Every finding on record at Souris Valley Care Center

Based on record review, review of the facility reported incident (FRI), review of facility policy, and resident and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 supplemental resident (Resident #27) who displayed physical behaviors towards another resident. Failure to protect Resident #31 from physical abuse may have resulted in pain or injury and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings include:Review of the facility policy titled Abuse and Neglect occurred on 06/11/26. This policy, dated 04/07/25, stated, . The resident/client has the right to be free from abuse . Residents/clients must not be subjected to abuse by anyone, including . other residents/clients . Procedure: . If it is an allegation of resident/client to resident/client abuse, the residents/clients will be separated immediately and both ensured a safe environment.The surveyor determined a deficient practice existed on 06/07/26 when Resident #27 slapped Resident #31's face. The facility immediately implemented corrective action and completed it on 06/08/26.-Review of Resident #31's medical record occurred on 06/11/26. Diagnoses included dementia and anxiety. The current care plan stated, The resident has impaired cognitive function or impaired thought processes R/T [related to] Dementia E/B [evidenced by] Confusion, wandering, talking to dolls, stuffed cats and bear, as if real.Cue, reorient and supervise as needed.-Review of Resident #27's medical record occurred on 06/11/26. Diagnoses included early onset Alzheimer's disease. A Brief Interview for Mental Status (BIMS), completed on 04/10/26, identified a score of 9, indicating moderately impaired cognition. Resident #27's current care plan stated, . The resident has a behavior symptom R/T dementia E/B being rude towards staff, pulling roommates privacy curtain while staff are doing cares. Inappropriate touching, altercations with other residents . Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident may at times strike out during altercations. If reasonable, discuss resident's behavior. Explain/reinforce to resident why behavior is inappropriate and/or unacceptable. Minimize potential of resident behavior problems by modifying environmental factors and daily routine redirecting resident to avoid potential conflict. The initial FRI report stated at approximately 11 a.m. on 06/07/26, Resident [#27] was annoyed that resident [#31] had put her own eye glasses on her therapy cat. Words were exchanged between the two residents and then resident [#27] apparently slapped [Resident #31] on the right check [sic]. There was no injury noted on resident [#31]. Nurse interviewed the resident involved and neither [Resident #27] or [Resident #31] could recall the encounter. Residents were separated immediately. Staff will monitor the two residents involved. Monitor resident [#31] for any injury. Proper notifications were completed.The final investigation stated, . In reviewing camera footage from the event, resident [#27] had reached for the eyes [sic] glasses that resident [#31] had put on the therapy cat. [Resident #31] pulled the eye glasses away when [Resident #27] reached for them. There was a short verbal encounter. Resident [#27] with her left hand made open hand contact with the right check [sic] of [Resident #31]. The residents were immediately separated. There was no visible injury or negative psychosocial outcome from this event. Either resident didn't remember the incident occurring when the charge nurse visited with the residents after the encounter occurred. Facility will monitor residents to ensure the safety of all residents.During an interview on 06/11/2026 at 1:26 p.m., when asked, Resident #27 stated she does not remember slapping anyone on Sunday (June 7, 2026), but her son told her she was involved in something with another lady a few days ago. The resident stated her memory was so bad, she didn't remember things and asked if she was in trouble. During an interview on 06/11/2026 at 1:31 p.m., an administrative nurse (#2) stated on Sunday (June 7, 2026), staff called and informed her and the Administrator of an incident. The staff reported the incident to the staff on the next shift and informed them to keep the residents separated. After the incident, staff monitored the residents, kept them part, and made sure they felt safe. The administrative nurse stated she asked both residents about the incident, neither remembered it, and Resident #31 showed no fear. The administrative nurse stated the facility recently held an all-staff meeting in April and provided abuse and neglect education, conducted scenarios with questions/answers, and had a power point presentation. The facility printed the information for the staff who were unable to attend in person. During an interview on 06/11/2026 at 1:46 p.m., when asked, Resident #31 stated her first name, then responded with nonsensical statements to further questions. Finally, when asked if anyone slapped her recently, she replied no. During an interview on 06/11/2026 at 1:55 PM, an administrative staff member (#3) stated staff followed the policy as they intervened in the altercation immediately, kept the two residents separated, reported the incident immediately, and assessed Resident #27.Based on the following information, non-compliance at F0600 is considered past non-compliance. The facility implemented corrective actions for the residents affected by the deficient practice as follows: *Staff immediately intervened, separated the residents, and assessed for injury.*Notified the Administrator and the Director of Nursing and reported the incident to the State.*Informed staff on upcoming shifts to ensure staff continue to monitor the residents.*Reviewed the camera footage and interviewed the residents.*Notified families and providers.*Reviewed and updated the residents' care plans.

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 12 sampled residents (Residents #3, #24, and #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: -Observation on all days of survey showed a pressure reducing mattress on Resident #3's bed. Review of Resident #3's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], failed to identify a pressure reducing device for the bed. During an interview on 06/11/26 at 9:16 a.m., an administrative nurse (#1) confirmed staff coded the quarterly MDS incorrectly, and resident does have a pressure reducing device for the bed. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2025, pages P-2 and P-5, stated, . P0100. Physical Restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . A. Bed rail . Code 0, not used: if the item was not used during the 7-day look-back period or it was used but did not meet the definition. - Review of Resident #24's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified bed rail used daily. Observation throughout the survey showed bilateral positioning bed rails on Resident #24's bed. The Physical Device and/or Restraint Evaluation and Review, dated 3/31/26, determined the resident used assist bars for independent bed mobility and were not restraints. During an interview on 06/09/26 at 4:57 p.m., an administrative nurse (#1) confirmed staff coded Resident's #24's quarterly MDS incorrectly for physical restraints. -Review of Resident #33's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified bed rails used daily. Observation on 06/09/26 at 4:24 p.m. showed bilateral assist bars on Resident #33's bed. The Physical Device and/or Restraint Evaluation and Review, dated 04/29/26, determined the assist/grab bar(s) were not restraints. During an interview on 06/09/26 at 4:25 p.m., Resident #33 confirmed using the assist/grab bars to reposition or get out of bed. Resident #33 denied the bars restrained movement.

Based on record review, review of facility policy, and resident and staff interviews, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 12 sampled residents (Resident #2 and #34). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.Findings include: Review of the facility policy titled Care Plan occurred on 06/10/26. This policy, revised 12/01/25, stated, . This plan of care will be modified to reflect the care currently required/provided for the resident . Review of the facility policy titled Trauma Informed Care occurred on 06/10/26. This policy, revised 12/31/25, stated, . PROCEDURE. Individualize Care Plan interventions to avoid re-traumatization . -Review of Resident #2's medical record occurred on all days of survey. Diagnoses included chronic embolism and thrombosis of deep veins of right lower extremity. Current physician's orders included Apixaban (an anticoagulant). Progress notes identified a hospitalization in April of 2026 for an upper GI (gastrointestinal) bleed. The facility failed to revise and update Resident #2's care plan to reflect problems and interventions related to anticoagulant use. During an interview on 06/10/26 at 1:26 p.m., an administrative nurse (#2) confirmed the facility failed to update Resident #2's care plan. -Review of Resident #34's medical records occurred on all days of survey. Diagnoses included depression and generalized anxiety. Current physician's orders included an antidepressant medication daily for generalized anxiety and depression. A trauma assessment, dated 03/17/26, identified Resident #34 experienced trauma from the death of her son. The assessment indicated the resident experienced nightmares, avoided situations that reminded her of the event(s), constantly on guard, watchful or easily startled, felt numb or detached from people, activities, or surroundings, and felt guilty or unable to stop blaming herself for the event(s). The assessment further identified heart palpitations, headaches, shortness of breath, changes in sleep patterns, sleep disturbances, pain, difficulty with movement, and changes in appetite when relieving a traumatic experience. The assessment identified playing games on phone as an intervention that is a helpful coping strategy. The current care plan lacked a problem, goals, or interventions related to Resident #34's trauma history and trauma-related symptoms. During an interview on 06/08/26 at 12:39 p.m., Resident #34 became tearful and visibly upset while discussing her son who had passed away and stated the facility was aware of her son's death.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure adequate monitoring for 2 of 5 residents (Resident #2 and #32) reviewed for psychotropic medications. Failure to complete a baseline assessment before starting an antipsychotic and periodically while on the medication may result in undetected side effects and adverse consequences related to the antipsychotic medication.Findings include:Review of the facility policy titled Psychotropic Medications occurred on 06/10/26. This policy, revised 12/09/25, stated, . If the physician prescribes an antipsychotic for the resident . If a resident is admitted on psychotropic medications or returns from hospitalization on new psychotropic medications . a registered nurse must complete the Abnormal Involuntary Movement Scale [AIMS]. Throughout the administration of psychotropic medication, the following must be completed. the Abnormal Involuntary Movement Scale [AIMS]. every six months.-Review of Resident #2's medical record occurred on all days of survey and identified an admission date of 12/02/25. Physician's orders included Quetiapine (an antipsychotic) started prior to admission. The record lacked a baseline assessment or an AIMS for the use of the antipsychotic medication.-Review of Resident #32's medical record occurred on all days of survey. Physician's orders included Risperidone (an antipsychotic) initiated on 05/28/26. The record lacked a baseline assessment or an AIMS for the use of the antipsychotic medication.During an interview on 06/10/26 at 1:26 p.m., an administrative staff member (#2) stated the facility failed to complete AIMS assessments for Resident #2 and #32 on antipsychotics.

Based on record review, review of facility policy, review of professional standards, and staff interview, the facility failed to ensure residents remained free of significant medication errors for 1 of 1 sampled resident (Resident #32) with a significant medication error. Failure to administer medication and monitor lab results according to physician's orders may inhibit the effectiveness of the medications and cause subtherapeutic levels.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, pages 838-851, stated, . Obtain the appropriate medication. Compare the label of the medication container or unit-dose package against the order on the MAR [medication administration record] or computer printout. Rationale: This is a safety check to ensure that the right medication is given. If these are not identical, recheck the prescriber's written order in the client's chart. Prepare the medication. While preparing the medication, recheck each prepared drug and container with the MAR again. Rationale: This second safety check reduces the chance of error . Perform appropriate assessments (e.g. laboratory results) specific to the medication . Review of the facility policy titled Medication Errors occurred on 06/11/26. This policy, revised 03/02/26, stated, . Medication Error. administration of medications . which are not in accordance with the prescriber's order. Amount . When the resident receives an amount of medication that is greater than or less than the amount ordered by the prescriber. Review of Resident #32's record occurred on all days of survey. Diagnoses included hypothyroidism (underactive thyroid gland). A provider's order, dated 01/08/26, identified levothyroxine (thyroid medication) 137 microgram (mcg) by mouth once daily, and lab work in two months to check the resident's thyroid-stimulating hormone (TSH). Review of Resident #32's nurses' notes identified the following:*02/22/26 at 4:23 p.m., . went to give resident her am Levothyroxine . noted that the dose was incorrect on the medication card in the med cart . the dose was changed on 01/08/26, dose was not given this am, unsure how long the incorrect dose was given as the medication cards are dated 01/21/26 and 02/05/26 . Resident's condition . no change noted. Dose Given: 125 mcg *02/23/26 at 5:19 p.m., Communication/Visit with Physician . orders received and observed per [physician] to continue levothyroxzine [sic] at 137 mcg po once daily, cancel tsh for 03/04/26, and move to mid [middle of] april [sic] 2026 instead. The medical record lacked documentation of a TSH level in mid-April, as ordered. During an interview on 06/11/26 at 12:44 p.m., an administrative staff member (#2) confirmed the facility failed to collect a TSH level for Resident #32 in mid-April as ordered after the med error was corrected. Resident #32 received 45 doses of levothyroxine at the wrong dose before facility staff realized the error and failed to obtain a TSH level as ordered by the provider.

Based on review of the facility reported incident (FRI) investigation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remain free from abuse for 1 of 5 sampled residents (Resident #2) who was subjected to physical abuse by another resident. Failure to ensure the facility had processes in place to meet the needs of residents resulted in a bruise to Resident #2's face and placed all residents at risk for physical harm, pain, mental anguish, and emotional distress.Findings include:Review of the facility policy titled Abuse and Neglect occurred on 04/08/26. This policy, dated 04/07/25, stated, . The resident/client has the right to be free from abuse, neglect . Residents/clients must not be subjected to abuse by anyone, including, but not limited to . other resident/clients. Review of the facility's initial FRI investigation, dated 03/20/26, stated, . Male resident became upset with female resident's vocalizations. Male resident told female resident to shut up and female resident told male resident to shut up. Male resident then slapped female resident on the cheek. Staff members immediately intervened and separated the residents. Staff are monitoring residents to ensure safety. Female resident doesn't remember the incident and does not appear to be impacted by the incident. A witness interview, dated 03/26/26, stated, [Medication aide] was passing medications at the time when she heard [Resident #1] tell the resident to 'shut up' and then [Resident #2] told him to shut up. [Resident #1] slapped her on the cheek.Review of Resident #1's medical record occurred on 04/08/26. Diagnoses included unspecified dementia, anxiety, and depressive disorder. The care plan stated, . The resident has impaired cognitive function impaired thought process R/T [related to] confusion E/B [evidenced by] poor recall, mixing up days and nights. Confusion, and poor recall. Interventions: resident understands consistent, simple, direct sentences. Provide resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed. Redirect reassure as needed.Review of Resident #1 nursing progress notes identified the following:* 03/20/26 at 8:08 p.m. on passing the other resident he told her to shut up and slapped her on her rt [right] cheek we pulled him away and put him in a safe place. * 03/21/26 at 3:55 p.m. call placed to [name of guardian] made aware that resident had slapped another resident last pm.* 03/23/2026 at 4:32 p.m. Resident to resident physical contact made - Date and time of event: 03/20/26 6:45 PM - Fractural account of what happened: Resident was yelling and calling out help me, Resident told resident to shut up, Resident then told resident to shut up. Resident B struck resident across her face on the right slide. CNAs saw what was happening and separated both residents and removed them to a safe place. Resident's condition after event: Resident quickly returned to baseline .Immediate intervention & education: Separated residents, educated them that this was inappropriate behavior. Review of Resident #2 medical record occurred on 04/08/26. Diagnoses included Alzheimer's disease and anxiety.Review of Resident #2's nursing progress notes identified the following: 03/20/26 at 8:10 p.m., resident was yelling help as per usual behavior the other resident told her to shut up and slapped her on her rt [right] cheek on passing her [sic] both resident [sic] were parted and taken to safe places 03/21/26 at 3:15 p.m., Resident to resident physical contact made- Date and Time of Event: 03/20/2026 6:45 p.m. - Factual account of what happened: small round bruise, size of a dime noted under right eye, bruise lines up with bottom of her glasses, denies pain. During an interview on 04/08/26 at 12:20 p.m., an administrative staff member (#1) stated this incident occurred only once and Resident #2's bruise resolved without issue.During an interview on the afternoon of 04/08/26, Resident #1 denied any concerns or issues with other residents, he denied being hit by anyone, and denied hitting any other residents.The facility failed to protect Resident #2 from physical abuse.

Based on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician for 1 of 1 sampled resident (Resident #3) reviewed for falls. Failure to notify the resident's physician of changes in condition promptly may prevent the physician from altering treatment/care.Findings include:Review of the facility policy titled Fall Prevention and Management occurred on 12/17/25. This policy, revised 10/14/25, stated, . For residents with suspected head injury, physicians should be notified by phone and not fax.Review of Resident #3's medical record occurred on 12/17/25. Diagnoses included Alzheimer's disease, dementia, and repeated falls. A care plan review, dated 09/29/25, identified falls, and gait/balance problems.Review of Resident #3's progress notes identified the following:* 12/06/25 at 6:40 a.m., Safety Event. Resident came up to the nursing station and stated, 'I fell in my room and hit my head and I have another knot on the back of my head.' She stated that 'He' helped her back to bed. Upon writer's assessment, resident was found to have a knot with bruising to the rt. [right] back of her head . Fax sent to Dr. [Doctor].* 12/06/25 at 2:07 p.m., Communication/Visit with Physician. notified by email . All neuro's [neurological] and VS [vital signs] have been stable.* 12/09/25 at 3:06 p.m., Communication/Visit with Physician . resident has had eight falls since 10-7-2025, six of them have been since 11-20-2025.During an interview the afternoon of 12/17/25, an administrative staff member (#1) confirmed the facility failed to notify Resident #3's physician by phone regarding a head injury 12/06/25.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 1 of 9 sampled residents (Resident #2). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include:Review of the facility policy titled Care Plan occurred on 12/17/25. This policy, dated December 1, 2025, stated, . Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, . needs.The interdisciplinary team will review care plans at least quarterly. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition.Review of Resident #2's care plan, revised 11/01/24, identified assistance of one staff member required for bed mobility, positioning up in bed, turning from side to side, oral care, dressing, and transfers between surfaces, and assistance of two staff members required to move from lying to sitting and sitting to lying positions. Resident #2's Minimum Data Set (MDS), dated [DATE], identified no impairment of the upper and lower extremity, independent with oral hygiene, dressing upper and lower body, bed mobility, sitting to standing, toilet transfers, and wheelchair mobility.The facility failed to update Resident #2's care plan for an improvement in physical mobility and ADL status.During an interview on 12/17/25 at 2:50 p.m. an administrative staff member (#1) confirmed facility staff failed to update Resident #2's care plan to reflect her current functional ability.

Based on observation, record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide appropriate supervision and use of assistive devices for 2 of 2 sampled residents (Resident #1 and #2) who required staff assistance while bathing. Failure to utilize the bath chair safety strap during bathing resulted in a fall with a fracture for Resident #1 and placed all residents at risk of accidents, falls, and/or injuries. During the on-site FRI investigation, the survey team determined noncompliance with regulatory requirements existed on 11/11/25 when facility staff failed to utilize the bath chair safety strap resulting in a fall/fracture.*On 11/18/25 at 2:03 p.m. the survey team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 11/11/25. *On 11/18/25 at 3:00 p.m., The survey team notified the administrator and the director of nursing (DON) of the IJ situation, provided the IJ template and requested a plan for removal of the immediate jeopardy.*On 11/18/25 at 5:35 p.m., The facility provided an IJ removal plan.*On 11/19/25 at 8:20 a.m., The SSA reviewed and accepted the IJ removal plan.The removal plan contained the following:*Signage posted in the bath area as a reminder to staff to use the safety belt at all times when using the bath chair.*Education was provided through video, on-shift messaging, and in-person training on the proper use of the safety belt while caring for a resident in the bath chair to prevent injury, with the staff members directly involved with the deficient practice, all nursing staff on duty, and on-coming staff.*On 11/20/25 at 2:00 p.m., The survey team verified the implementation of the removal plan. The deficient practice remained at a G scope and severity following the removal of the IJ.Findings includeReview of the facility policy titled Bathing occurred on 11/18/25. This policy, dated 08/29/25, stated, . PURPOSE . To promote safety for the resident in the bath . The use of safety measures and equipment are designed to reduce the risk of injury to residents during a bathing experience. PROCEDURE Tub (whirlpool) . Bathing . Use appropriate safety measures and equipment to prevent accidents. Safety belts are used for bathing units . and bathing lifts.Review of the FRI, submitted to the SSA on 11/12/25, identified Resident #1 fell from the bath chair and sustained a left femoral neck (hip) fracture on 11/11/25. - Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, . Impaired balance, Limited mobility and weakness. BATHING: Resident requires x1 [assist of one] staff assist . TRANSFER: Transfer - Between Surfaces: pivot x2 [assist of two] with gait belt.A physician's progress note, dated 11/11/25, stated, . fell when she had gotten out of the shower earlier today. Initially started having left hip pain. Impression and plan multiple falls . Fracture of femoral neck, left . admitting .During an interview on 11/18/25 at 11:12 a.m., a certified nurse aide (CNA) (#4) stated during Resident #1's bath on 11/11/25, she did not have the resident secured in the bath chair with the safety strap, and When I had finished her bath and was going to get her dried off and dressed she [Resident #1] reached for the door on the tub and fell out of the tub chair. When asked how the resident was transferred from the bath chair to the wheelchair the CNA (#4) stated, With the sit-to-stand lift.During an interview on 11/18/25 at 12:10 p.m., a CNA (#6) stated, [CNA (#4)] called for help on the walkie. I went in right away and [Resident #1] was wet, crawling on all fours and trying to get back into the tub. I asked her if she was ok and she said 'Get me off the floor I'm cold.' We waited for help to come and after no one came to help us we called again and no one came. We waited for help for 10-15 minutes and then we used the hoyer lift to get [Resident #1] off the floor into the bath chair. I asked her if she had any pain and she said 'No.' [CNA (#4)] put the lap belt on her and I left to get the nurse. During an interview on 11/18/25 at 12:25 p.m., a staff nurse (#5) stated, At 1:20 p.m., I saw the tub room light on and I went in there to do a skin check. [Resident #1] was in the bath chair without the belt on. This interview conflicts with the CNA (#4's) statement that she applied the belt before leaving to get a nurse. Review of nursing progress notes identified the following:* 11/11/25 at 4:11 p.m., . resident had a fall from the bath chair at 1305 [1:05 p.m.], resident was able to move all extremities . * 11/11/25 at 6:43 p.m. [daughter's name] phones stating 'resident left hip is broken .* 11/17/25 at 4:53 p.m. Resident arrived today via [by] Nursing home van . Resident did have a fall and fx [fracture] (sic) her left hip. - Review of Resident #2's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified dependent on staff for assistance with bathing and substantial/maximum assistance with transferring in and out of the shower/tub. Observation on 11/18/25 at 1:38 p.m. showed Resident #2 seated in the whirlpool tub filled with water, bath chair safety strap behind the bath chair and not secured. When asked about the bath chair safety strap not being secured, the CNA (#3) stated, He [Resident #2] was sliding down in the chair so I took it off. I just remembered I had not put it back on. Facility staff failed to utilize the safety belt with whirlpool bathing for Residents #1 and #2 and failed to perform a nursing assessment prior to Resident #1 being moved/assisted off the floor following the fall. During an interview on 11/18/25 at 2:00 p.m., an administrative staff member (#1) stated she expected staff to secure the safety belt for all residents in the bath chair and staff should never remove the safety belt during a bath for any reason .

Based on information received from the facility reported incident (FRI), record review, and staff interviews, the facility failed to thoroughly investigate and document an alleged violation of neglect for 1 of 1 sampled resident (Resident #1) who fell from a bath chair. Failure to thoroughly investigate an incident of potential neglect may result in future neglect and or harm to other residents. Findings include:Review of the FRI, submitted to the state survey agency (SSA) on 11/12/25, identified Resident #1 fell from the bath chair and sustained a left femoral neck (hip) fracture on 11/11/25.A physician's progress note, dated 11/11/25, stated, . fell when she had gotten out of the shower earlier today. Initially started having left hip pain. Impression and plan multiple falls .Fracture of femoral neck, left . admitting .During an interview on 11/18/25 at 11:12 a.m., the certified nurse aide (CNA) (#4) stated during Resident #1's bath on 11/11/25, she did not have the resident secured in the bath chair with the safety strap, and, When I had finished her bath and was going to get her dried off and dressed she [Resident #1] reached for the door on the tub and fell out of the tub chair. I called for help on my walkie and [CNA (#6)] came to help me. She got the hoyer [mechanical lift] and we transferred her [Resident #1] from the floor back to the bath chair. Then the nurse came in and checked [Resident #1] and did vitals and left the room. After that I called for help to transfer [Resident #1] from the tub chair to her wheelchair. When asked how the resident was transferred from the bath chair to the wheelchair the CNA (#4) stated, With the sit-to-stand lift.During an interview on 11/18/25 at 12:10 p.m., the CNA (#6) stated, [CNA (#4)] called for help on walkie. I went in right away and [Resident #1] was wet, crawling on all fours and trying to get back into the tub. I asked her [Resident #1] if she was ok and she said, 'Get me off the floor I'm cold.' We waited for help to come and after no one came to help us we called again and no one came. We waited for help for 10-15 minutes and then we used the hoyer lift to get [Resident #1] off the floor into the bath chair. I asked her if she had any pain and she said 'No.' [CNA (#4)] put a lap belt on her and I left to get the nurse. During an interview on 11/18/25 at 12:25 p.m., a nurse (#5) stated, At 1:20 p.m. I saw the tub room light on and I went in there to do a skin check. [Resident #1] was in the bath chair without the belt on and I noticed a hoyer lift sheet underneath her. I pointed to it and shrugged my shoulders and then [CNA (#4)] said, 'Did they tell you she fell.' [Resident #1] said she had no pain and moved her legs and arms without any concerns and then I left the tub room. Review of nursing progress notes identified the following:* 11/11/25 at 4:11 p.m., . resident had a fall from the bath chair at 1305 [1:05 p.m.], resident was able to move all extremities per her usual with skin check, when [daughter's name] comes to facility at 1400 [2:00 p.m.], she sits with resident to help her play bingo, resident then states 'she is having lots of pain,' grabbing at her left hip . resident was taken to her room to lay down, call was placed to [doctor's name] at 1445 [2:45 p.m.], made aware of fall and pain, orders received and observed to send resident to the hospital forx-rays (sic) . ambulance here at 1530 [3:30 p.m.] .* 11/17/25 at 4:53 p.m. Resident arrived today via [by] Nursing home van .Review of the facility Investigation dated, 11/17/25, occurred on 11/18/25 and stated, . INVESTIGATION SUMMARY: The resident [Resident #1's] care planned as assist of 1 with bathing and assist of 1 with pivot transfers. On 11/11/2025, at approximately 1300 [1:00 p.m.], CNA . finished the resident's bath, pivot transferred into the bath chair. Prior to securing the lap belt to the bath chair, the resident grabbed onto the open door to the whirlpool and fell forward. CONCLUSION: At the conclusion of the investigation, the facility determined there was no willful intent to neglect as the resident . spontaneous movement of grabbing the open tub door prior to securing the bath chair belt, resulted in the fall.Upon request, the facility provided staff interviews related to the incident. The interviews identified the following:* On 11/13/2025, DNS [director of nursing services] interviewed [CNA (#4)] on what had transpired the day of the fall. [CNA (#4)] stated that she transferred the resident [Resident #1] in the bath chair, collected v/s [vital signs], and put the resident in the whirlpool. When [CNA (#4)] was finished, she tated (sic) she opened the whirlpool tub door, and [CNA (#4)] expressed that the resident [Resident #1] was reaching and attempting to grab onto things and that [CNA (#4)] was guiding her hands back to the bath chair bars to hold on to. [CNA (#4)] stated that when she was moving the resident out of the whirlpool tub, is when the resident [Resident #1] started reaching for the open tub door and was attempting to grab onto it. [CNA (#4)] stated that she was reaching too far and ended up on the floor. * On 11/13/2025, DNS interviewed [(CNA (#6)] in regards to the incident on 11/11/2025. [(CNA (#6)] stated that the resident [Resident #1] was on the floor and that the resident stated, 'get me off the floor. [CNA (#6)] stated she went and got a sling and a hoyer and her and [CNA (#4)] assisted the resident off the floor. DNS immediately educated [(CNA (#6)] on fall management and to never move the resident without a nurse assessing the resident first. * On 11/13/2025, DNS spoke with [nurse (#5)] in regards to the incident. DNS asked for a run through of what happened. [Nurse (#5)] asked what happened and [CNA (#4)] told her that the resident had fallen out of the bath chair and that they [CNA (#4) and CNA (#6)] picked her up using the sling and hoyer.The facility's investigation failed to include specific details discovered during staff interviews that would raise concerns of staff negligence resulting in Resident #1's fall and subsequent fracture.

Based on record review, review of facility policy, review of the facility reported incident (FRI) and investigation, and staff interviews, the staff failed to provide treatment and care in accordance with professional standards of practice to maintain residents' highest level of functioning for 1 of 1 sampled resident (Resident #1) who experienced a fall from the bath chair. Failure to ensure a licensed nurse performed a full-body assessment after a fall may have resulted in further injury and/or pain to the resident.Findings includeReview of the facility policy titled Fall Prevention and Management occurred on 11/18/25. This policy, dated 10/14/25, stated, . For Fallen Resident . Procedure 1. Do not move resident. Stay with the resident and summon the licensed nurse . A nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident. Do not attempt to move the resident if . hip fracture is suspected.Review of the FRI, submitted to the state survey agency (SSA) on 11/12/25, identified Resident #1 fell from the bath chair and sustained a left femoral neck (hip) fracture on 11/11/25. Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, . I have an ADL [activities of daily living] self-care performance deficit R/T [related to] . Dementia, Impaired balance, Limited mobility and weakness. TRANSFER: Transfer - Between Surfaces: pivot x2 [assist of two] with gait belt.A physician's progress note, dated 11/11/25, stated, . fell when she had gotten out of the shower earlier today. Initially started having left hip pain. Impression and plan multiple falls . Fracture of femoral neck, left . admitting .During an interview on 11/18/25 at 11:12 a.m., a certified nurse aide (CNA) (#4) stated, during Resident #1's bath on 11/11/25 she did not have the resident secured in the bath chair with the safety strap, and When I had finished her bath and was going to get her dried off and dressed she [Resident #1] reached for the door on the tub and fell out of the tub chair. I called for help on my walkie and [CNA (#6)] came to help me. She got the hoyer [mechanical lift] and we transferred her [Resident #1] from the floor back to the bath chair. Then the nurse came in and checked [Resident #1] and did vitals and left the room. After that I called for help to transfer [Resident #1] from the tub chair to her wheelchair. When asked how the resident was transferred from the bath chair to the wheelchair the CNA (#4) stated, With the sit-to-stand lift.During an interview on 11/18/25 at 12:10 p.m., a CNA (#6) stated, [CNA (#4)] called for help on the walkie. I went in right away and [Resident #1] was wet, crawling on all fours and trying to get back into the tub. I asked her if she was ok and she said, 'Get me off the floor I'm cold.' We waited for help to come and after no one came to help us we called again, and no one came. We waited for help for 10-15 minutes and then we used the hoyer lift to get [Resident #1] off the floor into the bath chair. I asked her if she had any pain and she said 'No.' [CNA (#4)] put the lap belt on her and I left to get the nurse. During an interview on 11/18/25 at 12:25 p.m., a nurse (#5) stated, At 1:20 p.m. I saw the tub room light on, and I went in there to do a skin check. [Resident #1] was in the bath chair without the belt on and I noticed a hoyer lift sheet underneath her, I pointed to it and shrugged my shoulders and then [CNA (#4)] said, 'Did they tell you she fell.' [Resident #1] said she had no pain and moved her legs and arms without any concerns and then I left the tub room. Facility staff failed to complete a nursing assessment to evaluate potential injury or determine an appropriate transfer method prior to assisting the resident from the floor. Following bathing, staff utilized a sit-to-stand lift that was neither included in the resident's care plan nor assessed as a safe transfer option for Resident #1. These lapses may have contributed to additional injury and pain for the resident.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 1 of 1 sampled resident (Resident #18) with Multi-Resistant Staph Aureus (MRSA) (a type of contagious infection resistant to antibiotics) in a wound. Failure to follow infection control practices related to location of a dressing change and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/21/25 at 3:55 p.m. The IJ was identified when a staff nurse performed a dressing change in the medication room and failed to wear Personal Protective Equipment (PPE) (a gown). This finding placed all residents, staff, and visitors at risk for infection and/or spread of infection. *04/22/25 at 10:00 a.m., the survey team notified the administrator and director of nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. *04/22/25 at 1:45 p.m., the survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: *Facility issued a directive that the nurse's station (medication room) must not be used for wound care. *The nurse's station (medication room) was deep cleaned. *All residents with wounds will have their wound treatments completed in the resident's room with proper PPE. *1:1 education provided to the staff nurse who performed the wound care regarding appropriate location to perform wound care, the standards of EBP, and the correct use of PPE. *Educated all staff on proper use of PPE and guidelines of EBP. This training was conducted via On Shift (all employee text message) and in person to staff on duty or prior to next scheduled shift. *04/22/25 at 2:20 p.m., the survey team verified the implementation of the removal plan and the IJ removal. The deficient practice remained at an D scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Multidrug-Resistant Organisms, MRSA . occurred on 04/24/25. This policy, dated April 2024, stated, . Residents colonized with a CDC [Centers for Disease Control] targeted MDRO [Multi Drug Resistant Organism] and select epidemiologically important MDROs at the facilities discretion are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Summary of PPE Use . Enhanced Barrier Precautions . Applies to: All residents with any of the following: Wounds . Infection or colonization with a novel or targeted MDRO . PPE used for these situations: During high-contact resident care activities: Wound care: any skin opening requiring a dressing . Required PPE: Gloves and gown prior to the high-contact care activity . Face protection may also be needed if performing activity with risk of splash or spray . Review of the facility policy titled Enhanced Barrier and Transmission-Based Precautions occurred on 04/24/25. This policy, dated April 2025, stated, . Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer for multi drug-resistant organisms (MDROs) to staff hands and clothing. Enhanced barrier precautions are used for residents who are infected or colonized with a CDC-targeted MDRO . Review of the facility policy titled Personal Protective Equipment PPE . occurred on 04/24/25. This policy, dated January 2025, stated, . Wear a gown for direct resident/patient contact if the resident/patient is on Enhanced Barrier Precautions. to protect clothing from potential contamination. Review of the facility policy titled Wound Dressing Change occurred on 04/24/25. This policy, dated November 2024, stated, . Follow EBP (wash hands before entering and exiting the room, wear gloves and gown). Review of Resident #18's medical record occurred on all days of survey. Diagnoses identified chronic osteomyelitis (a bone infection) to the left ankle and foot, MRSA, and group B streptococcus (a type of bacterial infection). Physician's orders included Betadine (an antiseptic solution cleanser used to prevent the growth of and kill bacteria), wet to dry dressings to the wound on the left great toe, and Doxycycline (an antibiotic medication) daily for 14 days for MRSA. The current care plan stated . I require Enhanced Barrier Precautions (EBP) R/T [related to] open wounds, MRSA, & Strep B . wound to left toe . Observation on 04/21/25 at 3:55 p.m. showed a nurse (#12), with gloved hands, performed a dressing change to Resident #18's MRSA infected left great toe in the medication room. The resident's left foot rested on a disposable pad on the floor, and the soiled dressing, removed from the resident's foot by the nurse, also on the pad. Observation showed a spray bottle of wound cleanser nearby. At 4:05 p.m., Resident #18 exited the medication room and the nurse (#12) stated the dressing change should have been completed in the resident's room and not the medication room as the resident is on EBP. The staff nurse (#12) failed to complete the dressing change in the resident's room and failed to wear the appropriate PPE prior to completing the dressing change. During an interview on 04/22/25 at 10:00 a.m., an administrative nurse (#2) confirmed the medication room is considered a clean space. At 2:20 p.m., an administrative staff member stated he/she expected facility staff to perform procedures in the resident's room and wear appropriate PPE.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 4 of 13 sampled residents (Residents #3, #13, #28, and #189). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2024, pages I-5 and I-8, stated, . Active Diagnoses in the Last 7 Days - Check all that apply . Coding Instructions: Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status . medical treatments . during the 7-day look-back period . Review of Resident #189's medical record occurred on all days of survey. Medications included Buspirone (an anti-anxiety) and Sertraline (an antidepressant). The admission MDS dated [DATE], showed the facility failed to include the diagnoses of anxiety and depression. SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, page M-2 stated, . M01001 . Check A if resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence . Review of Resident #13's medical record occurred on all days of survey. Diagnoses identified Stage 1 and Stage 2 pressure ulcers on the buttocks. The quarterly MDS, dated [DATE], showed the facility failed to code the presence of pressure ulcers. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-1 to N-3 and N-7 stated, . N0300: Injections . Record the number of days that any type of injection (e.g., subcutaneous, intramuscular, or intradermal) was received . N0350: Insulin . A. Insulin injections - Record the number of days that insulin injections were received . B. Orders for insulin - Record the number of days the physician . changed the resident's insulin orders . N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the resident at any time during the 7-day look-back period . - Review of Resident #3's medical record occurred on all days of survey. The physician's orders identified Abilify (an antipsychotic medication). The quarterly MDS, dated [DATE], showed the facility failed to code the antipsychotic. - Review of Resident #28's medical record occurred on all day of survey. A physician's order, dated 06/24/24, identified Ozempic (an injectable non-insulin hypoglycemic medication) subcutaneously weekly. The significant change MDS, dated [DATE], showed facility the facility failed to code the Ozempic injection. A quarterly MDS, dated [DATE], showed the facility coded one insulin injection and one insulin order during the look back period, even though the resident received no insulin. During interviews on 04/24/25, an administrative nurse (#2) confirmed staff coded Resident's #3, #13, #28, and #189's MDSs incorrectly. 45873 46964

Based on observation, record review, review of the facility reported incident (FRI), review of the facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and proper use of assistive devices to prevent accidents for 1 of 2 sampled residents (Resident #13) and 4 supplemental residents (Residents #7, #12, #23, and #30) observed during full body mechanical lift (Hoyer) transfers. Failure to ensure staff use a mechanical lift properly placed residents at risk of serious injury from falls. Findings include: Review of the facility policy titled Safe Resident Handling Program (SRHP) occurred on 04/24/25. This policy, dated 12/23/24, stated, . The Safe Resident Handling Program (SRHP) is a loss prevention program that has proven to reduce negative outcomes related to resident injuries . Will perform a TIME OUT safety stop while the resident is in a sling or harness and still over the surface of the bed or chair to ensure that all straps are secure before moving away from the surface. This is to be completed once the straps are taut, but before the resident leaves a surface. [NAME] a resident's weight is supported by a solid surface, such as a bed, the loops on the slings are loose and can come off the lift. After raising the resident's weight up and off the support service [sic] and before moving the resident from the support surface, STOP, take a time out, and check/tug on each and every sling connection to be sure it is secure. Review of the FRI occurred on 04/21/25. The final report, dated 02/21/25, stated, . Resident was being transferred with a Hoyer lift with an assist of two staff when harness came off of hook and resident slipped out of the Hoyer sling with head resting on leg of it. Resident was assessed by nurse and no injuries were found. The right upper sling hook came off during transfer and resident slid out of sling to the floor, lying on her right side with her head resting on the leg of the total lift. A 'timeout' double check for proper sling hook placement was not performed prior to transfer. - Review of Resident #7's medical record occurred on all days of survey. The current care plan stated, . TRANSFER - Transfer Between Surfaces: Resident needs x2 [two staff] assist with hoyer and X [extra]-Large mesh sling. Observation on 04/21/25 at 1:48 p.m. showed two CNAs (#3 and #4) transferred Resident #7 from the wheelchair to the bed using a full body mechanical lift. After connecting the lift sling straps to the hooks on the lift, CNA (#3) raised the lift while CNA (#4) moved to the opposite side of the bed. The CNAs failed to perform a timeout to check the loops of the sling were securely connected to the lift before moving the resident from above the bed. - Review of Resident #12's medical record occurred on all days of survey. The current care plan stated, . TRANSFER - Transfer Between Surfaces: x2 staff assist with large high back sling and hoyer. Observation on 04/21/25 at 2:30 p.m. showed two CNAs (#9 and #11) transferred Resident #12 from the bed to the wheelchair using a full body mechanical lift. After connecting the lift sling straps to the hooks on the lift, CNA (#9) raised the lift while CNA (#11) moved to the opposite side of the bed. The CNAs failed to perform a timeout to check the loops of the sling were securely connected to the lift before moving the resident from above the bed. - Review of Resident #23's medical record occurred on all days of survey. The current care plan stated, . Transfer Between Surfaces: x2 assist with Hoyer lift w/ [with] medium sling . Observation on 04/21/25 at 1:26 p.m. showed two CNAs (#3 and #11) transferred Resident #23 from the wheelchair to the bed using a full body mechanical lift. After connecting the lift sling straps to the hooks on the lift, CNA (#11) raised the lift while CNA (#3) moved to the opposite side of the bed. The CNAs failed to perform a timeout to check the loops of the sling were securely connected to the lift before moving the resident from above the wheelchair. - Review of Resident #30's medical record occurred on all days of survey. The current care plan stated, . Transfer between surface: hoyer using large high back sling X2 staff assist . Observation on 04/21/25 at 12:53 p.m. showed two CNAs (#3 and #5) transferred Resident #30 from the wheelchair to the bed using a full body mechanical lift. After connecting the lift sling straps to the hooks on the lift, CNA (#5) raised the lift while CNA (#3) moved to the opposite side of the bed. The CNAs failed to perform a timeout to check the loops of the sling were securely connected to the lift before moving the resident from above the wheelchair. The staff failed to perform a timeout during full body mechanical lift transfers per education provided after a facility reported incident on 02/14/25. During an interview on 04/24/25 at 11:15 a.m., an administrative nurse (#2) stated she expected staff to perform a time out with every mechanical lift transfer. 46964

Based on observation, record review, review of facility policy and resident and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected resident's dignity and individuality for 1 of 9 sampled residents (Resident #7) who voiced concerns regarding sleep and toileting cares. Failure to honor Resident #7's choice for napping, bedtime, and toileting does not enhance the resident's quality of life and may result in decreased self-esteem, quality of life, and increased pain. Findings include: Review of the facility policy titled Resident Dignity occurred on 04/24/25. This policy, dated December 2024, stated, . PURPOSE . To maintain the dignity of all residents . To promote, encourage, support and enhance the residents' self-esteem . To promote a sense of self-worth . promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Review of Resident #7's medical record occurred on all days of survey. The current care plan stated, . I have . incontinence . TOILET USE: Resident is not toileted -Is checked and changed every 3 hours and PRN [as needed] . Resident requires x2 [2 staff] assist with check and change. TRANSFER-Transfer Between Surfaces: Resident needs x2 assist with hoyer [mechanical lift]. I have chronic pain/discomfort R/T [related to] osteoarthritis right knee and limited mobility. During an interview on 04/21/25 at 12:33 p.m., Resident #7 stated she would like to go to bed at 8:00 p.m. and must wait until 10:00 p.m. The resident stated staff tell her, Well we're busy, you have to wait. Observations on 04/21/25 identified the following: *12:53 p.m., a certified nurse aide (CNA) (#3) assisted Resident #7's roommate. Resident #7 stated to the CNA (#3), I'd like to lay down too. *1:04 p.m., the CNA (#3) finished assisting the roommate. Resident #7 stated, How about me? The CNA stated, I'll come back, I have a couple of things to do, and left the room. *1:30 p.m., Resident #7's call light on. *1:37 p.m., Resident #7's call light remained on. *1:41 p.m., a medication aide (MA) (#5) entered Resident #7's room and stated, Let me go finish my med pass. The MA turned off the call light and exited room. *1:42 p.m., Resident #7 turned the call light back on. *1:44 p.m., A staff member (#6) entered resident's room and asked, What do you need? The staff member turned the call light off, exited the room and spoke with a CNA (#3) in the hall. The CNA #3 stated, It's going to be a while. *1:47 p.m., Resident #7 turned the call light back on. *1:48 p.m., approximately 55 minutes from the first time Resident #7 requested to lay down, two CNAs (#3 and #4) brought the mechanical lift into Resident #7's room. CNA (#4) asked the resident, Are you ready to lay down? The resident stated, I was ready an hour ago, there's a mess in here and everything. Where have you been? A CNA (#3) stated, Busy helping people. The resident responded, What am I, Swiss cheese? They have to go find you to help me. You did all this for my roommate and then walked out. I'm supposed to be checked at 1 [1:00 p.m.], it's almost 2 [2:00 p.m.], you do this to me all the time. It hurts to sit here like this. I've been sitting here too long; I haven't been changed since 10:00 this morning. The two CNAs (#3 and #4) transferred the resident into bed, removed the wet brief, and performed perineal care. During an interview on 04/24/25 at 11:20 a.m., an administrative staff member (#2) stated she expected staff to answer call lights within 10 minutes and provide care as soon as possible.

Based on record review, review of the facility reported incident investigation, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 closed record (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hospitalization . This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 08/16/24. The facility implemented corrective action on 08/19/24 and completed staff education and began audits on 08/19/24. The final facility reported incident, dated 08/19/24 stated, . it was determined there was a transcription error on admission for the long-acting insulin dose. Instead of having an 8 PM scheduled long-acting insulin dose it was entered as an 8 AM dose. Review of Resident #1's medical record occurred on 08/27/24 and identified an admitted [DATE]. The physician's orders dated 08/16/24, stated, . Toujeo: [long-acting insulin] 7 units every day in the evening. Review of Resident #1's August 2024 medication administration record showed Toujeo 7 units in the morning. A nursing progress note, dated 08/17/24 at 8:48 a.m., stated: Resident blood sugar this morning was HI on our accucheck [sic] machine [device to check blood glucose] . PAtient [sic] given PRN [as needed] fiasp [rapid-acting insulin] as well as scheduled Fiasp. She came down to 475. At 0700 [7:00 a.m.] her vitals were 138/64 [blood pressure], 97.9 [temp], 121 [heart rate], 18 [pulse], 96% [oxygen saturation] RA [room air]. Resident now has a low-grade fever of 99.6 and she is vomiting brown bile. Resident's daughter, [name], called. She would like resident sent to ER [emergency room ] as well as resident requests to be seen by MD [medical doctor]. Dr [name] ordered to send to ER for evaluation. Review of Resident #1's hospital discharge notes from hospitalization on [DATE] - 08/19/24 identified a discharge diagnosis of diabetic ketoacidosis (a complication of diabetes in which acids build up in the blood), dehydration, and hyperglycemia (elevated blood sugar). During an interview on 08/27/24 at 2:00 p.m., an administrative nurse (#1) confirmed staff failed to administer Resident #1's long-acting insulin on the evening of 08/16/24. Based on the following information, noncompliance at F760 is considered past noncompliance. The facility implemented the corrective actions to ensure the deficient practice does not recur by: * The facility conducted an investigation on 08/19/24 with interviews of staff that determined the cause of the incident. Nursing staff failed to administer long-acting insulin as ordered due to a transcription error. * Provided 1 to 1 education on transcribing orders after the incident and on 08/19/24 with all nursing staff on insulin administration, blood glucose monitoring, and notification of change policy. Those not in attendance received education prior to start of their shift. * Suspended the nurse involved until the investigation was completed. * Reviewed medical records of all residents receiving insulin to ensure insulin administered at the appropriate time. * Implemented a secondary observer of management staff to review all new admission orders. * On 08/19/24 began audits on new admission orders, insulin administration, blood glucose monitoring, physician notification, and documentation of blood glucose parameters.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 5 sampled residents (Resident #35) who required staff assistance and a gait belt with transfers. Failure to provide adequate assistance and/or use the assistive devices appropriately during transfers placed the residents at risk for accidents, falls, and/or injuries. During the standard survey, the team determined an Immediate Jeopardy (IJ) situation existed on 04/16/24 at 5:15 p.m. The IJ resulted from staff failure to provide sufficient supervision and use the assistive device (gait belt) in a manner to avoid a fall and/or potential injury. * 04/16/24 at 5:29 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential immediate jeopardy (IJ). * 04/16/24 at 6:30 p.m., The survey team notified the administrator and the director of nursing (DON), of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the immediate jeopardy. * 04/16/24 at 6:35 p.m., The SSA notified the CMS (Centers for Medicaid & Medicare Services) location of the IJ situation. * 04/16/24 at 8:40 p.m., The facility provided (via email) an IJ removal plan. * 04/17/24 at 8:30 a.m., The SSA reviewed and accepted the IJ removal plan. The removal plan contained the following: * Inservice and education on appropriate actions/interventions per care plan specific to toileting and transfers to meet residents needs and prevent injury, with the staff member directly involved in the deficient practice, all nursing staff on duty, and on-coming staff. * Review of Resident's transfer requirements as outlined in their individual care plans. * Review of facility policies and resources for questions/concerns. * 04/17/24 at 10:12 a.m., the survey team verified the implementation of the removal plan. The deficient practice remained at a D scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled Fall Prevention and Management - Rehab/Skilled [R/S], Therapy & [and] Rehab occurred on 04/17/24. This policy, dated 04/02/24, stated, . To promote resident well-being by developing and implementing a fall prevention and management program . Proactive Approach before a Fall occurs . 2. Complete the Falls Tool UDA [user defined assessment] for fall screening and identifying fall risk factors. 3. Care Plan the appropriate interventions . 4. Communicate fall risks and interventions to prevent a fall before it occurs . Review of the facility policy titled Care Plan - R/S, LTC [Long Term Care], Therapy & Rehab occurred on 04/17/24. This policy, dated 11/01/23, stated, . Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being . The care plan will emphasize the care of the whole person ensuring that the resident will receive appropriate care and services. Review of Resident #35's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #35 had severely impaired cognition. The current care plan stated, . I am at risk for falls r/t [related to] balance difficulty, weakness and unsteadiness. I do have a hx [history] of falls r/t dementia and poor safety awareness, weakness and ambulatory dysfunction. I will not sustain serious injury through the review date. TOILET USE: I need extensive assist of two with transfers . TRANSFERS: Transfers with assist of two with gait belt . I will at times try to transfer myself in the restroom . Review of nursing progress notes identified the following: * 04/13/24 at 4:43 p.m., . Staff called nurse to resident room and stated that he is in the bathroom on the floor and bleeding from his head and blood on the floor and his hands and arms. Nurse assessed and resident cleansed and noted laceration to right side of forehead and skin tears to right elbow and top of hand. Resident was self transferring and lost balance and fell and then pulled call light. Pressure applied to laceration and vital signs obtained. Call placed to family and provider on call . and rec'd [received] verbal order to send to ER [emergency room ] via ambulance. * 04/13/24 at 5:00 p.m., . Call placed to . hospital switchboard and requested to be connected to provider on call . Updated that resident had unwitnessed fall with injury and has a laceration to right side of forehead and skin tears to right elbow and top of hand. She stated to send resident to ER for evaluation of head laceration and because this is the 3rd fall resident has had since 4/11/24 and 2nd within 24 hours. * 04/14/24 12:20 a.m., . Resident returned to facility following ER visit d/t [due to] fall with head laceration. Resident returns with 6 sutures to lacerated area on right side of forehead. Observations showed the following: * 04/14/24 at 12:13 p.m., Resident #35 seated in a wheelchair in the dining room eating lunch. The resident had sutures to the right side of the forehead and a tegaderm [transparent adhesive bandage] to the right forearm. * 04/14/24 at 4:30 p.m., Resident #35 sat in a wheelchair by the dining room and stated he needed to use the bathroom to staff member (#2). The staff member (#2) opened the door to the public bathroom in the hallway for the resident, and asked Are you good? Resident #35 responded Yes. The staff member (#2) walked away. Resident #39, also cognitively impaired, pushed Resident #35 in the wheelchair into the bathroom and closed the door. The surveyor notified the nurse (#3). The nurse (#3) entered the bathroom, stopped Resident #35 from self-transferring to the toilet, placed a gait belt on Resident #35 and assisted the resident to the toilet. Resident #35 used the toilet. The nurse (#3) assisted the resident to stand and pivot back into the wheelchair with a gait belt. * 04/15/24 at 4:35 p.m., Resident #35 sat on the bed and transferred himself from the bed to the wheelchair. No staff were present in the room. * 04/16/24 at 9:35 a.m., Two certified nurse aides (CNAs) (#4 and #5) assisted Resident #35 to transfer from the wheelchair to the toilet. The resident transferred himself to the toilet before they could apply the gait belt. Once the resident was seated on the toilet the CNA (#4) applied a gait belt to the resident. Resident #35 used the toilet and the CNAs (#4 and #5) lifted under Resident #35's arms to assist him to stand, completed perineal cares and both CNAs held the resident under his arms and by the waistband of his pants, to pivot transfer to the wheelchair. During an interview on 04/16/24 at 3:20 p.m., an administrative nurse (#1) confirmed she expected staff to follow the care plan for transfers to ensure resident safety, and to use gait belts appropriately. Facility staff failed to follow the care plan to provide sufficient supervision and assistance with transferring and toileting, and use a gait belt with a resident who was identified as a fall risk, who had a recent fall with injury, and had the potential to for further falls.

Based on record review, policy review, and resident and staff interviews, the facility failed to provide care and services to control pain for 1 of 1 sampled resident (Resident #31) reviewed for pain management. Failure to administer as needed (prn) pain medications and inform the physician of increased use of prn pain medication resulted in Resident #31 experiencing anxiety and mental anguish and may have contributed to the resident experiencing increased and/or unresolved pain. Findings include: Review of the facility policy titled Pain Management occurred on 04/17/24. This policy, dated February 2024, stated, . PURPOSE To provide residents assistance in pain management. To promote well-being by ensuring that residents are as comfortable as possible. Individualized approaches will be developed to address the resident's pain management in a holistic manner. Review of Resident #31's medical record occurred on all days of survey. A Minimum Data Set (MDS), dated [DATE], identified intact cognition and frequent pain rated 10 on a 0-10 scale. A second MDS, dated [DATE], identified pain affected her sleep occasionally and interfered with therapy activities and day to day activities frequently. Resident #31's care plan stated, . I have chronic pain/discomfort . E/B [evidenced by] limited mobility and verbalization of pain. I will not have an interruption in normal activities due to pain . Physician's orders included: * 01/19/24, Acetaminophen Oral Tablet (Acetaminophen) [tylenol] Give 1000 mg [milligrams] by mouth three times a day related to BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE . BILATERAL PRIMARY OSTEOARTHRITIS OF HIP. * 01/19/24, Ultram 50 mg (TraMADOL HCL) [narcotic analgesic] *Controlled Drug* Give 50 mg by mouth as needed for pain Take up to three times daily as needed if pain unrelieved by tylenol. * 01/29/24, LORazepam [antianxiety medication] Oral Tablet 0.5 MG Give 0.5 mg by mouth as needed for anxiety/agitation related to ANXIETY DISORDER . Take up to one time daily. During an interview on 04/14/24 at 12:54 p.m., Resident #31 stated, I have had issues getting my pain and anxiety medications which has created a lot of anxiety for me not knowing if I would get them [pain and antianxiety medications] or not. A nurse refused to give me my tramadol and Ativan [lorazepam] when I requested them. Review of Resident #31's progress notes and medication administration record (MAR) identified the following: *01/22/24 at 9:16 p.m. Resident . Stated she wanted her Ultram, Tylenol and Ativan so she can sleep. Did not give them. She stated she did not know why she cant [sic] get them three times a day like in the last place. Explained this is new facility and we don't have an order for it that often. The MAR identified Resident #31 did not receive any PRN doses of Tramadol or Ativan on this day. * 01/23/24 at 12:44 p.m. fax sent to Dr. [doctor] . re: [regarding] resident is very upset that her Tramadol is not scheduled at 0900 [9:00 a.m.], 1500 [3:00 p.m.], and at bedtime, Tramadol was scheduled at these times at her last place of residence, resident states she needs it scheduled because of her back and knee pain, can we schedule it as resident wishes? . * 01/23/24 at 3:58 p.m. fax received from Dr. stating NO Keep it prn referring to the Tramadol . * 01/26/24 at 11:31 p.m. Resident was calm and cooperative. Requesting Tramadol told her could not give she already received it 3 times today. Stated that I needed to go research and bring her the Tramadol. Restated I could not give her any because she already received it 3 times today. The MAR identified Resident #31 only received two doses of Tramadol on this day, and did not receive Ativan until 11:10 p.m., almost two hours after she requested it. The facility failed to administer prn pain and antianxiety medications as ordered and when Resident #31 requested. Review of a physician's progress note, dated 02/21/24 for Resident #31 stated, . She [Resident #31] states for years, she was on lorazepam 2-3 times daily as needed for anxiety . She also notes that the tramadol she has previously taken 2-3 times per day and that is not being given as often since her admission to the nursing home. She is wondering if those can be adjusted. She makes it a point that she is [AGE] years old and has been on the anxiolytics and tramadol for a number of years without problems and I do not see at this point any reason why we cannot be more liberal with the anxiolytics and the tramadol. She already has the tramadol ordered 3 times daily as needed if pain is unrelieved by Tylenol and I think that is adequate for now to continue with that order. The lorazepam however, will be increased to twice daily. Monthly pharmacy review progress notes for Resident #31 included the following: * 02/28/24 . Pain: freq [frequent] moderate - severe. PRN Meds: tramadol 76 (+58) [indicating the resident requested and received tramadol 58 more times in February then she did in January]. Lorazepam now scheduled, . assess need to schedule a dose of tramadol to help control pain. * 03/28/24 . Pain: frequent moderate-severe pain mostly relieved with PRN tramadol. PRN Meds: tramadol 75 [prn doses] . for pain control, may consider scheduling for better pain control next month. The facility failed to inform the physician of Resident #31's increased use of prn pain medication and suggestions for scheduled doses as indicated by the pharmacy reviews. During an interview on 04/16/24 at 11:50 a.m., an administrative nurse (#1) stated she was not aware of Resident #31's concerns with not receiving her prn pain and antianxiety medications. The also reported she did not notify the physician of the pharmacy monthly reviews since it was not noted specifically as a recommendation. During an interview on 04/16/24 at 1:29 p.m., an administrative nurse (#1) agreed Resident #31 could have received Tramadol and Ativan on 01/22/24 when she had requested it and on 01/26/24 she could have received prn tramadol when she requested it. The administrative nurse stated she expects staff to administer medications as ordered and as requested by the resident.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 14 sampled residents (Resident #20, #29 and #35) and one supplemental resident (Resident #44). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Failure to code discharge status may affect appropriate discharge planning and follow-up if needed. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised October 2023, Section A, page A-42 stated, . A 2105 Discharge Status . Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if the resident was discharged to a private home, apartment, board and care, assisted living facility . Review of Resident #44's medical record occurred on 04/17/24. A physician's order dated, 03/28/24, stated, Discharge to [facility name] Assisted Living . A progress note, dated, 03/28/2024 9:56 [a.m.] Discharge-Home, Assisted Living . Resident #44's Discharge MDS dated [DATE] identified facility staff coded item A2105 discharge status: 04 Short-Term General Hospital. The MDS is incorrectly coded for a discharge to a hospital. During an interview on 04/17/24 at 11:55 a.m., a staff member (#11) confirmed staff failed to correctly code Resident #44's discharge MDS. SECTION K: WEIGHT LOSS The Long-Term Care Facility RAI User's Manual, revised October 2023, Section K: Swallowing/Nutritional Status, pages K-3 through K-6, stated, . K0200B: Weight: 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Steps for Assessment: This item compares the resident's weight in the current observation period with their weight at two snapshots in time: . At a point closest to 30-days preceding the current weight. At a point closest to 180-days preceding the current weight. From the medical record, compare the resident's weight in the current observation period to their weight in the observation period 180 days ago. If the current weight is less than the weight in the observation period 180 days ago, calculate the percentage of weight loss. Coding Instructions . Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of . 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. - Review of Resident #35's medical record occurred on all days of survey. An admission MDS, dated [DATE], identified the resident's weight as 190 pounds. A quarterly MDS, dated [DATE], identified the resident's weight as 140 pounds, a weight loss of 25% in 180 days. The quarterly MDS failed to identify Resident #35's weight loss. During an interview on 04/17/24 at 12:00 p.m., a dietary manager (#12) confirmed she coded Resident #35's Quarterly MDS incorrectly for weight loss. SECTION M: SKIN CONDITIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages M-8 stated, M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage . Determine Present on Admission For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. 1. Review the medical record for the history of the ulcer/injury. 2. Review for location and stage at the time of admission/entry or reentry. Pages M-12 through M-13 stated, . M0300B: Stage 2 Pressure Ulcers . Steps for Assessment . Identify the number of these pressure ulcers that were present on admission/entry . Coding Instructions for M0300B . M0300B1 . Enter the number of pressure ulcers that are currently present and whose deepest anatomical stage is Stage 2 . M0300B2 . Enter the number of these Stage 2 pressure ulcers that were first noted at the time of admission/entry . Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission/entry or reentry. Review of Resident #20's medical record occurred on all days of survey. Diagnoses included pressure ulcer to right and left buttock, stage two. The annual MDS, dated [DATE], identified 2 for number of stage two pressure ulcers present and 2 for number of stage two pressure ulcers present on admission. The quarterly MDS, dated [DATE], identified 2 for number of stage two pressure ulcers present and 0 for number of stage two pressure ulcers present on admission. During an interview on 04/16/24 at 10:58 a.m., an administrative nurse (#1) confirmed Resident #20's bilateral stage two pressure ulcers to the buttocks were present on admission. During an interview on 04/17/24 at 11:55 a.m., an administrative nurse (#9) confirmed staff failed to code Resident #20's quarterly MDS correctly regarding pressure ulcers present on admission. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-1, and N-6 to N-8 stated, Section N Medications . N0415: High-Risk Drug Classes: Use and Indication . Coding Instructions . N0415E1. Anticoagulant (e.g., [for example] warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., . clopidogrel) was taken by the resident at any time during the 7-day observation period. Review of Resident #29's medical record occurred on all days of survey. A physician's order, dated 11/08/21, stated, Clopidogrel Bisulfate Tablet . Give 75 mg [milligrams] by mouth one time a day for antiplatelet/AFib [atrial fibrillation]. The quarterly MDS, dated [DATE], identified the use of an anticoagulant medication and failed to identify the use of an antiplatelet medication. During an interview on 04/17/24 at 12:16 p.m., an administrative nurse (#9) confirmed staff failed to code Resident #29's MDS correctly regarding anticoagulant/antiplatelet medication use. 45873

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 5 of 14 sampled residents (Resident #17, #27, #29, #35, and #41). Failure to revise the care plan limited the staff's ability to communicate care needs and ensure continuity of care for each resident. Findings include: Review of the facility policy titled, Care Plan .LTC [long term care] occurred on 04/17/24. This policy, revised, 11/01/23, stated, . Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. This plan of care will be modified to reflect the care currently required/provided for the resident. Care plans also will be reviewed, evaluated and updated when there is a significant change in the resident's condition. - Review of Resident #17's medical record occurred on all days of survey. Diagnoses included diabetes mellitus type 2, atrial fibrillation, and chronic congestive heart failure. Current physician's orders identified a diuretic and insulin. A progress note, dated 03/26/24 at 11:08 a.m., stated, . At risk for malnutrition . Has had a weight loss . Weight is down 17# [pounds] since 1/23/24 (9.2%). Resident #17's current care plan lacked problems and interventions related to risk for malnutrition, actual weight loss, use of a diuretic, diabetes, and insulin use. - Review of Resident #27's medical record occurred on all days of survey. Diagnoses included osteomyelitis right ankle, sepsis, and pneumonia. The current care plan stated, . The resident is on medications with FDA [federal drug administration] Boxed Warnings or warnings of adverse consequences R/T [related to] use of IV [intravenous] Vancomycin [antibiotic]. Physician's orders showed IV Vancomycin discontinued on 01/09/24, and Doxycycline (oral antibiotic) 500 mg (milligrams) twice a day ordered on 01/09/24. On 04/08/24, the Doxycycline was renewed to continue through 05/01/24. On 04/01/24, a physician's order stated, .100% weight bearing to right ankle, when wearing the cam boot [Controlled Ankle Motion boot - an orthopedic device prescribed for the treatment and stabilization of severe sprains, fractures, tendon, or ligament tears in the ankle of foot] . Resident #27's current care plan lacked updated information addressing the discontinuation of Vancomycin and addition of Doxycycline, and the care associated with the resident's cam boot. - Review of Resident #29's medical record occurred on all days of survey. A nursing progress note dated 01/29/24 at 3:29 p.m., stated, . Writer received written orders to d/c [discontinue] oxygen continuously . The current care plan stated, . Oxygen therapy: I am on 2L [liters] of O2 [oxygen] via NC [nasal cannula] continuously. The facility failed to update Resident #29's care plan related to oxygen use. - Review of Resident #35's medical record occurred on all days of survey. Diagnoses included diabetes mellitus type 2, chronic congestive heart failure, and lymphedema. Current physician's orders identified a diuretic and oral hypoglycemics (medications used to treat diabetes). Review of Resident #35's progress notes showed the following: * 11/20/23 at 2:11 p.m., . Nutrition Risk Note: . is triggering due to . poor meal intakes & low MNA [mini-nutritional assessment] score of 11. Wt [weight] -186# [pounds]. Intakes are averaging 59% at meals. * 01/17/24 at 3:09 p.m., . Nutrition Risk: . is triggering due to poor meal intakes. Wt-140.5# . (a 25% weight loss in 2 months) The current care plan failed to identify nutrition risk, actual weight loss, use of a diuretic, diabetes, and use of oral hypoglycemic medications. - Review of Resident #41's medical record occurred on all days of survey. Diagnosis included chronic congestive heart failure, atherosclerotic heart disease, and trochanteric fracture of right femur. Physician's orders showed Furosemide 40 mg and Spironolactone 25 mg (diuretics) every morning for heart failure. Oxycontin 10 mg twice a day, discontinued 03/06/24 and Oxycodone (narcotic pain medications) 5 mg every 8 hours as needed, discontinued 03/12/24. The current care plan stated, . I am on medications with FDA Black Boxed Warnings R/T [related to] use of Oxycontin [and] Oxycodone . The resident has acute/chronic pain/discomfort R/T arthritis & Right hip fracture E/B [evidenced by] able to vocalize pain. Takes scheduled Tylenol and Oxycontin. Has Oxycodone as needed. A review of Resident #41's progress notes, dated, 03/26/2024, showed, . Nutrition Risk Note: [resident name] is triggering due to weight loss, . Wt-110# . Weight is down 18# in 30 days (14.1%). The current care plan failed to identify nutrition risk and weight loss, use of diuretics, and discontinuation of oxycodone and oxycontin. During an interview on 04/16/24 at 4:40 p.m., an administrative nurse (#1) confirmed she expected care plans to be updated with the resident's current orders, medication changes, and when new problems are identified. 45873

Based on information provided by the complainant, record review, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 2 of 2 sampled residents (Resident #1 and #2) who sustained a burn. Failure to monitor the temperature of the baseboard heat register and position residents' beds away from the heat register resulted in Resident #1 receiving a first and second degree burn. Findings include: Information provided by the complainant indicated a resident fell from her bed and obtained a significant burn from a heat register. - Review of Resident #2's medical record occurred on 01/02/19. [DIAGNOSES REDACTED]. Resident #2's progress note dated, 12/23/19 at 3:35 a.m., stated, Resident yelling. Found between bed and wall. Lying on right side, legs caught under bed and left hand on register holding torso off of floor. Wedged between bed and wall. Register hot to touch. An investigation form completed on 12/23/18 stated, . Time Occurred 03:35 (3:35) a.m. Minimal Injury . bed in low position, attempted self transfer out of bed. Describe corrective actions taken . register heat lowered . Resident Injuries . Abrasion (right) lateral knee, Burn (left) hand, Skin discoloration red (right) hip, forearm, knee . During an interview on 01/02/19 at 2:22 p.m., an administrative staff member (#1) stated staff moved Resident #2's bed away from the heat register to ensure the resident's safety from [MEDICAL CONDITION] initiated one hour checks at night. The facility failed to ensure corrective actions occurred for all residents after Resident #2 received a burn from touching a hot heat register. - Review of Resident #1's medical record occurred on 01/02/19. [DIAGNOSES REDACTED]. The current care plan stated, The resident is at risk for falls . slid out of bed on 07/05/18 and 12/12/18. Found on floor by bed 12/26/18 . Resident requires assist of 2 staff and a total lift . Resident #1's progress note dated 12/26/18 at 1:35 a.m., stated, Resident found lying on floor between bed and wall. Right buttock, hip against heat register. Noted redness with large blisters to right buttock, hip. Skin intact measuring 12 cm (centimeters) x 27 cm. Administrator, DNS (direct nursing services), son notified. NP (nurse practitioner) notified with orders received to leave blister intact until it opens. Resident #1's progress are as follows: *12/26/18 at 3:00 a.m.: Noted blisters to right buttock to weep . noted to be shaking. Stated feels cold. BP (blood pressure) 70s/40s. *12/26/18 at 3:53 a.m.: son notified, updated on current condition. Agreed to transfer to ER (emergency room ) for evaluation. *12/26/18 at 11:18 a.m.: Room rearranged and bed was moved away from the heater. *12/26/18 at 7:00 p.m.: RN (registered nurse) from (hospital name) phones stating resident is receiving [MEDICATION NAME] dressing changes two times daily, pain control with Tylenol and is (sic) observation, should return on 12/27/18 to facility. *12/27/18 at 3:43 p.m.: resident returns from hospital . transferred to bed with assist of four. color is very pale with little duskiness noted . dressing intact to left lower leg and right buttock . *12/28/18 at 9:53 a.m.: resident moved to room (number) to be closer to the nurses station . Nursing order for q (every) 1 hour safety checks . Resident's bed has been placed in new room so it is not near the heater. *12/31/18 at 11:59 a.m.: Resident is somewhat lethargic. Her skin is cool to touch and grey in appearance. Resident has had very little food intake and very little output. Has been getting the MS ([MEDICATION NAME] sulfate) (pain medication) for pain and helps when resident keeps it in her mouth. O2 (oxygen) is at 70% (percent). 2 liters of O2 placed on resident a this time. Doctor notified. *12/31/18 at 1:13 p.m.: Resident has been sent to the ER in (hospital name) for evaluation, due to possible dehydration. An investigation form completed on 12/26/18 at 1:35 a.m., stated, . Immediate Action Taken: . Cool compress applied to right hip, buttock area. Resident's bed moved away from register and register adjusted to low setting. Injuries Observed at Time of Incident: Burn to Right Buttock and Burn to Right trochanter (hip). A hospital note dated 12/26/18 at 5:26 a.m., stated, History of Present Illness: . She sustained a large area of 1st and 2nd degree partial thickness burn to her right buttock with some blistering . During an interview the afternoon of 01/02/19, a facility certified nursing assistant (CNA) (#3) stated she entered Resident #1's room on 12/26/18 at 1:30 a.m. to assist when she heard the resident had fallen. The CNA stated she observed resident #1's buttocks up against the heater vent and identified the vent was hot to touch. The CNA (#3) stated she immediately turned down the temperature on the vent without using a plastic dial. The CNA verified the base board heaters in the residents' rooms can be adjusted without using the plastic dial, and that she has adjusted other residents' base board heaters without using the plastic dial. During an interview on the afternoon of 01/02/19 two administrative staff members (#1 and #2) stated staff implemented the following interventions to ensure residents safety : * All residents' beds were positioned away from the heat registers * Monitoring the temperatures of the heat registers * Hourly checks on Resident #1 after hospital return on 12/28/18

1. Based on record review and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #8) received the care and services necessary to attain the highest degree of safety possible while drinking hot coffee. Failure to provide coffee at a safe temperature resulted in Resident #8 sustaining burns on her body and caused unnecessary discomfort and pain. Failure of the facility to implement a system to monitor the temperature of the coffee dispensing machines used by residents has the potential to result in additional burns to residents who drink coffee. Findings include: Review of Resident #8's medical record occurred on March 12-13, 2014. Medical [DIAGNOSES REDACTED]. Review of Resident #8's "Incident Details" report, dated 07/29/13 at 6:00 p.m., stated, " . . . Comment: Resident spilled hot coffee on . . . herself resulting in a burn, red area with some blistering . . . Immediate Interventions: Closer monitoring needed in dining room." Review of Resident #8's progress notes stated the following: *07/29/13 at 7:00 p.m. - "resident sustained [REDACTED]. . ." A physician's order, dated 07/29/13, stated, "Apply ice PRN (as needed) to affected area. Vicodin (a pain medication) (every four hours) for pain. Bacitracian to affected area." *07/30/13 at 1:00 p.m. - ". . . Blisters to (right) thigh intact . . ." *08/16/13 at 2:00 p.m. - "Noted to (right) upper thigh where coffee spill was noted to have foul odor green drainage. Call to (provider's name) orders received/observed for silvadene (top) (topical) . . . to (right upper) thigh til (sic) healed. Keflex (antibiotic) . . . 10 days . . ." *10/07/13 - ". . . burn area is scarred." Observation on 03/13/14 at 8:55 a.m. showed Resident #8 seated in the dining room in a reclined wheelchair about two feet from the table. An unidentified Certified Nursing Assistant (CNA) handed the resident a cup of coffee with a lid and stated she, "added a little cold water cuz (because) it was hot." Observation showed Resident #8 drank the coffee independently. At 9:05 a.m., the survey team obtained a cup of coffee from the coffee dispenser, immediately checked the temperature, and found the temperature measured 165.4 degrees Fahrenheit. During an interview on the morning of 03/13/14, two administrative staff members (#1 and #2) stated they did not conduct an investigation related to Resident #8's coffee burn and they do not know what the coffee temperature was on the day of the incident. The staff member (#2) stated the dietary department periodically checked the temperature of the coffee. The staff member could not provide documentation of any completed temperature monitoring reading from the coffee dispensing machine. The staff member (#1) stated the incident happened around the time staff members were assisting/transferring residents into the dining room and Resident #8 should not have been alone with a cup of hot coffee. The staff members (#1 and #2) did not know whether Resident #8's coffee cup had a lid on it during the time of the incident. Failure to implement a systemic process to monitor and check the temperature of the coffee dispensing machine continues to place Resident #8 and all residents of the facility at risk of sustaining burns due to excessively hot coffee temperatures. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the proper use of assistive devices for 2 of 7 sampled residents (Resident #6 and #8) observed during gait belt transfers and 1 of 2 sampled residents (Resident #6) observed during a sit-to-stand lift transfer; and failed to lock the wheelchair brakes for 1 of 8 sampled residents (Resident #7) observed during a transfer into a wheelchair. Failure to ensure staff use gait belts and a sit-to-stand lift appropriately and lock the brakes of a wheelchair during a transfer placed Resident #6, #7, and #8 at risk for falls and injuries. Findings include: Review of the facility policy titled "GAIT (TRANSFER) BELT" occurred on 03/13/14. This policy, dated October 2013, stated: "PURPOSE: *To safely transfer or ambulate resident *To aid resident in maintaining balance *To avoid injury to both resident and staff member . . . PROCEDURE: 1. Show the resident the gait (transfer) belt and explain that it is a device used for stability and/or support for a short time during the actual transfer or ambulation. . . . 5 . . . The belt should not be used for lifting. It is for support and stability only. . . . 7. Do not use the pants/slacks belt as a gait (transfer) belt. . . ." Review of the facility policy titled "MECHANICAL LIFT" occurred on 03/13/14. This policy, dated September 2012, stated, "REFER TO MANUFACTURER'S SPECIFIC LIFT INSTRUCTIONS." The manufacturer's instructions for the Steady-Aid (sit-to-stand lift) stated, ". . . The front safety strap should be below the sternum level. Tighten the safety strap by pulling on the free end so that the harness is adjusted to a point where it fits snugly around the chest. . . ." - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #6's current care plan related to Activities of Daily Living (ADL) stated, "TRANSFER: Resident requires assist (assistance) of one to two staff participation with transfers." Observation on 03/11/14 at 9:50 a.m. showed a Certified Nursing Assistant (CNA) (#13) transported Resident #6 into the tub room to use the toilet. Another CNA (#4) entered the tub room with a sit-to-stand lift. The CNA (#13) applied the lift harness around the resident's upper chest area and tightened the safety strap. Observation showed the harness slid up to the Resident #6's neck, just below her chin, and her arms bowed outward during the transfer. Observation on 03/11/13 at 10:45 a.m. showed two CNAs (#13 and #15) utilized the sit-to-stand lift and positioned Resident #6 over the toilet. The harness had slid up to the resident's neck and her arms were bowed outward. When asked about the position of the harness, the CNA (#15) stated they always place the harness around Resident #6's upper chest to prevent her breasts from getting caught in the harness. Observation on 03/11/13 at 5:20 p.m. showed Resident #6 seated in a recliner in the activity room. The CNA (#6) applied a gait belt around the resident's waist and the CNAs (#6 and #7) both held onto the gait belt with one hand and lifted under the resident's arms with their other hand and transferred Resident #6 into her wheelchair. Observation on 03/12/14 at 9:55 a.m. showed two CNAs (#15 and #16) utilized the sit-to-stand lift and transferred Resident #6 from her wheelchair to the toilet. During the transfer, the harness slid up to the resident's neck, just below her chin, and her arms bowed outward. The resident stated, "I'm going to fall." - Review of Resident #8's medical record occurred on March 12-13, 2014. [DIAGNOSES REDACTED]. The current care plan related to ADLs stated, "TRANSFER: Resident requires 1 to 2 staff participation with transfers." Observation on 03/12/14 at 5:15 p.m. showed two CNAs (#10 and #11) transferred Residdnt #8 from her bed to a wheelchair. The CNA (#11) applied a gait belt around Resident #8's waist and lifted the resident under her arm with one hand and utilized the gait belt with the other hand. The other CNA (#10) lifted the resident under her other arm with one hand and pulled up her pants with her other hand. Observation on 03/13/14 at 9:50 a.m. showed showed two CNAs (#4 and #14) transported Resident #8 to her room via wheelchair. The CNA (#4) applied a gait belt around Resident #8's waist, asked the resident to give her a hug, and facing the resident, lifted her to a squatting position with the gait belt. While the CNA (#4) held onto Resident #8, the other CNA (#14) exchanged the wheelchair for a commode, pulled down her pants, and the CNA (#4) lowed the resident onto the commode. When Resident #8 had finished on the commode, the CNA (#4) lifted her as before and the CNA (#14) provided pericares.The resident became weak and The CNA (#4) lowered her to the commode for a moment. She then lifted her again and the CNA (#14) pulled up her pants and exchanged the commode with the wheelchair. The CNA (#4) lowered Resident #8 to her wheelchair. Observation showed Resident #8 unable to stand to a full upright position and unsteady on her feet. - Review of Resident #7's medical record occurred on March 11-12, 2014 and [DIAGNOSES REDACTED]. The resident's care plan stated, ". . . at risk for falls R/T (related to) Unaware of safety needs e/b (evidenced by) history of falls . . . TRANSFER: Resident requires 1 to 2 staff participation with transfers. . . ." Observation on 03/11/14 at 9:31 a.m. showed a CNA (#3) applied a gait belt around Resident #7's waist and she and another CNA (#4) transferred the resident from his wheelchair to his bed. Observation showed the CNAs failed to lock the wheelchair brakes prior to the transfer. Observation on 03/11/14 at 12:56 p.m. showed a CNA (#3) applied a gait belt around Resident #7's waist and she and another CNA (#5) transferred the resident from his wheelchair to his bed. Observation showed the CNAs failed to lock the wheelchair brakes prior to the transfer. During an interview on the morning of 03/13/14, an administrative staff member (#1) stated the CNAs can decide what method of transfer to use for each resident and they have the liberty to use more assistance or a lift if necessary, however, if the resident already requires a lift for transfers, the CNAs cannot step down and and use a gait belt or pivot transfer. Failure to evaluate the transfer needs of Resident #6 and #8 resulted in unlicensed staff members (CNAs) determining the level of assistance the residents required. This failure places residents at risk for avoidable falls and injury.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to implement dietary interventions to maintain adequate nutritional status and prevent weight loss for 2 of 5 sampled residents (Resident #2 and #6) identified with weight loss. Failure to implement nutritional interventions consistently resulted in Resident #2 and #6 experiencing severe weight loss. Findings include: Review of the facility policy titled "MONITORING RESIDENTS WITH IMPAIRED NUTRITION AND NUTRITIONAL RISK" occurred on 03/13/14. This policy, dated February 2013, stated, "POLICY: The center will ensure that each resident maintains acceptable parameters of nutritional status such as body weight, protein levels and hydration status unless the resident's clinical condition demonstrates that this is not possible. PROCEDURE: 1. Residents with impaired nutrition or nutritional risk may be identified by nursing, dietary and other members of the care plan team. . . . 5. The DDS (Director of Dietary Services) or designee will review resident weights monthly or more often to identify residents with significant weight loss/gain (5 percent (%) in 30 days, 7.5 percent in 90 days or 10 percent in 180 days) or insidious weight loss or gain. Insidious weight loss or gain refers to gradual unintended, progressive weight loss or gain over time. . . ." The Centers for Medicare and Medicaid Services (CMS) has outlined the parameters for evaluating significance of unplanned & undesired weight loss: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% - Review of Resident #6's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance for eating. The Care Area Assessment (CAA), dated 01/24/14, stated, "(Resident #6) is losing weight. She receives supplements and enhanced cereal daily." Resident #6's current care plan stated: "Focus: The resident has an ADL (Activities of Daily Living) self care performance deficit R/T (related to) Dementia e/b (evidenced by) needs assist of one to two with adl's . . . Interventions: Eating: Resident requires reminding and assistance to eat . . . Focus: The resident has nutritional problem or potential nutritional problem has had 10% weight loss . . . *Give resident fortified foods per dietary plan. House supplement with meals . . . *Scheduled resident specific snack/food intervention 3PM and HS (hour of sleep) *Scheduled resident specific snack/food intervention offer snack between meals if res (resident) eats less that 50% of breakfast lunch or supper." Review of Resident #6's weights identified the following: *07/10/13 - 115.5 pounds *08/14/13 - 111 pounds *09/18/13 - 110 pounds *10/23/13 - 103.5 pounds - 12 pound weight loss in 3 months (10.4% loss) *11/27/13 - 103 pounds *12/25/13 - 103 pounds *01/29/14 - 100 pounds - 15.5 pound weight loss in 6 months (13% loss) Review of Resident #6's dietary progress notes identified the following: *07/16/13 - "Wt (weight) review 115.5# (pounds) 5% (down) 3 mos (months). Intakes vary 0-100% - fluid intake (less than) 800 ml (milliliters) average at meals . . . Offer (high) cal (calorie) when eating. No aggressive support planned." *08/20/13 - ". . . 111# 3% (loss) 6 mo (months) 9.8% 3 mons. (months) gradual (decrease) . . . Staff cue refuses to be fed. Independent in choices. Try enh (enhanced) pudding or (high) cal ice cr (cream) for desserts." *09/17/13 - ". . . Wt. 110# 8% (decrease) 6 months . . . Supplements offered . . . Offering enhanced items & (and) supplements 4 x/day . . . Continue to monitor . . ." *10/15/13 - ". . . Wt 107.5# Continues to have wt loss . . . Continues to receive enh items & suppl (supplements) QID (four times a day) . . . Encourage suppl especially at meals & snacks." *11/19/13 - ". . . staff are assisting more at meals . . . Receives supplements at meals 3PM . . . Wt. stable 106# . . ." *02/18/14 - ". . . continues to have variable intake at meals . . . averaging 50%. Offered 5 - 6oz (ounces) health shakes . . . wt is stable 105# . . ." *03/12/14 (during the survey) - ". . . no longer gets supplement at meal time per physician, want to see if intake improves, she receives chocolate milk in place . . . Continues to get enhanced cereal at breakfast, does not care for it much, prefers toast with jelly . . . if weight loss occurs, will go back to offering supplement with meal . . ." (supplements changed from five times a day to twice a day on 01/31/14). Observations of meal and supplement intake by Resident #6 showed the following: *03/11/14 at 8:55 a.m. - a glass of whole milk, cup of coffee, glass of orange juice, one half of a banana, two slices of toast with peanut butter, and no enhanced cereal. Resident #6 consumed less that 51% of the meal. *03/11/14 at 12:25 p.m. - mashed potatoes, carrots, ground meat, one half of a slice of bread, bread pudding, and a glass of cranberry juice. Resident #6 consumed less that 51% of the meal. *03/11/14 at 5:00 p.m. - per interview with a staff nurse (#8), Resident #6 consumed 75% of a 6 oz supplement drink about 3:15 p.m. *03/12/14 at 8:25 a.m. - hot cereal with cream, one slice of toast with jelly, a glass of grape juice and a glass of water. Resident #6 consumed less than 25% of the meal. *03/12/14 at 10:45 a.m. - A nurse (#8) gave the resident a 6 oz strawberry supplement shake. The nurse stated, "She likes strawberry." *03/12/14 at 12:05 p.m. - chocolate milk, jello, ground Swiss steak, mashed potatoes with butter, beets, and one half of a slice of bread. Resident #6 consumed less that 25% of the meal. *03/13/14 at 8:20 a.m. - hot cereal with cream, two slices of toast with peanut butter, a scrambled egg, milk (not chocolate) and water. Resident #6 consumed the two slices of toast except for the crust and none of the hot cereal or egg. The dietary staff member had not recorded the percentage of consumption. During an interview on 03/12/14 at 9:25 a.m., a dietary staff member (#19) stated there is no place to document how much fortified foods a resident has consumed during a meal. If a resident consumes less than 50% of a meal, she writes the resident's name a piece of paper, gives it to the nurse, and someone gives the resident a supplement in between meals. Failure of the facility to re-assess Resident #6's continued weight loss, implement dietary interventions the resident prefers, and document or communicate the amount of fortified foods consumed, resulted in Resident #6 experiencing a severe weight loss of 15.5 pounds in 6 months. - Review of Resident #2's medical record occurred on March 10-13, 2014. Resident #2's medical [DIAGNOSES REDACTED]. Resident #2's quarterly MDS, dated [DATE], identified limited assistance with eating and weight loss (not physician prescribed). Resident #2's current care plan stated: "Focus: The resident has an ADL self care performance deficit R/[MEDICAL CONDITION] E/B left sided weakness . . . Eating: Resident requires reminding, prompting, cueing to eat slowly, assistance to eat. Divided plate used. Provide milkshakes or liquid food or nourishments when resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug . . . Focus: The resident has unplanned weight loss R/T poor food intake E/B decline in cognitive ability, dental or oral problems . . . Give fortified menu. Encourage slower eating by providing food in separate bowls, cueing, etc. to decrease risk of aspiration . . . ." Review of Resident #2's weights showed facility staff weighed the resident using several different scales (chair/wheelchair scale, bath scale, mechanical lift scale, and standing scale) to record his weight since admission. Resident #2's weights (using a chair/wheelchair scale) included: 09/15/13 - 179 pounds 11/03/13 - 170 pounds (The facility weighed Resident #2 two times in October 2013 upon return from the hospital using a different type of scale.) 12/15/13 - 163 pounds - 15 pound weight loss in 3 months (9% loss) 01/19/14 - 158.5 pounds 02/09/14 - 166.5 pounds 03/09/14 - 160.5 pounds - 18.5 pound weight loss in 6 months (10% loss). Review of Resident #2's Nutrition Assessments, dated 09/17/13 and 10/15/13, identified a weight goal of "180-190" pounds. The facility failed to complete additional Nutrition Assessments after October 2013 even though Resident #2 continued to lose weight. Resident #2's "Dietary Profile," dated 02/11/14, identified the resident received a regular, dental soft diet and an eight ounce nutritional supplement in the "PM, HS (before hour of sleep), and with meals." Review of Resident #2's dietary/nutritional notes, stated, *10/15/13 - "Nut (Nutritional) Risk 183 #. Returned from hospital yesterday. Had pneumonia . . . ." *01/21/14 - "Nurition (sic) risk has had significant wt (weight) loss in 4 months since admit. Eats quickly so was pureed but did not like it and did not eat well. Diet upgraded to dental soft. Ground meats provided. Food is served in divided plate. Meal intakes have improved slightly. He was also moved to a table with all men with staff assistance. Staff cue to slow down. Continues to receives supplements and 2 snacks at 3 p.m. and HS. Enhanced cereal at breakfast . . . Prefers sweet foods . . . ." *02/18/14 - "Nutrition risk . . . has variable intake at meals. He feeds himself after meal set up. staff cue and assist if needed . . . Wt is 162 (pounds) . . . Overall has lost 7% in 3 months. Offered HS sandwich and supplements 5 (times) per day for added nutrition . . . Supplements at meals and 3 p.m. taken well. Usually sleeping HS so does not take supplement or snack. Follow another month on nutrition risk. Observations of meal intakes for the breakfast meal on 03/11/14 at 8:45 a.m. and the lunch meal on 03/11/14 at 12:45 p.m. identified Resident #2 consumed 51%-75% of both of these meals. Observation showed the facility failed to provide any supplements during these meals. During interview on the afternoon of 03/12/14, an administrative nurse (#1) stated the facility discontinued offering meal time supplements "a few weeks" ago on the recommendation of a corporate consultant. An administrative nurse (#1) stated the corporate consultant recommended to only provide supplements if a resident consumed less than 50% of either breakfast, lunch, or supper. Review of Resident #2's meal intake logs dated March 01-12, 2014, identified the resident consumed less than 25% of the meal on three occasions (the lunch and supper meal on March 3, supper meal on March 6, and the supper meal on March 11), and staff members failed to provide Resident #2 with a snack/food intervention. During interview on the afternoon of 03/12/14 with a dietary staff member (#2), identified dietary staff provides a 3 p.m. house supplement (also known as a "Health Shake") for nursing staff to give to Resident #2. The dietary staff member (#2) stated the facility stopped providing the 8 p.m. snack related to Resident #2 being in bed and/or sleeping at that time. Review Resident #2's house supplement documentation records for the 3 p.m. supplement from March 01-12, 2014, identified the facility offered the house supplement on only one occasion (March 12). The facility failed to establish a system to ensure Resident #2 is weighed with the same scale each time, comprehensively assess his continued weight loss, implement existing dietary interventions (mealtime supplements and snacks at 3 p.m. and 8 p.m.), and document the amount of house supplements offered and consumed. These failures resulted in Resident #2 experiencing a severe weight loss of 18.5 pounds in 6 months.

1. Based on record review, review of facility policy and procedure, and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #7) who experienced a fall resulting in a [MEDICAL CONDITION] received the necessary care and services. Failure to ensure timely evaluation and treatment after the resident's fall resulted in Resident #7 experiencing unnecessary prolonged hip and leg pain while attempting to ambulate, and may have resulted in avascular necrosis of the right hip. Failure to monitor Resident #7's pain caused the resident unnecessary pain. Findings include: - Review of the facility policy and procedure "Pain Management - Resident Assistance," occurred on 04/28/11. This document stated "PURPOSE, To provide residents assistance in pain management. POLICY, All residents will receive interdisciplinary consultations on assistance in managing pain. . . . The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological. . . ." Review of Resident #7's medical record occurred on April 25-28, 2011. The facility admitted the resident in November 2005. Current [DIAGNOSES REDACTED]. Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], identified he usually understood others and sometimes made himself understood, had unclear speech, had severe cognitive impairment, had continuous disorganized thinking, and required extensive assistance of one person and a walker to ambulate and transfer. Resident #7's Cognitive Care Area Assessment, dated 11/26/10, stated ". . . does not have a MR (mental [MEDICAL CONDITION]) diagnosis, but it is suspected. . . ." Resident #7's current care plan, dated 06/01/10, stated "Problems . . . I have a hard time communicating my needs. . . . My speech is garbled and mumbly. . . . Approaches . . . Give me the time to express myself, I may repeat myself. Help me out with Yes or No questions. Sometimes I give nonverbal clues (pointing) to get my point known. . . . Problems . . . Potential for alteration in comfort m/b (manifested by) has complaint of pain, arthritis. . . . Approaches . . . Adm (Administer) pres (prescribed) [MEDICATION NAME] & (and) report unrelieved/persistent pain. Non-pharmacological interventions to be tried . . . Reposition for comfort as needed. . . ." Resident #7's physician orders included the following pain medications: Tylenol 1000 milligrams (mg) two times each day (BID) and Tylenol 650 mg every four hours (q4h), as needed (PRN). The resident's medication administration records (MARs) for the period March 01, 2011 through April 26, 2011 showed Resident #7 did not receive any of the PRN Tylenol during this period. Resident #7's medical record included the following entries: *Interdisciplinary Progress Notes (IDPN), dated 03/16/11 at 9:00 a.m., ". . . resident was on toilet (with) alarm on and took alarm off and self ambulate (sic) across bathroom. Lost balance and fell to buttocks. . . . 03/16/11, 6:00 p.m., "No c/o (complaints of) re: (regarding) fall this a.m. . . . 03/18/11, 11:00 a.m., "Fax sent to (physician) re: resident fall on 03/16/11 . . . Now c/o (R) (right) leg pain from hip to knee. Does bear some wt. (weight). Refuses to ambulate because it hurts. Should we do an x-ray(?)" *Fax Communication To Physician, dated 03/18/11, 8:48 a.m., ". . . Concern: Resident fell on [DATE] self transfer from toilet. Now c/o (R) leg pain from hip to knee. Does bear some wt. Refuses to amb. (ambulate) because it hurts. Should we do an x-ray(?)" 03/21/11, 10:45 a.m., Fax response from the provider, "How is he today, 03/21/11?" Undated, untimed, unsigned response to the provider on the same fax form, "No further complaints from (Resident #7) over the weekend or today. Thanks." *Restorative Program notes included Ambulation Distance, for the period March 01-15, 2011, which varied from 0 feet (due to refusal unrelated to pain) to 300 feet; and, from March 16-30, included Ambulation Distance, as follows: 03/16/11 - 30 feet; 03/17/11 - 30 feet; 03/18/11 through 03/20/11 - none; 03/21/11 - 300 feet; 03/22/11 - none; 03/23/11 - 100 feet; 03/24/11 - 50 feet; 03/25/11 - 100 feet; 03/26/11 through 03/28/11 - none; 03/29/11 - 50 feet; and 03/30/11 - none. Ambulation attempts have been on hold since 03/31/11. * Restorative Program narrative notes, all untimed, stated: 03/18/11, "Resident attempt to ambulate. C/o of right leg hurting." 03/19/11, "Resident (R) leg hurts him." 03/20/11, "Resident still c/o (R) leg hurting." 03/22/11, "Resident still c/o (R) leg hurting." 03/26/11, "Resident attempted to ambulate. No success. Resident stated 'that he could not get moving.' " 03/27/11, "Resident still c/o hurt leg hurting. Resident stated his leg still hurts." 03/30/11, "(Resident #7) is not himself - just doesn't have any energy." * IDPN, 03/31/11, 2:30 p.m., "Res. (Resident) continues to c/o pain to his (R) leg. There is no shortening of the leg or bruising. Res. does have decreased ROM (range of motion) and strength in (R) leg. Physical Therapy reports that res. does not bear wt. on the (R) leg. Called (provider) @ (at) (clinic) and received order to do x-ray on (R) leg tomorrow @ (clinic)." * IDPN, 04/01/11, 10:30 a.m., "Resident to (clinic) for x-ray of (R) leg as ordered/noted above. . . . Upon questioning this a.m., resident denied pain. Resident receives scheduled ES (Extra Strength) Tylenol X (times) 2 BID. Has not requested nor received any additional prn doses in past month." * IDPN, 04/04/11, 9:35 a.m., "Spoke (with) (provider). Hip is fractured. . . ." * IDPN, 04/05/11, no time, "Resident to . . . (orthopedic surgeon) to consult re: above. . . ." Resident #7's medical record included an orthopedic surgeon's note, dated 04/05/11, which identified an "impacted subcapital fracture" of the right hip with "early nonunion and avascular necrosis" and advised surgical repair. Surgical repair was scheduled for 04/26/11 and cancelled on the instruction of the resident's power of attorney. An Internet site, medilexicon.com, "Stedman's Online Medical Dictionary," 2006, Lippincott, Williams & Wilkins defines a subcapital femur fracture as "at the point where the neck of the femur joins the head" and avascular necrosis as tissue death "resulting from deficient blood supply." During interview, on 04/27/11 at 3:05 p.m., a restorative therapy staff member (#4), who authored the Restorative Program Notes of March 18-27, 2011, reported Resident #7 complained of right hip and leg pain and pointed to his right hip and leg during attempted ambulation on March 18-20, 2011. This staff member (#4) reported she did notify the charge nurse of the resident's leg pain and inability to ambulate. This staff member (#4) also reported she notified the charge nurse of Resident #7's leg pain and inability to ambulate on March 22, 26 and 27, 2011. During interview, on 04/27/11 at 5:45 p.m., a nursing management staff member (#2) and an administrative management staff member (#3) reported they were not aware of Resident #7's complaints of pain to the restorative therapy staff. During interview, on 04/28/11 at 8:15 a.m., staff members (#2) and (#3) reported the facility staff should have contacted the provider by phone on 03/18/11 to obtain orders for Resident #7's hip x-ray instead of waiting for a response to the fax. These staff members did not know why the charge nurse, who the restorative therapy member informed on multiple occasions of Resident #7's pain, did not assess and document the resident's reported pain in the IDPN. It is unknown why the facility staff did not administer PRN Tylenol to Resident #7. The facility failed to follow-up with Resident #7's provider in a timely manner following a fall which resulted in a [MEDICAL CONDITION]. Record review identified the following: evidence of right leg pain extending from his hip to his knee causing discomfort with ambulation two days after the fall; fax communication of this pain to the medical provider, which staff waited over three days for a reply; and staff failure to provide the provider with accurate information regarding Resident #7's complaints of right hip and leg pain as documented and reported by the restorative therapy staff member beginning on 03/18/11. These failures resulted in a 13 day delay in receiving an order for [REDACTED].#7 continued to experience untreated pain. This delay may have resulted in the orthopedic [DIAGNOSES REDACTED]. 2. Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to ensure 1 of 1 sampled resident with reduced bowel function and who experienced increased pain and inactivity after a fall and fracture (Resident #7) received the necessary care and services regarding dietary interventions to promote bowel function. Failure to provide dietary interventions may have resulted in reduced bowel function and an increased use of bowel medications. Findings include: Review of the facility policy and procedure "Bowel Assessment," occurred on 04/28/11. This document, revised 09/10, stated "PURPOSE, To assess bowel function appropriately; To identify effective bowel management programs. DEFINITIONS, Constipation: If the resident has two or fewer bowel movements during the seven-day look-back period . . . PROCEDURE, Assessment . . . 4. Use the following assessment data to determine the need for a program: a. Physical and Mental Status: Need to look at the nature of neurological alteration; cognition; ability to communicate; presence of related physical and emotional conditions. b. Bowel History: Consider past and present bowel history. Look at . . . episodes of constipation . . . c. Nutritional History: Food preferences . . . fiber and fluid adequacy . . . d. Functional Ability: . . . assistance for bowel management and for eating; energy/endurance level and joint diseases that limit mobility. e. Medications: What has been used in the past . . . Possible Interventions and Modifications, 1. Plan interventions based on the individual resident and the assessment: a. Diet: Add fiber to the diet . . . b. Fluid Intake . . . c. Activity . . . 2. The care plan interventions should be individualized based on the CAA (Care Area Assessment) assessment and modify the plan as appropriate based on an assessment of the resident's unique bowel elimination pattern. . . ." Review of Resident #7's medical record occurred on April 25-28, 2011. The facility admitted the resident in November 2005. Current [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance of one person with toileting, frequently incontinent of bowel, and on a toileting program. The resident's Dehydration/Fluid Maintenance CAA, dated 11/26/10, stated, ". . . will say that is enough when it comes to fluids. He will not take more when encouraged. . . ." Resident #7's Nutrition Assessment, dated 11/16/10, stated ". . . Hx. (History) constipation. Tried pears 1 X (time) day (with) no change. Bowel regular meds (medications)." Resident #7's Interdisciplinary Assessments and Summary Reviews stated the following: 11/19/10, Nursing, ". . . He is on scheduled/prompted toileting program to promote bowel continency. . . . He does have some problems (with) constipation. . . ." 11/23/10, Dietary, ". . . Receives [MEDICATION NAME] daily. Was recommended to give pears daily to promote regularity, did not change bowel pattern for past 3 weeks. . . ." 01/24/11, Nursing, ". . . He does use bowel aids. . . . He has potential for dehydration d/t (due to) refusal to drink all his fluids @ meals et (and) was offered during the day." Resident #7's current care plan, dated 06/01/10, stated, "Problems . . . I will not drink all of my fluids. . . . Approaches . . . Refuses drink (sic) supplements. Verbal reminders to finish fluids at meals. . . . (updated 08/24/10) Problems . . . Take me to BR (bathroom) per approach to promote bowel continency. . . . Approaches . . . Assist me to the toilet upon rising, one hr. (hour) (with) in meals, bedtime, when I state/gesture. . . ." Resident #7's current physician orders included orders for [MEDICATION NAME] (laxative) 30 milliliters at bedtime, with an original order date of 11/30/05; [MEDICATION NAME] S (stool softener and laxative combination) three tablets two times each day, and two tablets at 12:00 noon daily, with an original order date of 06/27/07; [MEDICATION NAME] (stool softener) 10 milligrams (mg) oral or suppository daily, as needed (PRN); and [MEDICATION NAME] (soluble fiber) in juice at breakfast. Review of Resident #7's PRN medication administration records (MARs) for January 2011 through 04/23/11 identified the resident received the [MEDICATION NAME], orally or suppository, as follows: January: 6 times February: 6 times March: 7 times April: 9 times Review of Resident #7's BM (Bowel Movement) Record for the period October 27, 2010 through April 27, 2011 showed a frequency of bowel movements approximately every two to four days. Bowel frequency in November 2010, during the trial of pears, was approximately every three to four days. During the period April 02-09, 2011, the resident did have PRN [MEDICATION NAME] on 04/06/11 and 04/08/11, and did not have a bowel movement until 04/09/11. Resident #7's medical record identified he experienced a fall on 03/16/11 with complaints of pain and further reduced activity beginning on 03/18/11 and this continued through 04/28/11. Observation of Resident #7 during the breakfast and noon meals on 04/26/11 and the breakfast meal on 04/27/11 showed he received juice with [MEDICATION NAME] added, water, coffee, and milk and consumed approximately half of these fluids at each meal. During interview, on 04/27/11 at 4:30 p.m., a dietary management staff member (#5) reported Resident #7 does not consume fluids well and pears were provided for three weeks in 11/10 for bowel assistance without change in his bowel pattern. This staff member reported she was not aware of any further communication with other facility staff regarding Resident #7's bowel frequency, including since his fall on 03/16/11 and reduced activity. This staff member (#5) confirmed the only additional dietary fiber Resident #7 receives is the [MEDICATION NAME] in his juice. This staff member agreed since Resident #7 does not consume all his juice, he does not receive the full amount of [MEDICATION NAME]. During interview, on 04/28/11 at 8:15 a.m. a nursing management staff member (#2) and an administrative management staff member (#3), agreed the facility's dietary interventions for Resident #7's bowel management had been limited. These staff members also agreed Resident #7's reduced physical activity and potential increase in pain and pain medications placed him at increased risk of constipation and did require re-assessment and intervention. These staff members reported the facility staff added pears to Resident #7's daily diet on 04/27/11. The facility identified Resident #7's fluid intake was poor and has a history of constipation. The resident received the same oral laxatives since 06/27/07, nearly four years. Dietary interventions remained limited to fiber added to his juice (which the resident consumed poorly) and a three week trial of pears in November 2010). Resident #7's fall with injury on 03/16/11, reduced activity, pain, and increased pain with activity places him at increased risk of constipation. The resident's bowel records show a reduced frequency of bowel activity and increased use of PRN laxative since the fall. Continued use of laxatives and stool softeners may have resulted in Resident #7 being dependent on these medications for bowel movements. Failure to provide dietary interventions placed him at increased risk of dependence on these medications and at risk of constipation. Failure to provide dietary interventions after his fall and reduced activity has resulted in increased constipation and increased use of laxatives.