Every finding on record at St Catherines Living Center

Based on record review, review of the facility reported incident (FRI) and investigation, and review of facility policy, the facility failed to ensure residents remained free from abuse for 1 of 1 closed record (Resident #51) who displayed physical behaviors towards another resident. Failure to protect residents from physical abuse resulted in injury and pain. 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 Prevention Plan occurred on 01/29/26. This policy, dated year 2017, stated, . In order to prevent abuse . the facility shall do the following . Identify, correct, and intervene in situations where abuse . occurs. Assess residents with needs and behaviors that might lead to conflict . The facility will develop an individual abuse prevention plan for each vulnerable adult who receives services in the facility. The plan shall contain an individual assessment of . The resident's risk of abusing other vulnerable adults; and Specific measures to be taken to minimize the risk of abuse . of residents and other vulnerable adults. Once suspected abuse . has been identified, safety measures will be implemented to ensure the safety of the suspected vulnerable adult and other residents.The surveyor determined a deficient practice existed on 03/27/25 when Resident #51 punched Resident #19 in the face. The facility implemented and completed corrective action on 04/03/25.Review of Resident #19's medical record occurred on all days of survey and identified diagnoses of traumatic brain injury and dementia with behaviors. A Brief Interview for Mental Status (BIMS), completed on 03/27/25, identified a score of 11 indicating moderately impaired cognition. Review of Resident #51's medical record occurred on all days of survey and identified diagnoses of mild vascular dementia with agitation and moderate recurrent major depressive disorder. A BIMS, completed on 03/27/25, identified a score of 13 indicating minimal cognitive impairment. The care plan identified . Behavioral Symptoms. I have a hx [history] of socially inappropriate/disruptive behavioral symptoms such as threatening to cause harm to other residents, not being receptive to staff when trying to redirect or re orientate, being verbally aggressive towards other residents, and a hx of becoming physically abusive towards other residents. Staff updated the care plan after the incident on 03/27/25. The medical record identified Resident #51 transferred to another facility on 04/03/25.Review of the FRI report/final investigation, dated 04/03/25, stated, . Resident [#19] was hit in the face by another resident [Resident #51]. Residents involved were immediately separated by staff witnessing incident. Resident [#19] sent to Emergency Department [ED] for further evaluation. Police on site investigating. Investigation indicated that allegation of abuse was verified as occurring and meeting the definition for abuse. [Resident #51] was asked in an interview with SSD [social service director] if he meant to cause physical harm and wished to cause pain, this resident stated 'yeah, that's why I punched him.' .Resident #51's progress note, dated 03/27/25 at 5:14 p.m., stated, At 4:45pm heard hollering coming from commons area. Assessed situation and witnessed resident [Resident #51] standing over a male resident [Resident #19] while holding his fist up towards resident. RN [registered nurse] present and intervened, preventing resident throwing another punch. This nurse assisted resident [#51] back to his room via wheelchair. Resident appeared angry with red eyes. Resident comments on how he 'hates that guy', 'I just wanted to hit him'. Interview completed with resident [#51]. Resident states, 'My lady bumped into him [Resident #19] and he [Resident #19] told her to knock it off. I told him [explicative] and punch [sic] him in the face'. Informed resident [Resident #51] there will likely be consequences, resident states 'I don't care, it was worth it!' Resident told to stay in his room. Resident states understanding. SW [social worker] and administrator informed right after.Resident #19's progress note, dated 03/27/25 at 4:45 p.m., stated, . On initial assessment, resident [Resident #19] complained of pain on left temporomandibular area. Noted redness on said area with no immediate swelling. Re-assess after 10 minutes and resident still complains of pain and claims to be increasing; resident rated 7-8/10 headache. Rated pain on mentioned area on face as 2/10; no worsening of swelling or redness noted. sending resident to ER [emergency room] for further evaluation. A note, dated 03/27/25 at 8:12 p.m., stated, . Resident returned from ED . with no new orders. Noted to have mild redness on left side of face without bruising developing. Resident rates pain on area 1/10 and denies headache.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, assessed for injury, and sent Resident #19 sent to the ER for further evaluation.*Notified the Executive Director and SSD. Camera footage reviewed.*Notified local law enforcement and law enforcement took statements.*Notified family, primary care providers, and psychiatric providers for both residents.*Notified the State Ombudsman.*Resident #51's medication reviewed by psychiatric provider.*Interviewed Resident #19 and #51.*Implemented one-to-one support and 15-minute safety checks for both residents. *Educated Resident #51 on nursing home guidelines and physical aggression is not tolerated. *Care plans updated for both residents.*Held a team huddle with staff on duty to discuss the incident, immediate actions taken, how to handle resident to resident altercations, and reviewed the facility abuse policy.

Based on observation and review of professional reference, the facility failed to maintain a clean and sanitary kitchen for 2 of 2 kitchens (North Kitchen and South Kitchen). Failure to ensure tableware is placed on resident meal trays in a sanitary manner and ensure floors, cabinets, and the warewashing machine are free from food, dust, and mineralization debris has the potential for contamination of dishware/food and may result in foodborne illness to residents, staff, and visitors. Findings include:The 2022 Food and Drug Administration (FDA) Food Code, Section 4-904.13, page 455, stated, The presentation or setting of . cleaned and sanitized utensils shall be done in a manner designed to prevent the contamination of food- and lip-contact surfaces. Section 6-501.17, page 476, stated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. Observations on 01/25/26 at 12:20 p.m. showed the following:* North Kitchen: Burnt loose and baked-on debris in two ovens located under a stove and scattered food/debris on the floors throughout the kitchen and in the mechanical warewashing room.* South Kitchen: Burnt loose and baked-on debris in the double ovens, an approximate 14-inch linear area of dried food on the side of a silver lower cabinet, scattered food/debris on the floors throughout the kitchen, and mineral buildup and food debris located under the handwashing sink.Observations on 01/27/26 at 9:30 a.m. showed the following:* North Kitchen: Loose debris, dust, and mineralization accumulated on the top of the mechanical warewashing machine and the scattered food/debris remained on the floors throughout the kitchen and the mechanical warewashing room.* South Kitchen: Dried food on the side of the cabinet and the scattered food/debris remained on the floors throughout the kitchen and under the handwashing sink. New debris present on the floor from cleaning the double ovens. - Observation on 01/28/26 at 8:20 a.m. showed two unidentified dietary staff members failed to perform hand hygiene and touched the rims of the water, juice, milk, and coffee cups with their bare hands when removing the covers and/or arranging them onto the resident meal plates.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure accurate medication labeling and storage for 1 of 1 resident (Resident #3) observed receiving insulin and 1 of 3 medication carts (cart #700). Failure to ensure proper medication labeling and storage may result in medication errors and unauthorized access to medications.Review of the facility policy titled Labeling of Medications due to order change occurred on 01/28/26. This undated policy stated, . 1. If change in medication dose pharmacy either A) sends a see mar for orders label . or B) sends new label . 2. If pharmacy does not send a see mar for order label the nursing staff are to continue to administer the correct does per the physician orders in the electronic records until pharmacy has complied.Review of the facility policy titled Administering Medications occurred on 01/28/26. This policy, revised on 08/31/23, stated, . 14. Medication cart is to be locked at all times when unattended. - Observation on 01/26/26 at 9:12 a.m. showed the label on Resident #3's insulin pen identified Lantus Solostar (an insulin medication) ten units in the morning. A nurse (#2) prepared twelve units of insulin and stated the provider changed the insulin order on 11/17/25, and the correct dose of 12 units is in the electronic medication administration record (eMAR).Review of Resident 3's eMAR occurred on 01/26/26 showed Lantus Solostar twelve units; with a start date of 11/17/2025. During an interview on 01/26/26 at 4:00 p.m., an administrative nurse (#1) confirmed the medication label did not match the physician's order in the eMAR. The administrative nurse (#1) stated the insulin pen labels typically say, See MAR for dose and she expects staff to follow the eMAR.-Observation on 01/25/26 at 4:00 p.m. showed a medication cart (#700) unlocked and unattended and a staff nurse (#4) down the hallway.-Observation on 01/27/26 at 7:45 a.m. showed a medication cart (#700) unlocked and unattended. Eight minutes later, an administrative nurse (#1) walked by the medication cart (#700) and locked it.During an interview on 01/27/26 at 3:39 p.m., an administrative nurse (#1) stated she expects staff to lock the medication cart when unattended.

Based on observation, review of facility policy, and resident and staff interviews, the facility failed to ensure a clean and homelike environment for 2 of 9 sampled residents (Resident #9 and #34) with a shared bathroom. Failure to maintain a clean and sanitary bathroom does not promote a homelike living environment or enhance the resident's quality of life. Findings include:Review of the facility policy titled Environmental Services - Cleaning occurred on 01/29/25. This policy, dated 2020, stated, . It is the policy of Benedictine communities that they be maintained in a clean and hygienic condition . Clean surfaces such as . toilet seats . according to the schedule established by EVS [environmental service] supervisor. Community trash containers should be lined .Observations of Resident #9 and #34's shared bathroom showed the following:*01/25/26 at 2:01 p.m., Bowel movement (BM) splattered throughout the inside of the toilet bowl and smeared on the back and top of the toilet seat. A trash can without a liner located beside the toilet contained several soiled wipes. Resident #34 stated housekeeping had not cleaned her bathroom yet today.*01/25/26 at 2:28 p.m., Resident #34 stated staff just completed her toileting cares in her bathroom. BM remained present in the toilet bowl and on the toilet seat.*01/26/26 at 8:10 a.m. and 1:54 p.m., BM splattered in the toilet bowl and smeared on the toilet seat. Resident #34 stated housekeeping had still not been in to clean her room/bathroom.*01/26/26 at 4:44 p.m., The toilet bowl and seat remained the same. Resident #34 stated no housekeeping occurred in her room again today.During an interview on 01/26/26 at 8:35 a.m., a housekeeping staff member (#5) indicated housekeeping staff are present at the facility seven days a week. During an interview on 01/26/26 at 4:53 p.m., an administrative staff member (#1) stated she expects staff to notify housekeeping to address bathroom cleanliness or clean areas with sanitizing wipes after care provided.

Based on observation, record review, review of facility policy and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents (Resident #14) and one supplemental (Resident #30) observed during cares. Failure to practice infection control standards related to glove use and hand hygiene has the potential to spread infection throughout the facility.Review of the facility policy titled Hand Hygiene occurred on 01/29/26. This policy revised September 2023, stated, . Times to Perform Hand Hygiene are, but not limited to: . Before and after direct resident contact . assisting a resident with personal cares . assisting a resident with toileting . After removing gloves . - Observation on 01/25/26 at 1:12 p.m. showed a certified nurse aide (CNA) (#3) transferred Resident #30 to the toilet using a stand lift. Without wearing gloves, the CNA (#3) removed the resident's wet brief, applied gloves without performing hand hygiene, placed a clean brief on the resident, removed her gloves and wiped her hands on her pants. Without completing hand hygiene, the CNA (#3) applied new gloves and completed perineal care for Resident #30, removed her gloves, assisted the resident to bed and exited the room without completing hand hygiene. During an interview on 01/28/26 at 10:45 a.m., an administrative nurse (#1) stated she expects staff to perform hand hygiene with an alcohol-based hand sanitizer after resident cares and in between glove changes. -Review of Resident #14's medical record occurred on all days of survey. The care plan stated, . I require enhanced barrier precautions [EBP] r/t [related to] chronic ulcer on right thigh and colostomy . suspected carrier of MRSA [methicillin resistant Staphylococcus aureus]. Observation on 1/26/26 at 10:10 am. showed a nurse (#6) applied a gown and gloves and entered Resident #14's room. The nurse (#6) obtained supplies from a dresser in the resident's room and placed the supplies on the bedside table. The nurse (#6) removed the dressing from Resident #14's right hip wound and cleaned the drainage from the wound. Without removing the soiled gloves, the nurse opened clean dressings, cleansed the wound with normal saline, and patted it with a gauze. The nurse (#6) opened another dressing, placed it on the wound, and taped the dressing in place. The nurse (#6) then removed the gown and soiled gloves and exited the room. The nurse failed to perform hand hygiene before entering and exiting the resident's room and failed to remove the soiled gloves and perform hand hygiene between soiled and clean dressing changes. During an interview on 01/28/26, an administrative nurse (#1) stated she expected staff to perform hand hygiene with dressing changes.

Based on record review, review of facility policies, and staff interview, the facility failed to provide the necessary care and treatment for 1 of 2 sampled residents (Resident #2) with impaired skin integrity of the feet/toes. Failure to assess, monitor, and treat skin issues in a timely manner resulted in a delay of treatment and contributed to Resident #2's hospitalization for amputation of fourth and fifth toes. Findings include: Review of the facility policy titled Prevention and Treatment of Skin Breakdown occurred on 03/11/25. This policy, dated 09/01/18, stated, . Skin integrity is monitored and abnormal findings are documented: Skin is observed daily with cares. Review of the facility policy titled Change in Condition occurred on 03/11/25. This policy, revised 10/02/23, stated, . Update the care plan as appropriate. Review of Resident #2's medical record occurred on 03/11/25. Diagnoses included peripheral vascular disease (PVD). Resident #2 tested positive for COVID (Coronavirus disease) and was placed in isolation from February 9-16, 2025. A physician's order, dated 02/11/24, stated, Monitor the wound every 7 days to include measurements. Notify MD [physician] if no change in 2 weeks Review of Resident #2's care plan identified the following: * Skin treatment as ordered and/or as needed. * Report any signs of skin breakdown (sore, tender, red or broken areas). Review of Resident #2's progress notes identified the following: * 02/10/25 at 1:37 p.m., SKIN ASSESSMENT In-between 4th and 5th toe on left. 4th toe, inner medial [in the middle]; eschar [dry, thick, leathery skin] noted measuring W [width] 0.7 cm [centimeter] X [by] L [length] 0.5 cm. Surrounding skin light red and blanchable [redness to the skin disappears when pressure is applied and reappears when pressure is released]. 5th toe, inner medial; eschar noted measuring W 2.2 cm X L 1.1 cm. Surrounding skin light red and blanchable. Anterior [in the front] toes also light red and blanchable. Not warm to the touch. Area cleansed with saline and gaze [sic]. Area covered with betadine [topical antiseptic] and Vaseline gauze, secured in place with dressing. Orders placed [no orders found in the resident's medical record] for dressing change every 3 days. PA [physician's assistant] informed and will assess when in house on 2/12/25. * 02/11/25 at 9:08 a.m., . IDT [interdisciplinary team] met to review plan of care. Nursing continues to monitor COVID symptoms and skin with new wounds to left 4th and 5th toes. * 02/12/25 at 11:12 a.m., Wounds to 4th and 5th toe, left assessed by [name of PA] Resident to be seen by podiatry once off of Isolation precautions. * 02/13/25 at 9:11 a.m., IDT met to review plan of care. Nursing continues to monitor COVID symptoms and skin with new wounds to left 4th and 5th toes. * 02/18/25 at 1:25 p.m., PA in facility for rounds. Notified regarding resident's left 4th and 5th toe. 5th toe appears to have black discoloration with inner aspect appearing to have black eschar. 4th toe appears purple in color with medial aspect of toe covered with black eschar, surrounding skin is red . Resident verbalized not [NAME] [sic] able to sleep last night due to pain to area. PA recommendation to have resident sent to [name of hospital] ER [emergency room ] for further evaluation and intervention. * 02/18/25 at 3:36 p.m., Resident has been hospitalized at [location of hospital] for possible PVD & foot infection. * 02/24/25 at 2:30 p.m., Note Text: Resident Returned from [name of hospital] Hospital at 12pm [12:00 p.m.] following admission for amputation of 4th and 5th toe, left d/t [due to] gangrene [death of skin tissue]. Resident denies pain. Dressing noted to left foot and is to stay in place until 1 [one] week follow up with provider, per orders. Nursing to monitor every shift to ensure dressing is CDI [clean, dry, intact]. Darco [brand of protective shoe] shoe to be worn when up with reminder to have resident put pressure on heel when standing. The February 2025 treatment administration record lacked documentation of skin assessment/treatment, and the electronic health record (EHR) lacked the orders for a dressing change every three days as stated in the progress note dated 02/10/25. The nurse documented a weekly skin check on 02/13/25, but failed to identify/assess the impaired skin integrity on resident #2's toes. The EHR lacked a progress note from the PA's inhouse visit on 02/12/25. During an interview on the afternoon of 03/11/25 an administrative nurse (#1) confirmed the PA did not document an assessment/progress note and/or orders from the visit on 02/12/25. The facility failed to initiate treatment for toe wounds in a timely manner, assess, monitor, and document abnormal skin conditions daily, ensure the availability of PA notes post visit, and effectively communicate with the provider regarding treatment.

Based on review of the facility reported incident (FRI) and investigation reports, record review, review of facility policy, and staff and resident interviews, the facility failed to provide an environment free of verbal abuse for 1 of 1 sampled resident (Resident #19) with an allegation of abuse. Failure to identify abuse and ensure residents are free from verbal abuse and abusive gestured language, which includes disparaging and derogatory terms caused fear, anxiety, mental anguish, and psychosocial harm. During the on-site recertification survey and FRI investigation, the team consulted with the State Survey Agency (SSA) on 11/21/24 at 8:44 a.m. and determined an immediate jeopardy (IJ) situation existed on 10/21/24. The facility failed to recognize the abuse, failed to assess the resident physically and mentally, failed to notify the IDT (Interdisciplinary Team), failed to update the care plan, and failed to notify the resident's provider. * 11/21/24 at 10:10 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. * 11/21/24 at 12:45 p.m., the survey team reviewed and accepted the facility's removal plan. The removal plan contained the following: * CNA (#AA)'s file was updated to include do not rehire. * All staff were retrained on immediate re-education on definitions of abuse and how to identify abuse. * Remaining facility staff were re-educated prior to the start of their next shift. * The facility's regional registered nurse re-education administrative staff members (#1 and #2) on definitions of abuse and how to identify abuse. * Remaining administrative staff to be educated by administrative staff members (#1 and #2). * An automated notification was sent to all staff regarding the mandatory re-education prior to start of next shift. * An education packet will be put in the employee newsletter for reference. * On 11/21/24 at 12:32 p.m., the survey team verified the implementation of the removal plan as of 11/21/24 and the IJ removal. The deficient practice remained at an G scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Abuse Prevention Plan occurred on 11/20/24. This policy dated 2017, stated, . 'Abuse': The willful infliction of . intimidation . resulting in . mental anguish. It includes verbal abuse . and mental abuse . use of . malicious oral . or gestured language toward a vulnerable adult or the treatment of a vulnerable adult which would be considered by a reasonable person to be disparaging, derogatory, humiliating, harassing, or threatening . Review of Resident #19's medical record occurred on 11/20/24. A care conference progress note, dated 10/09/24 at 4:10 p.m., stated, Resident is cognitively intact per BIMS [Brief Interview for Mental Status] score of 15, resident is his own decision maker. The care plan, revised 08/01/24, stated, . I am a vulnerable adult and need assistance to remain safe within the community. My vulnerabilities include needing assistance with my ADLS (activities of daily living), transfers, use of wheelchair, vision impairment, behaviors towards staff, and difficulty communicating due to unclear speech at times. * Review of the investigation report occurred on 11/20/24. The report dated 10/28/24, stated, Investigation indicated that allegation of abuse was unsubstantiated although through the investigation process it appears likely a verbal altercation did occur between [Resident #19] and alleged staff member [CNA #AA]. The resident [Resident #11] across the hall verified hearing yelling between the two. During an interview on 11/20/24 at 1:59 p.m., Resident #19 indicated a CNA put him to bed. After being put to bed CNA (#AA) came into his room, leaned over his bed, and said, If you don't stop talking about me, I'm going to put a pillow over your head and kill you. When asked if he was scared, Resident #19 said Yes, wouldn't you be? During an interview on 11/20/24 at 2:06 p.m., Resident #11 stated one night in October he/she heard yelling between Resident #19 and CNA (#AA). He/she could not make out what was being said, but recalled it was around 11:00 p.m. During a phone interview on 11/20/24 at 2:55 p.m., a CNA (#5) could not recall the day she conversed with CNA (#AA), but did recall CNA (#AA) stating, he would put a pillow over his [referring to Resident #19] head. She did not take CNA (#AA) seriously and failed to report the statement to management. During a phone interview on 11/20/24 at 3:28 p.m., a CNA (#3) recalled a conversation she had with Resident #19. She stated Resident #19 told her that she should have stayed another 15 minutes the night before because [expletive] went down. Resident #19 said CNA (#AA) had come in his room, leaned over his bed, and said, If you don't stop talking [expletive] about me, I'm going to put this pillow over your face and kill you. The CNA (#3) also recalled having a conversation with Resident #11 and he/she told her about the yelling that occurred the night before between Resident #19 and CNA (#AA). During a phone interview on 11/20/24 at 3:46 p.m., a CNA (#AA) denied the allegations against him. He stated, It never happened, and I did not go in his room. No one told me that I couldn't go in his room. I worked with him one more time after that. He was a little better, I did go in another time, when he was sleeping, to empty his urinal. During an interview on 11/20/24 at 5:00 p.m., two administrative staff member (#1 and #2) indicated they spoke with the consulting social worker and the consultant determined the facility had come to the right decision. Administrative staff member (#2) stated, We highly suggested CNA (#AA) should resign or that he would be terminated. Administrative staff member (#1) confirmed CNA (#AA) resigned from his position and confirmed they marked this employee is eligible for rehire on his employment information record. After the IJ was called, CNA (#AA)'s employment record was changed to do not rehire.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1) and staff interview, the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the residents' status for 3 of 3 sampled residents (Resident #19, #23, and #30) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page A22-A23, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . Review the Level I PASRR form to determine whether a Level II PASRR was required. Review the PASRR report provided by the State if Level II screening was required. Code 0, no: . if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening, or Level II screening determined that the resident does not have a serious MI [mental illness] . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Review of Resident #19's medical record occurred on all days of survey and identified a Level 2 PASRR completed 08/03/18 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS, dated [DATE], failed to identify a Level 2 PASRR had been completed and the resident had a serious mental illness. During an interview on 10/11/22 at 3:25 p.m., a nurse (#1) confirmed the admission MDS was miscoded for A1500. - Review of Resident #23's medical record occurred on all days of survey and identified a Level 2 PASRR completed 10/19/15 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS, dated [DATE], failed to identify a Level 2 PASRR had been completed and the resident had a serious mental illness. During an interview on 10/11/22 at 3:25 p.m., a nurse (#1) confirmed the annual MDS was miscoded for A1500. - Review of Resident #30's medical record occurred on all days of survey and identified a Level 2 Preadmission PASRR completed 05/21/08 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS, dated [DATE] failed to identify a Level 2 PASRR had been completed and the resident had a serious mental illness.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 12/03/20. Based on observation, review of facility policy/procedure, and staff interview, the facility failed to follow infection control practices for 5 of 14 sampled residents (Resident #7, #9, #11, #28 and #94) and 2 supplemental residents (Resident #31 and #38). Failure to practice infection control related to hand hygiene and glove use during cares (Resident #7, #9, #11, #28, #31, and #94), and during meal service/feeding (Resident #38) has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/16/21. This policy, dated, June 2017, stated, .all associates will be trained and competent in following proper hand hygiene practices . Times to perform hand hygiene are, but not limited to: . before and after direct resident contact . before and after eating or handling food . before and after assisting a resident with meals . before and after assisting a resident with personal cares . before and after assisting a resident with toileting . after contact with a resident's mucous membranes and body fluids or excretions . after handling soiled or used linens . after removing gloves. Observations showed the following: * 06/13/21 at 4:00 p.m., Resident #94 laid in bed as two certified nursing assistants (CNAs) (#9 and #11) donned gloves prior to providing cares. One of the CNAs (#11) performed perineal care, removed his gloves, and donned new gloves without sanitizing/washing his hands. Both CNAs (#9 and #11) put a clean brief on Resident #94, pulled up her pants, and placed blue boots on her feet. * 06/13/21 at 5:00 p.m., a dietary staff member (#5) wore gloves while plating food during meal service and handled ready-to-eat food while wearing the same pair of gloves. * 06/13/21 at 5:29 p.m., a CNA (#9) assisted Resident #38 to drink fluids. The CNA (#9) touched the front of his/her face mask and without performing hand hygiene continued to assist Resident #38 to drink his/her fluids. * 06/13/21 at 6:03 p.m., a CNA (#9) hugged another CNA that entered the dining room while waiting to serve meal trays. The CNA (#9) touched his/her hair, and the sticky side of taped name tag, and without performing hand hygiene, served meal trays and assisted residents with meal set up and eating. * 06/14/21 at 8:05 a.m., two CNAs (#6 and #7) transferred Resident #31 to the toilet for morning cares. The CNA (#6) rinsed his/her hands with water, did not use soap, then donned gloves. The CNA (#7) began morning cares for Resident #31. The CNA (#6) began making the bed. The CNA (#6) touched a soiled sheet, reached into his/her pocket for a bag without removing gloves, placed soiled sheet into bag, continued to straighten the room without removing gloves or performing hand hygiene. * 06/14/21 at 9:48 a.m., a CNA (#6) donned gloves and assisted Resident #7 to the bathroom using a gait belt. The CNA (#6) performed perineal care, pulled up Resident #7's pants, and transferred him/her to the wheelchair. The CNA (#6) wiped the resident's face with a tissue and then removed his/her gloves. The CNA (#6) failed to perform hand hygiene after perineal cares and before completing other tasks. * 06/14/21 at 10:03 a.m., two CNAs (#6 and #7) donned gloves prior to providing Resident #9 cares. A CNA (#6) removed the soiled brief and performed perineal care. Without removing gloves, the CNA (#6) applied a clean brief. Both CNAs adjusted Resident #9's pants and assisted him/her back to the wheelchair with a mechanical lift. The CNA (#6) removed his/her gloves and without performing hand hygiene left the room and returned the mechanical lift to the storage room. * 06/14/21 at 10:20 a.m., two CNAs (#12 and #13) provided morning cares prior to transferring Resident #94 into her wheelchair. A CNA (#13) exited the room without sanitizing/washing her hands and transported the resident to hair care. * 06/14/21 at 12:16 p.m., two CNAs (#3 and #4) donned gloves and performed perineal care for Resident #11 while in bed. The CNAs (#3 and #4) applied a clean brief, pulled his/her pants up, repositioned the resident, and removed gloves. The CNAs (#3 and #4) failed to perform hand hygiene after perineal cares before completing other tasks. * 06/14/21 at 4:30 p.m., Resident #94 laid in bed as two CNAs (#9 and #14) donned gloves prior to providing cares. A CNA (#9) performed perineal care, removed her gloves, and donned new gloves without sanitizing/washing her hands. Both CNAs (#9 and #14) put a clean brief on Resident #94 and pulled up her pants. The CNA (#14) exited the room at this time without sanitizing/washing her hands. * 06/15/21 at 9:51 a.m., a CNA (#3) donned gloves and assisted Resident #28 to ambulate to bathroom. The CNA (#3) removed the soiled brief. Without removing his/her gloves the CNA (#3) opened multiple drawers and doors searching for a clean brief and perineal cleansing cloths. The CNA (#3), while wearing the same gloves, performed perineal care, adjusted resident pants, and ambulated resident to the bed. The CNA (#3) then removed his/her gloves, adjusted the head of the bed, and emptied the trash before performing hand hygiene. During an interview on 06/15/21 at 3:00 p.m., an administrative nurse (#10), confirmed he/she expected staff to perform hand hygiene after glove removal, after exiting rooms, before handling food, before assisting with meals, after touching soiled linen, after performing perineal care, after providing cares to residents, and after touching soiled PPE.

Based on record review and staff interview, the facility failed to ensure the medical record accurately reflected each resident's code level for 1 of 12 sampled residents (Resident #28). Failure to ensure the residents' medical record accurately reflect their wishes prevents staff from following the residents' choice in the event of a medical emergency. Findings include: Review of Resident #28's medical record occurred on all days of survey. An Advanced Directive/Power of Attorney form, dated 10/25/02, signed by Resident #28 stated, I, [resident name], being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The banner in the electronic health record stated, DNR [Do Not Resuscitate] During an interview on 06/15/21 at 6:15 p.m., an administrative nurse (#2) confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #28's medical record reflected resident's code level choice and the signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record review, review of professional reference, review of facility policy and procedure, and staff interview, the facility failed to provide care in accordance with professional standards for 3 of 5 sampled residents (Resident #1, #2, and #7) who experienced an unwitnessed fall. Failure to complete neurological assessments and/or accurately document the results of the assessments following a fall has the potential for a head injury to go undetected. Findings include: [NAME] and Kluwar, Lippincott's Nursing Procedures, 5th Edition, 2009, pages 66-67 stated, Managing Falls . Provide first aid for minor injuries as needed. Monitor the patient's status for the next 24 hours. Even if the patient shows no signs of distress or has sustained only minor injuries, monitor vital signs every 15 minutes for 1 hour, then every 30 minutes for 1 hour, then every 1 hour for 2 hours, or until his condition stabilizes. Monitor neurological assessments with vital signs . Review of the facility policy titled Neurological Assessment occurred on 06/16/21. This undated policy stated, . Neurological observation and assessment is completed with a change in physical function, with an acute change of condition, upon physician order or following an unwitnessed fall and/or subsequent to a fall with a suspected head injury . - Review of Resident #1's medical record occurred on all days of survey. The record identified Resident #1 had severe cognitive deficits and had an unwitnessed fall on 05/06/21. Facility staff failed to complete neurological checks following this fall. - Review of Resident #2's medical record occurred on all days of survey. The record identified Resident #2 had severe cognitive deficits and had six unwitnessed falls on 03/02/21, 03/03/21, 04/19/21, 05/30/21, and (two falls on) 06/06/21. Facility staff failed to complete neurological checks following each of these falls. - Review of Resident #7's medical record occurred on all days of survey. The record identified Resident #7 had severe cognitive deficits and had seven unwitnessed falls on 12/28/20, 01/15/21, 01/26/21, 02/05/21, 02/13/21, 04/01/21, and 05/09/21. Facility staff failed to complete neurological checks following each of these falls. During two interviews on 06/15/21 at 10:25 a m. and 11:35 a.m., an administrative nurse (#2) reported, Nurses do neuro checks during the fall assessment, taking vitals, checking range of motion, looking for an injury. They would do full neuro checks, if there was an obvious head injury or the person reported they hit their head or there was a concern with the previous neuro check. Even if the first neuro check was within normal limits, they should continue with full neuro checks unless indicated by the provider,

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 1 sampled residents (Resident #28) who required supervision in the bathroom. Failure to follow specific supervision instructions for Resident #28 placed the resident at risk of an accident and/or injury. Findings include: Review of Resident #28's medical record occurred all days of survey. A fall risk completed on 04/21/21 identified Resident #28 as having a fall risk assessment score of 15 or high risk. Resident #28's care plan stated, . at risk for falling r/t [related to] decreased mobility requiring staff assistance with transfer and ambulation and decreased safety awareness and cognitive status and diminished eyesight . to be supervised when in the bathroom. Observation on 06/14/21 showed: * 3:51 p.m.: Resident #28 rested in bed, a nursing assistant (NA) (#7) assisted Resident #28 to ambulate to the bathroom, assisted the resident to sit on the toilet and gave the resident the call light. The NA (#7) waited in the hallway for the resident to pull the call light. * 4:08 p.m.: The NA (#7) checked on Resident #28, in the bathroom. Resident #28 stated he/she was not done toileting. The NA (#7) showed the resident the call light again. The NA (#7) stepped into the hallway. During an interview on 06/14/21 at 4:55 p.m., a staff nurse (#8) stated Resident #28 had fallen. Resident #28 the NA (#7) reported he/she asked Resident #28 numerous times about if they were finished in the bathroom. The NA (#7) then went to assist with cares in another resident room leaving Resident #28 alone in the bathroom. Nursing Progress Notes identified: * 06/14/21 5:34 p.m., Resident suffered a fall in [the] bathroom after utilizing the toilet. Bump noted to head at occipital [back of skull]. Resident reports mild pain to the area. No open skin noted. Neuro checks in place with no concerns at this time. No further injuries. SBAR [situation background assessment recommendation form] to provider. Resident's daughter informed. * 06/14/21 10:08 p.m., Resident complained of mild pain to occipital area post fall. PRN [as needed] Tylenol 650 mg [milligrams] PO [per oral] per standing order and applied ice pack to the area; resident verbalized interventions to be effective. Continues with neuro checks; no neuro deficits noted. Resident able to consume 100% of supper per self post set up. Resting in bed at this time; call light within reach. * 06/15/21 09:16 a.m., IDT [Inter Disciplinary Team] met to review fall from 6/14. Resident was in the bathroom when [resident] had a fall last evening. Bump to head, no major injuries noted. Continues with neuro checks. Daughter notified. Ice placed to bump on head, tylenol given. Resident has difficulty explaining what happened due to cognitive impairment. Continue to monitor, plan of care reviewed. * 06/15/21 01:30 p.m., Resident has no c/o [complaints of] pain following fall. Neuro checks done and WDL [within defined limits], VSS [vital signs stable], will continue to monitor. During an interview on 06/16/21 at 08:45 a.m., an administrative nurse (#2) agreed the facility failed to provide adequate supervision and follow the care plan for Resident #28.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 07/17/19. Based on observation, record review, review of the facility policy, and staff interview, the facility failed to ensure proper respiratory care for 1 of 3 sampled residents (Resident #10) with orders for oxygen (O2) therapy. Failure to provide oxygen as ordered may complicate the resident's respiratory status. Findings included: Review of the facility policy titled Oxygen Therapy occurred on 06/16/21. This undated policy, stated, . Obtain physician orders for specifics regarding administration . Document assessment of resident oxygen status, tolerance, vital signs, and respiratory status in medical record as necessary . Review of Resident #10's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan stated, RESPIRATORY: Resident at risk for respiratory distress/obstructed airway secondary to reports of shortness of breath when lying flat and with exertion and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Administer medications/treatments as ordered and monitor effects . Observations on 06/13/21 at 5:28 p.m. and 06/14/21 at 8:12 a.m. showed Resident #10 sitting in his/her wheelchair in the dining room with an empty oxygen tank. During an interview on 06/14/21 at 8:18 a.m., a nursing staff member (#1) confirmed Resident #10's oxygen flow rate is ordered at 2L continuously and confirmed an empty oxygen tank on the back of the resident's wheelchair.

Based on observation and staff interview the facility failed to post nursing staff data in a prominent place accessible to residents, families, and visitors for 4 of 4 days of the survey (June 13-16, 2021). Failure to post staffing data in an accessible place does not allow residents, families, and visitors to be aware of the numbers of licensed and unlicensed staff on duty for each shift. Findings include: Observation on 06/13/21 at 2:00 p.m., 06/14/21 at 8:00 a.m., 06/15/21 at 8:00 a.m., and 06/16/21 at 8:00 a.m. showed the daily staff data posted outside of the DON's (Director of Nursing) office, by the administrative offices. The location of the posted data made it difficult for residents, families, and visitors to read the staffing information. During an interview on 06/16/21 at 10:40 a.m., an administrative nurse (#2) stated, she/he was not aware of the correct placement of the posting and will place it in the correct spot where residents and families can view it. The facility failed to post the staff data in an accessible place for residents, families and visitors to view.

Based on observation, review of professional reference, record review, and staff interview, the facility failed to follow infection control standards for 2 of 2 residents (Resident #1 and #2) with a COVID-19 positive status. Failure to place properly sanitize personal protective equipment (PPE) and perform hand hygiene between COVID-19 positive and negative resident rooms and ensure appropriate isolation precautions has the potential to spread the COVID-19 virus to other residents, personnel, and visitors. During the infection control survey on December 2-3, 2020, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from observations of PPE use and staff interviews. These showed residents were placed in immediate dangerous situations due to improper PPE use, inadequate hand hygiene, and ineffective isolation practices. These situations failed to protect residents from the potential spread of the COVID-19 virus. * 12/02/20 at 11:50 a.m. - The survey team contacted the management staff at the State Survey Agency (SSA) to report the findings and to discuss a potential IJ situation. * 12/02/20 at 1:00 p.m. - The SSA notified the regional office of the immediate jeopardy situation. * 12/02/20 at 1:20 p.m. - The survey team notified the facility's administration (administrator, director of nursing (DON), and infection preventionist (IP)) of the IJ situation and requested they develop a plan for abatement of the immediate jeopardy. * 12/02/20 at 3:30 p.m. - The facility provided a written plan of correction for the IJ. * 12/02/20 at 6:10 p.m. - The survey team reviewed and accepted the facility's written plan. * 12/03/20 at 11:50 a.m. - The survey team determined the IJ situation at a scope/severity of K was abated and reduced to a scope/severity of E. * 12/03/20 at 1:30 p.m. - The SSA notified the regional office of the removal of the immediate jeopardy situation. Findings include: The Centers for Disease Control and Prevention (CDC) guidance for PPE use, found at: https://www.cdc.gov, stated, . Doffing (taking off the gear): . 7. Perform hand hygiene after removing the respirator/facemask . Eye Protection . Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. - Review of Resident #1's medical record occurred on all days of survey. The record identified Resident #1 as COVID-19 positive with a testing date of 11/22/20. Observation on 12/02/20 at 10:35 a.m. showed a sign on Resident #1's door identifying droplet precautions and the following: Keep door closed. A CNA (#1) identified Resident #1 was not COVID-19 positive. The CNA (#1) (wearing goggles) donned a new N95 mask, a gown, and gloves and entered Resident #1's room. The CNA emerged from the room wearing the goggles and a surgical mask. The CNA stated she left her N95 mask and gown in Resident #1's room as she planned to wear them throughout her shift when she provided cares to Resident #1. The CNA then removed her surgical mask with her bare hands and placed it in her pocket. Without performing hand hygiene, the CNA donned a new N95 mask, gloves, and a gown and entered the room of a COVID-19 negative resident. The CNA also failed to sanitize her goggles or don new ones before entering the room. The CNA stated she does not clean her goggles between rooms and wears the same ones for the entirety of her shift. Observation from approximately 10:40 a.m. until 11:20 a.m. showed the door to Resident #1's room was open anywhere from six to 12 inches. At 11:20 a.m., observation showed Resident #1 exited his room (wearing a mask) and ambulated down the hallway with his walker. The surveyor notified the CNA (#1) who stated he should not be walking without assistance. When asked if he could be out of his room, the CNA stated, if he's wearing a mask. - Review of Resident #2's medical record occurred on 12/02/20. The record identified Resident #2 as COVID-19 positive with a testing date of 11/22/20. Observation on the morning of 12/02/20 showed a sign on Resident #2's door identifying droplet precautions and the following: Keep door closed. Observations during the noon meal on 12/02/20 showed multiple staff members passed the open doors to Resident #1 and #2's rooms (both COVID-19 positive). Resident #2 coughed consistently throughout the meal. A CNA (#1) looked in on both residents from the open doorways during the meal, and three unidentified staff members also walked by the open doors without closing them. An interview with administrative staff (#2 and #3) on the afternoon of 12/02/20 confirmed staff should not reuse N95 masks and gowns in a COVID-19 positive room and should perform hand hygiene while donning and doffing PPE.

Based on observation, review of testing logs, review of facility policy, and staff interview, the facility failed to implement work restriction for 1 of 1 staff (Staff #1) who did not test for Covid-19 at the required testing intervals. Failure of the facility to address staff who do not test for Covid-19 at the required testing intervals has the potential to allow for the spread of Covid-19. Findings include: Review of the facility policy titled COVID-19 Outbreak Prevention Testing Guidance (North Dakota) occurred on 12/03/20. This policy, dated 10/12/20, stated Outbreak Testing . Associates refusing to participate in outbreak testing will be restricted from the building until procedures for outbreak testing are completed. Review of the facility's Covid-19 testing log and results documentation occurred on 12/03/20. These documents showed the facility conducted outbreak testing on November 4th, 11th, 15th, 18th, 22nd, 25th, and 29th. The documents lacked proof of testing for a certified nursing assistant (CNA) (#1) on the 22nd and the 29th. Observation showed CNA #1 worked all days of survey. During an interview with an administrative staff member (#4) on the morning of 12/03/20, the staff member confirmed a CNA (#1) failed to complete require Covid-19 testing on November 22nd and 29th. The administrative staff member (#4) also confirmed the facility failed to restrict the CNA (#1) from the building after the CNA (#1) failed to complete the required testing on both November 22nd and 29th.

Based on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #41) receiving supplemental oxygen. Failure to provide oxygen as ordered may compromise a resident's respiratory status. Findings include: Review of the facility policy titled, Oxygen Therapy occurred on 07/17/19. This policy, dated (MONTH) (YEAR), stated, . Oxygen therapy is provided to residents in a safe manner as identified by a prescribed provider. Review of Resident #41's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A physician's order, dated 7/15/19, stated Oxygen (O2) 2 liters (L) per nasal cannula (NC) to maintain saturation (greater than) > or (equal to) = 90%. Observation on 07/15/19 at 4:45 p.m., showed Resident #41 seated in her wheelchair in her room with her NC in place and the tubing connected to a portable oxygen tank on the back of her wheelchair. Inspection of the portable oxygen tank showed the regulator set at 2 L and the regulator gauge showed the needle in the red refill zone. During an interview on 07/15/19 at 4:58 p.m., Resident #41 (when asked about her oxygen) stated, Yes I had to start wearing oxygen when I was in the hospital. Observation on 07/15/19 at 5:36 p.m. showed a staff nurse (#1) inspected Resident #41's oxygen tank per surveyor request as tank gauge continued to read refill. The staff nurse (#1) agreed the oxygen tank regulator showed refill and switched the oxygen tubing from the portable tank to the in room oxygen concentrator. During an interview on 07/15/19 at 5:40 p.m., a staff nurse (#1) stated Resident #41's oxygen saturation was checked at 2:44 p.m. upon return from her clinic appointment, and it was 95% on two liters of oxygen. During an interview on the morning of 07/16/19, an administrative nurse (#2) confirmed the portable oxygen tank should not have been empty.

Based on observation, record review, review of professional reference, and facility policy review, the facility failed to provide care and services in a manner to maintain the highest practicable well-being for 1 of 1 sampled resident (Resident #24) observed leaning markedly to the left while eating. Failure to provide assistance and properly position Resident #24's upper body, placed the resident at risk for falls/safety, discomfort, and aspiration. Findings include: Nancy B. Swigert, The Source for Dysphagia: Third Edition, LinguiSystems Inc, 2007, page 125, identified . During the oral intake of . foods and/or liquids, it is optimal for a patient to be seated at a 90 degree angle, whether in bed or chair . prior to and during feeding . the 90 degree position allows the patient to control material in the oral cavity with a minimal impact of gravity. Review of the facility policy titled, Repositioning occurred on 07/11/18. This policy, dated 2013, stated, . Components to evaluate when a resident is in a chair: a. Does the resident need intervention to maintain postural alignment? b. Is the resident's weight distribution even? c. Does the resident need devices to maintain sitting balance? . Assist the resident to change his or her position in the chair. Place resident in a comfortable position in accordance with the resident's individualized care plan. Observation of Resident #24 during 3 of 3 meals (supper on 07/09/18, lunch on 07/10/18, and breakfast on 07/11/18) in the dining room, showed the resident sitting and leaning to her extreme left over the arm of the dining room chair. Staff failed to assist the resident with positioning to prevent falls and/or aspiration. Review of Resident #24's medical record occurred on (MONTH) 9-12, (YEAR). [DIAGNOSES REDACTED]. A physical therapy note, dated 06/21/18, for Resident #24 stated, increased left lateral trunk side bend with impaired upright posture and decreased stability. Review of Resident #24's current care plan identified staff failed to address Resident #24's positioning during meals to reduce the potential for falls or aspiration.

Based on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan for 2 of 12 sampled residents (Resident #8 and #23). Failure to review and revise the care plan limits the ability of staff to communicate care needs and ensure continuity of care for each resident. Findings include: - Review of Resident #23's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified rejection of cares occurred 4 to 6 days. Review of the Behavior Chart for the month of (MONTH) (YEAR) indicated the staff was to monitor for anxiety and restlessness behaviors. The current care plan stated, . Behavioral symptoms . She has declined both physically and cognitively and requires total care for her needs and she has difficulty making her needs known . Resident often carries doll for comfort and anxiety . offer reassurance, redirect and reorientate (sic) as needed, offer food/fluid, offer toileting, provide calm environment, validate resident concerns and respond to concerns appropriately, assess for pain, and monitor tremors and related medications . Observation on the morning of 07/10/18 showed the resident calling/yelling out wanting to get ready for the day. Throughout morning cares, Resident #23 showed agitation and would occasionally kick her legs at staff. Review of Resident #23's progress notes from 04/05/18 to 07/07/18 indicated 14 incidents of combative with cares (hitting, kicking, pinching, and scratching), yelling out, and rejection of medication. The care plan failed to address Resident #23's above behaviors and lacked specific interventions for staff to manage those behaviors. - Review of Resident #8's medical record occurred on all days of survey. The resident's current care plan stated, Resident displays increased anxiety . restlessness, hollering out for help, increased confusion and disorientation at times . Approaches to the problem included: attempt non pharmalogical (sic) interventions . Document interventions prior to use of prn (as needed) [MEDICATION NAME]. The record identified the physician discontinued the prn [MEDICATION NAME] on 10/13/17. An interview with a Licensed Social Worker (LSW) (#3) occurred on 07/12/18 at 8:40 a.m. The LSW stated she was unaware of the behaviors displayed by Resident #23 or that the physician had discontinued Resident #8's prn [MEDICATION NAME]. The LSW (#3) confirmed staff should have updated the residents' care plans regarding the behaviors and the medication change.

Based on record review, review of the North Dakota Provider Manual for Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures For Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 2 of 2 sampled residents (Resident #8 and #44) with a newly diagnosed mental illness. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs. Findings include: The North Dakota PASARR Provider Manual page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Ascend to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability (referred to in regulatory language as related conditions or RC)) was not identified at the Level I screen process, and that condition later emerged or was discovered. - Review of Resident #44's medical record occurred on all days of survey. The record showed an initial PASARR completed on 09/26/11 and identified no mental illness. The screening, dated 09/26/11, stated the Level I screen conducted for the individual determined there was no evidence to suggest presence or known conditions of mental illness, mental [MEDICAL CONDITION], or a condition related to mental [MEDICAL CONDITION]. Resident #44's medical record identified the following current Diagnoses: [REDACTED]. The record lacked evidence of an updated Level I screening/change in status assessment since the additional diagnoses. - Review of Resident #8's medical record occurred on (MONTH) 10-12, (YEAR) and identified staff completed a Level I screening for Resident #8 on 04/10/13. The record identified a new diagnosis, dated 07/25/13, of unspecified [MEDICAL CONDITION]. The record lacked evidence staff performed an updated Level I change in status assessment following this new diagnosis. An interview with a Licensed Social Worker (LSW) (#3) occurred on 07/12/18 at 8:40 a.m. regarding PASARR assessments for Resident #8 and #44. The LSW (#3) confirmed staff did not perform the updated Level I assessments for Resident #8 and #44 at the time of the new diagnoses.

ELOPEMENT 1. Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the safety of wandering residents for 1 of 2 sampled residents (Resident #8) who eloped from the special care unit. Failure to ensure the functionality of a locked door from the courtyard prior to residents from the special care unit (SCU) utilizing the yard placed this resident and all residents from the special care unit at risk of injury when leaving the unit without staff knowledge. During the standard recertification survey on 06/22/16, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from an observation at 10:00 a.m. in the courtyard which identified the 200 wing door did not latch shut. Residents from the special care unit have access to the courtyard. Review of Resident #8's medical record identified elopements from the courtyard. After observation and discussion, the survey team met at 10:09 a.m. and determined corrective action needed to occur. At this time, the team contacted the management staff at the State Agency (SA) to report the findings and to discuss a potential IJ situation. On 06/22/16 at 10:26 a.m. the survey team notified the facility administrator and the director of nursing that an IJ situation existed and that they must develop a plan for abatement. At 06/23/16 10:15 a.m. the facility provided an acceptable written plan of correction for the IJ. The survey team determined the IJ situation abated, abridged the scope and severity level to D, and informed the administrator of this action. On 06/23/16 at 1:14 p.m., the State Survey Agency notified the Regional Office of the IJ. Findings include: - Review of Resident #8's medical record occurred on June 20-23, 2016. This facility admitted Resident #8 on 01/06/16 with a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident with severely impaired cognition; wandered one to three days in the last seven; walked independently in his room; and required one person setup help for walking in the corridor and locomotion on and off the unit. Review of Resident #8's care plan, dated 01/15/16, stated, Problem: Behavior Symptoms. Resident was wandering in hallways and peers room. 5/02/16 off unit. 5/28/16 off unit. Approach: Staff will assess whether the behavior endangers the resident and/or others. Staff will intervene if necessary. Staff will avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Staff will convey an attitude of acceptance toward the resident. Staff will maintain a calm environment and approach to the resident. Problem: Cognitive Loss/ Dementia. Resident struggles with memory loss and wandering due to his Alzheimer's Dx (diagnosis). and (sic) cognitive impairment. Staff will repeat and clarify information as noted by resident's response. Staff will redirect and/or distract resident as needed by offering other activities and food options to decrease wandering. A care plan update, dated 06/21/16, stated, Problem: Behavior Symptoms. Monitor when outdoors in courtyard, maintenance assessing keypad system for entrances and egresses of courtyard. Allow and encourage time outside in courtyard weather permitting-assure gate locked prior to assisting out in courtyard. An Elopement Risk Assessment, completed on 01/11/16, identified the following for Resident #8: . Wandering with no rational purpose and attempting to open doors . recent move to facility . wandering in past 60 days . dementia . Based on assessment does resident present an elopement risk? Low. Nurse's notes identified the following: * 06/02/16 10:24 a.m. - Updated son with his weekly visit to this resident elopement on 5/31 (The actual date of the elopement was 05/28/16). showed son how resident exited courtyard through another door he saw, and then exited another door that was directly in his path to be outside of facility. Discussed facility plan to secure both doors, currently working with security company. * 05/28/16 7:50 p.m. - ELOPEMENT: Resident was let outside into the courtyard after supper so he could walk around. Nurse went back into SCU and was getting an update from CNA (certified nursing assistant) who is back there. At this time another CNA came into the unit and asked if this resident was supposed to be outside by the garbage bins. This nurse said no and ran out of facility followed by CNA to find resident. Resident got back by (name of college) track and was walking away from facility. This nurse ran up to resident and asked him what he is doing. Resident was reluctant to follow staff but did walk with us back into the facility. Resident back in special care and door is now locked. * 05/10/16 1:51 p.m. - ELOPEMENT: Resident continues to be pleasantly confused this morning. Resident becoming agitated after dinner wanting to get out of facility and to go uptown; staff opened living room door for resident to wander in the courtyard and resident immediately went to the south 200 wing door and entered there and began walking down the hallway. Staff deterred resident back to the courtyard; resident wandered for some time again and went back in the south 200 wing door, RN (Registered Nurse) there to deter resident from continuing to elope and guided him back out to the courtyard. Resident then started trying to manipulate fence in courtyard to leave the facility grounds. * 05/10/16 1:34 p.m. - ELOPEMENT: Resident restless after lunch within the last 10 minutes. Was inquiring at SCU entrance doors about 'getting out of here.' Resident states he wants to go outside. RN did call back to SCU and spoke with staff. RN told staff to let him out the courtyard doors and see if this would pacify him. Resident had coat on and walked out SCU courtyard door right to south side entrance. He then opened door and was going to walk immediately across to second door to get out of the building. He was being monitored by staff. Staff then caught up with him in (sic) and attempted to get him to go back to SCU. Resident stated he needed to be outside. Staff let him back out in the courtyard and closed door tight. Resident wandering in courtyard went to north enterance (sic) and couldn't get door to open. Went to the fence and was playing with the chain. Came back to south entrance where another resident had gone outside from and resident again able to open door and ended up in the south hallway. He was trying to go out the other door that would exit building. * 05/02/16 4:08 p.m. - ELOPEMENT: . Resident continued to wander around the SCU. This nurse was assisting another resident with cares when activities came back to see if there was anyone they could take outside for a walk. This nurse said that this resident has been asking to go out and would like to. Activities and this nurse could not find resident in his room or any other room. Home health staff brought resident back to SCU. When entering dinning (sic) room staff noticed that the window was open and the screen was taken off and that is how the resident escaped the unit. Resident screwed the window open with fingers due to there being no crank on the window. * 05/02/16 3:25 p.m. - ELOPEMENT: Resident climbed out dining room window and walked around the facility. He entered the south west door and was spotted by one of the home health nurses who assisted him back to SCU. Communication sent to Social Services and Administration regarding this issue as this resident has attempted this in the past. Will continue to monitor resident and attempt to keep safe. Resident is high elopement risk. * 04/14/16 8:58 p.m. - . Activities came back to SCU and opened the door so that some residents could enjoy the weather. This resident was told he could go outside at this time. Resident was told that yes he could in fact go outside. Once outside he started to walk around and got to an area with an opened gate. Activity lady went to check on resident and saw the gate was open. She asked him to come back to the doors with him (sic) and he got very upset and got in her face. Activities told resident that his son was on the phone for him so he would come back inside. * 04/11/16 6:21 p.m. - Many attempts to escape to the outside. He took the screen off dining room window and cranked window open by using his fingers. Crank was not on the window. Staff caught him stepping out of the window, hard to redirect . The nurses notes identified the following elopement attempts and/or elopements made by Resident #8: * June 2016: three attempts to elope and exit seeking behaviors. * May 2016: five elopements, two episodes of exit seeking behaviors. *April 2016: one elopement, seven episodes of exit seeking behaviors. * March 2016: eight episodes of exit seeking behaviors. On 06/22/16 at 10:00 a.m. the survey team walked through the 200 wing door to the courtyard, the alarm failed to sound. When in the courtyard, the survey team was able to re-enter the building through the 200 wing door, the door did not latch, and the door alarm failed to sound. The survey team also walked directly across the hall from the courtyard door and exited to outside the facility, the door failed to alarm. The survey team was able to go out to the courtyard and back to the outside of the facility three times. The door failed to alarm each time. Following this observation, an interview with an environmental service director (#12) on 06/22/16 at 10:55 a.m. identified when staff give a resident from the facility access to the courtyard, a staff member must turn off or disarm the system for the courtyard door. When asked when that system would be alarmed again, he stated the staff would re-alarm the door upon the resident returning into the building. The staff member (#12) confirmed another resident goes into the courtyard often and the nurse has to reset the alarm when he comes back inside which may leave the door disarmed for a period of time. On 06/21/16 at 1:50 p.m. a CNA (#6) stated residents go out the 200 wing door leading into the courtyard and can return into the facility as the door opens from the outside. On 06/22/16 at 4:00 p.m. during a confidential interview Resident A stated, My family takes me out into the courtyard. The door is left open so we can get back into the facility. (pointed to the 200 wing door leading into the courtyard) During an interview with Resident #11 on 06/23/16 at 9:00 a.m., the resident identified he has access to the courtyard and could go in and out of the courtyard on his own as the door was usually open and he would access the courtyard several times a day. The most current MDS for Resident #11 identified him as cognitively intact and not a resident on the SCU. During an interview with an administrative nurse (#5) on 06/22/16 at 10:26 a.m., the nurse (#5) stated staff are to be directly observing Resident #8 when in the courtyard. The nurse (#5) also stated that with seven residents on the special care unit the facility cannot justify more than one staff member to that area. The facility failed to adequately monitor Resident #8 when in the courtyard, and failed to secure the courtyard which resulted in Resident #8's multiple elopements placing him and all residents from the special care unit at risk of injury when leaving the building without staff knowledge. SUICIDAL ATTEMPT 2. Based on record review, the facility failed to recognize symptoms of suicidal ideation and avert a suicide attempt for 1 of 2 sampled residents (Resident #15) reviewed in a closed record. Failure to recognize suicidal indicators and respond appropriately, and ensure the environment was not conducive to potential for injury resulted in a suicide attempt within the facility. Findings include: Review of the closed record for Resident #15 occurred on June 22-23, 2016. [DIAGNOSES REDACTED]. The facility admitted Resident #15 to a locked special care unit (SCU). Six days following admission to the SCU, the facility transferred the resident to an acute care hospital due to a suicide attempt. The medical record included a progress note, dated 12/02/15, which identified the resident transfers per himself with no problems . independent in toileting and changing an ileostomy bag . a private person when it comes to personal cares and bathing . denies pain and has showed no negative behaviors. The record identified the resident oriented to self and family, hard of hearing and wore glasses. Review of the progress notes identified the following progression regarding the resident's mental health status during the stay at the facility: On 12/01/15: * At 3:23 p.m. a nursing progress note: ADMISSION: . has been feeling quite depressed and has been started on Celexa (antidepressant medication). He does have . major depressive disorder . He has memory impairment to both short and long term. He requires cues and supervision for safety. Resident does have poor safety awareness and family is afraid he might elope, so he was placed in secured unit. He will be working with PT/OT (physical and occupational therapy) s/p (status [REDACTED]. RN (registered nurse) did let resident know that with him being a new admission he will be on hourly safety checks to ensure he is okay. Family has requested that news stories regarding politics, ISIS and terrorism not be brought up as resident gets very upset . * At 4:26 p.m. a social services progress note: admission . for extreme anxiety & depression. * At 9:00 p.m. a nursing progress note: Skin assessment: . Noted; (L) (left) arm has scabbed over scratches, (L) index finger has (4) .50 cm (centimeter) cuts, (R) (right) index finger(1) .50 cut, (R) top of Thumb 1 cm cut . No areas of real concern at this time. During interview on the morning of 06/23/16, a supervisory nursing staff member (#5) said the medical record lacked information to determine the cause of the cuts on Resident #15's arm and hands. On 12/02/15 at 11:26 a.m. a physical therapy aide (PTA) note: . reports understands and accepts need for placement, though sad and lonely . On 12/03/15: * At 8:51 a.m. a licensed practical nurse (LPN) wrote: Resident refused to take his A.M. (morning) medications, resident wants to see his priest and his wife. Resident said 'I'm done, this is not the way God intended for me to live.' Medications will be attempted again later. * At 9:35 a.m. a registered nurse (RN) wrote: MOOD/AMBULATION: RN visited with resident today. He (sic) mood is flat and he states he is feeling down. He said to RN, 'I have been watching the man across the hallway. All he does is sleep and come out of room to eat. Is that what is going to happen to me here?' RN acknowledged residents concern and fear and let resident know that he can be as active as he would like to be. told resident that anytime he would like to go for a walk or sit in one of the common areas to ask for assistance. Will monitor. * At 2:31 p.m. the LPN wrote: Medicare: Resident is alert and orient (sic) to person and place. Resident walked up and down the halls twice this shift. Resident has been depressed this shift, wanting to stop taking his medications, talk to the priest, and wanting his wife to visit. Resident was weepy on and off through out the day. Nursing will continue to monitor. * At 3:22 p.m. the certified occupational therapy assistant (COTA) wrote: . able to communicate, well, his negative, 'bummed-out', and hopeless feeling due to being 'abandoned' by his wife and left here at this facility. Pt (patient) reports he wrote 'good-bye' letters to his 5 children and wife. Pt is a very sad man. He responded positively with encouragement and to take things 'one step at a time.' On 12/04/15: * At 7:59 a.m. a PTA wrote: pt reports with nursing confirmation that pt refusing medications/meals this a.m., requesting to see priest with desire for 'giving up'/end of life, though states will not harm self; . * At 12:10 p.m. a COTA wrote: . Wife present, remained close to pt and provided constant cues which increased agitation during self-care tasks. She made a comment, 'we'll just hang a rope from the ceiling for you' when pt became frustrated/confused during minor ADL (activities of daily living) task. She then stated, 'I'm just kidding.'. * At 1:44 p.m. the LPN wrote: Resident's wife her (sic) all shift. Wife brought in 3 blade razors in for resident to shave. Razor and blades are in resident's closet. On 12/05/15: * At 10:15 a.m. and 7:22 p.m., an LPN wrote: . Resident did have this author call his wife for assurance that she was coming this a.m. Resident is continually using his call light for no reason a lot of the time. Resident is quite needy and demanding. The progress notes showed the entry edited at 3:22 p.m. on 12/06/16 repeating the portion documented above. On 12/06/15: * At 3:41 p.m. a LPN wrote: . Resident does state that he is lonely especially after his wife and family leave. Resident is continually using his call light for no reason a lot of the time. Resident is quite needy. * At 6:00 p.m. a LPN wrote: This nurse took residents supper to him knocked on the door greeted resident he was sitting naked in a chair with blood on him, he told this nurse to get the hell out . I called 911 to report incident and get ambulance here. This nurse went back to the room to try and visually assess the situation. Resident was bleed (sic) from his hands bilaterally and from his left wrist. There was a lot of blood on the floor in the bedroom and the bathroom in the stool in the bathroom. he told me he wanted to die. Suicide note found and the blades from inside a disposable razor. He told this nurse that his biggest health problem was not his body it was in his head. He didn't think anyone could fix that so why live. Resident was discharged to (hospital) from (this facility) with a no bed hold. transported via . ambulance . for psych (psychiatric) eval (evaluation). On 12/07/15 at 11:04, a nurse wrote: . Noted res (resident) had taken apart disposable razors. Found 1 razor blade head with blades removed and approx. (approximately) 12 blades lying around the room, covered with blood. Found package of disposable razors in room with 3 razors missing . Emergency personnel found a note in a hardcover book that res had been reading, stating that it was a suicide note . Review of the care plan did not identify any interventions for Resident #15's behaviors including elopement risk as identified by the family on admission. No changes occurred after the resident displayed symptoms of suicidal ideation. The medical record lacked physician orders [REDACTED]. Failing to evaluate the resident for proper placement may have adversely affected the resident's psychological and social well-being. Failure to develop interventions to address Resident #15's severe depression and suicidal ideation, and failure to recognize the presence of razors as a safety risk contributed to the resident's suicide attempt.

Based on observation, record review, review of policy and procedure, and staff interview, the facility staff failed to provide adequate supervision and assistive devices necessary to prevent accidents for 4 of 13 sampled residents (Resident #1, #7, #8, and #12,) and 2 supplemental residents (Resident #21 and #22) with unwitnessed falls and/or observed during transfers and/or wheelchair transportation. Four of these residents reside in the special care unit (Resident #1, #8, #12, and #21). Failure to provide adequate supervision (Resident #12), use gait belts appropriately (Resident #1 and #12), and use wheelchair foot pedals during transportation (Resident #1, #7, #8, #12, #21, and #22) placed the residents at risk for accidents and injuries and resulted in a head injury for Resident #12. Findings include: Review of the policy titled "Wheelchair Bag Codes" occurred on 06/19/14. This policy, revised 04/14/11, stated, ". . . A yellow bag on the back of this wheelchair, means that the pedals for this chair are used for transportation and stored in the bag when not being used. . . ." Review of the policy titled "Transfer Belt Use" occurred on 06/19/14. This policy, reviewed/revised 07/10/13, stated, ". . . The purpose of a transfer belt (gait) is to provide support to residents who may be unsteady on their feet. The belt will protect the resident should they become weak or lose their balance when ambulating or transferring. POLICY: Nursing staff will use a transfer belt when ambulating or transferring a resident who requires hands on assistance. . . ." - Review of Resident #12's medical record occurred on June 18-19, 2014. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition; extensive assistance from one person for transfers, locomotion, and toilet use; limited assistance from one person for ambulation; two falls without injury; and two falls with injury. Resident #12's current care plan identified: ". . . Problem Start Date: 09/20/2012 ADL (activities of daily living) FUNCTION: Resident requires assist of 1 for ADLs related to severely impaired cognitive status, confusion, unsteady gait secondary to dx (diagnosis) hip fx (fracture) and dementia. . . . Approach . . . Foot pedals: W/c (wheelchair) with pedals for transport . . . Locomotion: Ambulatory (with) FWW (front-wheeled walker), Assist of 1 when possible. Encourage use of gait belt, often refuses and gets agitated; w/c with pedals for transport and when gait unsteady. . . . Transfer: Self and at times needs 1 assist with gait belt and FWW. Unable to use call light appropriately. . . . BLADDER: Resident experiences bladder incontinence R/T (related to) urgency, frequency, bladder neck obstruction and dementia. Resident states is able to feel urge but dribbles on way to BR (bathroom). . . . Resident often takes self to bathroom. 1 assist for transfers and toileting. Staff to encourage resident to void every 1-2 hours and prn (as needed) with staff assistance. Offer urinal at night prn. . . . FALLS: Resident at risk for falling R/T severely impaired cognitive status, impulsiveness, refusal of care when agitated and tired, unsteady gait, wandering secondary to dx. fx. right hip, dementia. . . . Approach . . . FALL on 06/03/14 from w/c with staff after abruptly putting feet down. he does not normally use w/c and staff didn't anticipate him to act in that manner. . . . continue 30 minute safety checks . . . monitor for whereabouts to assure no injuries to self with restlessness. . . ." Review of facility "Event Reports" and nurses' notes identified the following related to falls: *04/15/14 at 8:16 p.m.: ". . . Description . . . Found on floor sitting on his buttocks, in other resident room. . . . Notes . . . Staff found resident in other resident room sitting on his buttocks and holding onto his walker. kept saying get me up I have to find her. . . ." *04/21/14 at 7:05 p.m.: ". . . Description . . . Fall in another resident's room . . . Resident stated he was coming out of the bathroom. . . . Location of Injury . . . None at this time . . ." *04/23/14 at 8:35 p.m.: ". . . Description . . . fell in his bathroom. pants were around his ankles. Gripper socks on and he was laying on his left side. Head facing out of the door of the bathroom. . . . Location of injury right eye brow and eye area, inside mouth. . . . Notes . . . Res is sitting in the TV room in recliner, eyes closed. Res right eye is swollen shut . . . Steri strips to right eye are intact, has dried blood around his lips and around his eye, with blood that has run down the side of his nose. . . . 4/24/2014 01:15AM Res has been up to the BR, with assist of 1, gait belt, and walker. Res slow to move, unsteady. . . . 4/24/2014 02:00AM Res c/o aching all over, Tylenol 650 mg (milligrams) given . . . 4/24/2014 04:15AM Res has had some relief from the Tylenol . . . c/o rib pain . . . 4/24/2014 09:03 AM . . . Staff instructed to toilet resident every hour in attempt to prevent self toileting . . . 4/25/2014 09:56PM Resident has bruising on the R) side of his face and throat from fall. 4/27/2014 02:00PM Resident has been c/o increased R) rib pain since fall on the evening of the 23rd. Also L) (left) elbow has a pocket of fluid on it. . . ." *05/26/14 at 2:12 p.m.: ". . . Notes . . . Resident was heard yelling for help @ 2:05 p.m. He was sitting on the floor in the living room, with his back against the recliner and legs outstretched toward the window. He had appropriate shoes on. His dk (dark) blanket was on the floor next to his feet. He possibly could have tripped on the blanket. . . . 5/27/2014 02:11AM CNA reports to this writer that res (resident) was c/o (complaining of) feeling achy, and that she noticed an abraised area to res back. Res given Tylenol 650 mg (milligrams) at this time . . . 5/29/2014 09:43AM . . . Bruised area on his mid back, L) (left) side is healing slowly. It has a scab in the middle of the bruise. . . ." *05/30/14 at 8:26 p.m.: ". . . Description . . . witnessed fall . . . Notes . . . Resident had fall this evening at 815pm. Witnessed by staff member. Resident was trying to sit in recliner and got walker tangled in blankets and fell to his R) (right) side. . . Resident very anxious to get up, moving legs around and kepts (sic) telling staff 'get me up.' Resident assisted to feet x 2 assist and gait belt. Gait unsteady, taken to recliner. . . ." When asked why staff were not assisting Resident #12 into the recliner (as his care plan indicated assistance from one staff person for transfers and ambulation), staff provided no further information. *06/01/14 at 6:17 p.m.: "BEHAVIORS: Increased restlessness this shift. Not easily redirected. Increased up and down in recliner. To bathroom frequently. Forgets what he's doing. Appetite poor, distracted. Yelling at staff to help him. Staff ask him what he needs help with and he says 'my pants are getting fixed.' Does have pants on. Pacing up and down the hallway. Shakiness to hands. When trying to redirect resident becomes upset with staff." At 8:19 p.m. (after Resident #12's fall in the bathroom), the nurses' note was edited to include: "Voided in garbage can in nurse's station." *06/01/14 at 8:23 p.m.: ". . . Description . . . fall with injury . . . Pain assessment . . . Yes (location) - headache Location of injury . . . laceration to forehead, skin tear to R) elbow . . . Notes . . . 6/1/2014 07:34PM Resident found on the floor in bathroom. Resident bleeding from head and R) elbow. Resident anxious and stating 'get me up. OH Lord help me. I'm going to die.' . . . Stated that he fell 'trying to use the toilet.' resident sustained [REDACTED]. . . . Resident very shaky. . . . Ambulance called and hospital notifying transfer as resident may need possible stitches. . . . 6/2/2014 09:00AM Resident received 10 staples to forehead laceration last evening in ER (emergency room ). . . . Is slightly swollen and bruised/reddened. 6/2/2014 02:49PM . . . Resident continues to be unpredictable and due to severe cognitive impairments has no safety awareness and takes self to br. Staff do approach resident hourly and at times more often and assist when possible with transfers and toileting. . . ." Review of toileting records for 06/01/14 identified toileting times of 12:26 a.m., 3:57 a.m., and 11:27 a.m. It is unknown the last time staff toileted Resident #12 prior to his fall. When asked for more information regarding the fall (i.e. evidence of 30 minute checks by staff, recent toileting, etc.), the facility provided no further information. Toileting records for other days also identified that staff failed to toilet Resident #12 every 1-2 hours as care planned. During an interview on 06/19/14 at 8:37 a.m., a supervisory nurse (#14) stated staff are supposed to document each time they toilet a resident, and if the resident is dry, the toileting records would indicate "none" (meaning no void). Event reports and nurses' notes further identified: *06/01/14 at 9:48 p.m.: ". . . Returned from ER. Staples in place in forehead. . . . Seemed in good mood. . . ." The medication administration record (MAR) for 06/01/14 identified that at 10:15 p.m. (27 minutes after the nurse's note was written, staff administered Tylenol 650 mg for pain related to Resident #12's recent fall, as well as Seroquel (an antipsychotic) 25 mg for increased agitation and "at risk for self injury." When asked to provide more information regarding the simultaneous administration of a pain medication with an antipsychotic, the facility provided no further information. *06/03/14 at 3:08 p.m.: ". . . Description . . . Resident attempted to stand per self and lost his balance and fell to the floor. . . . Pain Assessment . . . Yes (location) - head ache . . . Location Of Injury . . . bridge of nose and on staples on forehead. . . . Notes . . . 6/3/2014 03:52PM Resident was assisted out of bathroom via w/c when resident put his feet down to stop w/c and tried to stand. Resident was unstable and landed on the floor before aid could get around the chair to catch him. Resident's wound on forehead with staples was bleeding and dressing was changed. Resident also received a wound on the bridge of his nose. . . ." During an interview on 06/19/14 at 9:54 a.m., a supervisory nurse (#14) stated staff did not use foot pedals because Resident #12 does not normally use a wheelchair, so the staff did not know Resident #12 would try to put his feet down on the floor. Observation on 06/17/14 at 7:56 a.m. showed Resident #12 seated in a wheelchair in the dining room. An unidentified certified nursing assistant (CNA) transported the resident from the dining room, down the hallway, and to the TV lounge without foot pedals in place. During the transport, Resident #12 put his feet on the ground, which caused the CNA to stop abruptly. The CNA stated, "Keep 'em up (Resident #12) (referring to his feet)." The CNA then transferred Resident #12 from the wheelchair to the recliner using a walker and no gait belt. The CNA grabbed the back of Resident #12's pants and lifted under his arm. At 8:02 a.m., Resident #12 stood from the recliner and used his walker to ambulate down the hallway and back to the dining room. A nurse (#9) directed him to the TV lounge and ambulated beside the resident with her hand under his arm. She assisted the resident back into the recliner by grabbing the back of his pants and under his arm. Observation on 06/17/14 at 2:20 p.m. showed an unidentified CNA ambulating with Resident #12 from his room to the TV lounge. Resident #12 did not have a gait belt on, and the CNA assisted him into the recliner by holding on to the back of his pants and under his arm. Observation on the afternoon of 06/17/14 showed Resident #12 eating an afternoon snack in the dining room. After finishing his snack, he got up from the table and began ambulating with his walker. A certified medication aide (#15) directed the resident to the TV lounge, but failed to offer assistance/gait belt to Resident #12. The resident ambulated down the hall and to the TV lounge, where he then sat in a recliner. Observation on 06/17/14 at 4:54 p.m. showed Resident #12 ambulating in the hallway with his walker. A CNA (#27) passed by the resident but did not stop to offer assistance. At 5:04 p.m., the CNA (#27) approached Resident #12, applied a gait belt, and assisted the resident with ambulation. Observation on the morning of 06/18/14 showed a staff nurse (#12) assisted Resident #12 up from the recliner by pulling under his arm and failing to apply a gait belt. The resident then ambulated down the hallway with his walker and no assistance from staff. Observation on 06/18/14 at 4:27 p.m. showed Resident #12 ambulating independently in the dining room with his walker. An unidentified CNA entered the special care unit and observed the resident ambulating. Without offering assistance, the CNA then left the unit. Observation on 06/18/14 at 4:59 p.m. showed a CNA (#13) pushing Resident #12 in a wheelchair down the hallway and to his room. Observation showed no foot pedals in place, and Resident #12's legs were crossed at the ankles with his heel brushing the floor. After toileting the resident, the CNA brought the resident to the TV area in his wheelchair without foot pedals in place. During an interview on 06/18/14 at 10:37 a.m., a CNA (#16) stated Resident #12 self transfers at times, but he is not supposed to ambulate independently, and staff are expected to assist him with ambulation and transfers. During an interview on 06/18/14 at 2:34 p.m., a CNA (#13) stated they are expected to ambulate with Resident #12 and use a gait belt and a walker. During an interview on 06/19/14 at 9:54 a.m., a supervisory nurse (#14) stated staff should ambulate with Resident #12 and offer/use a gait belt if resident allows. These staff interviews conflict with the most current care plan. Although Resident #12 experienced multiple falls attempting to use the bathroom and self transferrring, staff failed to develop/implement effective interventions to keep the resident safe from falls and injuries, and failed to provide appropriate supervision which resulted in a head wound, ER visit, and placement of staples. Failure to follow Resident #12's care plan related to the use of wheelchair foot pedals resulted in an avoidable fall with a head injury, and failure to use gait belts/provide assistance with ambulation may result in avoidable falls/injuries in the future. - Review of Resident #1's medical record occurred on June 17-19, 2014. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified severely impaired cognition, extensive assistance from two or more people for transfers, extensive assistance from one person for locomotion, two falls without injury, and two falls with injury. Resident #1's current care plan stated, ". . . FALLS: Resident is at risk for falls R/T hx of falls, unsteady gait, medication use, impaired cognition, independence with ADLs, use of assistive device secondary to Dx. of CHF (congestive heart failure), CVA (cerebrovascular accident), Dementia unspec (unspecified) with behavior disturb., Disorder depressive . . . Approach . . . FALL on 6/11/14- FOF (found on floor) BR. If found in BR stay with resident until done. If resident found up walking, walk with resident and or assist her to safe sitting area. . . . FALL - 5/31/14 - Continue to observe resident frequently, safety checks every 30 minutes. . . . Observe frequently and place in supervised area when out of bed. Staff to monitor closely with (sic) and be sure to give resident frequent reminders not to self transfer as resident is observed at times attempting to do things for herself d/t (due to) decreased cognition and poor safety awareness. . . . ADL FUNCTION: Resident requires assistance with ADLs R/T decline in funtional (sic) status, increased agitation and agitation exacerbation, decreased strength and mobility, poor safety awareness . . . Approach . . . Ambulation: 1 assist PRN with FWW . . . Locomotion, On and Off Unit and Wheelchair: Pedals for transport as tolerates and 1 assist. . . . Transfer . . . 1 assist and 2 assist PRN . . ." Observation during the initial tour (on 06/16/14 at 3:20 p.m.) showed Resident #1 seated in a recliner in her room. The resident yelled "Hey" repeatedly, while scooting forward in the recliner and attempting to stand. An unidentified staff member brought another resident back to her room (located across the hall from Resident #1's room) in a wheelchair but failed to offer assistance to Resident #1, who was still yelling "Hey." A few minutes later, an unidentified CNA entered Resident #1's room and offered assistance. Observation on 06/17/14 at 7:51 a.m. showed Resident #1 ate breakfast in the dining room while seated in her wheelchair (which had a bag marked with a yellow label that contained foot pedals). After breakfast, a CNA (#23) took Resident #1 down the hallway and into her bathroom in the wheelchair without utilizing foot pedals. The CNA cued the resident, "Lift your feet, (Resident #1)" as the resident's feet dropped down on the floor. After toileting, the CNA took Resident #1 to the TV lounge in the wheelchair without utilizing foot pedals. The CNA asked the resident if she would like to sit in a recliner. The resident responded, "Yes." The CNA then indicated she would be right back to transfer Resident #1. At 8:40 a.m., Resident #1 remained in her wheelchair in the TV lounge. At 9:21 a.m., Resident #1 was seated in a recliner in the TV area. A CNA (#23) indicated Resident #1 had transferred herself into the recliner at some point. Observation on 06/17/14 at 10:56 a.m. showed a CNA (#23) transported Resident #1 in her wheelchair (without utilizing foot pedals) from the TV lounge to her room to use the bathroom. After transferring Resident #1 to the toilet, the CNA left Resident #1 alone in the bathroom and exited her room to get an incontinence brief. Upon completion of toileting, the CNA brought Resident #1 back to the TV lounge in her wheelchair without utilizing foot pedals. Observation on 06/17/14 at 12:54 p.m. showed a CNA (#23) transported Resident #1 in her wheelchair (without utilizing foot pedals) from the dining room to her room. The CNA stated, "Pick up your feet, (Resident #1)," as Resident #1's feet brushed on the floor during transport. Observation on 06/17/14 at 2:32 p.m. showed a CNA (#27) transferred Resident #1 from a recliner to her wheelchair and transported her from the TV lounge to the dining room without utilizing foot pedals. Observation on 06/18/14 at 8:57 a.m. showed a CNA (#16) transported Resident #1 in her wheelchair (without utilizing foot pedals) from the dining room, down the hallway, and to the resident's room. Observation on 06/18/14 at 3:05 p.m., showed a staff member (#12) transfer Resident #1 from a recliner into a wheelchair with no gait belt and transport Resident #1 down the corridor without utilizing foot pedals. Observation on 06/18/14 at 4:24 p.m. showed a nursing staff member (#12) assisted Resident to stand from her wheelchair without using a gait belt. The staff member then attempted to ambulate with Resident #1 and her walker. Resident #1 was resistive to ambulation, so the staff member (#12) assisted her to sit back in her wheelchair. The staff member failed to apply a gait belt during this observation, although a gait belt was available on a nearby medication cart. Observation on 06/18/14 at 5:02 p.m. showed Resident #1 in the dining room in her wheelchair. The resident yelled "Hey" repeatedly, although no staff were available to assist her. After several minutes, Resident #1 stood up from her wheelchair and attempted to walk. At that time, two surveyors approached Resident #1 and encouraged the resident to sit in her wheelchair. The resident handed one surveyor a magazine and stated, "I can't do this." Resident #1 eventually sat back down in her wheelchair. Observation showed no staff available to assist Resident #1 during this time. During an interview on 06/18/14 at 10:37 a.m., a CNA (#16) indicated Resident #1 frequently transfers herself and attempts to ambulate independently. The CNA stated Resident #1 is not supposed to ambulate without staff assistance, and the staff frequently check on Resident #1 (every 30 minutes). - Review of Resident #21's medical record occurred on 06/19/14. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified severely impaired cognition and extensive assistance from one person for transfers and ambulation. Observation on 06/18/14 at 10:03 a.m. showed an unidentified staff member brought Resident #21 back to the special care unit from an off unit activity in her wheelchair. Observation showed no foot pedals in place, although a yellow bag on the back of the resident's wheelchair (indicating foot pedals used for transport) contained foot pedals. Observation on 06/18/14 from 2:38 p.m. until 3:04 p.m. showed Resident #21 awake and sitting up on the edge of her bed. The resident repeatedly attempted to stand from her bed during this time, but was unable to do so. Observation showed no staff available to assist the resident. At 3:07 p.m., a nursing staff member #12 assisted Resident #21 out of bed and brought her to the dining room in her wheelchair (without utilizing foot pedals). - Review of Resident #8's medical record occurred on June 16-19, 2014. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified severely impaired cognition, extensive assistance for transfers, and extensive assistance for locomotion. Resident #8's current care plan stated, ". . . ADL FUNCTION . . . Approach . . . Wheelchair locomotion with assist of 1 . . ." Observation on 06/17/14 at 2:35 p.m., showed a CNA (#15) transported Resident #8 into the dining room without utilizing foot pedals on the wheelchair. The resident's wheelchair showed a bag with a yellow label on the back (indicating foot pedals used for transport). Observation on 06/18/14 at 7:42 a.m., showed a CNA (#16) transported Resident #8 into the bathroom, out of the bathroom, and down the corridor into the dining room with no foot pedals on the wheelchair. The resident's wheelchair showed a bag with a yellow label on the back of the wheelchair (indicating foot pedals used for transport). - Review of Resident #7's medical record occurred on June 19, 2014. Resident #7's current care plan states, ". . . Problem . . . ADL FUNCTION . . . Approach . . . Wheelchair with pedals for transport . . ." Observation on 06/19/14 at 8:37 a.m., showed an unidentified CNA transporting Resident #7 from the dining room into the lounge area with no foot pedals on the wheelchair. The resident's wheelchair showed a bag with a yellow label on the back of the wheelchair (indicating foot pedals used for transport). - Observation on 06/19/14 at 9:20 a.m., showed an unidentified CNA transporting Resident #22 from a North hallway to the South chapel with no foot pedals on the wheelchair. The resident's wheelchair showed a bag with a yellow label on its back. Resident #22's current care plan stated, ". . . PROBLEM: ADL FUNCTION . . . APPROACH: Wheelchair with foot pedals for transport. . . ." Facility staff failed to utilize assistive devices (gait belts and wheelchair foot pedals) as well as adequate supervision to prevent falls and injuries for multiple residents. Failure to provide gait belts and wheelchair foot pedals and provide appropriate supervision to ensure resident safety placed residents at risk for continued harm related to falls and other avoidable accidents.

1. Based on observation, review of professional literature, record review, and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #1) who experienced bruising, neck pain, and headache after she hit her head during a fall. Failure to promptly notify the physician about Resident #1's head injury resulted in delayed treatment and delayed identification of a C2 (cervical neck, second vertebrae) fracture, placing the resident at risk of serious injury or harm. Findings include: The American Academy of Orthopedic Surgeons website, at orthoinfo.aaos.org, states the following information regarding cervical fractures: "The seven bones in the neck are the cervical vertebrae. They support the head and connect it to the shoulders and body. . . . Any injury to the vertebrae can have serious consequences because the spinal cord, the central nervous system's connection between the brain and the body, runs through the center of the vertebrae. Damage to the spinal cord can result in paralysis or death. Injury to the spinal cord at the level of the cervical spine can lead to temporary or permanent paralysis of the entire body from the neck down. . . ." Review of Resident #1's medical record occurred on all days of survey. Resident #1's medical [DIAGNOSES REDACTED]. Observations of Resident #1 on all days of survey showed the resident wearing a cervical brace around her neck. "Resident Progress Notes," dated 04/09/12 at 3:12 p.m., stated, "Guest was here walking by resident's room. Saw resident fall forward on to her head. Went to room did full range of motion no complaints. Resident only complaint was that her head hurt. Large 4 inch by 4 inch lump on left side of temple. starting to get black n (and) blue. resident was able to answer simple questions. Sat resident up on buttocks, and no pain noted. got resident into bed. She was able to stand and walk to bed. No complaints at that time." The "Event Report" from the fall on 04/09/12, completed by a nursing staff member at 3:26 p.m. on 04/09/12, identified the following: ". . . PAIN ASSESSMENT: Does resident exhibit or complain of pain related to the fall? If so describe location. Yes - head. . . . BODY ASSESSMENT: Note any injury to the head, extremities, or trunk. - Bruising, Bump, Swelling. . . NEUROLOGICAL CHECK . . . Left Eye - Pupil Response/Shape - Round/Sluggish . . . Right Eye - Pupil Response/Shape - Round/Sluggish . . . NOTIFICATION GUIDELINES: Notify MD/NP(nurse practitioner)/PA (physician's assistant) immediately by phone or beeper for any of the following. - Suspected head injury/abnormal neuro checks from resident baseline. . . . (NOTE: The nurse checked the box which indicated the MD/NP/PA should be notified immediately). NOTIFICATIONS: Attending Faxed: No. Physician Notified: Yes Date/Time: 4/15/2012 6:11 a.m. Family Notified: Yes. Date/Time: 4/15/2012 6:11 a.m. . . ." Review of "Resident Progress Notes" after the fall continue as follows: 04/09/12 *8:05 p.m. - ". . . did complained (sic) of neck pain later in the evening gave PRN (as needed) Tylenol. . . ." 04/10/12 *1:44 a.m. - "Had a hard time getting resident to open her eyes to check her pupils. Pupils are reactive to light, no C/O (complaints of) pain at this time . . ." *9:41 a.m. - Resident complained of neck pain, gave scheduled [MEDICATION NAME]. . . ." *9:06 p.m. - "Resident very confused on PM shift. . . . Resident C/O headache from fall and Tylenol was given. This seemed to help for the pain. . . ." 04/11/12 *1:47 p.m. - "Resident C/O mild headache this shift but when offered prn [MEDICATION NAME] refused, stated they made her feel worse. . . ." *10:19 p.m. - "(Name of health care provider (HCP)) here this afternoon, [MEDICATION NAME] 100 mg (milligrams) BID (twice a day) ordered; . . ." NOTE: A "Physician/NP/PA Communication" form, dated 04/11/12 identified the following: "Has had large increase in falls over the past month, resulting in several mild injuries. She states that often these falls are d/t (due to) dizziness, has had some BP (blood pressure) readings that have noted drop from laying to standing. Will be monitoring ortho (orthostatic) BP's Q (every) shift x (times) 3 days. However, noted more confusion, sleepiness, etc over past month or so. Can we trial a decrease in her [MEDICATION NAME] at this time? She has had an increase in falls since this was increased from 100 mg bid to 100 mg TID (three times a day) in December." NOTE: The HCP responded to the above concern on the "Communication Form" with an order for [REDACTED]. pain or headache since the fall. 04/12/12 *12:12 p.m. - "C/O pain on C-spine (cerebral spine) area on backside of neck to PT (physical therapy). Noted large, (sic) firm nodule to area. States that it has been much worse since last fall. MSG (message) left to update RN (registered nurse) and MD (medical doctor)." *1:19 p.m. - "Per (name of health care provider) to send to ER (emergency room ) for X-rays of Spine and eval (evaluation) of neck pain." *8:00 p.m. - "Resident returned . . . Resident has C-2 Fx (fracture) . . . new orders: Tylenol 650 mg po Q 6 hours prn. PT eval and TX (treatment). . . Fall precautions. C-Collar (cervical collar) to be worn continuously except to sleep and to wash. No falls at all, if possible. F/U (follow-up) in Neuro surgery clinic . . ." Although the assessment data on Resident #1's Event Report, completed shortly after Resident #1's fall on 04/09/12, identified symptoms which indicated an immediate call to the physician (suspected head injury, sluggish pupils, bruising and swelling on the head), facility staff failed to notify the physician. Documentation in the medical record showed communication with a HCP on 4/11/12 (2 days after the fall), but the documentation failed to indicate the HCP was informed of the specific fall on 04/09/12 in which the resident hit her head. Resident #1 continued to complain of pain in the neck area, and staff sent the resident to the clinic for x-rays on 4/12/12, three days after she fell and hit her head. Failure to immediately notify the physician caused a delay in treatment interventions and a delay in the identification of a C2 fracture. During interview, the morning of 07/19/12, two administrative staff members (#11 and #12) agreed staff should have immediately called the physician after Resident #1 fell and hit her head. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 08/31/11. 2. Based on record review, review of the facility's standing orders, review of professional reference, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being regarding episodes of low blood sugar levels ([DIAGNOSES REDACTED]) and/or high blood sugar levels ([MEDICAL CONDITION]) for 2 of 3 sampled residents (Resident #11 and #14) with a [DIAGNOSES REDACTED]. Failure to follow the facility's protocol for hypoglycemic episodes and failure to establish individualized high and low blood sugar parameters for each diabetic resident (and notify the physician when results are outside these parameters) placed these residents and all diabetic residents at risk of complications. Findings include: The American Medical Directors Association, "Managing Diabetes in the Long-Term Care Setting, "Clinical Practice Guideline, 2002, pages 27-29, states, "WHEN TO CALL THE PHYSICIAN . . . Develop protocols that guide first-line care givers (nurses and nursing assistants) in deciding when a prompt physician referral is necessary for a diabetes-related problem. . . When patients' blood glucose levels are poorly controlled and when patients are extremely frail or cognitively impaired, the physician may wish to note specific individual blood glucose or symptom parameters in the orders. . . . It is recommended that the physician be called as soon as possible when: The patient has a blood glucose value < (less than) 60 mg/dl (milligrams per deciliter) or < 75 mg/dl if the patient has signs and symptoms suggestive of [DIAGNOSES REDACTED]. (treatment of [REDACTED].) TREATING [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] is defined as blood glucose level < 60 mg/dl. Symptoms may or may not be present. . . . The same threshold should be used to diagnose [DIAGNOSES REDACTED] in patients with dementia as in those who are not cognitively impaired. . . . [DIAGNOSES REDACTED] is the most feared short-term complication of treatment for [REDACTED]. . . . It is recommended that all long-term care facilities develop and implement a policy and procedures for treating [DIAGNOSES REDACTED]. . . . Patients who are obtunded (incoherent but not comatose) may be treated with oral glucose paste rubbed onto the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or intravenous 50% [MEDICATION NAME]. . . . Administration of 1 mg [MEDICATION NAME] can achieve sufficient clinical recovery to enable safe consumption of oral carbohydrates . . . " - Review of the facility policy and procedure, "[DIAGNOSES REDACTED]" occurred on July 18-19, 2012. This document, revised in October 2011 stated, "OBJECTIVE: To provide appropriate interventions with hypoglycemic episode. Hypoglycemic symptoms may include: Weakness, sweating, [MEDICAL CONDITION] palpitations, tremor, nervousness, irritability, tingling in the mouth and tongue, hunger, nausea (unusual) and vomiting (unusual), headache, hypothermia, visual disturbances, mental dullness, confusion amnesia, [MEDICAL CONDITION], coma. Follow facility standing orders unless otherwise specified by the physician: 1. If resident is feeling or presents with symptoms of [DIAGNOSES REDACTED], test blood sugar. 2. If blood sugar is low: Provide resident with carbohydrate and protein . . . if resident able to eat/drink. Give [MEDICATION NAME] 1/2 -1 tube orally for symptomatic [DIAGNOSES REDACTED] plus BS (blood sugar) < (less than) 50. Repeat in 10 minutes as need. (sic) Give [MEDICATION NAME] 1 mg (milligram) IM (intramuscular) x (times) 1 for symptomatic [DIAGNOSES REDACTED] plus BS <30 and notify physician/extender of results. 3. Monitor resident - retest blood sugar. 4. If blood sugar continues to be low, call medical doctor according to orders or if unable to increase blood sugar to acceptable level for that resident." Review of the facility's standing orders, revised in October 2006, included the following: "DIABETES MONITORING and/or TREATMENT. Follow facility protocol. If no protocol: 1) Blood glucose check pm nurse discretion. 2) Glucose 1/2 -1 tube orally for symptomatic [DIAGNOSES REDACTED] plus BS < 50. Repeat in 10 minutes as needed. 3) [MEDICATION NAME] 1 mg 1M X 1 for symptomatic [DIAGNOSES REDACTED] plus BS < 30 and notify physician/extender (sic) of results." - Review of Resident #11's medical record occurred on July 16-19, 2012. Admission [DIAGNOSES REDACTED]. Resident #11's medications included scheduled and sliding scale insulin. Resident #11's physician orders included the facility's standing orders. The medical record lacked individualized low blood sugar parameters for physician notification. Resident Progress Notes stated the following: *12/01/11, 5:15 p.m., "Res.(Resident) very sweaty and clamy (sic). responding only to name. BS is 31 (mg/dl). Gave res. 120 cc (cubic centimeters) orange juice, res. barely responded to this. Tried to give res food but she kept coughing this up. res. would put head to the side and slipping into unresponsive stage. Wheeled res. to n (nurse's) station and administered glucogon (sic) im (intramuscularly) to L (left) deltoid area." *12/01/11, 5:20 p.m., "Res. responded to [MEDICATION NAME] im. Now talking to nurse and holding head up. Ate about 25% of her food and drank another 120 cc of orange juice." *12/01/11, 7:00 p.m., "Res. BS up to 100 (mg/dl) at this time. CNA (Certified nursing assistant) fed res. pudding at this time." Resident #11's care plan, dated 06/01/11, stated "Problem: Resident receives Insulin related to risk for [MEDICAL CONDITION] secondary to dx. (diagnosis) of Diabetes Mellitus . . . Approach: Administer insulins as ordered. Monitor blood sugars as ordered;" and dated 08/18/11, "Problem; Nutrition: Receives therapeutic diet r/t (related to) dx DM with mechanically altered textures. . . . Approach . . . Monitor for excessive coughing when drinking fluids. . . ." Resident #11 experienced a hypoglycemic episode with symptoms of unresponsiveness on 12/01/11. The resident's history included excessive coughing when drinking liquids. Facility staff initially administered orange juice and attempted to give food for a BS of 31(mg/dl) (instead of the protocol to administer 1/2 to 1 oral glucose tube for symptomatic [DIAGNOSES REDACTED] < 50 mg/dl). After the resident did not respond to the orange juice and became unresponsive, staff administered intramuscular [MEDICATION NAME]. The staff failed to follow the facility protocol for symptomatic [DIAGNOSES REDACTED] with a BS < 50 mg/dl and failed to notify the physician or extender, limiting their ability to ensure the quality of resident care. During interview, on 07/19/12 at 9:30 a.m., two supervisory nursing staff members (#9) and (#10) reported they would investigate this episode and provide additional information. These staff members failed to provide any documentation for further review. - Review of Resident #14's medical record occurred on July 18-19, 2012. Admission [DIAGNOSES REDACTED]. The resident's quarterly MDS, dated [DATE], identified the resident as rarely or never understood, short and long-term memory impairment, received insulin injections, and physician's orders to change insulin dosage daily during the seven day look-back period. Resident #14's physician orders in addition to the facility wide standing order pertaining to diabetes, included: -07/28/09 -"Do not hold [MEDICATION NAME] (type of insulin injection) d/t (due to) low food intakes unless instructed by the MD (medical doctor). Report any changes in appetite or low blood sugar to MD prn." -04/08/11 -"Give [MEDICATION NAME] after resident eats, NOT BEFORE, HOLD [MEDICATION NAME] if intakes at meal time are less than 50%." -10/06/11 -''Accuchecks four times a day at 5:30 a.m., 10:30 a.m., 4:30 p.m., and 7:30 p.m. and "Special instructions" to "Call MD if blood sugars > (greater than) 300." -04/05/12 -"[MEDICATION NAME]-four units SQ twice a day at 11:00 a.m. and 5:30 p.m" and "Special Instructions" to "DO NOT GIVE UNTIL RESIDENT HAS EATEN! HOLD IF INTAKES ARE <50%. [MEDICATION NAME]six units SQ daily at 7:30 a.m." and "Special Instructions" to "DO NOT GIVE UNTIL RESIDENT HAS EATEN! HOLD IF INTAKES ARE <50%. [MEDICATION NAME] 15 units SQ every AM at 7:30 a.m." Review of the Resident #14's blood sugar records from April-July 2012 identified the following blood sugar levels: 31 mg/dl on 04/16/12 at 8:00 p.m. 340 mg/dl on 05/08/12 at 4:29 p.m. 47 mg/dl on 05/28/12 at 10:30 a.m. Resident #14's Progress Notes stated the following: *04/16/12 at 9:31 p.m. "Blood sugar 31 at 8:00 p.m. Was awake and responsive so fed a container of chocolate pudding, ate without difficulty, skin diaphoretic (a sign/symptom of [DIAGNOSES REDACTED]) at this time. Rechecked blood sugar at 8:30 and was 47, HS (before bed) sanck (sic) fed to resident without difficulty, again ate an ensure pudding and 1/2 of his apple dessert." *05/08/12 -The record lacked an entry or evidence facility staff contacted/informed the health care provider of the blood sugar result of 340 mg/dl. *05/28/12 at 10:13 a.m. The facility staff held AM dose of [MEDICATION NAME]due to the resident's refusal to eat breakfast. At 10:30 a.m., an entry stated, "Reported by staff that resident juswt (sic) didn't seem right, color pale and very listless (sign/symptoms of [DIAGNOSES REDACTED]). Accucheck 48. pudding fed to resident and he was able to swallow. Will recheck and observe." The record showed facility staff rechecked Resident #14's blood sugar at 10:41 a.m. and showed a reading of 61 mg/dl and noted "Resident more responsive but still sleepy. Will monitor." Facility staff obtained another blood sugar reading of 48 mg/dl at 10:45 a.m. Resident #14 experienced a symptomatic [DIAGNOSES REDACTED] episode (blood sugar 31 mg/dl and skin diaphoretic) on April 16, and facility staff failed to follow the established protocol of giving 1/2 to 1 oral [MEDICATION NAME] tube and repeat in 10 minutes as needed. In addition, the medical record lacked evidence facility staff notified a HCP. On the evening of 05/08/12, Resident #14's blood sugar reading exceeded 300 mg/dl. Resident #14's medical record lacked evidence the facility informed the HCP (Special Instructions on the Physician's orders stated "Call MD if BS >300"). On 05/28/12, Resident #14 exhibited symptomatic [DIAGNOSES REDACTED] and facility staff provided oral intake of pudding while the resident was "very listless" instead of implementing the physician protocol of oral [MEDICATION NAME] for symptomatic BS <50, repeat in 10 minutes as needed. 3. Based on observation, record review, professional literature review, family interview, and staff interview, the facility failed to ensure oxygen placement for 1 of 2 sampled residents (Resident #10) with a physician order for [REDACTED]. Findings include: The Fundamentals of Nursing Concepts, Process, and Practice 8th Edition by Berman, Snyder, Kozier, and Erb copyright 2008 by Pearson Education, Inc, page 1372, stated, "Clients who have difficulty ventilating all areas of their lungs, those whose gas exchange is impaired, or people with heart failure may benefit from oxygen therapy to prevent [MEDICAL CONDITION] . . . Oxygen therapy is prescribed by the primary care provider, who specifies the concentration, method of delivery, and depending on the method, liter flow per minute . . ." During an interview on 07/16/12 at 5:35 p.m., a family member (#1) stated Resident #10 rarely received oxygen while in bed. The family member stated he/she discussed this concern with facility staff two or three months ago, however there has been no improvement. Review of Resident #10's medical record occurred on July 16-19, 2012. [DIAGNOSES REDACTED]. Resident #10's care plan, dated 05/23/12, stated: Problem: "Resident requires oxygen therapy R/T (related to) End Stage [MEDICAL CONDITION]." Approaches: "Administer oxygen at 2 lpm (liters per minute) via nasal cannula while lying down in bed and q (every) hs (hour of sleep)." "Monitor respiratory status every shift. Ensure O2 (oxygen) on while in bed." Resident #10's physician orders, dated 03/27/12, stated, "O2 2 lpm QD (every day) while lying down and at HS." Observation on 07/17/12 at 3:40 p.m., showed a certified nursing assistant (CNA) (#2) transferred Resident #10 from her wheelchair and laid her down in bed. The CNA (#2) failed to apply the resident's oxygen. The resident remained in bed without oxygen from 3:30 p.m. to 5:25 p.m. During an interview on 07/19/12 at 9:05 a.m., two administrative nursing staff members (#3 and #4) stated nursing should monitor to ensure oxygen is applied and confirmed Resident #10's oxygen should be administered when she is in bed.