R65 should not administer any medications herself without supervision, and medications should not be left on her bedside.

Based on observation, interview, and record review, the facility failed to provide an appropriate indication for the use of an antipsychotic medication, monitor targeted psychotic behaviors to warrant the use of Seroquel (antipsychotic) medication, and failed to ensure a clinical rationale and justification was established by a physician for the continued use of Lorazepam (anti-anxiety) PRN (as needed) medication beyond the 14-day evaluation period, for two of five residents (R2 and R13) reviewed for psychotropic medications in the sample of 36.Findings include:The facility's Psychotropic Medication Policy, dated 4/4/25, documents, Policy: The facility ensures that psychotropic medications are used only when clinically indicated, in the lowest effective dose, for the shortest duration necessary, and in accordance with resident rights, IDPH (Illinois Department of Public Health) regulations, and federal requirements. Psychotropic medications are not used for staff convenience or as a chemical restraint. Definitions: Psychotropic Medications- Drugs affective mood, behavior, or mental processes, including: (1) antipsychotics, (2) antidepressants, (3) antianxiety agents, and (4) mood stabilizers. Unnecessary Durg: Any medication that is excessive in dose or duration, lacks adequate indication, lacks monitoring, or results in adverse consequences without appropriate adjustment. Procedures and Guidelines: Psychotropic medications may only be used when (1) there is a documented diagnosis or target symptom, (2) the medication is clinically justified and beneficial, (3) benefits outweigh risks and contraindications. 1.R2's admission Record documents R2 is an [AGE] year-old male who was admitted to the facility on [DATE], with the following diagnoses: Unspecified Dementia (unspecified severity) with other Behavioral Disturbance, Gout, Anxiety Disorder, Retention of Urine, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. R2's MDS (Minimum Data Set) Assessment, dated 4/17/26, documents R2 is severely cognitively impaired and receives an antipsychotic medication. R2's Psychiatry Initial Evaluation, dated 3/12/26 and signed by V12/Behavior Advance Practical Nurse, documents a past medical history of the following: Anxiety, Dementia with Behavior Disturbance, Obstructive Uropathy with Urinary Tract Infection, Benign Prostatic Hyperplasia, Hypertension, Abnormal Gait, Irritable Bowel Syndrome, and Diverticulitis. This same Psychiatry Note documents, Review of Symptoms: Mood and Affect- Denies depression, appears calm at the time of exam. Anxiety- Denies anxiety. Thought Content: Denies suicidal ideation. Through Process- No concerns reported. Perception: Denies Hallucinations. Mental Status Evaluation: Behavior- Calm at the time of exam, abrupt with responses. Mood- Calm. Thought Content- No delusion, no suicidal ideation, no homicidal ideation, no paranoia. R2's Physician Orders documents R2 has a Physician Order for Seroquel (antipsychotic) 100mg tablet- take one tablet by mouth one time a day related to Dementia with Other Behavior Disturbance. R2's Care Plan documents R2 receives antipsychotic treatment for Anxiety Disorder, Obsessive Compulsive Disorder, and Behavioral Disturbance related to Major Neurocognitive Disorder. R2's (PASRR) Preadmission Screening and Resident Review, dated 1/11/26, documents there are no known mental health behaviors which affect R2's interpersonal interaction or any known mental health symptoms affecting R2's ability to think through or complete tasks which R2 should be physically capable of completing. This same PASRR documents, (R2's) Level I screen does not show that (R2) has a serious mental illness or an IDD (intellectual/developmental disability). (R2) does not need more screening unless (R2) has or may have a serious mental illness or an IDD and experience a significant change in treatment needs. On 4/27/26 from 11:45 AM through 12:05 PM, R2 was sitting at the dining room table with other residents feeding himself. R2 had no behaviors observed throughout this time and ate well. On 4/27/26 at 12:05 PM, V15/Licensed Practical Nurse stated the only behavior she is aware of is R2 can get easily agitated and yell or shove the staff with his walker. V15 stated she has not witnessed R2 being harmful to himself or other residents, or observing R2 to have any psychosis. On 4/27/26 at 12:30 PM, V21/Clinical Care Coordinator confirmed she manages psychotropic medication tracking for the 200 hallways. V21 noted R2 is prescribed Seroquel for Dementia with Behaviors, specifically citing agitation and physical aggression, such as shoving a walker toward staff. However, V21 acknowledged the electronic medical record currently lacks any additional diagnoses to support the medication's use. V21 expressed uncertainty regarding whether Dementia with Behavioral Disturbance alone justifies a Seroquel prescription and confirmed she is unaware of R2 exhibiting psychotic behaviors or having a formal psychosis-related diagnoses. 2. R13's current Physician Order Sheet documents to give Lorazepam (Benzodiazepine/antianxiety) 0.5mg (milligrams), 1 tablet every six hours as needed for Anxiety/Restlessness, initiated 3/25/26. This form documents R13 is to take Lorazepam 0.5mg three times a day, initiated 3/19/26. R13's Progress Notes, dated 2/18/26 at 4:40PM, documents R13 refused all meds besides Lorazepam and Dilaudid (opioid analgesic) this shift and has had poor intake. This form documents R13 is very sleepy today and not easily aroused by physical or verbal stimuli. R13's Progress Notes, dated 2/26/26 at 7:38PM, R13 was sleeping through most of the lunch meal and ate a small amount of food. R13's Progress Notes, dated 3/2/26 at 6:32PM, documents R13 refused her medications. This form documents R13 is very sleepy and refused to open her mouth. R13's Progress Notes, dated 3/3/26 at 8:18PM, documents R13 refused her afternoon medications and med pass supplement, with clenched jaw and refused to open her mouth. This form documents scheduled (pain) medications and Lorazepam were given by a syringe. R13's Progress Notes, dated 3/19/26 at 1:17PM, R13 refused noon medication, was sleepy, and not eating or drinking. On 4/27/26 at 10:00AM, R13 was in her high-back reclining chair, sleeping. At 12:15PM, R13 was in the dining room, sleeping on and off in her high-back reclining chair. R13 had to be woken up and assisted with lunch. On 4/29/26 at 12:30PM, R13 was being assisted to her room, sleeping in her high-back reclining chair. At 1:00PM, R13 was in bed sleeping and would not rouse when her name was called out. R13 was observed at various times of the day throughout the survey and did not exhibit any adverse behaviors. On 4/29/26 at 12:20PM, V19, Resident Clinical Care Coordinator, verified she tracks the psychotropic medications and behaviors. V19 stated the only adverse behavior R13 had was grinding her teeth. V19 stated Hospice ordered R13's Lorazepam and was unable to provide a rationale for the continued use of the as-needed Lorazepam past 14 days.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent potential accidents for one resident (R44) with known wandering behaviors of three residents reviewed for incidents and accidents, in a sample of 36. Findings Include: On 4/29/2026, during a continued observation from 10:26AM through 10:40AM., R44 was propelling herself in a wheelchair, in the (facility) 300 hall kitchenette, with no staff present. An unlocked half brown swinging door separated the dining room from the kitchenette. A 3-compartment steam table, located on the counter and accessible to anyone, was turned to the high position. Steam was escaping from around the covered compartments. Upon removal of the lids, boiling water was noted. An accessible radiant warmer, with a Caution Hot warning, was turned on. Upon entrance through the unlocked half door, an open-top three- burner grill was turned on to 300 degrees and an active single deep fat fryer with 390-degree oil was unattended. On 4/29/26 at 10:40AM, V6/Cook entered the 300-hall kitchenette and confirmed the unattended hot appliances and R44's accessibility to the appliances. At that time, V6 stated the cooks for all three of the facility satellite kitchens turn the appliances on around 10:30AM, leave the area to go to their lunch break, and return to serve the meal, which begins at 11:30AM. V6 stated staff turn the appliances on so the food they serve will be hot.On 4/29/26 at 10:45AM, V4/Dietary Manager also verified the hot appliances. V4 stated she was unaware the kitchen staff were turning the appliances on and leaving the area unattended and accessible to any resident. V4 also stated any wandering facility resident could potentially get seriously burned. R44's current Physician Order Sheet, dated April 2026, includes the following diagnoses: dementia, cognitive impairment.R44's current Minimum Data Set Assessment, dated 3/9/26 documents Section C0500 documents R44's cognitive status as cognitively impaired and Section E0900 documents R44 wanders frequently.R44's current Behavioral Progress note, dated 4/23/26 and signed by V12/Behavioral Advanced Practice Nurse documents R44 wanders impulsively.R44's current Care Plan documents R44 has impaired decision making and requires cues/reminders and assistance in order to ensure her needs are met and her safety is maintained.On 4/30/26 at 9:06AM, V3/Executive Director confirmed R44 was cognitively impaired and wandered throughout the facility.

Based on observation, interview, and record review, the facility failed to address a resident's significant severe weight loss, notify the Dietician, and implement interventions to prevent further weight loss for one of three residents (R50) reviewed for weight loss in the sample of 36.Findings include:The facility's Weight Loss policy, dated 1/27/26, documents, To ensure early identification, evaluation, and intervention for residents experiencing actual or potential weight loss, promoting optimal nutritional status and compliance with regulatory requirements. The facility will monitor resident weights routinely, identify clinically significant weight changes, and implement timely intervention to prevent avoidable weight loss. Clinically significant weight loss: equal or greater than five percent in 30 days, equal or greater than seven and a half percent in 90 days, equal or greater than ten percent in 180 days. This policy also documents Identification of weight loss. Nursing or dining service staff members will review weights weekly. Any significant weight loss triggers: reweigh within 24 hours, initiation of evaluation process. Interventions based on root cause may include (not limited to): dietician consult and revised care plan, nutritional supplements (such as high calorie/ protein), meal assistance or adaptive equipment, appetite stimulants. Update care plan immediately after identification. Include: problem (weight loss risk/actual), measurable goals, individualized interventions. Notify physician of significant weight loss and obtain orders. Notify resident and/or responsible party per facility policy and document. Documentation: record all weights and reweights, assessment findings, interventions, notifications, ongoing monitoring and response.R50's Physician Order sheet, dated 4/28/26, documents R50 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Dementia, Muscle Weakness, Anemia, and Vitamin D Deficiency. This order sheet also documents R50 has orders for a regular diet and is to be weighed daily, both started 3/23/26.On 4/27/26 at 11:40 AM, the facility's 100-hall dining room began serving residents' lunch. At this time outside of the dining room in a common area, R50 was seated in a recliner chair with her eyes closed and covered with a blanket.R50's Weight Summary since admission documents R50's admission weight on 3/23/26 was 135.4 pounds. This record also documents on 4/20/26 R50's weight was 122.2 pounds, a 9.75 percent significant weight loss in four weeks. This same weight summary documents R50's weight on 4/27/26 was 113.2 pounds, a 16.4 percent severe significant weight loss in five weeks.R50's Nutrition Note, dated 4/17/26 and completed by V11 (Dietician), documents Initial visit. Weight stable for one month. Goals: maintain weight without significant change. Refer RD (Registered Dietician) PRN (As Needed).R50's electronic medical record does not document any further assessment from a dietician or any nutritional notes after 4/17/26.R50's current Care Plan, dated 3/23/26, does not document a plan of care for R50's nutrition, address R50's weight loss, or document interventions to prevent weight loss.On 4/29/26 at 9:23 AM, V7 (Licensed Practical Nurse/ Care Manager) stated she does see in R50's record where she has triggered for a significant weight loss and R50 does not have a nutritional assessment, aside from the 4/17 visit by V11. V7 stated, (R50) has had significant weight loss. I don't see any Dietician notes since 4/17 in her record, and I am not sure if that visit was in person. We don't really have any flags that alert us with weight loss. I just discover those things when going through the chart and that's how it's recognized. I don't know if the Dietician or a physician was notified about (R50's) weight loss.On 4/29/26 at 11:45 AM, V2 (Director of Nursing) stated V17 (Dietician) comes into the facility to see residents and is available to be contacted as needed. V2 stated, I think she comes a couple times a month, but I am not sure. I don't know who (residents) is on her list to see.On 4/29/26 at 12:10 PM, V11 (Dietician) stated, I just started seeing residents at the facility in March 2026. If there is a concern with a resident's diet or weight I am to be notified by the Dietary manager (V4) or by nursing. I did a note on (R50) for her admission and then I think I was going to do another look at her record today because she is on my list from a couple days ago. V11 confirmed the facility has not notified her of any concerns with R50. V11 stated, I just checked, and I don't have any communications from the facility about (R50) since my last visit. I am supposed to be notified by email if there are weight loss concerns and I do not have any notifications for (R50) specifically.

Based on observation, interview and record review, the facility failed to ensure a resident's Oxygen administration was documented in the medical record for one of two residents (R5) reviewed for Oxygen in the sample of 36.Findings include:The facility's Oxygen policy, dated 1/27/26, documents, When the unit nurse initiates oxygen therapy for a resident, she must; transcribe the physician's order in the EMAR (Electronic Medication Administration Record). Physician's order should include indication for use. In addition, this record should state the type of respiratory equipment to use. Document in the nurses' notes and EMAR initiation or discontinuation of Oxygen therapy. Monitor and document every shift route and liter flow of oxygen administration and SpO2 (Peripheral Oxygen Saturation) reading.R5's Physician Order sheet, dated 4/28/26, documents R5 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Interstitial Pulmonary Disease, Obstructive Sleep Apnea, Hypertension, Asthma and Atrial Fibrillation. This order sheet documents R5 has an order for Oxygen two to five liters, to keep SpO2 equal to or above 90 percent, with a start date of 3/26/26.R5's Care Plan, dated 3/26/26, documents, (R5) is at risk for complications related to use of Oxygen via nasal cannula at night due to obstructive sleep apnea and refusal of CPAP (Continuous Positive Airway Pressure) use. Interventions: Administer oxygen as ordered by physician.On 4/27/2026 at 10:05 AM, R5 was sitting in bed in his room. R5's bedside contained an Oxygen unit and tubing. R5 confirmed he wears Oxygen when he needs it, which is usually when he is in his room or when he's sleeping.R5's Oxygen Saturation summary, dated 3/26/26 to 4/28/26, documents R5's Oxygen saturation levels were recorded at various times of day on 93 occasions. Out of the 93 Oxygen saturation checks, 36 entries document R5's Oxygen level was taken while on Oxygen via nasal cannula.R5's electronic medical record from admission, including all Medication Administration Records (MAR), Treatment Administration Records (TAR), and Nursing Progress notes, does not document the time that Oxygen administration started, the number of liters per minute administered or the duration of each Oxygen administration that R5 was provided.On 4/29/26 at 9:23 AM, V7 (Licensed Practical Nurse/ Care Manager) confirmed R5's medical record does not document his Oxygen administration times, amount given, or length of Oxygen administration. V7 sated, The Oxygen is not on the MAR, TAR or the task charting for nurses to document the detailed administration. I am not sure why.

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of hypertension was administered a physician ordered medication to treat high blood pressure and notify the physician of the missed medication administrations for one of ten residents (R50) reviewed for medication administration in the sample of 36.Findings include:The facility's Medication Administration policy, dated 3/23/26, documents, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer medication as ordered in accordance with manufacturers specifications. This same policy documents All medication errors will be addressed promptly to ensure resident safety. The nurse will immediately assess the resident, notify the physician and responsible party as indicated, implement any necessary interventions, and monitor for adverse side effects. Incident will be reported to nurse management for appropriate corrective actions, staff education, and system improvements will be implemented to prevent recurrence.R50's Physician Order sheet, dated 4/28/26, documents R50 was admitted to the facility on [DATE], with diagnoses of Dementia, Rheumatic Tricuspid Insufficiency, Hypertensive Chronic Kidney Disease, Hypertension, and Congestive Heart Failure. This order sheet also documents R50 has an order for Nifedipine (anti-hypertensive medication) Extended Release (ER) 60 milligrams (mg), take two tablets (120 mg) by mouth one time daily for Primary Hypertension, start date 3/23/26.R50's Medication Administration Record, dated 4/1/26-4/30/26, documents R50 did not receive Nifedipine ER 120mg on 4/9/26, 4/12/26, or 4/13/26. This record also documents R50's blood pressure reading on 4/12/26 was 180/59 and on 4/13/26 was 177/51.R50's Nursing Progress notes, dated 4/9/26 at 10:10 AM, documents R50's Nifedipine was not administered due to unavailable.R50's Nursing Progress notes, dated 4/12/26 at 8:05 AM, documents R50's Nifedipine was not administered due to Medication unavailable, reordered from pharmacy. Unavailable in STAT safe (pharmacy back-up medication box).R50's Nursing Progress notes, dated 4/13/26, do not document why R50's Nifedipine was not administered.R50's electronic medical record does not document a physician was ever notified of R50 not receiving three scheduled doses of Nifedipine used to treat high blood pressure, or of R50's subsequent elevated blood pressure readings.On 4/29/26 at 12:45 PM, V2 (Director of Nursing) confirmed if a resident's medication is unavailable, the nursing staff should pull the medication from the facility's emergency box and notify the pharmacy. V2 then verified Nifedipine is not available in the emergency medication box and stated, Pharmacy delivers every day except Sunday, and they even make special trips sometimes to deliver medications. I would hope that if that medication was unavailable, the nurse would reach out to the pharmacy and in (R50's) case, with it being for Hypertension, the doctor should be notified.

Based on observation, interview, and record review, the facility failed to ensure the hot water sanitation rinse cycle was maintained and failed to run test strips to test the surface temperature of the dishwasher. This has the potential to affect all 74 residents residing in the facility. Findings include: The facility's Dishwashing Machine policy, dated 2011, documents the following: The dining services staff shall maintain the operations of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. This form documents to check the dishwashing machine each morning before first set of dishes are to be washed. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow the dishwashing machine to heat up. The facility's Dishwasher Instructions,, revised 12/96, documents, The minimum water temperatures for the hot water wash is 150 degrees Fahrenheit, and the rinse is 180 degrees Fahrenheit. On 3/24/25 at 09:32 AM, a kitchen tour was conducted with V4, Dietary Manager/DM. The dishwashing machine hot water wash cycle temperature gauge documented 159 degrees Fahrenheit, and the rinse cycle temperature gauge documented 178 degrees Fahrenheit. V4 stated the temperature gauge on the dishwashing machine is used to determine the accuracy of the high temperature rinse cycle. At that same time, V4 stated no other testing is done, and V4 has never used test strips to check the temperature of the water. V4 verified the rinse temperature should reach at least 180 degrees Fahrenheit. On 3/24/25 at 12:45 PM, V1, Administrator, stated a test strip has never been done to check the internal hot water wash and rinse cycle temperatures of the dishwashing machine. The facility's Resident Bed List Report, dated 3/25/25, documents 74 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure infection control and prevention practices were utilized per policy for three (R13, R45, R55) of 24 residents reviewed in a sample of 24. This failure has the potential to affect all 74 residents who reside in the facility. Findings include: The Transmission-Based (Isolation) Precautions policy, dated 10/24/22, documents, Contact precautions refer to measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA/Environmental Protection Agency-registered disinfectant for healthcare use at least daily and when visibly soiled. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicate in transmission through environmental contamination (Clostridium-difficile). Residents experiencing fecal incontinence or diarrhea that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions. The Enhanced barrier Precaution (EBP) policy, dated 3/20/24, documents, EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves during high contact resident care activities. EBP will be initiated for residents with wounds and a physician's order is not required. EBP will be identified by a small sign reading EBP placed on the door frame. PPE for EBP is only necessary when performing high-contact care activities. High-contact resident care activities include wound care. The Hand Hygiene policy, dated 1/30/24, documents, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning and doffing gloves and immediately after removing gloves. The Center for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, documents, To conduct hand hygiene before moving from work on a soiled body site to a clean body site on the same patient and immediately after glove removal. When to change gloves and clean hands: if gloves become soiled with blood or body fluids after a task, if moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. C-difficile is a spore-forming bacterium that can lead to a common healthcare-associated infection causing severe diarrhea. Spores are inactive form of the germ and have a protective coating allowing them to live on surfaces for months. The CDC's Infection Control Appendix A: Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE) documents A gown should gown fully cover torso from neck to knees, arms to end of wrist, and wrap around the back and fasten in back at neck and waist. The facility's Standard Precautions Policy, undated, documents the following: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing care services. 1. R13's Facesheet documents R13 was admitted on [DATE], with diagnoses of Hypertensive Chronic Kidney Disease, Venous Insufficiency, Major Depressive Disorder and Generalized Weakness. On 2/19/25, R13 returned from a hospital stay with diagnoses of Clostridium Difficile (C-diff/Infection of the large intestine), Sepsis (Infection in the blood stream), Pneumonia, Acute Respiratory Failure, and Gastro-Esophageal Reflux Disease with Esophagitis. R13's Stool Culture results, dated 3/21/25, documents R13 tested positive for C-difficile, and antibiotics were ordered. R13's Physician Order, dated 3/13/25, documents to initiate Contact Precautions/Isolation for C-difficile infection. On 3/25/25 at 10:05 AM, R13's door frame had a Contact Precaution sign posted and a sign with instructions to wash hands with soap and water. R13's bathroom had brown substance (stool) on toilet seat, toilet base, and on floor from the doorway to the toilet. The bathroom sink was the only sink available for hand hygiene, and staff would have to walk through the door and past the toilet to get to the sink. On 3/25/25 at 11:00 AM, V5 (Registered Nurse) went into R13's Contact Isolation room and administered medications and cleaned the bathroom. V5's gown was not tied in the back. On 3/25/25 at 10:05 AM, R13 stated she is still having diarrhea stools and had a mess in the bathroom. 2. R55's Face sheet documents R55 was admitted on [DATE], with diagnoses of Closed Fracture Right Femur, Muscle Wasting and Atrophy, Diabetes Mellitus Type 2, Glaucoma, Sacral Wound and Anemia. R55's Physician Order, dated 3/6/25, documents to apply collagen sheet into the coccyx wound and cover with calcium alginate and bordered gauze daily. On 3/25/25 at 1:55 PM, V5 (Registered Nurse) was observed to open the treatment cart, remove dressing change supplies and scissors. V5 proceeded to open the collagen package, cut the collagen sheet with scissors from the drawer without cleaning them, then opened the calcium alginate package and walked down the hall to R55's room to conduct wound care on R55. On 3/25/25 at 2:01 PM, R55's doorframe had an EBP sign posted. On 3/25/25 at 2:01 PM, V5, RN, donned a PPE gown and did not button the front of the gown up. At that same time, R55's sacral wound dressing change was conducted. V5 removed R55's dirty dressing and V5 removed gloves and donned new gloves without conducting hand hygiene. On 3/25/25 at 10:50 AM, V2, DON/Director of Nursing, agreed a staff member would have to walk through the brown substance (stool) to get to the sink to wash hands, and could potentially contaminate the environment outside of R13's room. V2 stated, I will get that cleaned up immediately. On 3/27/25 at 11:30 AM, V2, DON, stated, All gowns should have been secured in the back; hand hygiene should have been conducted after gloves were removed; (R13's) bathroom should have been cleaned as soon as possible after being soiled; the wound dressing should have been opened at (R55's) bedside; and scissors should have been disinfected prior to use and prior to placing them back in the treatment cart. On 3/27/25 at 2:20 PM, V1 (Administrator) stated, We like to keep nurses on the same unit because they get to know their residents. It's stable staffing but of course, if someone needs assistance or whatever, the nurses can go anywhere in the facility to care for residents. 31285 3. On 3/25/25 at 10:15 AM, V4, CNA/Certified Nursing Assistant, provided incontinence care for R45, who was incontinent of stool. V4 did not change gloves after providing incontinence care for R45's bowel movement. At that same time with the same soiled gloves, V4 rolled R45 side to side in bed and placed a clean incontinence brief under R45. With the same soiled gloves, V4 then assisted V6, CNA, with placement of a full mechanical sling under R45 and transferred R45 from his bed into a wheelchair. During R45's transfer, V4 supported R45 and positioned him over the wheelchair while in the sling, and V6 lowered R45 into the wheelchair using the mechanical lift's controls. On 3/25/25 at 10:30 AM, V4, CNA, verified she did not change her gloves or perform hand hygiene throughout R45's incontinence cares and transfer. On 3/26/25 at 1:45 PM, V2, DON/Director of Nursing, stated gloves should be removed, hand hygiene performed, and clean gloves donned after performing incontinence cares and before placing a clean incontinence brief for a resident. The facility was unable to provide a policy identifying appropriate infection control procedures for the donning and doffing of gloves during incontinence care. The facility was also unable to provide a policy and procedure for incontinence care. The facility's Resident Bed List Report, dated 3/25/25, documents 74 residents reside in the facility.

Based on interview, record review, and observation, the facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms. This failure has the potential to affect all 76 residents residing in the facility. Findings Include: Current facility map documents their are four hallways in the nursing home. The facility policy named, Enhanced Barrier Precautions/EBP, dated 3/20/24, documents, It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of Multidrug-Resistant Organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of Multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident activities, such as dressing, bathing, providing hygiene, wound care: any skin opening requiring a dressing. The facility policy named, Transmission-Based (isolation) Precautions, dated 1/30/2024, documents, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens mode of transmission. 1. R334 did not have any signage on the door to show R334 was in isolation or EBP precautions. R334's Wound Round-description, dated 4/23/2024, documents, Site one: Infection, back 2.7 x 6 x 0.4CM (Centimeters). Negative Pressure Wound Therapy twice a week. R334's wound culture results of R334's back, from a local hospital, dated 3/26/2024, documents, Heavy Methicillin Resistant Staph Aureus. R334's Care plan, dated 4/10/2024, documents, (R334) requires intravenous antibiotic therapy due to MRSA (Methicillin- resistant Staphylococcus aureus) resulting from an infection in the wound on his back. R334's Wound Evaluation and Management Summary, dated 4/23/2024, documents, Wound Back Full Thickness, etiology: infection, duration over 21 days. Primary Dressing: Negative pressure wound therapy. Apply twice a week and as needed for 16 days. Site one: Surgical Excisional Debridement Procedure: Remove Necrotic Tissue and Establish the Margin of Viable Tissue. On 4/21/2024 at 10AM, R334 was laying in his bed resting, watching television. R334's wound vacuum to his back and tubing is laying in the bed. R334 stated, This is used for the infection I have in my back. R334 did not have any signage on the door to show R334 was on isolation precautions. On 4/23/2024 at 12:30PM, V2/DON (Director of Nurses) stated, (R334) is not on any isolation right now. (R334) has a wound vac that is in place all the time. The infection that (R334) has is always contained. We did not place him on Enhanced Barrier Precautions or Contact Isolation. On 4/23/2024 at 12:45PM, V3/Infection Preventionist stated, No, we did not put (R334) on Contact isolation or Enhanced Barrier Precautions. (R334) has a wound vac in place so, he does not need to be isolated. On 4/23/2024 at 1:10PM, V12/LPN(Licensed Practical Nurse) stated, R334 is not in isolation. When his wound vac is changed, we only use gloves, and no gowns are needed. On 4/24/2024 at 10:30AM, V16/Bath Aide stated, I give every resident in the facility a bath or shower, except for 200 halls. I go to all halls. (R334) gets a bath from me. He can come down to the shower room and gets into the bath carefully. The nurse who is on duty will take his wound vac off and leave it off while he gets his bath. I only use gloves when bathing (R334). The gloves get a lot of water in them when bathing him, but I still have to use them because his wound is infected. On 4/23/2024 at 1:20PM, V13/CNA(Certified Nursing Assistant) stated, When I take care of (R334) I only use gloves. I do not use a gown when taking care of (R334). At that same time, V13 verified she helps out on any hallway that needs help to make sure the residents are taken care of. On 4/23/2024 at 1:30PM, V14/CNA (Certified Nursing Assistant) stated, The only thing I use is gloves during (R334) cares. He is not on any isolation that I know of. At that same time ,V14 verified she helps out on any hallway that needs help to make sure the residents are taken care of. 30722 2. On 04/22/24 at 10:02 AM, V5, Infection Preventionist, was observed changing R45's sacral area wound. V5 was assisted by V4 who was wearing gloves. V5 washed her hands, donned gloves and cleaned R45's wound with cleanser. V5 then removed her gloves and washed her hands again before donning new gloves, packing R45's wound with calcium alginate and applying a border gauze. V4 and V17, both CNAs, then utilized a mechanical lift to transfer R45 to the recliner. During the transfer, V4 and V17 wore only gloves. Both CNAs verified they only wear gloves for R45, and did not know they needed to wear anything else. V4 and V17 both verified they help out on any hallway that needs help to make sure the residents are taken care of. No gowns or signage indicating R45 required enhanced barrier precautions due to wounds was seen in R45's room. On 04/22/24 at 10:12 AM, V4, Assistant Director of Nursing/Infection Preventionist, was observed administrating R17's Vancomycin through a peripherally inserted central catheter (PICC) line in R71's left arm. V4 donned gloves, identified R71, then cleaned and flushed the PICC line with Normal Saline prior to connecting the Vancomycin. At that same time, V4 verified she only wears gloves with R17's IV. V4 did not wear a gown and there was no signage for Enhanced Barrier Precautions in R71's room. The Centers for Medicare and Medicaid Services form 671 entitled Long Term Care Facility for Medicare and Medicaid, dated 4/21/2024, and signed by V1/Administrator documents 76 residents currently residents in the facility.

Based on observation, record review, and interview, the facility failed to provide a homelike environment when an alarm was placed on a restroom door affecting two (R29, R69) of 18 residents reviewed for homelike environment in a sample of 31. Findings include: Facility policy, dated 01/30/24, and titled Safe and homelike environment documents, The facility will provide a safe, Clean, comfortable and homelike environment. Definition for comfortable sound levels means levels that do not interfere with the resident's hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired. On 04/22/24 at 9:48 AM, the bathroom door of R29 and R69's was noted to have a tab alarm active. R69 had a chair alarm and an alarmed mat on the floor next to her bed. R69's Minimum Data Sheet (MDS), dated [DATE], documents R69 has a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment. R29's 03/15/24 MDS R29 has severe cognitive impairment. On 04/22/24 at 9:48 AM, a tabbed alarm was noted to be attached to the frame of R29's and R69's bathroom door with the tab mounted to the door. On 04/23/24 at 12:59 PM, V5, Care Plan Coordinator, stated the tabbed alarm on the bathroom door was intended to keep R69 from attempting to go into the bathroom independently and potentially falling.

Based on interview and record review the facility failed to prevent diversion of residents' narcotic pain medication for six of six residents (R1, R2, R3, R4, R5, R6) reviewed for misappropriation of resident property in a sample of six. Findings include: An Abuse, Neglect and Exploitation policy, dated 10/24/22, states, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. This policy states that misappropriation of resident property, Means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A Police Report, dated 3/29/23, documents the local Police Department was notified on 3/28/23 that the facility suspected, One of the nurses is taking Morphine and then diluting the bottle with water. The color of the Morphine is pink when in the bottle new, but a nurse reported that some of the bottles are light pink. A Facility initial and final abuse investigation, dated 3/28/23 and 3/31/23, documents on 3/28/23 V8 (Licensed Practical Nurse/LPN) raised a concern a bottle of Morphine on her medication cart looked discolored when it had looked normal on 3/23/23. This investigation includes residents who were alleged victims of this incident as R1, R2, R3, R4, R5, R6. This investigation further documents V6 (LPN) reported V13 (Registered Nurse/RN) had a morphine bottle in her pocket during the shift-to-shift report on 3/27/23, but when investigated, the resident whom the Morphine belonged to had not been administered Morphine during V13's shift. This investigation documents all open bottles of Morphine were replaced with new bottles, and on 3/31/23 V7 (RN) found a bottle of the new morphine with a color discrepancy after taking report from V13. In addition, this investigation documents V13 was taken in by the police for questioning, during which time, V13 confessed to diverting medication from R1's bottle of Morphine Sulfate during the night shift from 3/30/23 into the morning of 3/31/23. R1's physician's order, dated 6/18/22, documents R1 was prescribed Morphine Concentrate 20mg (milligrams)/1 ml (Milliliter) bottle with dose of 0.25ml, 0.5ml, or 1.0ml every four hours as needed and Morphine Concentrate 20mg/1 ml bottle with dose of 0.5ml scheduled four times daily. R2's physician's order, dated 3/18/23, documents R2 was prescribed Morphine Concentrate 100mg/5ml bottle with dose of 0.25ml every four hours as needed. R3's physician's orders, dated 2/11/23, documents R3 was prescribed Morphine Concentrate 20mg/1ml bottle with dose of 0.25ml every four hours as needed. R4's physician's orders, dated 3/9/23, documents R4 was prescribed Morphine Concentrate 100mg/5ml bottle with dose 0.5ml every four hours as needed. R5's physician's order, dated 3/3/23, documents R5 was prescribed Morphine Concentrate 20mg/1ml bottle with dose of 0.25ml, 0.5ml, or 1.0ml every four hours as needed. R6's physician's orders, dated 10/24/22, document R6 was prescribed Morphine Concentrate 100mg/5ml bottle with dose of 0.25ml every two hours as needed. On 4/6/23 at 9:00a.m. and 10:20a.m.,V2 (Director of Nurses/DON) stated on 3/28/23 in the early morning after the change of shift, V8 (Licensed Practical Nurse/LPN) reported during the narcotics count, she noted R3's bottle of Morphine Concentrate was much lighter than it was supposed to be. V2 stated the facility drew up some of R3's Morphine into a syringe and noted the medication was almost clear, instead of the dark pink that it was supposed to be. V2 stated she suspected R3's Morphine Concentrate may have been diverted. V2 stated she and other supervisory staff inspected all the opened bottles of Morphine Concentrate in the facility. V2 stated those bottles were located on three of the four units and belonged to R1, R2, R3, R4, R5, R6. V2 stated all the opened bottles of Morphine for these six residents were lighter than they should have been, but R1, R2, and R3's were especially light. V2 stated V4 (Police Detective) instructed the facility to remove all the open bottles of Morphine belonging to R1, R2, R3, R4, R5, R6, and replace them with new bottles, which they opened. V2 stated the facility had narrowed the suspects down to one nurse, V13 (Registered Nurse/RN), who had worked on all three halls that week. V2 stated they suspected V13 right away because during staff interviews, V8 recounted during a previous shift change narcotic count, one of the Morphine Sulfate bottles was missing from the narcotic box. V2 stated V8 was counting the narcotics with V13, who was the night shift nurse. V2 stated when V8 noticed the bottle was missing, V13 pulled the bottle out of her pocket, and told V8 she had administered a dose of Morphine to a resident during the night, and had forgotten to replace the bottle in the narcotic drawer. V2 stated later, V8 looked through that resident's Medication Administration Record (MAR) and didn't see any documentation V13 had administered any Morphine to that resident. V2 stated on the morning of 3/31/23, V7 (RN), who was the oncoming day shift nurse, and V13 were counting the narcotics for the end of shift narcotic count. V2 stated when the Morphine bottles were placed on the medication cart, V7 noted R1's Morphine Concentrate was a much lighter color of pink. V2 stated V7 alerted V2 right away. V2 stated she examined the bottle, and noted R1's Morphine was a much lighter color. V2 stated she proceeded to call V4, who came to the facility to question V13, who had not left yet. V2 stated V13 confessed to taking R1's Morphine Sulfate and replacing the used doses with water. V2 stated V13 was arrested for misappropriation of residents' narcotic medications. V2 stated V13 was new to the facility as of 1/2023. V2 stated there is no way of knowing if V13 may have been diverting Morphine Sulfate since that time, as they only have visual proof of diluted Morphine from R1-R6's current bottles. V2 stated R1, R2, and R3's Morphine Concentrate bottles were highly diluted, with the color of the Morphine being clear when drawn up in a syringe. V2 stated R4, R5, and R6's Morphine Sulfate was only a little lighter. On 4/6/23 at 9:51a.m. and 10:20a.m., V4 stated the facility called him to report suspected diversion of Morphine Concentrate on 3/28/23 after a nurse noted a bottle of Morphine looked funny. V4 stated the medication in the bottle was light pink instead of darker pink like it is supposed to be. V4 stated the facility told him the Morphine was clear when they drew it up in a syringe, when it should have been pink. V4 stated the facility found several additional bottles, which were also not the right color. V4 stated there were initially six bottles which were a lighter color of pink than they should have been. V4 stated he instructed the facility to gather all six bottles, and turn them over to him as evidence. V4 stated he then instructed the facility to replace the bottles with new, opened, and unused bottles. V4 stated the facility told him they had narrowed down the list of suspects to V13. V4 stated he told the facility to watch her closely to see if she diverts any Morphine Concentrate. V4 stated on Friday morning 3/31/23, after V13 had worked the night before, facility staff called him because they suspected V13 had diverted R1's Morphine Concentrate during her shift, because R1's new bottle was a lighter color of pink. V4 stated he went to the facility, and asked V13 to come to the police station for questioning, where she confessed to diverting R1's Morphine. V4 stated so far, the police crime lab has only tested R1's bottle of Morphine to see if it had been diluted. V4 stated V13 is being charged with felony misappropriation of narcotic medications, and has been referred to the States Attorney's office for prosecution. A facility Nurses' Schedule, dated 3/23/23 to 3/31/23, documents V13 worked the 12 hour evening/night shift on R1, R4, R5, R6's hall on 3/23/23 and 3/30/23; R2's hall on 3/26/23, and R3's hall on 3/27/23. On 4/6/23 at 11:00a.m., V6 (LPN) stated on 3/28/23 V14 (Wound Nurse/ Quality Assurance Nurse) and another supervisor nurse came to her and asked to check her narcotics drawer. V6 stated they took the bottle of Morphine Sulfate belonging to R2, and drew some up in a syringe to look at it. V6 stated once the medication was in the syringe, it looked clear instead of a dark pink like it normally is. V6 stated R2 only took his Morphine sporadically, and hadn't had any administered since before 3/24/23. V6 stated V14 and the other nurse took R1's opened bottle of Morphine Sulfate, and told V6 to replace it with a new, unused, but open bottle of Morphine Sulfate. On 4/6/23 at 11:17a.m., V7 (RN) stated on 3/28/23 V2 and V3 (Certified Nurse Aide Supervisor) asked her to line up all her bottles of Morphine Sulfate oral solution on the medication cart for comparison. V7 stated she had never compared the colors of the medication in the bottles like that before. V7 stated when she lined up the bottles, the medication could be seen through a clear vertical window in the side of the bottle, which is used to measure the number of doses left. V7 stated when all the bottles were next to each other, there was a difference in color for R1, R4, R5, and R6's opened bottles of Morphine then to a sealed, unused bottle of the same medication. V7 stated R4, R5, and R6 all used Morphine Sulfate oral solution on an as needed basis, but R1 is administered scheduled doses of Morphine four times daily, in addition to as needed doses. V7 stated that's when the facility decided someone was diverting residents' oral Morphine medication. V7 stated she knew the facility suspected V13 of diverting the Morphine. V7 stated during her day shift on 3/30/31, she was instructed by V2 to give her all opened bottles of Morphine, and to open new bottles right before the change of shift. V7 stated when V13 came in that evening, she made a comment that all the bottles were newly opened. V7 stated at that time, V13's nose was very runny and V13 broke out in a sweat during their nurse-to-nurse report, which makes V7 think V13 might have been exhibiting signs of drug withdrawal. V7 stated when she returned to work for the day shift the next morning on 3/31/23, V7 lined up all the bottles of Morphine Concentrate on the top of the medication cart. V7 stated R1's bottle was obviously a lighter color. V7 stated she did not mention this to V13, but instead alerted V2, who came to the floor to evaluate the bottle. V7 stated V13 was still at the facility attending an in-service. V7 stated V2 called the police, who took V13 to the police station for questioning. V7 stated later, V4 came back to the nurses' desk asking for all V13's belongings. On 4/6/23 at 12:30p.m. V8 (LPN) stated on 3/28/23 she came into work for the day shift. V8 stated the night shift nurse had already left, so she planned to count narcotics with another nurse from another unit. V8 stated while she waited for the other nurse, V8 lined up two bottles of Morphine Concentrate oral solution from her narcotic drawer on the top of the medication cart. V8 stated she noticed a marked difference in the color of the opened bottle of Morphine compared to an unopened bottle. V8 stated the Morphine is visible in the bottle through a clear window on the side of the bottle used for measuring the medication. V8 stated normally the Morphine is a dark pink in color. V8 stated she had two other nurses look at the bottle, and they agreed the medication was lighter than it should be. V8 stated V10 (Unit Coordinator) looked at the bottle, then drew up some of the Morphine into a syringe. V8 stated the Morphine in the syringe was completely clear instead of being pink. V8 stated V10 examined all the contents in the Morphine bottle, and all the medication was clear. V8 stated a medication discrepancy form was filled out and the discrepancy was reported to V1 (Administrator) and V2. V1 stated on 3/28/23 when V8 reported the color of R3's Morphine bottle didn't look right, that was the first time the facility became aware that someone might be diverting residents' Morphine. V1 stated R3's bottle of morphine was a lighter pink in the bottle, but when the nurses drew up the medication into a syringe, it looked clear when it should have been pink. V1 stated although V13 only admitted to diverting R1's Morphine when she was questioned by the police, through the course of the facility's investigation, they determined a total of six residents had opened bottles of Morphine, which appeared to have been diluted, and which V13 had access to those residents' medications when she worked that week. V1 stated R1, R2, and R3's Morphine was significantly lighter, but R4, R5, and R6's Morphine was a slightly lighter pink, which made them suspect all six residents' Morphine Sulfate was diverted.

Based on observation, interview, and record review, the facility failed to provide supervision during toileting for a resident with a diagnosis of Dementia and failed to ensure fall prevention alarms were functioning for two of two residents (R25, R84) reviewed for falls in the sample of 31. Findings include: The facility's Fall Prevention Program, dated 10/24/22, states Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 6. High risk protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 1. R84's Fall Risk Assessment, dated 1/11/23, documents R84 is at moderate risk for falls. R84's Pre-Admission History and Physical, dated 11/27/22, documents R84 had a couple falls at home. R84's Minimum Data Set assessment, dated 1/17/23, documents R84 requires extensive assistance with transfers, ambulation, and toileting. R84's Care Plan, dated 1/2/23, documents the following: R84 had a fall at home, prior to facility admission, that resulted in a sacral fracture; R84's post fall intervention, dated 1/06/2023, to implement a pressure pad alerting device in bed and chair at all times to notify staff if R84 is attempting to self-transfer/ambulate as she does not always remember to ask for assistance. R84's Event Report, dated 1/6/23, documents R84 fell in her room while trying to move a bedside table and lost her balance. The Event Report ,dated 1/6/23, documents the Root Cause Analysis for R84's fall was (R84) attempting to self-transfer without assistance. R84's Hospital Record, dated 1/6/23, documents R84 fell at the facility and sustained a Lumbar Compression Fracture with Sacral Pain and a Scalp contusion. R84's Event Report, dated 2/8/23 at 2:37 AM, documents R84 was found on the floor next to her bed on her hands and knees. On 2/8/23 at 11:20 AM, V2 (Director of Nursing) stated investigation of R84's fall on 2/8/23, determined R84's pressure pad alerting device was not sounding when staff found R84 on the floor. V2 stated the pressure pad alerting device should be functioning at all times. 31283 2. R25's current medical record documents R25's diagnoses to include: Dementia, Cognitive Communication Deficit, and Other Symptoms and Signs Involving Cognitive Functions and Awareness. R25's most recent Fall Risk Assessment Tool (dated 02/06/23) documents a score of 21, indicating R25 is at high risk for falls. R25's current medical record documents R25 fell at the facility on the following dates: 12/12/22, 12/19/22, 01/20/23, 02/02/23, and 02/06/23. On 02/07/23 at 08:00 AM, R25 was sitting in a wheelchair with a fall prevention alarm in place at a table in the dining room. R25 was eating breakfast, and V6 (R25's daughter) was sitting next to R25. A large hematoma was present on the left side of R25's forehead and an extensive amount of dark purple facial bruising was present on R25's forehead extending down into R25's orbit areas. R25's daughter stated she sustained the injuries after a recent fall. R25's Event Report (dated 01/20/23) documents the following: (R25) was left in the bathroom without supervision. She attempted to stand and pull pants up independently and fell to the ground. The following fall prevention intervention was implemented after R25's 01/20/23 fall and was documented on her current care plan: (R25) will not be left alone in the bathroom. On 02/08/23 at 3:15 PM, V2 (Director of Nursing) stated, (R25) should not have been left alone in the bathroom. She is a high risk for falls, has a history of multiple falls, and has poor safety awareness due to her Dementia. R25's Event Report (dated 02/02/23) documents the following: (R25) was found on the floor lying on her left side at 03:00 PM. R25's current care plan documents the following fall prevention intervention was implemented on 02/02/23 after R25's fall: Staff to ensure that chair alarm is on and functioning properly. On 02/08/23 at 3:30 PM, V2 (Director of Nursing) stated R25's fall prevention alarm was not functioning at the time of R25's fall on 02/02/23.

Based on observation, interview, and record review, the facility failed to prevent resident to resident abuse for one resident (R2) out of three residents reviewed for abuse in a sample of three. Findings Include: Facility Abuse Prevention Program policy, revised 1/2017, documents: (The Facility) affirms the right of our residents to be free from abuse, neglect, misappropriation of property, and exploitation. Our goal is to achieve and maintain an abuse-free environment. (The Facility) is committed to protecting our residents from mistreatment, neglect or abuse by anyone including, but not limited to, employees, other residents, physicians, consultants, volunteers, and staff from other agencies serving the resident, family members or legal guardians, friends, visitors, or any other individual. (The Facility) therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that (The Facility) is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse. This will be accomplished by: Preventing ~ Continually monitor policies, procedures, training programs, systems, etc. to assist in preventing resident mistreatment, neglect or abuse. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, neglect or abuse; Identification ~ Identifying occurrences and patterns of potential mistreatment, neglect or abuse; Protection ~ Immediately protecting residents involved in identified reports of possible mistreatment, neglect or abuse; Procedure for prevention: Resident Assessment As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. Protection of Residents: (The Facility) will take steps to prevent mistreatment, neglect or abuse of residents while the investigation is underway. Residents who allegedly mistreat, neglect or abuse another resident will be removed from contact with that resident during the course of the investigation. The nursing staff is additionally responsible for reporting resident-to-resident altercations on a (The Facility) Incident Report as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the residents, reviewing the documentation and reporting to the Administrator or designee. Refer to Policy on Resident-to-Resident Altercations The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his/her safety, as well as the safety of other residents and staff of (The Facility). Accused individuals not employed by (The Facility) will be denied unsupervised access to the resident during the course of the investigation. Employees of (The Facility) who have been accused of mistreatment, neglect or abuse will be immediately removed from resident contact until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of alleged mistreatment, neglect or abuse shall not complete their shift as a direct care provider to residents. Policy on Resident-to-Resident Altercations: All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nurse Supervisor, the Director of Nursing Services, and the Administrator. (The Facility) staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and the Administrator. If two residents are involved in an altercation, staff will: Separate the residents, and institute measures to calm the situation; identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; notify each resident's representative and Attending Physician of the incident; review the events with the Nurse Supervisor and Director of Nursing Services, including interventions to try to prevent additional incidents; consult with the Attending Physician to identify treatable conditions that may have caused or contributed to the problem; make any necessary changes in the care plan approaches to any or all of the involved individuals; document in the resident's clinical record all interventions and their effectiveness; consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; complete a (The Facility) Incident Report and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; if, after carefully evaluating the situation, it is determined that care cannot be readily given within (The Facility), transfer the resident; and report incidents, findings, and corrective measures to appropriate agencies as outlined in (The Facility's) abuse reporting policy. Facility Incident Report dated 5/29/22, documents (R3) was seated in her wheelchair in the Sun Room when (R2) was seated in his wheelchair and propelled himself up to (R3). (R2) patted the right armrest of (R3) wheelchair. In response to (R2), (R3) made contact with (R2)'s left forearm and left Knee. Residents were immediately separated assessed for injury. Facility Incident Report, dated 7/4/22, documents, (R2) was ambulating about the memory care common area where (R1) was seated in his wheelchair. (R2) began to walk toward (R1) and waved to say hello. (R1) made a hand gesture indicating for (R2) to back away. (R2) misread the gesture and moved closer to (R1). (R1) struck (R2) once in the center of his abdomen. Staff responded immediately. Both residents were assessed for injury; neither were injured. Facility Incident Report, dated 7/13/22, documents, (R2) and (R1) were seated next to each other at dinner. (R1) was in a wheelchair and (R2) in a stationary chair. (R2) reached for a food item of (R1)'s believing it was his own. (R1) made contact to (R2)'s right hand with the fork he was holding in his right hand. Staff responded immediately. Both residents were assessed for injury; (R2) has two small superficial areas to his right hand below his thumb. R1's medical record documents R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's current care plan documents Problem: (R1) becomes irritated at times when he feels other residents are within his personal space. At times he will verbalize for them to get away and put up his hand as a warning signal. Goal: (R1) will not harm himself or others at times when he feels his personal space is being crowded through next assessment. Approach: Start Date 7/4/22. Staff should approach (R1) as quickly as possible to determine his needs if (R1) is observed making hand gestures. Assist in guiding other residents out of (R1)'s personal space when (R1) his noted to be upset about them approaching him. R1's medical record, dated 7/4/21 at 5:56 PM, documents, Resident agitated. Another resident was behind him touching his wheelchair/ and resident began getting upset and raising fists. Staff is able to intervene to keep both parties safe at this time. Offered to take resident to bed and he raised fist at staff. Currently giving resident space to lessen agitation. R1's medical record, dated 7/4/21 at 8:21 PM, documents, This resident struck peer (R2) in the abdomen when peer approached to closely. Peer misread this resident's physical gestures and instead of moving away, peer moved closer. This resident reacted by striking out with his right hand to the center of peer's abdomen. Staff intervened immediately. Resident assessed, No injury to either resident. R1's medical record, dated 7/20/22, documents, (R1) was unable to answer any of the questions on the BIMS (Brief Interview for Mental Status). (R1) is oriented to his name only. He has minimal signs of depression but will act out with little or no warning. R1's medical record, dated 7/13/22, documents, Resident became upset after another resident (R2) at dining table reached toward his food and made contact with that resident's hand with his fork causing two small puncture wounds. Resident immediately removed from that table and placed at long table in activity room away from other residents. Administrator notified. Intervention: plastic silverware only and place resident away from other residents with bedside table in front of him at mealtimes. R2's medical record documents R2's has the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record, dated 7/4/22 at 8:15 PM, documents, This resident was struck in the abdomen by peer (R1) when approaching peer and moving to close to peer. Staff intervened immediately. R2's medical record, dated 7/13/22 at 5:22 PM, documents, Resident (R2) reached toward another resident's (R1) food at the same table and the other resident took his fork and made contact on R2's hand leaving two small puncture wounds. Other resident immediately removed from the table and administrator notified. R2's medical record, dated 7/13/22 at 6:24 PM, documents, Resident's puncture wounds on his right hand cleansed with wound cleanser, triple antibiotic ointment (TAO) applied. New small 0.3 centimeter self-inflicted wound identified on right side of face where he scratched his face and was bleeding. That wound cleansed with wound cleanser, TAO and border foam applied, and five minutes of pressure held on wound to encourage clotting due to bleeding. R3's medical record documents R3 has the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's current care plan documents, Problem: (R3) can become startled and upset when staff and other residents approach her from behind which causes her to swing out at the person approaching her as an reflexive defense mechanism. Goal: R3 will not harm herself or others when reacting defensively to actions she perceives as a threat. Approach: Encourage (R3) to sit in a position that prevents other residents from approaching her from behind such as with her back towards the bistro or other walls in the common areas. R3's medical record, dated 5/19/22, documents, Resident was sitting in the sunroom peacefully when another resident (R2) approached her via wheelchair. when the approaching resident reached his hand out to pat resident's arm/arm rest, this resident struck resident on left arm and left knee lightly. no injuries noted. On 7/21/22 at 9:05 AM, V3, Registered Nurse (RN) verified she was the nurse on duty on 7/13/22 when the altercation between (R1) and (R2) occurred and stated, (R1) was sitting at that table over by the window and (R2) was sitting next to him on (R1)'s right side. (R2) reached over towards (R1)'s food and that's when (R1) stabbed (R2) with the pointed end of the fork. I didn't know (R1) and (R2) had a previous altercation on 7/4/22. (R2) is a very friendly individual and has a habit of getting into other residents' personal space. On 7/21/22 at 9:07 AM, V4, Unit Coordinator, stated So, (R2) is a very friendly individual. He used to be in sales. He'll go up to you and want to shake your hand and get close to you. The problem with that is that (R1) doesn't like anyone in his personal space or anyone coming up behind him. (R2) is ambulatory and anytime he's out of his room, the staff all know to have eyes on because he likes to get in peoples personal space, but he's very easily retractable. He's always smiling. (R2) is just a friendly guy. Since the incident on 7/13/22, I implemented a seating chart. You can see on the chart we posted at the nurse's station that (R1) now sits over there by himself. We had to do something similar with (R3). That's (R3) over there in the pink shirt with the sparkles on it. You can see how (R3)'s back is to the wall. She doesn't like anyone in her personal space and has been known to be physical with other residents. I'm surprised (V3, RN) said she didn't know about the altercation that happened between (R1) and (R2) on 7/4/22 because we have a morning huddle every morning and I would think the nurses would pass on important information like that. R2's current care plan does not address (R2) getting into other residents' personal space. On 7/21/22 at 10:20 AM, V5, Care Plan Coordinator, verified (R2)'s care plan does not address him getting into other residents' personal space. V5 stated, I don't have it care planned for (R2) to redirect him when he gets into other residents' personal space because that's kind of a commonsense thing. (R2) is a busy body. He's all over the unit. I have the personal space care planned for the residents who are aggressive when you get in their personal space, I just didn't think to put in (R2)'s care plan. I can see how if the staff all know that they have to keep an eye on him when he's in the common area, how it probably should be on there. I'll go ahead and add something. On 7/21/22 at 11:28 AM, V6, Quality Assurance Nurse, stated, Everyone knows to keep an eye out for (R2) because he likes to get into other residents' personal space and there are some residents that don't like that. On 7/21/22 at 11:31 AM, V7, Certified Nursing Assistant (CNA), stated, It's common knowledge that we all keep an eye on (R2) because he's ambulatory and he likes to get into other resident's personal space. There are some residents like (R3) who don't like that and will lash out, so we all watch him. On 7/21/22 at 11:32 AM, observation on R2's right hand. Two small, healed marks could be seen. On 7/21/22 at 11:40 AM, observation of staff setting R1 up to eat by himself with a bedside table next to the memory care kitchen entry that is situated in the dining room. On 7/21/22 at 1:35 PM, V8, CNA, stated, I was feeding a resident when I saw another CNA jump up and respond to (R2). I didn't see what happened, but from what I understand (R2) grabbed food off of (R1)'s tray, so (R1) hit (R2) with his fork. I wasn't aware there was an altercation between (R1) and (R2) prior to the incident on 7/13/22. We all have to keep an eye on (R2) because he's confused and ambulatory. He likes to pat people on the shoulder.

Based on record review and interview, the facility failed to implement interventions as outlined in a fall prevention plan of care and provide toileting assistance, for one of three residents (R1) reviewed for falls, in a sample of three. These failures resulted in R1 falling, hitting the left side of her head, and sustaining a large acute subdural hemorrhage on [DATE], and subsequently dying later that day. Findings include: The Fall Risk Prevention and Monitoring Policy (no date), documents, 1. The Fall Risk Assessment Process begins prior to the resident's admission to the facility via the nurse liaison, social service designee, and DON (Director of Nursing)/Nurse Admin Team consultation about resident history information. Parameters are assessed via the nursing assessment and history. Fall histories are obtained as well as current prevention strategies that may have been used in the resident's previous setting, such as bed checks, (high/low) beds, etc. 2. The fall risk assessment will be completed upon admission, quarterly and with significant changes. 3. Evaluate risk factors and develop interventions to address the risk factors. 4. Prevention interventions will be established based upon risk factors, not total score. 5. If prevention strategies have been unsuccessful and an incident occurs, resident specific trends/patterns will be identified to further assess the prevention need. 6. If a fall occurs, the nurse on duty will do a complete assessment and follow the physician notification policy and procedure. 7. An incident report will be completed entirely, including but not limited to: Assessment of the conditions - what caused the fall, addressing the contributing factors - Investigation Process; Implementing resident specific interventions to prevent further occurrences; notifying the POA (Power of Attorney) and physician; Care planning the event on the care plan and adding interventions to the resident's care plan; Determine if the incident is medication related, if so send a (medication review) to the pharmacy. The Electronic Medical Record documents R1 was admitted to the facility on [DATE], with the diagnoses of Difficulty Walking, [CONDITION(S)], Abnormal Gait, Lack of Coordination, weakness and [CONDITION(S)]. A Fall Risk Assessment, completed on [DATE], determined that R1 was at moderate risk for falling. A Plan of Care, initiated on [DATE], documents (R1) is at risk for falls due to periods of increased confusion, incontinence, unsteady/shuffling gait, and medications she receives. She does not always remember to ask for staff assistance with transfers/ambulation and requires frequent reminders to do so and instructs staff to provide toileting assistance every 2 hours and as needed. The Plan of Care also documents (R1) has difficulty making her needs known and understanding others at times due to cognitive impairment, with periods of increased confusion and [CONDITION(S)]. She needs monitoring for verbal, as well as nonverbal, indicators of needs. A Minimum Data Set assessment, dated [DATE], documents R1 has significant cognitive impairment, is only occasionally incontinent of urine and is continent of bowel, and requires extensive assistance of one staff member for toileting. A Nursing Progress Note dated [DATE] at 3:19 am, documents (R1) was found on the floor of the room across from hers at (2:45 am) after a sound was heard when she fell . She states, 'I bumped my head.' She is assisted to a sitting position in a wheelchair. Her left occipital region has a quarter sized bump which has an ice bag applied. Her vital signs and neuro checks are normal. She has full range of motion of her extremities. A Post Fall & Neuro-Check assessment dated [DATE], documents R1 had visible left occipital bruising. The next Nursing Progress Note, on [DATE] at 7:27 am, documents (R1) showed no changes throughout the night neurologically as neuro checks were done per protocol. Vital signs showed no change staying around ,d+[DATE] (blood pressure), 98.6 tympanic (temperature), 60 (pulse), and 16 (respirations). At 6:30 (a.m.) she showed more lethargy and was not responding verbally. At (6:50 am) she was unresponsive. (Emergency Medical Services) was alerted and she was transported to (emergency room ). A CT (Computed Tomography) scan of R1's brain, dated [DATE] at 8:45 am, documents R1 sustained a large acute left cerebral convexity subdural hemorrhage with 1.3 cm (centimeters) of left-to-right midline shift and subfalcine herniation, mild left uncal medialzation and early central herniation. Recommend emergent neurosurgery consultation if within goals of patient care. Hospital Records, dated [DATE], document no surgical intervention was provided for R1, she was placed on Hospice and comfort measures only and expired shortly after. R1's Death Certificate, dated [DATE], documents R1's immediate cause of death as Subdural Hematoma, related to a fall. The facility's Incident Report for R1's fall, dated [DATE], documents Investigation revealed that at (2:38 am) on ([DATE], R1) ambulated independently out of her room across hall to room 107 where an unwitnessed fall occurred. Staff immediately responded to the sound as a result of fall. (R1) was found lying on the floor of room, where she reports she bumped her head. (R1) told the staff she was looking for the bathroom. (R1) had been observed sleeping comfortably in passing (approximately) 20 (minutes) prior to the fall. At the time of the fall, (R1) denied pain. (Neurological) checks and vitals were (normal). (R1) was assisted back to room, toileted and placed back in bed. (R1's) pressure pad alarm was found to be turned off and not sounding at the time of fall. Post fall huddle reveals at the time of last rounds, pressure pad was under resident and functioning. It appears that (R1) turned off the alarm. (R1) has had no falls during admission or in the last month prior to admission. Due to confusion and lack of safety awareness to ask for help, a pressure pad alarm had been put in place after admission. (Neurological) checks were initiated per protocol and remained normal until (approximately 6:30 am), when (R1) became more lethargic and at (approximately 6:45 am) was non-responsive. (Emergency Medical Service) was called and resident sent to (emergency room ) for further evaluation. (Power of Attorney and Physician) were notified. The above-mentioned subdural hemorrhage was discovered, and neurosurgery consulted. (Power of Attorney) made decision that resident would not want extreme measures taken. (R1) was admitted to hospital for comfort care and passed away at (2:49 pm). On [DATE] at 12:29 PM, V7 (Certified Nursing Assistant) stated on [DATE] at approximately 7:30 pm, she toileted R1, put R1 to bed for the night and made sure her pressure alarm was working and in place. V7 stated she checked on R1 after that, and R1 stayed in bed then for the remainder of her shift, which was over at 11:00 pm, but she did not toilet R1 again. V7 indicated she was unaware R1's Plan of Care directed staff to toilet R1 every two hours and as needed. On [DATE] at 12:18 PM, V5 (Certified Nursing Assistant) stated R1 was in bed sleeping when she started her 11:00 pm shift on [DATE]. V5 stated she did her rounds on all of the residents every two hours, which included checking in on them and maybe taking vital signs. V5 stated R1 was asleep in bed with the pressure alarm in place each time she did her rounds, and she did not get R1 up to toilet at any point. According to V5, at approximately 2:30 am, she heard a boom down the hallway. V5 and V8 (Certified Nursing Assistant) looked for the source of the noise and found R1 on the floor of another resident's room. V5 stated R1 had peed on herself and R1 indicated she was looking for a bathroom. V5 stated she was unsure of when R1 was last toileted, but thought she was likely taken to the bathroom before bed. V5 was unaware R1's Plan of Care directed staff to toilet R1 every two hours and as needed. On [DATE] at 10:01 am, V6 (Lead Certified Nursing Assistant) stated it is her responsibility to help guide Certified Nursing Assistant (CNA) staff in resident care needs. V6 confirmed that she was working on [DATE] when R1 fell but did not arrive in the room R1 fell in until V5, V8 and V4 (Registered Nurse) were already assisting her. V6 stated R1 appeared unstable, had a visible injury to the side of her head, had urinated on herself and was being assisted to a wheelchair at that time. V6 stated she has the CNAs rely on a written list that is made for each hallway, which identifies each individual resident's care needs during nightly rounds. V6 indicated, if a resident's plan of care identifies that they are to be toileted every two hours, that information is to be on that written list. On [DATE] at 2:00 pm, V2 (Director of Nursing) stated the facility does not keep the written task list for each hallway that the CNAs use, because that information changes almost daily; however, V2 stated that task list should be reflective of each individual resident's plan of care. At 3:00 pm, V2 stated she reviewed video surveillance from the night of the fall, and the only time someone was in R1's room for a length of time that would allow for toileting was at 10:37 pm on [DATE], but she did not interview that staff member to determine if R1 was actually toileted at that time. V2 stated the video surveillance she reviewed did show staff rounding on R1, but nothing further. V2 stated her investigation into R1's fall on [DATE] did conclude that R1 had not been toileted every two hours, or even at all during the night as directed per R1's Fall Prevention Plan of Care, and R1 was looking for a bathroom when she fell .

Based on interview and record review, the facility failed to ensure all required members attended the QAA (Quality Assessment & Assurance) meetings. This failure has the potential to affect all 82 residents residing in the facility. Findings include: The facility's Quality Assurance and Performance Improvement Guidelines, no date available, documents, Committee Membership: Required Members: Administrator serves a chairperson, Director of Nursing, Medical director or other attending Physician designated by the center, at least three other center staff responsible for direct patient care and services. The facility's QAPI (Quarterly Assurance Performance Improvement) Agenda, dated 10/26/21, documents the following members attended: V1 (Administrator) and V9 (Medical Director). The Agenda has no documentation of two other facility staff attending the meeting. The facility's QAPI (Quarterly Assurance Performance Improvement) Agenda, dated 1/25/22, documents the following members attended: V1 (Administrator), V2 (Director of Nursing), V9 (Medical Director), and V10 (Pharmacist). The Agenda has no documentation of two other facility staff attending the meeting. Meeting minutes reviewed and documentation of making effort to resolve concerns. On 4/20/22 at 1:15 PM, V1 stated, No we don't have two additional staff members attending the QAA meetings. It's just myself, (V2), (V9), and (V10). The facility's CMS (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents Form 672, dated 4/18/22 and signed by V11 (Certified Nursing Assistant Supervisor), documents 82 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure treatments and/or services to address limitations in range of motion were implemented for four of nine residents (R4, R14, R36, R58) reviewed for range of motion in the sample of 27. Findings include: 1. On 4/20/22 at 12:30 PM, R14 was up in a wheelchair at the dining room table for lunch. On 4/19/22 at 10:42 AM, V16 (Licensed Practical Nurse/LPN) stated R14 is dependent on staff for most cares, is unable to ambulate, uses a wheelchair for locomotion, and is transferred with a mechanical lift and two staff assist. R14's Minimum Data Set assessment, dated 1/28/22, documents R14 has functional limitation in Range of Motion of one side of her lower extremity and is unable to ambulate, but R14 does not receive physical/occupational therapy or a range of motion program. R14's current computerized Care Plan, documents R14 is at risk for contractures due to impaired cognition and limitations in her physical and functional abilities but does not include any interventions to maintain, prevent avoidable decline in, and/or improve R14's mobility and range of motion. 2. On 4/20/22 at 12:15 PM, R36 was sitting in a wheelchair at the dining room table, with protective heel booties on both feet. On 4/19/22 at 10:30 AM, V16 (Licensed Practical Nurse) stated R36 is unable to ambulate. and has limited mobility in R36's lower extremities. R36's Minimum Data Set assessment, dated 3/1/22, documents R36 is unable to ambulate and has functional limitation of range of motion to bilateral lower extremities, but does not receive physical/occupational therapy or a range of motion program. R36's current computerized Care Plan (prior to 4/19/22), does not document R36's limitation of range of motion in bilateral lower extremities or include interventions to maintain, prevent avoidable decline in, and/or improve R36's mobility and range of motion. 3. On 4/19/22 at 11:45 AM, R58 was sitting in a wheelchair in the dining room. On 4/19/22 at 10:51 AM, V16 (Licensed Practical Nurse) stated R58 is unable to ambulate and can't stand for any length of time. R58's MDS assessment, dated 3/21/22, documents R58 has limited range of motion in one lower extremity, but is not receiving any physical/occupational therapy or range of motion program. R58's current computerized Care Plan documents R58 is at risk for contractures due to R58's dependence on staff for cares, R58's impaired cognition, and impaired physical and functional abilities, but does not document any interventions to maintain, prevent avoidable decline in, and/or improve R58's mobility and range of motion. 4. R4's Minimum Data Set assessment, dated 1/17/22, documents R4 has a functional limitation in range of motion to both lower extremities. This same MDS assessment documents R4 is not receiving physical or occupational therapy services, or passive/active range of motion therapy. R4's Activities of Daily Living (ADL) Analysis for Restorative Nursing Program, dated 1/15/22, documents R4 has a functional limitation in range of motion to both R4's lower extremities. This same form documents R4's Restorative Nursing Plan includes: Staff will encourage (R4) to complete as much of her transfers as she can safely complete independently, with assist of (two) staff. Staff will walk (R4) up to 100 ft (feet) with wheeled walker and assist of one staff. This ADL Analysis does not indicate R4 will have a range of motion exercise program developed, or that R4 will receive range of motion exercises to address the functional limitations to R4's lower extremities. R4's current Care Plan does not include a range of motion plan or interventions to address R4's functional limitation in range of motion. On 4/19/22 at 11:22 AM, R4 was seated in a wheelchair self-propelling into the dining room. R4 was alert but confused and unable to answer questions. On 4/20/22 at 9:06 AM, V7 (Certified Nurse Aide/CNA) stated V7 assists R4 with some leg exercises at times, but states there is no range of motion program in place for R4. On 4/20/22 at 1:45 PM, V6 (Care Plan Coordinator) stated R4, R14, R36 and R58 did not have any type of therapy or range of motion program in place at this time. V6 stated R4, R14, R36 and R58 had no documentation they refused range of motion programs in the past, or any other rationale for the facility not initiating therapy or range of motion programs for them at this time. The Facility's Resident Mobility and Range of Motion policy (undated) states, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. As part of the resident's comprehensive assessment, the resident care coordinator will identify the resident's: current range of motion of his or her joints; current mobility status; limitations in movement or mobility; opportunities for improvement; and previous treatment and services for mobility. The Care Plan will include interventions to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observation, interview, and record review, the facility failed to re-evaluate fall interventions, implement fall interventions, and ensure staff were aware of resident specific fall interventions for one of seven residents (R[AGE]) reviewed for falls in the sample of 40. These failures resulted in R[AGE] falling on two separate occasions and sustaining an eyebrow laceration, closed head injury, and a left [MEDICAL CONDITION]. Findings include: The facility's Falls Clinical Protocol Assessment, Cause, and Intervention policy, dated 2-2-18, documents, The need for changes in interventions will be assessed and changed as need by the medical doctor, nursing personnel, or interdisciplinary team. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. R[AGE]'s Admission Physician Orders, dated 11-1-19 through 11-30-19, document R[AGE] has [DIAGNOSES REDACTED]. R[AGE]'s Admission Minimum Data Set (MDS) Assessment, dated 11-20-19, documents R[AGE] is severely cognitively impaired, and R[AGE] requires extensive assistance of one person physical assistance for bed mobility, transfers, walking, and toilet use. R[AGE]'s physician progress notes [REDACTED]. Over past few weeks, more confusion, unable to find room, not recognizing family, and requires higher level of care. Moved to skilled nursing facility. R[AGE]'s Event Report, dated 11-15-19 (three days after admission to facility), documents, (R[AGE]) in recliner and tried to stand unassisted. (R[AGE]) was found on bottom with feet in front of her. No visible injuries. Care Plan Intervention: 15 minute checks x [AGE] hours. R[AGE]'s Event Report, dated 11-29-19, documents, (R[AGE]) on floor in front of recliner and laying on right side. (R[AGE]) pointed to head when asked where her pain was. Laceration noted above right eyebrow. Pressure applied above right eyebrow. Sent to hospital emergency room via ambulance. Care Plan Intervention: Encourage (R[AGE]) to utilize seating in common areas versus sitting in her room alone. R[AGE]'s Fall Investigation and Summary, dated 11-29-19 and signed by V9 (ADON/Assistant Director of Nursing), documents, (R[AGE]) was found on the floor in front of her recliner laying on her right side. Laceration above right eyebrow with active bleeding. Body alarm has been put into place. R[AGE]'s emergency room Note, dated 11-29-19, documents, Primary Impression: closed head injury. Additional Impressions: Fall-laceration above right eye three centimeters in length. Closed laceration with five sutures. R[AGE]'s Event Report, dated 12-16-19 and signed by V7 (RN/Registered Nurse), documents, Description: Fall. Pain Observation: Severe pain to the left hip. (R[AGE]) got to the bathroom without assist. (V8/Housekeeper) saw (R[AGE]) by bathroom door and then (R[AGE]) fell to the floor. V9 (Assistant Director of Nursing/ADON) present and aware. Fall prevention plan interventions completed: Educate resident, hi-low bed, gripper socks, and encourage (R[AGE]) to remain in common areas when sitting in her room alone. R[AGE]'s Event Report Section Fall Prevention Plan Interventions Completed, dated 12-16-19, documents R[AGE] did not have a body alarm on at the time of the fall on 12-16-19. R[AGE]'s Radiology Report, dated 12-16-19, documents, Impression: Acute mildly displaced fracture left femoral neck (left hip). R[AGE]'s Fall Care Plan documents the following fall intervention dated 11-15-19: 15 minute checks times [AGE] hours. The same care plan does not include any other fall intervention after the 15 minute checks were completed (11-18-19) and before the fall on 11-29-19 resulting in a closed head injury and right eyebrow laceration. R[AGE]'s Fall Investigation and Clinical Record does not include documentation of a re-evaluation of R[AGE]'s fall interventions after R[AGE]'s 15 minutes checks were completed on 11-18-19. R[AGE]'s Fall Care Plan documents the following fall interventions dated 11-29-19: Place body alarm on R[AGE] to alert staff of attempt to transfer. Encourage R[AGE] to utilize seating in common areas versus sitting in her room. This same Fall Care Plan documents R[AGE]'s body alarm was discontinued by an unknown staff member on the same day implemented (11-29-19). R[AGE]'s Clinical Record does not include documentation of re-evaluation of R[AGE]'s fall interventions or the reason for discontinuation of R[AGE]'s body alarm after 11-29-19. On 2/02/20 at 9:15 AM, and 02/05/20 at 9:05 AM, R[AGE] was in her room, alone, sitting in her recliner. On 2/03/20 at 2:21 PM, V8 (Housekeeper) stated, On 12-16-19 I was across the hallway from (R[AGE]). I looked into (R[AGE]'s) room and saw (R[AGE]) fall to the floor in front of the bathroom door. I immediately got a nurse and CNA (Certified Nursing Assistant). I do not remember who the nurse and CNA were. I do not remember an alarm sounding. On [DATE] at 12:00 PM, V7 (Registered Nurse) stated, On 12-16-19 (V8) saw (R[AGE]) lying on the floor in the doorway of her bedroom. (V8) immediately summoned me. When I assessed (R[AGE]) she was complaining of pain to the left hip. I sent (R[AGE]) to the emergency room . (R[AGE]) did not have a body alarm on when she fell . (R[AGE]) had gotten up out of bed and tried to walk to the bathroom by herself. On [DATE] at 12:15 PM , V2 (Director of Nursing) stated, When (R[AGE]) fell on [DATE] we (facility staff) decided to do 15 minute checks for [AGE] hours to determine (R[AGE]'s) baseline and how (R[AGE]) was going to adjust to the facility. The facility only did 15 minute checks for [AGE] hours after (R[AGE]'s) fall and we did not reassess (R[AGE]'s) fall interventions after the [AGE] hours. We should have re-evaluated (R[AGE]'s) fall interventions. (R[AGE]) did not have any other fall interventions implemented after the 11-15-19 fall. On 11-29-19 (R[AGE]) was found on the floor in front of her recliner. (R[AGE]) sustained a laceration of the right eyebrow that required sutures. After (R[AGE]'s) fall on 11-29-19, we decided to implement a body alarm to (R[AGE]) at all times to prevent further falls. On 12-16-19 (R[AGE]) had gotten up out of bed and fell in the doorway of (R[AGE]'s) room. (R[AGE]) sustained a fracture to the left hip from that fall. On [DATE] at 12:35 PM, V9 (ADON) stated, (R[AGE]) should have had a body alarm when she fell on [DATE]. I was the one that completed (R[AGE]'s) fall investigation and faxed the investigation to the state agency. The report to the state agency documented that (R[AGE]) would have a body alarm applied. I updated (R[AGE]'s) care plan with the new fall intervention to apply a body alarm to (R[AGE]) at all times to alert staff when (R[AGE]) attempts to get up on her own. I was walking up the hallway the day (R[AGE]) fell (12-16-19) and did not hear an alarm sounding when (R[AGE]) fell . I was not aware that anyone had discontinued (R[AGE]'s) alarm off of the care plan. On [DATE] at 2:17 PM, V3 (R[AGE]'s Physician) stated, (R[AGE]) was admitted to the facility from an assisted living facility due to (R[AGE]) falling and needing more help with cares. I am not involved in developing fall interventions in the facility. The nursing supervisors develop fall interventions. Whatever fall interventions were developed for (R[AGE]) should have been implemented and followed. (R[AGE]'s) fall directly caused the right [MEDICAL CONDITION]. On 2/05/20 at 10:10 AM, V11 (CNA) stated, I am going to be honest. I do not know where to find what (R[AGE]'s) fall interventions are. I was not aware that we (facility staff) are to try to encourage (R[AGE]) to sit in common areas. I am not aware of a care plan book being available with (R[AGE]'s) care plan. I thought we were suppose to take (R[AGE]) to her room and put her in the recliner whenever she was not in activities or eating. On 2/05/20 at 10:20 AM , V12 (CNA) stated, I know I can find fall interventions on the computer. I am not aware of a care plan book with care plans. (R[AGE]) is supposed to be in her room in the recliner or in activities. On 2/05/20 at 10:36 AM, V13 (CNA) stated, I have worked here for about five years. I was (R[AGE]'s) CNA on the day (R[AGE]) fell (12-16-19). I had put (R[AGE]) in the recliner that day and she had gotten up by herself and fell . I know (R[AGE]) was supposed to have an alarm on. (R[AGE]) had an alarm for approximately two weeks prior to this fall. I do not know why (R[AGE]) did not have her alarm on the day of her fall (12-16-19). I did not know that (R[AGE]) was to be encouraged to sit in common areas. (R[AGE]) was in her room alone prior to the fall. On 2/05/20 at 11:29 AM, V2 stated, I do not know who discontinued (R[AGE]'s) body alarm fall intervention off of (R[AGE]'s) care plan. The alarm should not have been discontinued. The alarm was implemented after (R[AGE]'s) fall on 11-29-19. I should have been aware if some one discontinued (R[AGE]'s) alarm since I am the Director of Nursing. I will be finding out who discontinued that alarm. On 2/05/20 at 12:15 PM, V1 (Administrator) stated, When I was notified about (R[AGE]'s) fall on 11-29-19, I made the decision to discontinue (R[AGE]'s) alarm. I did not let (V2) know, that was my decision. The staff were supposed to bring (R[AGE]) out to the common areas and not leave (R[AGE]) in her room alone. Staff should have known to bring (R[AGE]) out to common areas.

Based on observation, record review and interview, the facility failed to follow policy and procedure related to altered skin integrity, including the development and implementation of pressure ulcer prevention interventions, follow physician ordered treatment/interventions, and the monitoring and assessment of wounds, for five of six residents reviewed (R66, R77, R94, R102 and R34) for skin breakdown, in a sample of 22. These failures resulted in R66 developing a Stage IV Pressure Ulcer on the coccyx, measuring 4.5 cm (centimeters) x 3.5 cm x 3.0 cm, which resulted in the placement of a [DEVICE] dressing. Findings Include: The facility's Skin/Pressure Ulcer Policy last revised 6/26/17 documents the following: Policy: It is the policy to assess all residents for alteration in skin integrity, injury or factors that place them at risk for developing pressure ulcers. Skin assessment must be completed upon admission and as outlined below. 3. A licensed nurse will complete a Braden Scale on the day of admission, weekly for 4 weeks, then quarterly or as needed relating to a change in a resident's status. Additional risk factors are included on the pressure ulcer prevention plan. 6. When risks are identified as identified on the Braden Scale, prevention measures are implemented to eliminate or reduce risk for pressure ulcer development. All patients will be turned and repositioned at a minimum of every two hours, however, the frequency may be more or less depending on patient's risk factors and mobility. These are included in the resident's plan of care and are evaluated quarterly and as indicated with a change in status. 1. R66's electronic medical record documents R66 was admitted to the facility on [DATE]. R66's electronic Admission Observation dated 10/17/17 at 6:27 PM documents the following under the section titled skin: [MEDICAL CONDITION]. R66's interim care plan dated 10/17/17 documents the following: skin, left great 2nd and 3rd toe; Coccyx, [MEDICAL CONDITION], no interventions were implemented to prevent further breakdown or deterioration. R66's Braden Scale for Predicting Pressure Sore Risk dated 10/17/17 documents R66 is at high risk for developing pressure sores. R66's Braden Scale for Predicting Pressure Sore Risk dated 11/5/17 and 11/11/17 document R66 is at high risk of developing pressure sores. These same forms have a section titled: pressure ulcer risk prevention plan, goal, interventions and summary. These sections contain boxes to check for indicated treatments and goals, but no areas were checked and failed to advise staff on interventions to utilize to prevent further skin breakdown for R66. R66's Wound Care Specialist Initial Evaluation form dated 10/18/17 does not contain any notes regarding R66's coccyx. On 10/25/17 R66's Wound Care Specialist Evaluation document the following: unstageable (due to necrosis) coccyx-Initial evaluation. This same form did not include any measurements of R66's coccyx wound. R66's Wound Care Specialist Evaluation dated 11/8/17 documents the following: Unstageable (due to necrosis) Coccyx, wound size 6cm (centimeters) wide x 7.5 cm long x not measurable deep. This form documents 10% thick adherent necrotic tissue (eschar) and 90%thick adherent devitalized necrotic tissue. R66's Wound Care Specialist Evaluations dated 11/15/17, 11/22/17, 11/29/17, 12/7/17 all document the coccyx wound had improved. The evaluation dated 12/7/17 documents the following: pressure wound coccyx 3.5 cm x 3.5 cm x Not measurable with moderate serous exudate and 40% thick adherent devitalized necrotic tissue. R66's Wound Care Specialist Evaluation dated 12/14/17 documents the following: Stage 3 pressure wound of coccyx measuring 6.5 cm x 5cm x not measurable, wound progress: deteriorated. The facility was unable to provide Wound Care Specialist Evaluations for R66 between the dates of 12/14/17 and 1/3/18. R66's progress notes dated 12/24/17 at 1:39 AM document the following: Dressing changed on coccyx area, old dressing soaked in dark black drainage. Two large holes noted in coccyx area with noticeable odor present, Area's of breakdown black inside and appears to becoming larger from yesterdays site. R66's progress notes dated 12/24/17 document, left side of mouth has red line running down to chin from laying on that side. A Wound Care Specialist Evaluation dated 1/4/18 documents R66 has a Stage 3 pressure wound on the coccyx measuring 6.5 cm x 4.5 cm x not measurable, due to necrotic tissue/eschar and describes the wound as deteriorated. This record also documents R66's wound was cultured on 12/28/17 and was found to be infected with ,[MEDICAL CONDITION]. Ramosum, Bacteroided Thetaiotamicron. R66's Wound Care Specialist Evaluations documented improvement in the wound from 1/4/18-1/25/18, with the coccyx wound measuring 5.5 cm x 5 cm x 3 cm at that time; however, on 2/01/18 R66's Wound Care Specialist Evaluation form documents the coccyx wound as deteriorated and measuring 6 cm x 4.2 cm x 3 cm, with undermining of 8 cm at 12 o clock. R66's wound care evaluation dated 2/22/18 documented the coccyx wound measured 5.5 cm x 4 cm x 2.5 cm with undermining at 6 cm at 12 o clock. A physician's orders [REDACTED]. The most current Wound Care Specialist Evaluation, dated 3/05/18, document R66's has a Stage 4 pressure wound on the coccyx, measuring 4.5 cm x 3.5 cm x 3 cm. On 3/5/18 at 2:25 pm, V5 (family member) stated when R66 was admitted to the facility R66's coccyx area was red, but not open. V5 stated that (V5) is at the facility everyday and R66 is supposed to be repositioned every two hours but V5 is not sure staff are doing it. V5 stated in R66's room has a turn and reposition log book and it is often blank or not filled in. On 3/8/18 at 12:34PM V8 LPN (Licensed Practical Nurse) stated she was the staff member assigned to round with the wound physician at the time R66's wound developed. V8 was unable to identify what interventions were put in place to prevent R66's pressure ulcers. R66 stated the wound doctor was on vacation and did not see R66 from 12/15/17- 1/3/18. V8 stated the floor nurses should document would measurements if the doctor does not come. Upon review of all Progress Notes dates 12/14/18 through 1/3/18 there was no documentation of wound measurements. R66's care plan dated 11/9/18 documents the following: (R66) has a pressure ulcer over his coccyx, unstageable with eschar. This same care plan documents R66's care plan had not been reviewed or revised with new goals or interventions after 12/29/17. R66's Turn Schedule for Every 2 Hours forms, located at the bedside, were reviewed from 1/10/18 through 3/6/18. These forms have multiple 2 hour turns not initialed as completed. On 1/12/18 the turn schedule form indicating R66 was turned every 2 hours was initialed at midnight and 2 a.m., those are the only 2 documented turns on 1/12/18. On 1/16/18 R66's Turn Schedule form documented R66 was on his left side at 4 a.m. and not turned again until 4 p.m. The only documentation of R66 being turned on 1/18/18 was to his right side at 9:30 AM. R66's turn schedule documents R66 was turned on 1/19/18 at 11AM and then not again until 1/20/18 at 2AM. R66's turn schedule documents R66 was turned on 1/26/18 at 2PM on R66's right side and not positioned again until 1/27/18 to R66's right side. R66 was turned to his right side at 10AM on 1/28/18 and not turned again until 4PM. On 2/1/18 R66 was turned on his left side at 10AM and then not turned again until 4 PM when R66 was in his chair. This same form documents R66 was not turned from 4 AM until 2:30PM. R66's turn schedule form documents the following: 2/3/18 turned at 1PM and then not again until 10:30PM; 2/9/18 turned at 2PM and then not turned again until midnight on 2/10/18; 2/16/18 R66 was positioned at noon and then not repositioned again until 6PM. R66's tuning schedule documents on 2/18/18 R66 was repositioned at 4AM, 4:30PM, 6:30PM and 9:15 pm; 2/22/18 repositioned at 4:30PM and not repositioned again until 2/23/18 at 6AM; no documentation of turning and repositioning on 2/27/18; 3/3/18 contains no documentation of repositioning; and 3/6/18 the form was blank indicating R66 had not been repositioned every two hours. On 3/6/18 at 1:41 p.m. R66's [DEVICE] system was changed per V6, RN (Registered Nurse). The surrounding skin was pink with a small white area of tissue at 6 o clock, heavy serous exudate, tunneling at 12 o clock. 2. On 3-8-18 at 10:58 am, R34 was up in a wheelchair with canvas shoes to both feet. When R34's sock to the right foot was removed, there was a fingertip sized open wound to the second toe. R34's Wound Care Specialist Evaluation dated 3-5-18 documents R34's right second toe wound measures 1 x 0.8 x not measurable, is unstageable with necrosis and the wound has deteriorated. This form also documents unstageable (due to necrosis) of the right, second toe - deteriorated due to patient non-compliant with wound care, will not wear slippers as recommended. R34's care plan dated 2-17-18 does not contain any interventions related to R34's actual pressure sore, only the potential for a pressure sore. There are no interventions related to R34's refusal to wear an open toed shoe or slippers. On 03/06/18 at 01:30 PM V8 (Resident Unit Coordinator) stated the following: (R34's) right toe is a pressure ulcer. It developed on 9-22-17. An open toe shoe to right foot until healed was ordered. The area is from the canvas shoe rubbing the top of the toe. At that time is measured 1 cm x 0.4 cm, reddened with no depth. The care plan does not include (R34) having a pressure ulcer to right second toe. The care plan should include interventions of a weekly wound assessment, treatments as ordered by the wound physician, monitoring for signs and symptoms of infection, open toe shoe. The wound doctor said it could be a slipper R34's Braden Scales for Predicting Pressure Sore Risk were completed 3-20-17, 7-25-17 and 12-12-17 scoring R34 as low risk. R34's Braden assessments were not completed quarterly per the facility's policy. 3. A Wound Care Specialist Evaluation note, dated 3/05/18, documents R77 currently has an unstageable (due to necrosis) coccyx wound, etiology: pressure, which measures 2 cm (centimeters) x 2 cm x 4 cm. The current physician's orders [REDACTED]. On 3/07/18 9:33 a.m., R77 was taken from the dining room following breakfast by V15 (Certified Nursing Assistant) to her room via a reclining high back wheelchair. At that time, R77 did not have a 2 inch cushion in place in the wheelchair, as ordered by the physician. R77's 2 inch seat cushion was on the floor in R77's room next to the storage closet. V15 (Certified Nursing Assistant) stated R77 did not have any seat cushion in her wheelchair at all that morning and stated she was agency staff and not that familiar with the resident. 03/08/18 8:59 a.m., R77 was again up in her reclining high back wheelchair for breakfast with no 2 inch seat cushion in place. R77's seat cushion was on the floor next to the storage closet in R77's room at that time. On 3/08/18 at 10:21 a.m., V9 (Registered Nurse/Unit Coordinator) stated R77 is to utilize a 2 inch seat cushion when in the wheelchair to alleviate pressure on the coccyx. 4. Resident Progress Notes, dated 12/25/17, document R94's coccyx as red with 2 small areas of shearing. There is no documentation at that time that the red area of the coccyx or the two areas of shearing were measured to determine size. Electronic Treatment Administration Records document staff continued to use Calazyme on the coccyx, that had previously been ordered on [DATE]. Resident Progress Notes document R94's coccyx as being red or having redness on 1/05/18, 1/08/18, 1/09/18, 1/10/18, 1/11/18, 1/14/18, 1/17/18, 1/18/18, 1/19/18, 1/24/18, 1/27/18, 1/28/18, 1/29/18, 1/31/18, 02/01/18, 02/02/18, 2/05/18, 2/07/18, 2/08/18, 2/10/18, 2/14/18, 2/16/18 and 2/20/18. There is no documented evidence that the facility developed or implemented any new interventions related to altered skin integrity on R94's Plan of Care (dated 3/07/18). On 2/13/18, (R94) scored a 12 on her Braden Scale assessment, indicating high risk for pressure ulcers. Resident Progress Notes, dated 2/22/18, document R94's buttocks has several small areas where skin had been sheared, but at present (R94) has an open area measuring 2 cm (centimeters) x 1 cm x <0.1 cm that appears to be shearing. The physician's orders [REDACTED]. On 3/07/18 at 10:16 a.m., V14 (Certified Nursing Assistant) provided incontinence care to R94, and at that time R94 had multiple small, superficial opened areas on the skin between the lower back and coccyx, and two larger open areas on the coccyx. V14 stated R94's coccyx had looked like that for several days. A Faxed physician's orders [REDACTED]. On 03/08/18 at 10:21 AM, V9 (Registered Nurse/Unit Coordinator) stated all wounds should be measured upon being identified and once weekly until healed. All new areas of skin breakdown need to be identified in the residents plan of care along with treatment orders and new preventative measures to be implemented. V9 was unable to provide any documented evidence that staff had measured the areas of shearing on R94's buttocks on a weekly basis or that the physician had been notified on 2/22/18 when R94's coccyx redness progressed to an open wound. 5. Resident Progress Notes, dated 2/19/18, document R102 developed 2 open areas noted to (left) and (right) buttocks. Appears to be caused by shearing. (Left) buttock 0.8 cm x 0.3 cm. (Right) buttock 1 cm x 0.5 cm. R102's Resident Progress Notes contain no further documentation regarding the appearance of or additional measurements of R102's buttock wounds. The physician's orders [REDACTED]. That same physician's orders [REDACTED]. A Plan of Care, dated 3/06/18, documents R102 was identified at risk for impaired skin integrity related to incontinence and dependence of staff to make significant changes in body position, beginning 8/22/16. The Plan of Care further documents R102, Has a history of pressure injury to right foot. On 2/15/18, (R102) scored 13 on her Braden Scale Assessment, indicating high risk for pressure ulcers. The last intervention documented on the current Plan of Care, related to impaired skin integrity, was on 11/07/18. The Plan of Care fails to identify any new interventions related to impaired skin integrity after the two open areas of shearing on R102's buttocks was identified 2/19/18. On 3/07/18 at 1:45 p.m., V9 (Certified Nursing Assistant) and V16 (Unit Coordinator/Registered Nurse) provided incontinence care to R102. R102's coccyx/buttocks skin was intact at that time, with some slight redness noted on the coccyx. R102 did not have any evidence of residual Z-Guard (a white zinc based paste) on the buttock or coccyx at that time. Once R102's incontinence care was complete, V9 did not apply Z-Guard to R102's skin and a clean incontinent brief was put on R102. At that time, V9 stated R102 was no longer receiving a treatment to the coccyx, since it was healed out the day before.

Based on interview and record review the facility failed to promptly notify a physician with a resident's change in level of consciousness for one of three residents (R1) reviewed for notification of changes in a sample of nine. This failure resulted in a delay in treatment for [REDACTED]. Findings include: A Guidelines for Assessing and Documenting: Change in Resident Condition and Post-Occurrence Evaluation policy dated 10/03/13 states, Criteria for physician notification includes but is not necessarily limited to: change and/or fluctuation in resident's vital signs from established baseline. Change in level of consciousness, mental status and/or behavior. Change in neurological signs such as change in speech, sudden onset of behavioral changes, increased confusion. R1's nurse's notes dated 2/23/17 at 12:01p.m., document that R1 had a temperature of 100.2 and was administered Tylenol by E6. The nurse's note also documents, Passed on to oncoming nurse to monitor and to obtain a urine dip for UTI. E6's nurse's note do not explain what condition R1 had that prevented E6 from administering R1's scheduled medications. There is no documentation that Z2 (R1's physician) was notified of R1's condition. On 7/19/17 at 3:05p.m., and on 7/24/17 at 12:30p.m. E6 verified that R1 had a fever of 100.2. E6 stated that R1 was very sleepy during her entire 12 hour shift. E6 stated that R1 was so sleepy that E6 had to crush her Tylenol in order to administer it. E6 stated that Z12 (R1's son) was so concerned with R1's sleepiness that he wanted to send R1 to the hospital. E6 stated that she told Z12 that R1 only had one symptom which was a fever so instead of sending R1 to the hospital, E6 told Z12 they should check a urine sample to see if R1 had a Urinary Tract Infection [MEDICAL CONDITION]. E6 stated that she did not notify R1's physician of R1's sleepiness, fever, or Z12's concern over R1's condition. On 7/19/17 at 3:50p.m., E9 (CNA) stated that E9 was R1's CNA on 2/23/17 between 2:30p.m. and 11:00p.m E9 stated that sometime during the shift E9 noted that R1 was moaning a little bit. E9 stated that R1 was unable to get up to go into the bathroom because she was so tired. I didn't know how R1 normally behaved. I didn't know if that was her normal. I told the nurse. R1's nurse's notes dated 2/24/17 at 12:03a.m., documented by E8 (LPN) states that R1 was asleep her entire shift and that because of recent behaviors a urine sample would not be obtained until R1 woke up. E8's nurse's note also documents that E8 placed a Fax sheet into a folder for Z2 to be sent in the morning requesting an order to check R1's urine for a possible UTI. On 7/20/17 at 2:54p.m., E8 stated E8 was R1's nurse on 2/23/17 from 6:30p.m. to 11:30p.m E8 stated she knew R1 had been having some kind of symptoms for a few days, but she didn't know what those symptoms were. E8 stated that on her shift, R1 was very hard to arouse and that E8 could not get R1 to wake up enough to take her medications or any fluids. E8 stated that she did not notify Z2 about R1's condition because to her, It didn't seem urgent. R1's MAR indicated [REDACTED]. There are no nurse's notes on 2/24/17 from 12:04a.m. to 6:30a.m. documenting that Z2 was notified R1 was Restless/anxious/crying. R1's nurse's note on 2/24/17 at 3:22p.m., documented by E10 (Registered Nurse/RN) states that R1 was somnolent and wasn't responding when spoken to, and wouldn't follow commands. E10 documented that R1's blood pressure was only 78/50 mmhg (millimeters of mercury) at which time E10 notified Z2 of R1's change in condition. On 7/19/17 at 11:10a.m., E10 stated that on 2/24/17 she was R1's nurse from 6:30a.m. until R1's discharge. E10 stated that because she is an agency nurse, she doesn't know the residents very well and relies on the CNAs to tell her when there is a problem with a resident. E10 stated that one of the CNA's told her that R1 was not acting normally. E10 stated R1 was not very responsive and somnolent. E10 stated that R1 was drooling a little bit. E10 stated that R1 could be roused but would fall right back to sleep. E10 stated that she didn't send R1 out to the emergency room right away because of the process of getting permission from the physician. On 7/20/17 at 12:50p.m. and on 7/24/17 at 4:40p.m., Z2 ( R1's physician) stated that he had not been notified that R1 had a temperature and was not able to be aroused to take medications or drink fluids until the afternoon of 2/24/17. Z2 stated that the first time he was notified was when E10 stopped him in the hall on the afternoon of 2/24/17 at which time he ordered for R1 to go to the hospital. Z2 stated that if R1 had been prescribed an antibiotic sooner it may have made a difference. R1's Emergency Department (ED) note dated 2/24/17 at 4:06p.m., documented by Z4 (emergency room Physician's Assistant) states that R1 was admitted with the [DIAGNOSES REDACTED].

Based on interview and record review the facility neglected to provide prompt medical care following a change in mental status and abnormal vital signs, neglected to assess once a change in condition was noted, and neglected to monitor for fluid intake for one of three residents (R1) reviewed for a change in condition in a sample of nine. This neglect resulted in R1 requiring hospitalization for intravenous fluids. Findings include: A Guidelines for Assessing and Documenting: Change in Resident Condition and Post-Occurrence Evaluation policy dated 10/03/13 states, Signs/symptoms of potential change in resident condition will be assessed and documented in the nursing notes and shift communication report from the onset through resolution. physician progress notes [REDACTED]. All resident occurrences will be assessed and resident condition monitored and documented in the nursing progress notes and shift communication report by each shift for a period of no less than 72 hours following the occurrence. Criteria for physician notification includes but is not necessarily limited to: Change and/or fluctuation in resident's vital signs from baseline. Change in level of consciousness, mental status and/ or behavior. Change in neurological sign such as speech. A Resident Hydration and Prevention of Dehydration policy dated 8/1/16 states, The facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Minimum fluids needs will be calculated and documented on initial, annual, and significant change assessments, using current Standards of Practice. Nursing will assess for signs and symptoms of dehydration during daily care. Intake will be documented in the medical record. If potential inadequate intake and/or signs and symptoms of dehydration are observed, by nursing staff. Physician will be informed. A Recommendations sheet (undated) documents that a Fever is a temperature over 100 degrees Fahrenheit (F) orally. A Medication Administration policy dated 10/02/13 states, The resident's physician must be notified of any withheld medication, and the Unit Nurse must document the notification and the physician's response. A [MEDICAL CONDITION] Medication Use policy dated 1/1/14 states, When a resident first exhibits behavior requiring intervention, the nursing staff will first attempt non-medical interventions. Document the behavior and include all interventions attempted and outcomes. R1's physician's orders [REDACTED]. R1's Minimum Data Set assessment dated [DATE] documents R1 is moderately cognitively impaired, and requires the assist of one person for walking and transfers, used a walker for ambulation, and requires set up with supervision for eating. R1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. R1's nurse's notes for the same date do not document that Z2 (R1's physician) was notified that R1's medications were withheld as is stated in the Medication Administration policy. R1's nurse's notes dated 2/23/17 at 12:01p.m., but recorded as a late entry on 3/1/17, document that R1 had a temperature of 100.2 and was administered Tylenol by E6. The nurse's note also documents, Passed on to oncoming nurse to monitor and to obtain a urine dip for UTI. E6's nurse's notes do not explain what condition R1 had that prevented E6 from administering R1's scheduled medications. E6's nurse's notes do not include if R1 had any fluid intake during E6's shift. E6's nurse's notes also do not document that R1 was assessed for signs and symptoms of dehydration as instructed in the Hydration policy. R1's Observation Report dated 2/23/17 at 1:05p.m., and documented by E14 (Certified Nurse Aide) states, Resident was not responsive enough to give w/p (whirlpool) to, very tired, did not get weighed. R1's nurse's notes from 2/23/17 do not document that Z2 was notified of this change in condition as instructed in the Guidelines for Assessing and Documenting: Change in Resident Condition and Post-Occurrence Evaluation policy. R1's nurse's notes dated 2/24/17 at 12:03a.m., documented by E8 (LPN) states, Resident has been asleep all this shift. Staff will attempt to obtain a urine dip, when she awakens, d/t (due to) resident behaviors lately. T (temperature) 100.2 earlier and prn (as needed) Tylenol given. Resident T later was 98.6 axillary (under the arm). Fax placed in Z2's folder requesting an order for [REDACTED]. R1's MAR indicated [REDACTED]. E22 did not document any nurse's notes, assessments, R1's fluid intake, non-pharmacological interventions tried prior to administering [MEDICATION NAME], or whether R1's temperature was monitored during E22's 11:00- 7:30 a.m. shift. R1's MAR indicated [REDACTED]. R1's nurse's note on 2/24/17 at 3:22p.m., documented by E10 (Registered Nurse) states, R1 was somnolent this morning, not responding when being spoken to and would not follow commands. She would arouse, but would go back to unresponsive state right away. V/S (vitals) b/p (blood pressure) 78/50 mmhg (millimeters of mercury), pulse 94, Temp 99.6F, respirations 20, Spo2 (oxygen status) 94%. Nurse spoke to Z2 and received an order to send to (hospital). R1's Emergency Department (ED) note dated 2/24/17 at 4:06p.m., documented by Z4 (emergency room Physician's Assistant) states that R1 was admitted with the [DIAGNOSES REDACTED]. R1's ED note documents, Patient presents with Altered Mental Status. Family states that the pt (patient) has been altered since Wednesday (2/22/17). Pt has not been eating or drinking since Wednesday. The note documents, [MEDICAL CONDITION] definition:[MEDICAL CONDITION]-induced tissue hypo-perfusion or organ dysfunction (any of the following thought to be due to the infection),[MEDICAL CONDITION]-induced [MEDICAL CONDITION], [MEDICATION NAME] level greater than or equal to 2, Creatinine greater than 2.0mg/dl (milligrams per deciliter), Platelet count less than 100,000ul. (micro liter). R1's laboratory (lab) results dated 2/24/17 document R1's [MEDICATION NAME] level was 4.19mmol/l ( millimoles per liter), Creatinine 3.66mg/dl, Platelet count 73,000. In addition R1's BUN (blood urea nitrogen) was 59mg/dl with the normal value stated as 5-20mg/dl; Troponin 0.247ng/ml (nanograms per milliliter) with the normal value stated as 0.000 to 0.040ng/ml. Z4's progress note dated 2/24/17 at 7:10p.m., documents that Z4, Spoke with (R1's) family at length about lab work and imaging. I explained that the patient's condition is not something that happens overnight. Son (Z12) explained that he was at the (facility) yesterday and that R1 was altered last night. The family said they were insisting to send R1 to the hospital but the (facility) stated that she did not need to go to the hospital. The next day (today) the family insisted again to send her to the hospital. I explained that she has a(n) elevated Troponin and is acute [MEDICAL CONDITION]. I feel that both are related to her severe dehydration. On 7/19/17 at 3:05p.m., and on 7/24/17 at 12:30p.m. E6 verified being R1's nurse on 2/23/17 from 6:30a.m. to 6:30p.m E6 stated that she had been told in report that R1 had been awake all night before her shift. E6 stated that R1, ate a little of breakfast then fell asleep in the recliner. E6 stated that she had the CNAs move R1 to the bed to make her more comfortable. E6 stated that R1 slept for the rest of her 12 hour shift. E6 stated she thought R1 was just sleepy from being up all night. E6 stated that around 5:00p.m. to 5:30p.m., Z12 (R1's son) came to the facility and was concerned that R1 was so sleepy. E6 stated that she took R1's temperature which was 100.2 F at that time. E6 stated she administered Tylenol crushed in apple sauce to R1. E6 stated that R1 normally takes her pills whole but because she was so sleepy E6 decided to crush the medication. E6 stated that Z12 wanted to send R1 to the hospital but that E6 told R1 that for just one symptom of a low grade fever; that was no reason to send R1 to the hospital. E6 stated that she told Z12 that a urine sample (Urine Dip) would be collected and checked at the facility to see if it indicated R1 had a UTI. E6 stated that since it was about 40 minutes before the end of her shift, she did not get the urine sample. E6 stated that she passed on to the next nurse (E8) that R1 had been very sleepy and needed a urine dip to see if R1 had a UTI. E6 stated that R1 did not eat any lunch. E6 also stated that she did not know whether or not R1 drank any fluids. E6 stated, I told the CNA's to offer drinks. On 7/19/17 at 3:50p.m., E9 (CNA) stated that E9 was R1's CNA on 2/23/17 between 2:30p.m. and 11:00p.m E9 stated that sometime during the shift E9 noted that R1 was moaning a little bit. E9 stated that R1 was unable to get up to go into the bathroom because she was so tired. I didn't know how R1 normally behaved. I didn't know if that was her normal. I told the nurse. On 7/20/17 at 2:54p.m., E8 verified E8 was R1's nurse on 2/23/17 from 6:30p.m. to 11:30p.m E6 stated, R1 had symptoms in the previous days. I'm not sure what the symptoms were. E8 stated that R1 was very hard to arouse, We couldn't get R1 to take any fluids. I couldn't get R1 to take any medications or fluids. I didn't take her blood pressure. R1 didn't get up all evening and we weren't able to get it (urine dip). E8 stated that she did not notify Z2 about R1's condition because, It didn't seem urgent, that's why I put a fax sheet in Z2's file which is sent, usually, the next day by day shift. E8 stated that she normally works the first shift, during the day, and was not sure if the difficulty waking R1 up to take drinks and medications was normal for R1. On 7/19/17 at 11:10a.m. E10 (RN) stated that E10 was R1's nurse from 6:30a.m. until R1 was sent to the hospital at approximately 2:40p.m E10 stated that E10 was an agency nurse and did not know R1 very well. E10 stated, My CNAs told me R1 is not acting like R1 this morning. She was not very responsive, somnolent. She was kind of drooling. Drooling a little bit and the CNAs said that was not R1's usual. It made me think we needed to call the doctor. R1 could still rouse but she would go right back to sleep. I didn't send her out (to the emergency room ) right away because of the process of getting permission from the physician. On 7/18/17 at 9:20a.m. Z12(R1's son) verified asking E6 (LPN) on 2/23/17 at around 5:00p.m., to send R1 to the hospital because R1 was unresponsive. Z12 stated that E6 told him it was probably a UTI and that they should wait until the facility could check a urine sample. Z12 stated that the next day on 2/24/17 in the early afternoon, Z12 went to the facility to check on R1. Z12 stated that R1 was still unresponsive and he told E10 (RN) that he was concerned about R1 because she was still unresponsive. Z12 stated that E10 took R1's blood pressure and when E10 saw that it was really low, she contacted Z2 to have R1 sent to the emergency room . Z12 stated R1's lips were dry and blistered. Z12 stated that the emergency room physician told Z12 that R1 was severely dehydrated, septic, and her kidneys were failing. Z12 stated that R1 never regained consciousness while she was in the hospital. On 7/20/17 at 11:35a.m., Z4 verified treating R1 when R1 arrived in the emergency roiagnom on [DATE]. Z4 stated that R1 was so severely dehydrated that her lips were cracked and dry, and her mucous membranes were extremely dry. Z4 stated that R1's dehydration was so severe that R1 was hypotensive (low blood pressure) and required intravenous fluids and a drug called [MEDICATION NAME] to help increase R1's blood pressure. Z4 stated that R1's low fluid volume resulted in kidney damage which was why R1's Troponin level was so elevated. Z4 stated that R1 did not become so dehydrated in just one or two days. Z4 stated that R1 needed fluids indicating that her dehydration did not occur in just one or two days. Z4 stated that R1 had a decreased level of consciousness and was unable to answer questions the whole time R1 was in the emergency room . On 7/20/17 at 12:50p.m. and on 7/24/17 at 4:40p.m., Z2 (R1's physician) stated that he had not been notified that R1 had a temperature and was not able to be aroused to take medications or drink fluids until the afternoon of 2/24/17. Z2 stated that the first time he was notified was when E10 stopped him in the hall on the afternoon of 2/24/17 at which time he ordered for R1 to go to the hospital. Z2 stated that if R1 had been prescribed an antibiotic sooner it may have made a difference.

Based on interview and record review the facility failed to assess for adequate hydration for one of five residents reviewed for hydration in a sample of nine. This failure resulted in R1 requiring hospitalization for intravenous fluid, medications to increase R1's blood pressure, and antibiotics for the treatment of [REDACTED]. Findings include: A Resident Hydration and Prevention of Dehydration policy dated 8/1/16 states, The facility will endeavor to provide adequate hydration and to prevent and treat dehydration. Minimum fluids needs will be calculated and documented on initial, annual, and significant change assessments, using current Standards of Practice. Nursing will assess for signs and symptoms of dehydration during daily care. Intake will be documented in the medical record. If potential inadequate intake and/or signs and symptoms of dehydration are observed, by nursing staff. Physician will be informed. A Recommendations sheet (undated) documents that a Fever is a temperature over 100 degrees Fahrenheit (F) orally. R1's Minimum Data Set assessment dated [DATE] documents R1 is moderately cognitively impaired. R1's Nutrition-Dietitian Nutrition Observation dated 8/17/16 and signed by E5 (Dietitian) documents that R1's estimated daily fluid recommendation as 1609cc (cubic centimeters/ about 6 1/2 cups). On 7/19/17 at 3:05p.m., and on 7/24/17 at 12:30p.m. E6 verified being R1's nurse on 2/23/17 from 6:30a.m. to 6:30p.m E6 stated that she had been told in report that R1 had been awake all night. E6 stated R1, ate a little of breakfast then fell asleep in the recliner. E6 stated that she told the next nurse, E8 (LPN), that R1 had been very sleepy and needed a urine dip to see if R1 had a UTI. E6 stated R1 did not eat any lunch and that E6 didn't know whether or not if R1 drank any fluids. R1's nurse's notes dated 2/23/17 at 12:01p.m., document that R1 had a temperature of 100.2 and was administered Tylenol by E6. The nurse's note also documents, Passed on to oncoming nurse to monitor and to obtain a urine dip for UTI. E6's nurse's note does not explain what condition R1 had that prevented E6 from administering R1's scheduled medications. E6's nurse's notes do not include if R1 had any fluid intake during E6's shift. E6's nurse's notes also do not document that R1 was assessed for signs and symptoms of dehydration. On 7/20/17 at 2:54p.m., E8 verified E8 was R1's nurse on 2/23/17 from 6:30p.m. to 11:30p.m E8 stated, R1 had symptoms in the previous days. I'm not sure what the symptoms were. E8 stated R1 was very hard to arouse that night stating, We couldn't get R1 to take any fluids. I couldn't get R1 to take any medications or fluids. I didn't take her blood pressure. R1 didn't get up all evening and we weren't able to get it (urine dip). R1's nurse's notes dated 2/24/17 at 12:03a.m., documented by E8 (LPN), states, Resident has been asleep all this shift. T (temperature) 100.2 earlier and PRN (as needed) Tylenol given. Resident T later was 98.6 axillary (under the arm). R1's nurse's notes do not include R1 was assessed for dehydration during care or if R1 had any fluid intake during E8's shift. R1's nurse's note on 2/24/17 at 3:22p.m., documented by E10 (Registered Nurse) states, R1 was somnolent this morning, not responding when being spoken to and would not follow commands. She would arouse, but would go back to unresponsive state right away. V/S (vitals) b/p (blood pressure) 78/50 mmhg (millimeters of mercury), pulse 94, Temp 99.6F, respirations 20, Spo2 (oxygen status) 94%. Nurse spoke to Z2 (R1's physician) and received an order to send to (hospital). E10's nurse's notes do not describe if R1 was being monitored for fluid intake during E10's shift. R1's Emergency Department (ED) note dated 2/24/17 at 4:06p.m., documented by Z4 (emergency room Physician's Assistant) states that R1 was admitted with the [DIAGNOSES REDACTED]. R1's ED note documents, Patient presents with Altered Mental Status. Family states that the pt (patient) has been altered since Wednesday (2/22/17). Pt has not been eating or drinking since Wednesday. Z4's progress note dated 2/24/17 at 7:10p.m., documents, I explained that R1 has [MEDICAL CONDITION] and is in need (of) antibiotics and fluids. I explained that she has a(n) elevated troponin and is acute [MEDICAL CONDITION]. I feel that both are related to her severe dehydration. On 7/20/17 at 11:35a.m., Z4 verified treating R1 when R1 arrived in the emergency roiagnom on [DATE]. Z4 stated that R1 was so severely dehydrated that her lips were cracked and dry, and her mucous membranes were extremely dry. Z4 stated that R1's dehydration was so severe that R1 was hypotensive (low blood pressure) and required intravenous fluids and a drug called [MEDICATION NAME] to help increase R1's blood pressure. Z4 stated that R1 did not become so dehydrated in just one or two days. On 7/20/17 at 12:50p.m. and on 7/24/17 at 4:40p.m., Z2 stated that he had not been notified that R1 had a temperature and was not able to be aroused to take medications or drink fluids until the afternoon of 2/24/17. Z2 stated that the first time he was notified was when E10 stopped him in the hall on the afternoon of 2/24/17 at which time he ordered for R1 to go to the hospital. Z2 stated that if R1 had been prescribed an antibiotic sooner it may have made a difference.

Based on record review and interview the facility failed to notify the physician in a timely manner of an acute change in condition of 1 of 9 residents (R4) experiencing pain in a sample of 16. R4 complained of right hip/groin pain for over 30 hours before facility staff notified the physician. R4 was sent to the hospital and was found to have a fractured right hip. Findings include: The POS (Physicians Order Sheet) for R4 dated 04/01/11 documents the following Diagnoses: [REDACTED]. The nurses notes for R4 dated 01/15/11 at 2:00 PM documents that R4 had fallen earlier that morning while ambulating to the bathroom. R4's physician was notified at the time of fall of no injuries. The nurses notes for R4 dated 01/22/11 at 1:30 PM and signed by E15 (RN/Registered Nurse) documents the following: "[MEDICATION NAME] one tablet given at 9:30 AM and 1:30 PM for complaints of right groin pain. Ice pack applied to groin area for comfort. The nurses notes for R4 dated 01/22/11 at 9:00 PM and signed by E13/RN documents the following: "Continues to complain of right groin pain. Describes it (pain) as shooting pain that is aggravated with movement. Scheduled pain medication given to control pain. Will continue to monitor." The nurses notes for R4 dated 01/23/11 at 1:45 PM and signed by E15/RN documents the following: "[MEDICATION NAME] given at noon for right hip and groin pain. Ice applied to groin then. Daughter here at lunch and assisted resident to bathroom and stated resident limping slightly. Fax to Z1 (R4's attending physician) requesting x-ray of right hip and groin." The MAR (Medication Administration Record) for R4 from the dates of 01/22/11 at 9:30 AM through 01/25/11 at 5:15 AM documents that R4 received 5 doses of [MEDICATION NAME] 5/325 mg (milligrams) in addition to the regularly scheduled dose of [MEDICATION NAME] 5/325 mg BID (Twice daily). On 04/20/11 at 1:45 PM E13/RN stated, "(R4) was having pain in hip and groin all day. The pain continued through the evening shift that I worked. (R4) kept trying to stretch the right leg to see if it would help with the pain." On 04/20/11 at 2:00 PM E2 (DON/Director of Nursing) stated, "I was very involved in that. R4 fell earlier in the month but did not have any trouble ambulating. When (R4) developed pain in the right hip the doctor did not want the x-ray done by a mobile x-ray service." On 04/20/11 at 10:20 AM Z1(Attending physician for R4) stated, "That x-ray should have been done earlier. I didn't know (R4's) pain was that severe. I thought it was just mild pain." On 04/19/11 at 1:30 PM R4 stated, "I remember when the pain started. It was terrible pain. I seemed to get worse when I tried to move my leg. The pain pills just didn't hold my pain then." On 04/21/11 at 1:49 PM E2 (DON/Director of Nursing) stated, "(R4) didn't have pain in the right hip and groin area until that day (01/22/11)." Hospital History and Physical for R4 dated 01/25/11 documents the following impression: "This is an [AGE] year old female with a right intertrochanteric fracture."

A. Based on record review and interview the facility failed to provide timely care for 1 of 9 residents experiencing acute pain in the sample of 16. R4 complained of right hip and groin pain. R4 did not receive an x-ray until 3 days later. X-ray documented that R4 had a [MEDICAL CONDITION]. Findings include: 1. The POS (Physicians Order Sheet) for R4 dated 04/01/11 documents the following Diagnoses: [REDACTED]. The nurses notes for R4 dated 01/15/11 at 2:00 PM documents that R4 had fallen earlier that morning while ambulating to the bathroom. R4's physician was notified at the time of fall of no injuries. The nurses notes for R4 7 days later, dated 01/22/11 at 1:30 PM , and signed by E15 (RN/Registered Nurse) documents the following: "[MEDICATION NAME] one tablet given at 9:30 AM and 1:30 PM for complaints of right groin pain. Ice pack applied to groin area for comfort. The nurses notes for R4 dated 01/22/11 at 9:00 PM and signed by E13/RN documents the following: "Continues to complain of right groin pain. Describes it (pain) as shooting pain that is aggravated with movement. Scheduled pain medication given to control pain. Will continue to monitor." The nurses notes for R4 dated 01/23/11 at 1:45 PM and signed by E15/RN documents the following: "[MEDICATION NAME] given at noon for right hip and groin pain. Ice applied to groin then. Daughter here at lunch and assisted resident to bathroom and stated resident limping slightly. Fax to Z1 (R4's attending physician) requesting x-ray of right hip and groin." The Nurses notes for R4 dated 01/24/11 at 2:00 PM document the following: "Appointment made at (hospital) for right hip and pelvis x-ray for 01/25/11 at 8:45 AM. The Nurses Notes for R4 dated 01/25/11 at 7:00 AM documents the following: Resident up at 12:00 AM crying and appearing real anxious. Stated Right hip/pelvic area hurt and requested pain medication. Resident received 2 [MEDICATION NAME] and [MEDICATION NAME] 1 mg (milligram) at midnight. At 5:15 AM resident was crying again and stated pain level was a 12 on a scale of 0 to 10. Resident received [MEDICATION NAME] 2 tablets at 5:30 AM and [MEDICATION NAME] 1 mg at 6:00 AM. The Nurses Notes for R4 dated 01/25/11 at 8:00 AM documents the following: "Out per facility van for hip/pelvis x-ray at hospital. At 10:05 AM facility van driver calls back and states 'right hip is fractured.' POA(Power of Attorney) called and informed." The MAR (Medication Administration Record) for R4 from the dates of 01/22/11 at 9:30 AM through 01/25/11 at 5:15 AM documents that R4 received 5 doses of [MEDICATION NAME] 5/325 mg (milligrams) for complaints of right hip/groin pain, in addition to the regularly scheduled dose of [MEDICATION NAME] 5/325 mg BID (Twice daily). On 04/20/11 at 1:45 PM E13/RN stated, "(R4) was having pain in hip and groin all day. The pain continued through the evening shift that I worked. (R4) kept trying to stretch the right leg to see if it would help with the pain." On 04/20/11 at 2:00 PM E2 (DON/Director of Nursing) stated, "I was very involved in that. R4 fell earlier in the month but did not have any trouble ambulating. When (R4) developed pain in the right hip the doctor did not want the x-ray done by a mobile x-ray service." On 04/20/11 at 10:20 AM Z1(Attending physician for R4) stated, "That x-ray should have been done earlier. I didn't know (R4's) pain was that severe. I thought it was just mild pain." On 04/19/11 at 1:30 PM R4 stated, "I remember when the pain started. It was terrible pain. It (pain) seemed to get worse when I tried to move my leg. The pain pills just didn't hold my pain then." Hospital History and Physical for R4 dated 01/25/11 documents the following: Right lower extremity is mildly shortened. (R4) has pain with palpation of the groin and with range of motion of hip and with logrolling of the hip. Impression: "This is an [AGE] year old with a right intertrochanteric fracture." B. Based on interview and record review, the facility failed to develop and implement individual pain management plans and facility nurses failed to follow their policy and routinely document resident's rating of pain in relation to administration of [MEDICATION NAME] (pain relieving) medications and its follow-up effectiveness for 9 of 12 residents (R1, R2, R4, R5, R14, R16, R9, R8, R12) with assessed pain/comfort issues in sample of 16. Findings include: The facility's Pain Assessment policy dated 1/12/10 instructs nurses to "ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool." The pain policy continues, instructing nurses to "assess pain including onset and duration, location, severity, alleviating and aggravation factors, possible causes, and accompanying signs and symptoms. This policy instructs nurses to document pain on the MAR (Medication Administration Record) using 0 - 10 scale. Nurses are instructed to do a follow -up assessment within two hours after the administration of the medication and document response to pain medication of the PRN (as needed) and nurses notes. 1. R1's physician order [REDACTED]. Facility Pain-Clinical Protocol dated 01/12/10 documents the following: The staff and physician will identify the nature and severity of pain including characteristics ( location, intensity, frequency, duration, etc.). The staff will assess and indicate pain using 0-10 pain scale. R1's physician order [REDACTED].) by mouth every four hours as needed (PRN) and [MEDICATION NAME] 5-325 mg. one to two tablets by mouth PRN for pain. R1's PRN, medication administration record (MAR) from 01/01/11 through 02/28/11 indicate R1 had 18 instances where she requested and was given a PRN [MEDICATION NAME]. In these 18 instances a pain scale rating by R1 was noted either prior to or after [MEDICATION NAME] administration but not both, and nine out of those 18 instances had no pain scale rating by R1 at all. 2. R2's "Resident [DIAGNOSES REDACTED]. R2's physician order [REDACTED].) by mouth every four hours as needed (PRN). R2's PRN, medication administration record (MAR) from 02/01/11 through 03/31/11 indicate R2 had 10 instances where she requested and was given a PRN [MEDICATION NAME]. In one of those instances out of 10, a pain scale rating by R2 was noted only prior to [MEDICATION NAME] administration and nine out of those 10 instances had no pain scale rating by R2 at all. 3. The POS (Physicians Order Sheet) for R4 dated 04/01/11 documents the following Diagnoses: [REDACTED]. The same POS documents the following medication for pain control: [MEDICATION NAME] 5/325 mg (milligrams) one tablet every morning and 2 tablets at hs (hours of sleep), and [MEDICATION NAME] 5/325 mg every 4 hours one or two tablets for mild to severe pain prn (as needed). The MAR for R4 from 01/01/11 through 01/31/11 documents that R4 received 9 doses of prn [MEDICATION NAME] during that time frame. The same MAR has no documentation of pain intensity following the facility pain scale. The MAR for R4 from 02/01/11 through 02/28/11 documents that R4 received 21 doses of [MEDICATION NAME] 5/325 mg. The same MAR for R4 has no documentation of pain intensity following the facility pain scale. 4. The POS (Physicians Order Sheet for R5 dated 04/01/11 documents the following Diagnoses: [REDACTED]. The same POS documents that R5 was admitted on [DATE]. The same POS for R5 documents the following medication orders for pain: [MEDICATION NAME] 5/325 mg(milligrams) one tablet ever 4 hours prn for mild pain and two tablets every 4 hours prn for moderate to sever pain. The MAR (Medication Administration Record for R5 for 03/11/11 through 03/31/11 documents that R4 received 10 doses of [MEDICATION NAME] prn. The MAR has no documentation of pain intensity following the facility's pain scale for 7 out of the 10 prn doses given to R5. On 04/19/11 at 2:00 PM E14 (RN/Registered Nurse) stated, "We are supposed to document what the residents pain scale is at the onset of pain and again after receiving pain medications, according to the policy." 5. The POS (Physicians Order Sheet) for R14 dated 04/01/11 documents the following Diagnoses: [REDACTED]. The MAR (Medication Administration Record) for R14 for 02/01/11 through 02/28/11 documents that R14 received 18 doses of [MEDICATION NAME] prn (as needed) and 18 doses of [MEDICATION NAME] Sodium prn for complaints of headaches. The same MAR for R14 for 03/01/11 through 03/31/11 documents that R14 received 16 doses of [MEDICATION NAME] prn and 8 doses of [MEDICATION NAME] Sodium prn. There is no documentation in R14's medical record of pain intensity following the facility's pain protocol. R14 does not have routine pain medications ordered. On 04/21/11 at 1:15 p.m. E2 DON (Director of Nursing) stated, "(R14) has excruciating headaches and the [MEDICATION NAME] is all that seems to work." 6. The Minimum Data Set ((MDS) dated [DATE] documented that R16 had [DIAGNOSES REDACTED]. The MDS also documented that R16 was on a scheduled pain medication and has received as needed (PRN) pain medication. MDS documented that R16's pain was occasional, and that the intensity was moderate and rated a 7 on a scale of 1-10. The History and Physical for R16 dated 2/22/11 that R16 had a fall at home on 5/2010 and has been complaining of back pain since 7/2010. Physician order [REDACTED]. The POS dated 4/1/11-4/30/11 documented that R16 had orders for [MEDICATION NAME] Patch 25 micrograms (MCG)per hour to be changed every 72 hours, Tylenol 1000 milligrams (MG) three times a day and Tylenol 1000 mg PRN, one extra dose daily. The MAR's dated 2/1/11-4/30/11 documented that R16 received PRN Tylenol of 650 mg once,100 mg once, and 500 mg seven times. Tylenol 1000 mg prn was not given as ordered. The facilities protocol dated 1/12/10 documented "The staff and physician will identify the nature and severity of pain including characteristics (location, intensity,frequency, duration, etc." The policy also documented "Staff will assess pain every shift on the MAR and indicate pain using 0-10 pain scale." The MAR's dated 2/1/11-4/30/11 and the Nurses Notes dated 1/7/11-4/20/11 do not show documentation of the residents pain intensity, frequency,duration or a rating of R16's pain on a scale of 1-10. R16's pain care plan initiated 2/21/2010 does not specify or instruct nursing to rate pain before and after administration of a pain medication. On 4/20/11 at 11:20 am E5 Registered Nurse stated "we chart location of pain and rate the pain on a scale of 1-10 on the PRN portion of the Medication Administration Record (MAR). Surveyor pointed out to E5 on the current MAR for R16 dated 4/1/11-4/30/11 on 4/5/11 and 4/17/11 location of pain was documented, not the intensity or rating rated on a scale of 1-10. E5 stated "our policy states to rate pain on a scale of 1-10 and that is what I do." E5 then stated "You may want to check the nurses notes because some nurses prefer to chart pain there and not on the MAR. the nurses notes for 4/5/11 and 4/17/11 did not document a pain medication administration, intensity or rating of the pain on a scale of 1-10. 7. According to the April physician's orders [REDACTED]. The annual MDS (Minimum Data set) dated 06/30/10 indicates that R9 has daily moderate back pain. The pain assessment form dated 02/24/11 notes that R9 is on scheduled and as needed pain medications. The nurse documents on this form that R9 stated in the five days before the assessment she (R9) had occasional pain that she rated as a 5 on a 1 - 10 scale. On 04/18/11 at 1:40 p.m. R9's right heel pressure sore was a round, dry, necrotic black pressure sore approximately 5 centimeters (cm.) in size. This ulcer and the skin surrounding this pressure ulcer were dry and scaly. On 03/14/11 at 1:30 p.m., the nurses notes document that R9's heel is very dark and mushy to touch and that R9 complains of discomfort whenever her heel is touched. The Medication Administration Record for March 2011 documents that in addition to the routine administration of [MEDICATION NAME] 75 milligrams every 72 hours, nurses administered three doses of [MEDICATION NAME] / [MEDICATION NAME] 5/500 one tablet and nine doses of two tablets (from 03/02/11 - 03/30/11). also during this same time, nurses document the administration of six doses of Tylenol 650 milligrams. Nurses failed to document R9's pain scale for 15 of the 18 times they administer pain medication and failed to document the effectiveness of the pain medication for 8 of the 18 doses. The Medication Administration Record for April 2011 shows that in addition to the routinely administered 75 milligram [MEDICATION NAME] every 72 hours for R9's pain, nurses administered narcotic [MEDICATION NAME]/ [MEDICATION NAME] 5/500 milligrams 1 tablet three times and two tablets five times from April 2 to April 20, 2011. Also during this time nurses administered 650 milligrams of Tylenol for R9's pain. Nurses documented at various times that R9 has leg pain, burning, back pain, rectal pain and pain all over. The nurses did not document a pain scale prior to the administration of the pain medication for six of the ten times they administered pain medication. According to the current care plan dated 03/03/11 no pain management plan has been developed. This care plan does not address R9's pain concerns and does not provide pharmacological or non pharmacological interventions for staff to implement to control R9's pain. 8. The April 211 physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] indicates that R12 has moderate joint pain on a daily basis. A Pain assessment form dated 03/16/11 states that R12 receives both routine and prn pain medication and continues to have frequent pain. This assessment indicates that R12 was unable to provide an answer when asked to rate his pain. On 04/20/11 E24 ( Licensed Nurse) confirmed that R12 experiences pain and stated that he can usually give a pain rating. According to the March 2011 MAR, in addition to the routine twice daily doses of narcotic [MEDICATION NAME] 5/325, nurses administered four additional doses of [MEDICATION NAME] for R12's pain and failed to rate R12's pain level. In addition to the routine [MEDICATION NAME] doses in April, 2011, the MAR notes that nurses administered five additional doses of [MEDICATION NAME] and failed to rate R12's pain level. The current care plan dated 03/15/11 indicates that R12 has " long standing complaints of right arm pain" and includes a care plan goal for mood/behavior/pain that R12" will show some decrease in severity of aggressive behavior." This care plan includes no pain management plan and includes pharmacological or non pharmacological interventions for staff to implement to alleviate R12's pain. 9. On 04/18/11 at 11;15 a.m., R8 was sitting in the recliner in her room. R8 has gastrostomy and jejunostomy tubes for feedings and medications and a [MEDICAL CONDITION]. R8 was alert and aware of her surroundings, and able to vocalize her concerns. The April 2011 physician's orders [REDACTED]. The Admission Minimum (MDS) data set [DATE], states that R8 has received as needed pain medication and has occasional pain, but was not able to rate her pain. On the March 2011 Medication Administration Record, nurses documented they administered 15 doses of Tylenol 650 milligrams for R8's abdominal pain, leg pain, headache, or generalized discomfort. Nurses failed to rate R8's pain for 13 of the 15 doses they administered. From April 1 -18, 2011, the nurses administered thirteen doses of Tylenol and failed to document R8's pain level for all thirteen and failed to document the effectiveness of the medication twice. The current care plan dated 01/10/11 states that R8 has occasional complaints of low back pain, but no pain management plan has been developed. This care plan includes no goals for pain management and provides no direction for staff approaches of pharmacological or non pharmacological interventions to alleviate R8's pain.

Based on observation, interview, and record review, the facility failed to accurately assess pressure sore development potential, failed to implement pressure relieving methods, and failed to closely monitor for pressure sores for 1 of 2 residents (R9) reviewed for pressure sores on the sample of 16. R9 has a history of previous pressure sores, was assessed at low risk, developed three stage II pressure areas and an unstageable pressure area on her right heel. Findings include: On 04/18/11 at 11:25 a.m., R9 was sitting in the dining room with a large foam boot on her right foot. At 1:40 p.m.(04/18/11), E24 (Licensed Nurse) performed a skin check as R9 was lying in bed. R9's right heel was had a round, dry, black pressure sore approximately 5 centimeters (cm.) in size. This ulcer and the skin surrounding this pressure ulcer were dry and scaly. The facility nurses assessed R9 for pressure sore risk using the Braden Scale on 03/18/10 and scored R9 as low risk at a 20. On 06/03/10, 08/26/10 and 11/25/10, R9 scored 17 and remained at low risk for pressure ulcer development. R9 still remains at low risk for pressure sore development at a score of 15 on the most recent assessment of 02/18/11. Nurses notes document that R9 had previously been treated for [REDACTED]. R9's weight log shows that R9 has had weight loss of 10% in a six month time frame from 08/07/10 when R9 weighed 158 pounds until 02/07/11 when R9 weighed 141 pounds. The Annual Minimum Data Set (MDS) of 06/30/10 and the most recent quarterly MDS of 02/24/11 indicate that R9 is incontinent at times, non ambulatory, requires staff assist with her care needs and mobility. The comparison of these two assessments shows that R9 has declined in her ability to feed herself. These issues could place R9 at an increased risk for pressure sore development. Nurses notes dated 02/02/2011 and the Wound Assessment flow sheet document that R9 developed a stage II pressure ulcer on her coccyx measuring 2 cm by 1.5 cm. Nurses notes document that nutritional interventions of a high calorie supplement were not started until 02/07/11. The wound flow sheet notes that this pressure ulcer was healed on 02/16/11. Nurses notes document on 02/10/10 at 5:30 a.m., that R9 has developed another pressure ulcer, a stage II on her buttocks. The March and April treatment records document that nurses administered Calazyme to R9's pressure sore on her buttocks until 04/15/11. On 03/04/11 at 6:00 a.m., the nurse writes that R9 has developed another pressure sore, a new open area on her left hip, measuring 1.25 cm. x 0.3 cm. The nurse documents that Hydrogel and a 2 x 2 dressing was applied and wound assessment flow sheet documents that this pressure sore was healed on 03/08/11. The nurses notes dated 03/05/11 at 9 p.m., document that an aide found a large "hematoma" on R9's right heel that may be caused by pressure to that area while R9 is in bed. The Wound assessment flow sheet states that an unstageable pressure ulcer on R9's right heel was discovered on 03/05/11. According to the wound flow sheet, this area initiated as a blister measuring 5.5 cm x 4 cm.. On 03/14/11 at 1:30 p.m., the nurse documents that R9's heel is very dark and mushy to touch and that R9 complains of discomfort whenever her heel is touched. Nurses notes of 03/05/11 at 9 p.m., document that R9's pressure ulcer may have been caused during transfer with the standing lift. On 04/20/11 at 2:20 p.m., E24 stated that R9's right heel pressure sore was determined to be from pressure while in bed and that the standing lift was ruled out as a possible cause. The care plan dated 03/03/11 notes that R9 has an unstageable pressure ulcer on her right heel, but does not include any interventions for staff to implement to promote heeling of this ulcer and does not include a goal. R9's care plan does not address the stage II pressure ulcer on R9's buttocks which developed 02/25/11 and was being treated until 04/15/11. R9's care plan was not updated to address the pressure sore on R9's right hip that was found on 03/04/11. R9's care plan addresses R9's Braden scale of 17 and includes a goal to show no evidence of pressure related skin issues. Under interventions, this care plan indicates that positioning pillows, turning/ positioning schedule and heel protectors have not been implemented as a preventative interventions. The care plan notes that after the development of R9's pressure ulcer, pressure relief boots were initiated on 03/05/11. According to the prevention care plan weekly skin checks have been in place since R9's admission. On 04/21/11 at 9:30 a.m., E25 (Assistant Director of Nurses -ADON) stated that CNAs perform weekly skin checks on shower days for all residents. E25 provided a shower skin check form for R9 for 02/24/11 and 03/03/11. This form is blank for skin concerns and fails to identify any pressure sores including the area on R9's buttocks which developed on 02/25/11 and was treated until 04/15/11. Neither the pressure sore on R9's left hip noted on 03/04/11 nor the large, black pressure ulcer noted on 03/05/11 were documented on the skin check of 03/03/11. On 04/21/11 at 9:30 a.m., E25 verified that R9's right heel wound was determined to be a pressure sore. E25 confirmed that R9 had a history of [REDACTED]. E25 verified that R9 was assessed to be at low risk for pressure ulcer development and stated that she would consider R9 to be at high risk due to her pressure sore history. E25 stated that she is in the process of training nurses regarding better assessments. On 04/21/11 at 1:30 p.m., E25 stated that she and E2 (Director of Nurses) are working on a process to determine if pressure sores are avoidable or unavoidable. E25 stated that she had not yet evaluated R9's pressure ulcer for this determination. On 04/22/11, E25 provided an evaluation for unavoidable pressure ulcer for R9's heel pressure ulcer. This evaluation states that R9 has factors including [MEDICAL CONDITION], a history of pressure ulcers, cognitive impairment with noncompliance, and decreased mobility which would place her at increased risk for pressure sore development. This evaluation states that R9 was resistant toward sleeping in bed. This evaluation states that R9 was placed on comfort care in January 2011. Nurses notes dated 01/21/11 at 1:30 a.m., document that R9 slept in her recliner. Nurses notes of 01/25/11, 01/27/11 and 02/04/11 document that R9 is in bed. On 04/21/11 at 1:30 p.m., E25 verified that R9 now sleeps in bed but stated she was not sure how long R9 has been going to bed instead of sleeping in a recliner. R9's clinical record, including assessments and care plan does not indicate that R9 was reassessed for pressure sore risk or re-evaluated for bed mobility ability when R9 began sleeping in bed. There is no documentation that heel protectors, a turning and repositioning schedule or other pressure prevention measures were implemented when R9 began sleeping in bed. No pressure ulcer reassessment or additional pressure prevention measures were implemented when R9 changed to comfort care status in January 2011.

Based on observation, interview, and record review, the facility failed to obtain and clarify physician orders [REDACTED]. The facility failed to develop and implement a plan of care regarding R8's gastrostomy and jejunostomy tubes,which would address R8's adverse symptoms of nausea, burping/hiccupping, and abdominal pain, and repeated occluding of R8's jejunostomy tube. R8's jejunostomy tube became clogged three times in six weeks requiring emergency room treatment each time. Findings include: The physician's orders [REDACTED]. physician's orders [REDACTED]. Physician orders [REDACTED].-tube with 100 cc water every four hours. R8 also has a gastrostomy tube ([DEVICE] - a tube inserted into the stomach) and physician's orders [REDACTED]. The April 2011 physician's orders [REDACTED]. This physician order [REDACTED]. [MEDICATION NAME] daily and [MEDICATION NAME] twice daily are ordered to be administered via the Jejunostomy tube. [MEDICATION NAME] is ordered to be administered twice daily with no route designated. The physician's orders [REDACTED]. R8's clinical record including nurses notes and hospital forms indicate that R8 has had problems with her gastrostomy tube and /or jejunostomy tube clogging up and problems with nausea and hiccups at times since her admission in January 2011. Nurses notes dated 1/11/11 at 5:30 a.m., state that R8's feeding was running through her J tube and the feeding bottle was compressed so tightly that the nurse questioned if the feeding was going into the correct port, so turned the feeding off. At 6:30 (01/11/11) the nurses notes state that there was a discussion regarding R8's tube feeding and "the consensus was the tube feeding goes in the [DEVICE]. Feeding was turned on, feeding into the [MEDICAL CONDITION] port." At 7:00 a.m. (01/11/11) the nurse documents that she found the order for the feeding to go via J-tube. This note continues,"Went down to resident's (R8's) room and found blood somewhat bright on resident's fingers, linens, and in mouth. Turned feeding off. " The nurse also documents that R8 complained of nausea. At 10:00 a.m. (01/11/11) the nurse documents that R8's medication was administered via the J- tube and the feeding was turned on at 9:30 a.m. On 01/16/11 at 5:00 a.m., the nurse writes a conflicting note stating that R8 has G-J tube running at 70/hour flushed easily. On 01/20/11 at 1:30 a.m., the nurse writes that R8 woke up complaining of stomach pain and was given Tylenol 650 milligrams via her J-tube. On 01/23/11 at 11:00 a.m. the nurse documents that Medications and feeding were through R8's J-tube. On 01/25/11 at 2:30 p.m.,nurses notes state that R8 had a 101.2 degree fever, lungs full and diminished and that R8 complained of feeling very full and nauseated during flushes. At 4:15 p.m. (01/25/11) nurse documents that R8 is being admitted to the hospital. On 02/08/11 R8 returns from the hospital and at 6:00 p.m., the nurse documents that R8 states she has abdominal pain, rating it at a 6 on a 1- 10 scale and was given Tylenol 650 milligrams. It is unclear whether the Tylenol was given via [DEVICE] or J-tube as the documentation shows both written on top of each other. The note continues that J-tube had zero residual and flushed easily and medications went through easily. On 02/10/11 st 3:30 p.m., nurses notes state that R8's physician spoke with staff and that R8's [DEVICE] should be clamped 23 hours and when the feeding is off from 8:30 - 9:30 a.m., the [DEVICE] should be open for one hour to drain. On 02/20/11 at 2:00 p.m., the nurse documents that R8 complained of nausea and was medicated with [MEDICATION NAME]. On 02/21/11 at 6:00 p.m. the nurse documents that R8's medications were administered via her J-tube. At 11:00 p.m., R8 complains of nausea and dry heaves and the feeding was stopped. R8 rated her pain around her [DEVICE] site at a 6 or 7. On 02/22/11 at 12:00 a.m., the nurse writes that R8 has not vomited, but is still nauseated and burping/ hiccupping and that the feeding remains off. At 2:00 a.m.(02/22/11) the nurse writes that R8's burping and hiccupping has lessened, that her nausea is better, but that R8 is still complaining of pain at the G-J tube sites and rates tit at 5. At 5:00 a.m., the nurse documents that she restarted R8's feeding pump at 70 cc/ hour. At 6:00 a.m. (02/22/11) nurses notes state that R8 is complaining of nausea and the feeding is stopped and the J- tube flushed. At 9:00 a.m. (02/22/11) the nurses notes state that R8's J-tube feeding was turned back on at 70 cc/hour and that medications were given per J-tube. R8 complained of abdominal pain at a level 5 and that approximately 200 cc of yellow drainage with flakes were in the [DEVICE] drainage bag. On 02/22/11 at 2:00 p.m., R8's physician was called and ordered that R8's tube feeding be reduced to 35 cc/ hour. On 02/23/11 at 9:00 a.m., the nurse documents that R8's [DEVICE] is open and "continues to drain yellow discharge, and that R8's feeding continues at 35 cc/hour via J-tube. On 02/24/11 at 2:00 a.m., R8 is burping , hiccupping and complaining of nausea, abdominal pain, and itching all over. [MEDICATION NAME] and [MEDICATION NAME] were given via J- tube and the feeding was stopped. On 02/24/11 at 9:30 a.m., R8's physician ordered [MEDICATION NAME] to be administered on a regular basis twice a day per J tube. On 02/25/11 at 11:15 p.m. R8 complained of nausea, burping /hiccupping and the tube feeding which had been at 70 cc/ hour was turned off. [MEDICATION NAME] suppository was given. On 02/25/11 at 3 a.m., the nurse documents that R8 is still complaining of nausea, but doesn't seem to be belching as much, and that the feeding was restarted at 35 cc/hour. R8 complained of calf pain and just hurting all over and was medicated with Tylenol 650 milligrams via J- tube. At 5:30 a.m. 02/26/11), R8's blood sugar was 65 and the nurse documents that she put two packets of sugar into R8's J-tube and increased the feeding to 70 cc per hour. Review of physician orders [REDACTED]. On 02/26/11 at 6:00 p.m., the nurse documents that R8's "formula tube very hard to remove from J-tube. Finally removing white insertion from J-tube with feeding tube." On 02/27/11 at 12:00 a.m., R8 complained of nausea, the feeding tube was turned off and [MEDICATION NAME] was given through the J-tube. the nurse documents that R8's feeding was restarted at 1:30 a.m. at 35 cc/hour and increased to 70 cc/hour at 3;30 a.m. (02/27/11). Nurses document on 02/27/11 - 03/03/11 that R8 had no complaints of nausea. On 03/03/11 6:30 a.m. - 6:30 p.m., nurse documents that R8 had no complaints of discomfort, and that R8's abdomen was distended but soft. At 11:00 p.m. on 03/03/11 the nurse writes that R8's J-tube had no residual, no flush, no feeding, that the tube was completely plugged up. R8's physician was called and instructed nurse to try coke and if not resolved to leave feeding off and call office in the morning. Nurse documents at 1:00 a.m., that J-tube won't flush or pull back any residual. On 03/04/11 the nurse documents that physician's office was called at 9:00 a.m., attempts of coke and bionix declogger plastic item were unsuccessful to open R8's tube. At 11:45 a.m. on 03/04/11, R8 was sent to the hospital emergency department. At 2:00 p.m., on 03/04/11 nurses notes state that the hospital called and wants all medications to be given through the [DEVICE] only and feedings through the J-tube only. R8 returned from the hospital on [DATE] at 2:00 p.m. On 03/16/11 at 2:15 a.m., R8 complained of upset stomach and hiccupping, and was medicated with Tylenol 650 milligrams and [MEDICATION NAME] 0.5 milligrams. On 03/17/11 at 5;30 am, R8 had hiccups and received [MEDICATION NAME] 0.5 milligrams. On 03/20/11 form 6:30 a.m. to 6:30 p.m., the nurse documents that R8's tube feeding was infusing at 75 cc/ hour, above the ordered rate of 70 cc/ hour. On 03/30/11 at 10:00 p.m., the nurse writes that family reported that R8 had been hiccupping. On 03/31/11 at 3:30 a.m., R8 complained of nausea, burping/ hiccupping, and the tube feeding was turned off at 2:00 a.m. The nurse documents that R8 was medicated with [MEDICATION NAME] for restlessness, Tylenol for discomfort and [MEDICATION NAME] for nausea. Feeding was resumed at 2;45 a.m. On 03/31/11 at 2:20 a.m., R8 was complaining of hiccups. On 04/02/11 at 5:00 p.m., R8 complained of stomach ache and burping continuously and the feeding was stopped. At 6:00 p.m., R8 continued to complain of stomach cramping pain. On 04/07/11 at 1:00 p.m., the nurse documents that she was unable to flush R8's J tube, that J-tube was clogged. The nurse documents that she tried unsuccessfully to milk the tube, and tried using warm soda without success. The nurse documents that she had two other nurses try to unclog R8's J-tube without success and that when trying to flush the J-tube the "tube balloons out." On 04/07/11 at 2:25 p.m., R8 was sent to the emergency department due to her clogged feeding tube and returned on 04/08/11 at 6:15 p.m. R8 complained of hiccupping on 04/09/11 at 6:00 a.m. and on 04/10/11 at 1:00 a.m. On 04/15/11 at 3;30 p.m., the nurse documents that R8's "J-tube will not accept tubing, keeps popping off. trying other tubing et taping tubing which also popped out." On 04/17/11 at 5:00 p.m., Nurse writes that R8 was medicated with Tylenol and [MEDICATION NAME] for discomfort and hiccups. On 04/18/11 at 11:15 a.m. R8 was up in her recliner and R8's tube feeding formula was infusing via her jejunostomy tube at 70 cc (cubic centimeters) per hour. At this time R8 voiced no complaints of nausea or hiccups. On 04/18/11 at 3:30 p.m., the nurse documents that R8's feeding infused without difficulty this am, but is leaking this afternoon. The next entry dated 04/18/11 at 2:30 p.m., another nurse documents that R8's J-tube is occluded and formula is pooling around connection port to tubing. Unable to flush (J-tube) with water and another nurse was able to instill a small amount of water with plunger action in and out. At 4:25 p.m. (04/18/11) nurse documents that she was unable to flush J-tube, and R8 was being transported to the hospital emergency department. The kardex portion of the current care plan for R8 dated 01/10/11 states that R8 is NPO and has a J/GT (jejunostomy/ gastrostomy tube), receives Diabetisource feedings per tube at 70 cc/hour per JT, flush JT with 100 cc of water every 4 hours and GT with 30 cc water every 8 hours. R 8' s' care plan does not include any interventions regarding routine care and monitoring of R8's G- or J and does not instruct staff on site care, elevating the head of the bed, or checking for placement. R8's care plan does not address or provide interventions for R8's adverse symptoms of abdominal pain, hiccupping and burping and does not address or provide any interventions regarding the repeated clogging of R8's J-tube. This care plan does not have any goals related to R8's [DEVICE] and J-tube. The Nutritional risk assessment completed by the Registered dietitian on 01/11/11 addresses that R8 is at nutritional risk due to a 12.4 % weight loss while in the hospital prior to admission, low [MEDICATION NAME], hemoglobin, and hematocrit. The registered dietitian's note dated 02/24/11 addresses that R8's tube feeding was reduced to 35 cc/hour and recommended to gradually raise the tube feedings by 20 cc until tube feeding was returned to 75 cc/hour. Registered Dietitian's note dated 03/09/11 states that per nurse R8 is tolerating tube feeding well. There is no further Registered Dietitian's note after 03/09/11 and no documentation that the Registered Dietitian was notified or consulted regarding R8's abdominal pain, hiccupping, burping and nausea. On 04/22/11 at 3:00 p.m., E1 (Administrator) stated that the facility had recently had changed their consulting Registered Dietitian. The facility policy for Feeding tubes/ Jejunostomy Tubes dated 01/01/2001 under Medications instructs nurses to flush the tube with 30 cc of water, administer medication, flush with 15 cc of water between each medication unless contraindicated and if the resident has a G/J tube to follow specific orders as indicated by the MD. R8's physician orders [REDACTED]. Review of R8's April 2011 Medication Administration Records and Treatment records do not include any documentation of water flushes prior to, after or between medication administration. The intake and output record dated 04/11/11 - 04/18/11 does not provide a separation of flushes for J-tube from the [DEVICE] and both are calculated together under flushes. On 04/12/11 11-7 and 3-11 shifts documented 230 cc. There is no documentation entered for day shift. On 04/13/11 all shifts, 04/14/11 days and second shifts, 04/16/11 and 04/17/11 third and second shifts, and 04/18/11 days and second shifts, nurses documented 230 cc total water flush for the shift. 04/15/11 is omitted from the form. The ordered 100 cc water flush via J- tube would equal 200 cc per shift and the 30 cc every eight hour [DEVICE] flush would bring the shift total to 230 cc. When nurses documented a total of 230 cc water flush, this amount could not include any additional flushes with medication administration. A fax note dated 03/15/11 states "please clarify feedings to be delivered via J-tube and all medications via [DEVICE]. Is this correct?" The physician's response is "correct" The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"All meds thru [DEVICE]." This same Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses have signed that they have administered [MEDICATION NAME] 50 milligrams without indicating what route was used. On 04/19/11 at approximately 10:30 a.m., E15 (Registered Nurse) stated that after being hospitalized last month, all of R8's medication was to be through her [DEVICE] and all feedings through her J-tube. E15 reviewed R8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E15 said that she had talked with the emergency room staff and charted that all medication should be only per [DEVICE], and that R8 had a previous abdominal abscess. E15 also confirmed that the Medical Administration Record and treatment records do not include any documentation of water flushes with medication administration. E15 stated that 30 cc of water should be flushed through G - tube prior to medication, 15 cc between medicines, and 30 cc after last medication. E15 did not know why R8's medication record did not include documentation of water flushes with medication. On 04/21/11 at 3:30 p.m., E2 (Director of Nurses) confirmed that there has been confusion over R8's G and J tubes and orders. E2 verified that the orders should be specific and water flushes with medications should be performed be facility policy and included on the medication administration record. On 04/26/11 at 9:05 a.m., Z4 (physician) stated that all of R8's feedings should be through the J-tube and all medications through the [DEVICE]. Z4 stated this has never changed and should have been that way since day 1 (admission). Z4 stated that he was aware that there was some confusion about the administration of R8's feedings and medication and this led to some of R8's problems and tube clogging. Z4 said that water flushes should be done prior to and after medication administration, that it is standard practice. Z4 stated he was not aware that 2 packets of sugar had been poured into R8's J-tube on 2/26/11 for blood sugar of 65. Z4 stated he did not order this and would not have advised it.