Every finding on record at St Clara's Rehab & Senior Care

Based on interview and record review, the facility failed to follow its procedure for transportation and failed to adequately supervise and safely secure resident during transport to prevent a fall for one (R1) resident of three residents reviewed for accidents/incidents in a sample of three. These failures resulted in R1 sustaining a subdural hematoma and left scapula fracture. Findings include: The facility's (State) Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, dated 11/28/18 documents: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and, Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical levels.The facility's Passenger Carrier Safety Orientation-Return Demonstration Procedure dated 5/21/2015 (Signed and Dated 9/10/25 by V5 licensed Practical Nurse/LPN) documents: Any employee who will be a designated driver of a passenger carrier must complete the assigned online training as well as behind the wheel training by the facility's designated driving coach. 9. Employee backs the resident into the van. 10. Employee securely fastens and secures the resident into the van. R1's Hospital Notes dated 9/27/25 document: Radiology Report: Impression: Left subdural hematoma along the posterior falx. Minimally displaced left scapular fracture medially. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview of Mental Status) score of 15. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R1's diagnoses include: History of Transient Ischemic Attack (TIA), Cerebral Infarction, Hemiplegia and Hemiparesis affecting left non-dominant side, Type 2 Diabetes, Depression, Obstructive Sleep Apnea; Dementia with other behavior disturbance, psychotic disturbance, mood disturbance; Chronic obstructive pulmonary disease (COPD), Acquired absence of left leg above knee, Traumatic subdural hemorrhage without loss of consciousness, Displaced fracture of body of scapula, left shoulder. R1's recent Care Plan documents: (R1) is at risk for falls related to needing assist with mobility and transfers, history of fall; use of psychotropic medication, left above the knee amputation. (R1) has been noted to be non-compliant with non-weight bearing and not to wear shoes. Facility's Initial and Final Reports to (State Department of Public Health) for R1 dated 9/27/25 and 10/3/25 document: On 9/27/25 at (1:50am), (R1) was being transported via facility van from an (Emergency Room) evaluation, fell over backwards, hitting his head on the rear door of the van. (R1) was diagnosed with an intracranial bleed and was transferred to (City) Medical Center for admission. Conclusion: (R1) was transported to the (Emergency Room), was diagnosed with a superficial abrasion to the scalp, a left subdural hematoma along the posterior falx measuring 0.8 centimeters, and a minimally displaced left scapular fracture. (R1) returned to facility on 10/2/25. (Documentation and Interviews indicated that V5 Licensed Practical Nurse/LPN was the driver of the facility van on 9/27/25.) On 10/14/25 at 1255pm, V8 Transport/Certified Nursing Assistant/CNA, stated that she did train (V5 Licensed Practical Nurse/LPN) on how to secure residents in the van during (V5's) transportation training and orientation. On 10/15/25 at 9:01am, V5 LPN stated that on the day of R1's accident, that V5 used the van for the first time; had just gotten his license to drive it to transport residents. V5 stated that he had been trained on how to secure wheelchairs in the van but that he only locked R1's wheelchair wheels and that was it, stated that the facility was only a block away (from hospital). V5 stated, It was around 1:30am in the morning; figured it was just a block away to the facility. I stopped at the stop sign out of the hospital parking lot; stepped on gas and (R1) rolled backwards. At this same time, V5 stated that he was no longer at the facility; stated I felt so bad about this; I resigned the next day. On 10/15/25 at 10:50am, V1 Administrator stated: (V3 Power of Attorney/POA to R1) was called after the accident. Both myself and (V3) agreed that the accident could have been avoided. When I called (V5 LPN) about the accident, he said he is getting too old for all the new technology; and said he was putting in his resignation immediately. (V5) was responsible for securing residents in the van.

Facility failures resulted in two deficient practices.A. Based on record review and interview the facility failed to provide skin treatments as ordered by the physician for two of three residents (R1 and R2) reviewed for skin alterations in the sample of three.B. Based on record review and interview the facility failed to obtain blood sugars as ordered by the physician for one of three residents (R2) reviewed for blood sugar monitoring in the sample of three.Findings include:A. The facility's Wound and Ulcer policy dated 3/28/24 documents, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessment. Document wound/ulcer treatment provision on the treatment administration record. Treatment continues per the physician orders until the wound and/or ulcer is healed.1.R1's Physician Order Summary Reports and TARs (Treatment Administration Records) dated 6/1/25 through 8/22/25 document, Start date 12/13/24 Emollient ointment apply to BUE (Bilateral Upper Extremities) every shift for dry skin. Start date 6/19/25 apply barrier cream to buttocks once daily and as needed for wound prevention.R1's TARs dated 6/1/25 through 8/22/25 document R1 did not receive the emollient ointment to the BUE as ordered on five occasions and R1 did not receive the barrier cream to the buttocks as ordered on three occasions.On 8/23/25 at 10:15 AM V2 (Director of Nursing/DON) verified that according to R1's TARs dated 6/1/25 through 8/22/25 R1 did not receive the emollient ointment to the BUE as ordered on five occasions and R1 did not receive the barrier cream to the buttocks as ordered on three occasions.2. R2's Physician Order Summary Reports and TARs (Treatment Administration Records) dated 6/1/25 through 8/22/25 document, Start date 11/12/24 skin preparation to left heel daily every night shift. Start date 6/18/25 cleanse wound, apply triple antibiotic ointment, abdominal pad, and wrap until healed every day (left forearm). Start date 7/30/25 cleanse areas, apply xeroform (petroleum dressing), abdominal pad, and (rolled gauze) to left arm every day until healed. R2's TARs dated 6/1/25 through 8/22/25 document R2 did not receive the skin preparation to the left heel as ordered on two occasions, R2 did not receive the triple antibiotic, abdominal pad, and wrap to the left forearm as ordered on one occasion, and R2 did not receive the petroleum dressing, abdominal pad, and rolled gauze to the left arm on three occasions.On 8/23/25 at 10:15 AM V2 (DON) verified that according to R2's TARs dated 6/1/25 through 8/22/25 R2 did not receive the skin preparation to the left heel as ordered on two occasions, R2 did not receive the triple antibiotic, abdominal pad, and wrap to the left forearm as ordered on one occasion, and R2 did not receive the petroleum dressing, abdominal pad, and rolled gauze to the left arm on three occasions.B. The facility's Blood Glucose Testing and Monitoring policy dated 8/2024 documents, Policy: Blood glucose levels will be monitored and obtained per licensed health care practitioner's orders. Blood glucose testing it to be performed by a licensed nurse.R2's Physician Order Summary Reports and MARs (Medication Administration Records) dated 6/1/25 through 8/22/25 document, Start Date 1/26/25 (Blood Glucose Testing) before meals and at bedtime. Diagnosis Type II Diabetes Mellitus.R2's MARs dated 6/1/25 through 8/22/25 document R2's blood glucose testing was not obtained as ordered by the physician on 6/29/25 at 11:30 AM and 7/2/25 at 5:00 PM.On 8/23/25 at 10:15 AM V2 (Director of Nursing) verified R2's blood glucose was not obtained as ordered on 6/29/25 at 11:30 AM and 7/2/25 at 5:00 PM.

Based on record review and interview the facility failed to administer insulin as ordered for one of three residents (R1) reviewed for medication errors in the sample of three.Findings include:The facility's Medication Administration policy dated 1/11/2010 documents, Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of the facility to accurately administer medication following physician's orders. Medications should be charted during the medication pass in a consistent manner before going to the next resident.R1's Physician Order Summary Reports and MARs (Medication Administration Records) dated 6/1/25 through 8/22/25 document, Start Date 6/13/25 Insulin Aspart insulin inject 15 units subcutaneously before meals related to Type II Diabetes Mellitus. Insulin Apart insulin per sliding scale subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus. If 0-150 (blood glucose) = (equals) 0 units. 151-200 =2 units. 201-250 = 4 units. 251-300 = 6 units. 301-350 = 8 units. 351-400 = 10 units. Start Date 7/22/25 Humalog insulin 15 units subcutaneously before meals for Diabetes Mellitus.R1's MARs dated 6/1/25 through 8/22/25 document R1's Insulin Aspart 15 units was not administered as ordered by the physician on 6/18/25 at 4:30 PM, 6/24/25 at 4:30 PM, 6/29/25 at 4:30 PM, 7/12/25 at 4:30 PM, and 7/13/25 at 4:30 PM. R1's MARs dated 6/1/25 through 8/22/25 document R1's blood sugar on 7/12/25 was 188 and R1's Aspart insulin 2 units sliding scale was not administered at 4:30 PM as ordered by the physician. R1's MARs dated 6/1/25 through 8/22/25 document R1's Humalog insulin 15 units was not administered as ordered by the physician on 7/27/25 at 5:30 PM, 8/9/25 at 5:30 PM, 8/13/25 at 5:30 PM, and 8/19/25 at 5:30 PM.On 8/22/25 at 1:20 PM V5 (R1's Physician) stated, (R1) should receive her insulin as ordered.On 8/23/25 at 10:15 AM V2 (Director of Nursing) verified that according to R1's MARs R1 did not receive Aspart insulin as ordered on 6/18/25 at 4:30 PM, 6/24/25 at 4:30 PM, 6/29/25 at 4:30 PM, 7/12/25 at 4:30 PM, and 7/13/25 at 4:30 PM, and R1 did not receive Humalog insulin as ordered 7/27/25 at 5:30 PM, 8/9/25 at 5:30 PM, 8/13/25 at 5:30 PM, and 8/19/25 at 5:30 PM. V2 also confirmed that R1 not receiving her insulin as ordered is considered a medication error.

Based on observation, interview, and record review, the facility failed to develop and implement specific pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission as directed by the facility's Wound and Ulcer Policy for one of four residents (R9) reviewed for facility acquired pressure ulcers in the sample of 33. These failures resulted in R9 developing a painful pressure ulcer to the right heel that deteriorated from a blister to a stage four pressure ulcer to R9's right heel, that required surgical debridement. Findings include: The Wound and Ulcer Policy and Procedure dated 3/28/24 documents It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management. Procedure: All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale- Ulcer Risk Assessment. The resident will be assessed upon admission, once a week for four weeks, quarterly, and any significant change in condition after admission. A skin assessment (skin check) will be documented at admission, once a week for four weeks, quarterly, and any significant change in condition after admission. A skin assessment (skin check) will be documented on the ETAR (electronic treatment administration record). A skin assessment (skin check) will be documented daily for residents assessed by the Braden Scale - Ulcer Risk Assessment to be moderate or high risk for development of pressure ulcer(s). Moderate Risk Protocol: Daily skin check-completed by direct care staff. The Skin Observation Report may be used to communicate skin observation(s) or changes to the nurse. Mattresses with documented pressure reduced/relieving properties may be placed on the resident's bed. Equipment, Prevention, and Treatment Resources: Equipment- Positioning aids; special mattress and/or chair cushion (low air loss, alternating pressure, etc. (example) with pressure reducing/relieving properties. Prevention: The following prevention measures may be initiated to address pressure, moisture, friction, and/or shearing. The facility may also implement additional measures. Pressure: Support heels on pillow or in splints. R9's Admission Record, dated 2/4/25, documents R9 was admitted to the facility on [DATE]. This same record documents R9 has the following, but not limited to diagnoses: Type Two Diabetes Mellitus, Nontraumatic Intracerebral Hemorrhage in Hemisphere, Personal History of Other Venous Thrombosis and Embolism, Weakness, Hypertension, Unsteadiness of Feet, Muscle Wasting and Atrophy. R9's Admission MDS (Minimum Data Set) Assessment, dated 8/20/24, documents R9 was moderately cognitively impaired. This same assessment documents R9 had no pressure ulcers on admission, R9 was at risk for developing pressure ulcers, R9 required substantial to maximal assistance with transfers, lower body dressing, and taking off shoes, and required partial to moderate assistance with rolling left to right or right to left. R9's Admission Progress Note, dated 8/13/24, documents Skin: Skin warm and dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: New. Issue type: Lesion. Location: Right ear. New. Issue type: Lesion. Location: Mandible (lower jaw). Skin note: Has one area of skin cancer on left side of face and right ear. No other skin issues were documented. R9's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 8/28/24, documents 2. Sensory Perception (ability to respond meaningfully to pressure-related discomfort)- slightly limited: responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfit in one or two extremities. 5. Mobility- very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 7. Friction and Shear: problem- requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent reposition and maximum assistance. Spasticity, contractures, or agitation leads to constant friction. R9's Assessment Outcomes for Braden Scale, dated 2/5/25, documents 8/14/24- Braden Score 15: At risk. 8/22/24- Braden Score 13: Moderate risk. 8/28/24- Braden Score 15: At risk. R9's Medical Record has no evidence of a Braden Scale for Predicting Pressure Sore Risk Assessment being completed the fourth week after R9's admission. R9's Plan of Care, dated 8/15/24, documents R9 is at risk for skin impairment/Deep Tissue Injury related to fragile aged skin, need for assistance with mobility and transfers, and use of an indwelling catheter. Interventions dated 8/15/24 document: Administer medications as ordered. Monitor/document side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Inform R9/R9's family/caregivers of any new area of skin breakdown. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) to follow up as indicated. Provide incontinence care after each episode according to facility protocol. R9 requires the bed as flat as possible to reduce shear. R9 requires the use of pressure relieving mattress for his bed to adequately relieve pressure. There are no individualized specific interventions documented to prevent pressure ulcers from developing to R9's heels after a risk for skin breakdown was noted from the Braden Scale on 8/14/24, 8/22/24, and 8/28/24. R9's Ulcer/Wound Documentation, dated 9/12/24, documents an in-house wound/ulcer was identified on 9/12/24. This same form documents Site: right heel. Type: Blister: Length 8.5cm (centimeters). Width 7cm. Peri-wound skin: Clear fluid-filled blister with 2.5cm x 2.5cm purple area in center. R9's Wound Evaluation and Management Summary, dated 11/4/24 and signed by V17/Wound Physician, documents Stage three Pressure Wound of the Right Heel Full Thickness. Etiology: Pressure. Wound Size 7cm x 6cm x 0.1cm. Exudate: Light Serous (yellowish/clear fluid). Slough (non-viable tissue) 5% (percent). Wound Progress: Not at goal. Dressing Treatment Plan: Betadine apply once daily for 16 days. To eschar only, Leptospermum honey apply once daily for 16 days. Alginate with silver apply once daily for 16 days. Secondary Dressing: Abdominal pad once daily for 16 days. Gauze roll (stretch) 4 inches apply once daily for 16 days. Recommendations: Off-load wound; float heels in bed; no shoe on right foot for now; elevate leg(s) for one hour after meals three times a day; Cleanse with wound cleanser at time of dressing change; (pressure relieving boot) to use when out of bed. R9's Wound Evaluation and Management Summary, dated 1/14/25 and signed by V17/Wound Physician, documents Stage four Pressure Wound of the Right Heel Full Thickness. Etiology: Pressure. Wound Size: 5cm x 6cm x 0.2cm. Exudate: Moderate Sero-Sanguinous (pinkish-red fluid). Wound Progress: Not at goal. Primary Dressing: Santyl applies once daily for two days. Alginate Calcium is applied once daily for 23 days. Secondary Dressing(s): Abdominal pad applied once daily for 16 days. Gauze roll 4.5 inches apply once daily for 23 days. Recommendations: Off-load wound; float heels in bed; no shoe on the right foot for now; elevate leg(s) for one hour after meals three times a day; Cleanse with wound cleanser at time of dressing change; (pressure relieving boot) to use when out of bed; No (pressure relieving boot) while in bed. R9's Wound Evaluation and Management Summary, dated 2/4/25 and signed by V17/Wound Physician, documents Stage 4 Pressure Wound of the Right Heel Full Thickness. Etiology: Pressure. Wound Size: 6cm x 5.8cm x 0.2cm. Exudate: Moderate (pinkish-red fluid). Today Wound bed is mostly subcutaneous sloughy/necrotic tissue, although some granulation is visible. There is some new peri area erythema-marked for continued assessments. Area is not warm or tender suspect it may be from wound vac adhesive. Edges are macerated (softened). Necrosis and slough remain very adherent. Will take a break from vac and return to Santyl and alginate to assist with breaking down necrosis/slough. Wound bleeds easily with debridement. Cauterized to stop bleeding. Recommendations: Off-Load Wound: Please float heels on two pillows while in bed; Float heels in bed; Elevate Leg(s): For one hour after meals, three times a day; Cleanse with wound cleanser at time of dressing change; (pressure relieving boot) to use when out of bed; No (pressure relieving boot) while in bed. The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade pick-ups were used to surgically excise 6.96 cm^2 of devitalized tissue and necrotic muscle level tissues along with slough and biofilm were removed at a depth of 0.21 cm and healthy bleeding tissue was observed. On 2/2/25 from 9:45 AM to 9:58 AM R9 was lying in bed in his room. R9's bilateral heels were lying directly on the mattress without offloading of pressure. On 2/2/25 from 1:45 PM to 2:00 PM R9 was sitting in his wheelchair in the dining room. Residents right heel was sitting directly on the floor with a sock on. No (pressure relieving boot) was observed to R9's right heel. On 02/03/25 from 9:00 AM to 9:15 AM R9 was sitting in his wheelchair in his room. R9's right heel was sitting directly on the floor with a sock on. No (pressure relieving boot) was observed to R9's right heel. R9 stated I have a wound on my right heel. It is very painful. I kept telling staff my foot was hurting but they just thought it was the way my shoes were fitting. No one looked at my foot for a while when I was complaining about it. Finally, someone looked at it and said I had a spot on my right heel. The staff have not been putting my (pressure relieving boot) on my right heel or putting my feet on pillows while I am in bed. They were doing it sometimes but haven't been for a while. I just figured they didn't have to do it anymore. On 2/4/25 at 11:55 AM V5/Registered Nurse/Infection Preventionist stated, I monitor the wounds in the facility for the most part. (R9) has not had his (pressure relieving boot) on the past two days at least because no one could find it. We (the facility) just found it last night and put it on (R9) today. (R9) should not have any pressure to his right heel and should be always wearing the boot while out of bed to prevent (R9's) right heel wound from worsening. V5 also verified R9's left and right heels should be offloaded while in bed. On 2/4/25 at 2:40 PM, V17/Wound Physician stated, When I consulted with my company, they stated (R9's) right heel should be classified as pressure. V17 stated, I changed (R9's) wound documentation to classify (R9's) right heel area to pressure. If (R9) is not wearing his (pressure relieving boot) it can cause the wound to worsen. (R9) should always have his heels floated while in bed and should never wear his (pressure relieving boot) while in bed. On 2/4/25 at 2:45 PM V5/Registered Nurse/Infection Preventionist, V17/Wound Physician, and V18/CNA (Certified Nursing Assistant) were preparing treatment for R9's right heel. R9 was lying in bed with a (pressure relieving boot) on R9's right heel. V17 verified R9 had his (pressure relieving boot) on his right foot while in bed. V17 stated, I have told the facility (R9) is to not have his (pressure relieving boot) on while in bed. (R9) needs to have his left and right heel offloaded on a pillow while in bed to help with healing. V17 cleansed R9's right heel and measured the area. R9's right heel wound was 6cm x 5.8cm x 0.2. R9's right heel wound bed was 100 percent necrotic (dead tissue). V17 proceeded to surgically debride R9's right heel wound. Blood drainage was observed to R9's right heel. On 2/5/25 at 10:00 AM V5/Registered Nurse/Infection Preventionist verified specific interventions were not implemented to relieve pressure to R9's right and left heel after a Braden assessment was completed and indicated R9 was at risk for pressure ulcers. V5 also verified a Braden assessment should have been completed once a week for four weeks after R9's admission and was not. V5 stated (R9) should not have had his heel resting directly on the floor or had his boot on while in bed since (R9's) wound to his right heel was caused from pressure.

Based on observation, interview and record review, the facility failed to use temperature testing strips that reflect the required dish surface temperature and check the surface temperature daily, to ensure dishes reach the required temperature during the rinse cycle of a high temperature sanitation dish machine, and complete and record cool down temperatures for meals containing meat that were prepared ahead and stored in the facility's freezer for future use. These failures have the potential to affect all 96 residents residing in the facility. Findings include: The facility's Dishwasher Technical Manual (undated), documents the required incoming water temperature for hot water sanitation is a minimum of 180 degrees Fahrenheit. On 2/2/25 at 12:10 PM, V4 (Dietary Manager) stated the facility uses a high temperature dishwashing machine. At this time V4 placed a sticker temperature testing strip on a plate and ran the dishwasher cycle. V4 verified that the sign on the front of the dish machine documents the rinse cycle should reach a minimum of 180 degrees Fahrenheit. V4 also verified the sticker strip that was used will turn the expected color (black) when it reaches 160 degrees Fahrenheit (F). V4 stated the dietary staff check the dish machine temperature three times daily by recording the number on the machine's outer digital thermometer. V4 stated I only do a strip through the machine about once every week when I de-lime the machine. We do not run a thermometer strip through everyday. The facility's (supplier) parts description (undated), provided by V4, documents the facility uses testing strips to check dishwasher temperature of 160 degrees (F) and documents Description: Test strip 160 degrees (F). Same sticker as what (state agency) uses. Directions attach to a dry metal surface. Then place in dish machine. Label will change color to verify proper sanitizing temperature is reached. The facility's Cooling Hot Foods policy, dated 2/2022, documents Food will be properly cooled to reduce the potential for food borne illness. Check the temperature of the food item after cooking is completed. Cool food from 135 degrees to 70 degrees F in two hours. Check the temperature of the food after two hours and record the temperature on the temperature log. If the food does not reach a temperature of less than or equal to 70 degrees in two hours, you must reheat item to 165 degrees F and start cool down process again. Cool down from 70 degrees to 41 degrees F in four additional hours (this is a total of six hours). Check the temperature of food after the additional 4 hours and record the temperature on the temperature log. If the food has not cooled to the appropriate temperatures in the time allotted, discard the food. The facility's Cooling Hot Foods logs for January 2025 and February 2025 document the only hot foods that were cooled down for both months was pork loin. On 2/2/25 at 12:00 PM, the facility's walk-in freezer contained two large metal pans. One pan was labeled Goulash, 2/2/25 and the other pan was labeled Lasagna, 1/29/25. At this time V4 (Dietary Manager) confirmed both the goulash and the lasagna contain cooked meat and she does not have cool down logs to show they were monitored for hazardous temperatures during the cooling process. V4 stated The only cool down items I have logs for are pork loin. The Lasagna and the Goulash were cooked ahead, and both contain hamburger and they will need thrown out because I do not have cool down logs for them. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 2/2/25 and signed by V2/Administrator in Training documents 96 residents currently reside within the facility.

Based on interview, observation, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for four of five residents (R2, R5, R54, R82) with a diagnosis of dementia and failed to do a gradual dose reduction for one of five residents (R54) reviewed for antipsychotics in a sample of 33. Findings include: The facility's policy titled Psychotropic Medication revised 11/28/17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but not limited to 1) Antianxiety, 2) Antidepressant, 3) Antipsychotic, 4) Hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. A) Indications for Use for psychotropic medication may include but not limited to 1) Expressions or indications of distress, 2) Symptoms are clinically significant that is causing a functional decline, 3) Non-pharmacological approaches were implemented and not effective or were clinically contraindicated. Additionally, Antipsychotic medication may be indicated for use if 1) Behavioral symptoms present a danger to the resident or others; 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and/or 4) GDR (Gradual Dose Reduction) was attempted, but clinical symptoms returned. B) Dose, Duration, Monitoring: 1) Evaluation of pharmacological ongoing effectiveness towards therapeutic goal. 2) Evaluation of the effectiveness of the non-pharmacological approaches prior to medication administration. 3) Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. C) Gradual Dose reduction: 1) Resident's should receive the lowest effective dose of psychotropic medication for the resident's physical, mental, and psychosocial well-being. 2) GDR is to be attempted within the first year in two separate quarters, (with at least one month between attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. 3) If treating expressions or indications of distress related to dementia, the GDR may be contraindicated for the following reasons: a) target symptoms returned or worsened after a recent attempt of GDR, and b) Physician has documented rationale why a reduction would impair residents' function or increase distressed behavior. 4) Treating disorder other than dementia, the GDR may be contraindicated for the following reasons: a) Physician has documented rationale why a reduction would impair residents' function or exacerbate the disorder, or b) Target symptoms returned or worsened after recent attempt of GDR, and physician has documented why a reduction would impair function or exacerbate disorder. 1. R2's Admission Record documents that R2's date of admission to the facility was 3/22/22 and her diagnoses on admission include Dementia, Severe, with Other Behavioral Disturbance, Major Depressive Disorder, and Insomnia. R2's Minimum Data Set (MDS) assessment dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment, and Section N indicating R2 takes antipsychotic medication. R2's Physician Orders dated 10/15/24, documents R2 has an order for Seroquel/Quetiapine (Antipsychotic medication) 200 mg (Milligrams) by mouth twice a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R2's current Care Plan documents R2 uses an antipsychotic medication related to behaviors secondary to dementia. On 2/02/25 at 10:25 AM, R2 was lying in bed with eyes closed, calm, and in no distress. On 2/03/25 at 8:48 AM, R2 was lying in bed asleep but aroused when spoken to. R2 kept closing eyes as she spoke but appeared calm and smiled during conversation. 2. R5's Admission Record documents that R5's date of admission to the facility was 4/6/21 and her diagnoses on admission include Unspecified dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Major Depressive Disorder, Anxiety Disorder, and Insomnia. R5's Minimum Data Set (MDS) assessment dated [DATE], documents in Section C that R5 is rarely/never understood, Section E indicated no behaviors, and Section N indicated that R5 is on an antipsychotic medication. R5's Physician Orders dated 12/19/24, documents R5 has an order for Seroquel/Quetiapine (Antipsychotic medication) 25 mg by mouth two times a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R5's current Care Plan documents R5 uses an antipsychotic medication related to agitation secondary to dementia. On 2/03/25 at 9:04 AM, R5 was sitting up in her high back, reclining wheelchair by the nurse's station. R5 stated I have been tearful, but they help me (pointing to the nurse). R5 also denied discomfort and was easily redirected with conversation. On 2/03/25 at 12:19 PM, R5 was sitting in high back, reclining wheelchair at nurses' station, she appeared calm and in no distress. On 2/04/25 at 9:10am, R5 was sitting at nurses' station in high back, reclining wheelchair, calm and smiling as people walked by. 3. R54's Admission Record documents that 54's date of admission to the facility was 8/1/23 and his diagnoses on admission include Parkinson's Disease Without Dyskinesia, without Mention of Fluctuations, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, With Psychotic Disturbance, Major depressive Disorder, Insomnia, and Cognitive Communication Deficit. R54's Minimum Data Set (MDS) assessment dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 14, indicating cognition intact, Section E indicated no behaviors, and Section N indicated R54 is on an antipsychotic medication. R54's Physician Orders dated 1/12/24, documents R54 has an order for Seroquel/Quetiapine (Antipsychotic medication) 25 mg give two tablets by mouth at bedtime related to Unspecified Mood (Affective) Disorder. R54's current Care Plan documents R54 uses an antipsychotic related to unspecified mood affective disorder. On 2/02/25 at 12:18 PM, R54 was lying in bed asleep in no discomfort. Arouses when spoken to but closes eyes and will not speak. On 2/03/25 at 8:50 AM, R54 was sitting up in his wheelchair in the TV (Television) lounge, calm, watching television. R54's Behavior Tracking Task documents no behaviors the last 30 days. R54's Monthly Medication Review (MMR) dated 7/5/24, documents request for Gradual Dose reduction (GDR) on Seroquel/Quetiapine (Antipsychotic medication) rejected by physician with no clinical rationale or evidenced symptoms documented. 4. R82's Admission Record documents that R82's date of admission to the facility was 3/29/24 and her diagnoses on admission include Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Hallucinations, Anxiety Disorder, and Major Depressive Disorder, Recurrent. R82's Minimum Data Set (MDS) assessment dated [DATE], documents in Section C Brief Interview or Mental Status (BIMS) score of 4, indicating severe cognitive impairment and Section N indicated R82 is on an antipsychotic medication. R82's Physician Orders dated 4/10/24, documents R82 has an order for Seroquel/Quetiapine (Antipsychotic medication) 12.5 mg by mouth two times a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Hallucinations, Unspecified. R82's current Care Plan documents R82 uses an antipsychotic medication related to agitation secondary to dementia. On 2/02/25 at 10:48 AM, R82 was standing in room dressed in clean clothes, well groomed, talking to herself and conversation was nonsensical. R82 smiled and giggled when spoken to. On 2/03/25 at 10:11 AM, R82 was walking around in room in no distress, pleasant and friendly when spoken to. On 2/05/25 at 9:31 AM, V3/DON (Director of Nursing) verified that R2, R5, R54, and R82 did not have appropriate diagnoses for the use of their Seroquel/Quetiapine (Antipsychotic medication) per CMS (Central Management Services) guidelines. V3 also verified that R54 has not had a GDR and stated R54 has not had any documented behaviors that would justify a declination of a GDR attempt.

Based on Observation, Interview and Record Review, the facility failed to complete hand hygiene and glove changes prior to administering invasive medications and failed to ensure the facility implemented and followed Enhanced Barrier Precautions for four of 27 residents (R59, R63, R77, R347) reviewed for Infection Control in the sample of 33. Findings include: The Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Diseases documents Standard Precautions: Gloves- gloves (clean, not sterile) should be worn whenever there is direct contact with blood, body fluids, mucous membranes, non-intact skin and other potentially infected material. Hand hygiene should be performed before and after removing gloves. Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Hand hygiene should be performed before and after removing gloves. After gloves are removed, clean hands immediately to avoid transfer of microorganisms to other residents or environments. ebp (Enhanced Barrier Precautions)- Used in addition to Standard Precautions to prevent transmission of novel or targeted MDROs (Multi-Drug Resistant Organisms). Expands the use of PPE (Personal Protective Equipment) beyond situations which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDROs) to staff hands and clothing. Examples of high-contract resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing, Gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Regardless of the type of precautions, the following guidelines should be adhered to: Post clear signage on the door or wall outside resident's room indicating type of precautions & (and) PPE required. Make sure all PPE is readily available. Position a trash can inside resident room and near exit, if possible, for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. EBP All residents with any of the following: Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. Infection or colonization with a novel or targeted MDRO when Contact Precautions do not apply. 1. On 2/3/25 at 1:33 PM, V9 (Licensed Practical Nurse/LPN) applied gloves to both hands then retrieved medication cart keys from her pocket. V9 opened a medication drawer and removed a box of eye drops. V9 then wearing the same gloves entered R77's room, touched the door and bedside table. Without completing hand hygiene or changing gloves, V9 instilled antibiotic eye drops (Ciprofloxacin) into each eye for R77. On 2/3/25 at 1:38 PM, V9/LPN applied gloves to both hands and entered the facility's medications room. V9 then touched the door handle, the medication fridge, and shelves where needles and syringes are located. With the same gloves, V9 opened syringe and needle packaging and withdrew Hepatitis B vaccine into a syringe for injection. V9 took the syringe of vaccine into R347's room and gave R347 an intramuscular injection while continuing to wear the same gloves. On 2/3/25 at 1:43 PM V9/LPN applied gloves to both hands then retrieved medication cart keys from her pocket. V9 opened the medication cart and pulled out a box of lubricating eye drops. Wearing the same gloves, V9 went back into R77's room, touched R77's face and instilled one eye drop into each eye. On 2/3/25 at 1:47 PM, V9 confirmed that once she applied gloves during her medication administration for R77 and R347, she did not remove them or apply new ones before giving the medication. V9 stated she usually changes her gloves a lot because she doesn't like germs. V9 then confirmed that she would be potentially giving R77 and R347 germs when she touches surfaces and does not change those gloves before administering eye drop or injections. On 2/4/25 at 11:25 AM, V5 (Registered Nurse/Infection Control Preventionist) confirmed that nurses can wear gloves when passing medications if they choose. V5 stated When passing invasive medications, washing hands and donning gloves is expected just prior to the administration. If a nurse touches items on the medication cart or environmental surfaces, those gloves should be removed and clean gloves applied before administering eye drops or injections. 49187 2. R63's current Physician Order Sheet, dated 2/5/25, documents Cleanse areas to bilateral buttocks with wound wash or normal saline, pat dry, then apply hydrocolloid every night shift every three days. Start Date: 12/26/2024. R63's Ulcer/Wound Documentation Assessment, dated 1/30/2025 documents R63 has a facility acquired stage two pressure wound to R63's left buttock that was identified on 12/18/2024. This same assessment documents R63's left buttock wound is open and has sanguineous drainage. On 2/3/25 at 11:55 AM no EBP sign or PPE was observed inside or outside of R63's room. On 2/4/25 at 10:00 AM no EBP sign or PPE was observed inside or outside of R63's room. 50962 3. R59's Admission Record documents that R59's date of admission to the facility was 12/17/24 and his diagnosis on admission include Cerebral Infarction, Hemiplegia Affecting Right Dominant Side, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Atherosclerotic Heart Disease of Native Coronary Artery. R59's Minimum Data Set (MDS) assessment dated [DATE], documents in Section H, R59 has an indwelling urinary catheter. R59's Physician Orders dated 12/17/24, documents #(Number)16/10ml (Milliliter) foley for urinary retention/bladder outlet obstruction every shift, Catheter care every shift and irrigate foley catheter with 60 ml piston syringe twice daily and as needed for bloody urine output, foley obstruction or urine output with blood clots. R59's current Care Plan documents R59 has an indwelling urinary catheter in place. On 02/02/25 at 11:50 AM, R59 was lying in bed, dressed in clean clothes, well-groomed with indwelling catheter hanging on bed with cover over it. No EBP sign was noted on door and no PPE available. On 02/03/25 at 9:01 AM, R59 sitting up in bed with indwelling urinary catheter hanging on the side of the bed. R59's room continues to have no EBP sign on door or PPE available. On 2/03/25 at 1:00 PM, V7 (CNA) observed doing indwelling urinary catheter care on R59. V7 placed a clean towel over a bedside table then placed clean wash cloths and towels with a fresh tub of warm soapy water on the table. V7 performed hand hygiene and donned gloves but no gown and proceeded to complete catheter care on R59. R59's room remains without EBP sign on door or PPE available. V7 stated she has not heard of Enhanced Barrier Precautions. On 2/4/25 at 11:20 AM, V5 (Registered Nurse/Infection Control Preventionist) confirmed R59 has an indwelling urinary catheter and R63 has a wound requiring dressing changes. V5 stated EBPs are for anyone with a catheter, feeding tube, tracheostomy or any wounds with dressings. Those resident rooms should have a PPE cart outside of their room, a sign (indicating the type of precautions) on the door and receptacles inside the rooms for linen and trash collection. (R63) has a wound on his buttocks and he is not in EBP. I just must have missed him and need to implement that today. (R59) did not have a sign or equipment outside of his room on Sunday or Monday. I realized this yesterday after it was pointed it out. He should have been in EBP due to his indwelling urinary catheter.

Based on Observation, Interview and Record Review, the facility failed to complete hand hygiene and glove changes prior to providing urinary catheter care for one of two residents (R51) reviewed for indwelling urinary catheters in the sample of 33. Findings Include: The Catheter Care/Incontinent Care policy dated 8/1/05 documents Objective: To cleanse the urinary meatus and adjacent catheter. Procedure: 1. Obtain wash basin, washcloth, soap, water, and vinyl gloves. 4. Wash hands thoroughly. 6. Expose genitalia. 7. Put on vinyl gloves. The Infection Prevention and Control Standard and Transmission-Based Precautions for Communicable Diseases documents Standard Precautions: Gloves- gloves (clean, not sterile) should be worn whenever there is direct contact with blood, body fluids, mucous membranes, non-intact skin and other potentially infected material. Hand hygiene should be performed before and after removing gloves. Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Hand hygiene should be performed before and after removing gloves. After gloves are removed, clean hands immediately to avoid transfer of microorganisms to other residents or environments. R51's current computerized medical record, documents R51 was admitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. R51's current Physician Order Sheet, dated 2/4/25, document the following order, Catheter care every shift. This order has a start date of 10/21/2024. R51's current Care Plan documents (R51) uses a urinary catheter r/t (related to) BPH (Benign Prostatic Hyperplasia), Obstructive Uropathy, and Neurogenic Bladder. On 2/3/25 at 2:47 PM, V8/CNA (Certified Nursing Assistant) put on Personal Protective Equipment/PPE (gown and gloves) and entered R51's room carrying a washbasin, washcloths, towels, and a bottle of soap. V8 placed the items on R51's overbed table then took the washbasin to the bathroom to fill with water. V8 carried the washbasin back to the overbed table and placed the washcloths in the washbasin. V8 then removed R51's disposable brief and did urinary catheter care for R51, readjusted R51's catheter tubing, then reapplied R51's disposable brief. V8 did not wash her hands or change her gloves from the time she entered R51's room until V8 had emptied the washbasin in the bathroom before leaving the room. On 2/4/25 at 1:03 PM, V3/Director of Nursing verified that V8/Certified Nursing Assistant should have washed her hands and changed her gloves before providing urinary catheter care for R51.

Based on record review and interview the facility failed to ensure physician ordered daily weights were obtained and the physician notified of a significant weight increase for one of one resident (R347) reviewed for daily weights in the sample of 33. Findings include: The Weight Management Policy and Procedure revised 2023 documents Policy: Each resident will be weighed at least once a month on a predetermined schedule. All residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. Weights may be obtained more frequently than monthly if warranted based on resident condition or physician order. A resident with a weight fluctuation of greater than five pounds (+ or -) will be re-weighed for accuracy. The new weight will be recorded in the medical record. The physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian. R347's current computerized medical record, documents R347 was admitted to the facility on [DATE] with diagnoses which included Essential (Primary) Hypertension, Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms, Atherosclerosis of Aorta, and Type 2 Diabetes Mellitus without Complications. R347's current Physician Order Sheet, dated 2/4/25, document the following order, Daily Weight: notify provider on greater than 3 (three) pound increase in 24 hours, or 5 (five) lbs. (pounds) in one week. This order has a start date of 1/21/2025. R347's current Care Plan Care Plan documents Daily Weight: notify provider on greater than 3 (three) pound increase in 24 hours, or 5 lbs. in 1 (one) week. R347's Weights and Vitals Summary Log dated 1/21/25 through 2/3/25 document R347 has not been weighed daily as ordered by the physician on five days within this timeframe. R347 was not weighed on 1/22, 1/24, 1/26, 1/27, and 1/28/2025. R347's weight on 1/31/25 was 233.7 pounds and 249.4 pounds on 2/1/25 (15.6 pound increase). On 2/4/25 at 12:35 PM, V3/Director of Nursing verified that there was a physician's order for daily weight and there were five days the weights were not done in a two-week period. V3 also verified that R347's weight on 1/31/25 was documented as 233.7 pounds and on 2/1/25 as 249.4 pounds (15.6 pound increase). V3 stated I did not see anywhere that the doctor was notified of the weight increase but should have been.

Based on observation, interview, and record review, the facility failed to place an oxygen sign on the door (R346) and failed to obtain a physician's order for oxygen use (R84) for two of two residents (R84 and R346) reviewed for oxygen in the sample of 33. Findings include: The Oxygen Administration policy dated 1/28/2025 documents Policy: To administer oxygen in conditions in which insufficient oxygen is carried by the blood to the tissues. Oxygen is administered by an LPN (Licensed Practical Nurse) or RN (Registererd Nurse) per physician's orders. (Other staff may not regulate, start, or discontinue oxygen.) Oxygen may not be dispensed without a physician's order. Each resident's room with oxygen shall be marked with an oxygen in use sign. Equipment: Oxygen sign Procedure: 2. Place sign OXYGEN IN USE outside the room of the resident. Smoking is prohibited. 12. Nasal cannulas, oxygen tubing, humidifiers and reservoirs will be tagged with date and initials of date changed. Date and initial the bag when placed and change weekly. 1. R346's current computerized medical record, documents R346 was admitted to the facility on [DATE] with diagnoses which included COPD (Chronic Obstructive Pulmonary Disease) and Acute Respiratory Failure with Hypoxia. R346's current Physician Order Sheet, dated 2/4/25, documents the following orders, Oxygen to keep SpO2 (Saturation of peripheral oxygen) above 92 percent. Order dated 1/27/25. Oxygen at 3 (three) liters per nasal cannula continuous. This order has a start date of 2/4/2024. R346's current Care Plan documents (R346) has COPD and history of respiratory failure r/t (related to) smoking. Initiated 1/28/2025. Intervention - O2 (Oxygen) to keep SpO2 (oxygen saturation) above 92 % (percent). On 2/2/25 at 9:23 AM, R346 was observed lying in bed wearing oxygen. There was no Oxygen sign on R346's door. On 2/3/25 at 10:52 AM, V3/Director of Nursing verified that R346 wears oxygen and there should be an Oxygen in use sign on R346's door. 49187 2. On 2/2/25 at 10:20 AM R84 was lying in bed with oxygen flowing at two liters per nasal cannula. R84's current Physician Order Sheet, dated 2/4/25, does not contain a physician order for the use of oxygen. On 2/4/25 at 10:35AM V3/Director of Nursing verified R84 did not have a current physician order for oxygen. V3 stated, We (the facility) should have got an order to administer oxygen to (R84) prior to (R84) wearing oxygen.

Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the medical record notification to the Ombudsman of residents that were reviewed for notices before transfers. This failure has the potential to affect all 94 Residents residing in the Facility. Findings include: Admission and Discharge/Transfer log reviewed with multiple residents discharged /transferred. On 5/1/24 at 8:41 AM, V1 Assistant Administrator was unable to provide any documentation the Ombudsman was notified of resident transfers. We notify the Ombudsman of resident admits and discharges out of the building but not if they transfer to the hospital. Facility Application for Medicare/Medicaid, dated 5/1/24, documents 94 Residents reside in the Facility.

Based on observation and interview, the facility failed to ensure pressure ulcer wound treatment was completed in a manner to prevent potential cross contamination of the wound for one resident (R55) of five residents reviewed for pressure wounds, in a total sample of 39. FINDINGS INCLUDE: On 05/01/24, at 11:00 a.m., V6/Licensed Practical Nurse provided wound care for R55's stage II (dime-sized/no drainage) coccyx area pressure wound. V6 turned R55 on R55's left side; opened R55's incontinence brief and exposed R55's wound/no dressing noted on wound; washed the wound area with spray cleanser and patted dry with 4 by 4 gauze; V6 allowed R55 to roll back on to the incontinence brief with the cleansed wound touching the incontinence brief; prepared R55's medication and dressing (Peptospermum Honey and Hydrocolloid), rolled R55 back on to R55's left side; applied the medication and dressing (Peptospermum Honey and Hydrocolloid) leptospermum to the wound; assisted R55 back on to incontinence brief; and then pulled up the front of the R55's incontinence brief. At 11:10 a.m., V6 confirmed after cleansing R55's pressure wound, R55 should not have allowed R55 to roll back over resulting in the cleansed wound touching the incontinence brief which was on R55 prior to and during R55's wound care.

Based on observation, interview, and record review the facility failed to identify target behaviors to warrant the use of an antipsychotic medication, failed to ensure a resident received the lowest effective dose of psychotropic medication (R17), and failed to ensure PRN (as needed) psychotropic medication had a 14 day stop date (R295) for two of six residents (R17 and R295) reviewed for unnecessary medications in the sample of 39. Findings include: 1. The facility's Psychotropic Medication Policy revised 11/28/17 states, Intent: Residents are free from unnecessary psychotropic medication use. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. B. Dose, Duration, Monitoring: 1. Evaluation of pharmacological ongoing effectiveness towards therapeutic goal. 2. Evaluation of the effectiveness of the non-pharmacological approaches prior to medication administration. 3. Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. C. Gradual Dose Reduction: 1. Residents should receive the lowest effective dose of psychotropic medication for the residents' physical, mental, and psychosocial well-being. The Policy also documents Initial PRN (as needed) order of antipsychotic medication should not exceed 14 days. A new order must be obtained after the physician or prescribing practitioner believes that to extend beyond the 14 days and has documented to rationale and indicated the rationale. R17's Face Sheet documents R17 admitted to the facility on [DATE] with diagnoses to include but not limited to: Unspecified Dementia with Psychotic Disturbance; Anxiety Disorder, and Depression. R17's current Care Plan documents R17 takes an antipsychotic medication related to psychosis. This same Care Plan does not document R17's specific behaviors related to R17's antipsychotic use. R17's Note to Attending Physician/Prescriber dated 2/7/24 documents a pharmacy recommendation to decrease R17's Seroquel Antipsychotic medication from 50 mg to 25 mg in an effort for a dose reduction. This same note documents V5 (R17's Physician) signed and agreed with the recommendation. R17's Physician Order Sheet dated July 2023-May 2024 documents orders for Seroquel (Antipsychotic) 25-50 milligrams/mg by mouth at bedtime for unspecified Psychosis with R17 currently receiving 50 mg by mouth at bedtime. R17's Medication Administration Records (MAR) dated February 2024 documents between 2/1/24 and 2/22/24 R17 received Seroquel 50 mg by mouth nightly. This same MAR dated 2/23/24-2/29/24 documents R17 received Seroquel 25 mg by mouth nightly. The MAR for the entire month of February 2024 documents NO behaviors exhibited by R17 were observed. R17's MAR dated March 2024 documents between 3/1/24 and 3/26/24 R17 received Seroquel 25 mg by mouth nightly. This same MAR documents between 3/27/24-3/31/24 R17 received Seroquel 50 mg by mouth nightly. The MAR for the entire month of March 2024 documents NO behaviors exhibited by R17 were observed. R17's MAR dated 4/1/24-4/30/24 documents R17 received Seroquel 50 mg by mouth nightly for the entire month. This same MAR documents NO behaviors exhibited by R17 were observed. R17's Behavior Tracking Logs dated 12/30/23-5/1/24 documents No Behaviors Observed for this period. On 4/30/24 at 11:10 AM, R17 was sitting up in a chair in R17's bedroom. R17 was calm, alert, oriented and able to answer questions well. R17 stated R17 could not recall why R17 was on the antipsychotic medication Seroquel. R17 stated, I think I was angry when I first came in, so they put me on Seroquel. I have Dementia too. That might also be why. Around 12:30 this same day, R17 was observed ambulating independently throughout the facility, socializing, and interacting with other residents well. No abnormal behaviors were observed. On 5/2/24 at 8:52 AM, V4 (Licensed Practical Nurse) stated that R17's Seroquel dose was decreased from 50 mg to 25 mg in February 2024 in response to V5's (R17's Physician) physician response to a Pharmacy Recommendation. V4 stated R17's Seroquel dose was increased back to 50 mg from 25 mg because R17 and V11 (R17's Power of Attorney) refused the reduction. V4 denied that R17 exhibited behaviors to justify the medication dose increase. On 5/1/24 at 3:14 PM, V7 (Regional Director of Operations) verified R17's behavior tracking logs were not specific to R17's behaviors for antipsychotic use and verified R17's behavior logs did not document any behaviors to warrant the use of R17's antipsychotic medication. V7 stated psychotropic medications cannot be increased for family preference if there are no associated behaviors. On 5/1/24 at 3:20 PM, V1 (Assistant Administrator) denied that R17 exhibits any behaviors to justify the use of an antipsychotic medication. 34542 2. R295's Electronic Medical Record (EMR) document R295's diagnosis to include: Unspecified Dementia; Gastro-Esophageal Reflux Disease, Anxiety Disorder, Hallucinations, and Hypertension. R295's EMR document Physician's Order, dated 4/10/24, Lorazepam Oral Tablet 0.5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for Anxiety. indefinite. On 5/2/24, at 11:55 a.m., V8/Regional Nurse Consultant confirmed the PRN medication should have had a 14-day stop date.

Based on interview and record review the facility failed to meet the needs for one of three residents (R1) reviewed for call lights in a sample of eight. Findings Include: The Call Light Policy dated 8/1/05, documents To respond to resident's requests and needs. It is the policy of this facility to maintain the highest quality of care for its residents. If you are unable to meet residents request or need, leave call light on and obtain assistance from charge nurse. R1's current Care Plan documents I am at risk for falls related to Gait/balance problems. Interventions: Call Don't Fall sign placed in room. Be sure (R1's) call light is within reach and encourage him to use it for assistance as needed. Remind (R1) to use call light for assistance. I am at risk for an ADL self-care performance deficit related to activity intolerance. Interventions: (R1) requires one-person physical assist for stand-pivot transfers. Use a gait belt and a walker. He will often self-transfer without staff supervision. (R1) requires one-person physical assist. He prefers to sleep in his recliner. R1's Minimum Data Set assessment dated [DATE] documents R1 is an extensive assist of one-staff for transfers. On 2/7/23 at 9:38 AM, R1 stated that one evening he wanted to go to bed, and his call light got turned off three times. On 2/8/23 at 7:40 AM, V18 (Licensed Practical Nurse/LPN) stated that she was told by a day shift aide that R1 said his call light was turned off three times when he was wanting to go to bed. No one went back to help R1, so he did it himself. V18 notified V12 (R1's Power of Attorney) and V23 (LPN) that worked the night of 1/27/23 when the incident happened. On 2/8/23 at 3:05 PM, V20 (Agency Certified Nursing Assistant) stated (R1) put his call light on and when I got to this room he was sitting in his wheelchair and stated he wanted to go to bed. I wasn't sure how (R1) transferred so I wanted to go get some help. I shut the light off and told (R1) I would be back. I saw (R1's) light come on again and (V21/CNA) went into the room. Later I asked (V21) how (R1) transfers and if she would help me put him to bed. (V21) said that (R1) had decided he didn't want to go to bed and was going to sleep in his recliner. On 2/8/23 at 3:30 PM, V21 (Certified Nursing Assistant/CNA) stated I came to work at 6:00 PM on (1/27/23) and sometime after 7:00 PM, I was going past (R1's) room to look for a sling to transfer another resident. I saw (R1's) light on and asked what he needed. (R1) said that he wanted to get ready for bed. I told him that he was not my resident, and I would get his aide. He said that he had already asked someone to help him, and they said they were busy and would come back but didn't. (R1) was (V20's/Agency CNA) resident that night. (V20) was sitting at the nurse's desk not doing anything. I went and told (V20) that (R1) wanted to go to bed. (V20) asked how (R1) transferred, and I told her a transfer of one. I also told (V20) that (R1) sleeps in his recliner not his bed. Later I went by and (R1) was sitting by the door in his wheelchair saying he got tired of waiting on somebody and got himself ready for bed. (R1) said he had asked for help three times. It made me mad that (V20) didn't help (R1). The next morning (V23/Licensed Practical Nurse) told me to write a statement about what happened. On 2/8/22 at 3:38 PM, V22 (CNA) stated I was not aware at the time what happened between (R1) and (V20/Agency CNA). Later I was told that (V20) shut off (R1's) light a couple of times and did not help him to bed. (R1) doesn't take a lot of assistance and sleeps in his recliner. On 2/8/23 at 4:04 PM, V23 (Licensed Practical Nurse/LPN) stated that she worked the night shift on 1/27/23. In the morning right before V23 left V21 (CNA) told her about V20 (Agency CNA) shutting off R1's call light and not helping R1 to bed. V23 told V21 she should write a statement about what happened. On 2/8/23 at 4:22 PM, V24 (CNA) stated that between 7:00 PM and 8:00 PM she heard V21 (CNA) tell V20 (Agency CNA) that R1 wanted to go to bed. On 2/8/23 at 5:09 PM, V1 (Administrator) stated that someone should have helped R1 get to bed. A statement written by V21 (Certified Nursing Assistant/CNA) dated 1/28/23 documents (R1) rang saying he wanted to go to bed. I went to answer the light as it was in overtime. I told (R1) I was looking for a sling and I'd let (V20/Agency CNA) know as she had (R1). I went to tell (V20) as she was at the desk doing nothing. (R1) then rang again two times while I was putting (a resident on another hall) to bed. (V20) had answered (R1's) light and said she would be back. (V20) then proceeded to go in the break room for her lunch. (R1) got upset and put himself to bed in chair! I let (V23/Licensed Practical Nurse) know what was going on and how I told (V20) I answered (R1's) light the first time and (R1) was ready for bed. R1's Health Status Note written by V18 (Licensed Practical Nurse/LPN) dated 1/28/23 at 10:51 AM, documents Informed by aide (R1) informed her (R1) requested assistance (three) different times from (three) different persons on 1/27/2023 to get ready for bed and each person informed him they would return to help him get ready for bed and none of the three returned to help him which resulted in (R1) getting himself ready for bed. (V18) spoke with (R1) and (R1) informed (V18) of same information he gave aide. (V18) spoke with (R1) and apologized and informed (R1) (V18) will correct situation by speaking and informing night shift (V23/LPN) of last night's situation.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for three of twenty residents (R10, R47, R68) reviewed for care plans in the sample of 36. Findings include: The facility's Resident Assessment and Care Planning policy dated 11/2017 documents, The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, as well as preferences for care and goals. 1. On 11/14/22 at 11:51 AM, R10 was alert leaning over to her right side in her recliner. R10 stated that she has no function in left side due to her cerebral palsy. R10's Contracture Risk Evaluation, dated 9/6/22, documents, ROM limited on left related to Cerebral Palsy. R10's MDS (Minimum Data Set), dated 9/6/22, documents in Section G Functional Status that R10 has functional limitation in range of motion on one side of her upper and lower extremities. R10's current care plan has no documentation of a comprehensive care plan addressing R10's ROM limitations. On 11/16/22 at 1:24 p.m., V7 (MDS Coordinator) confirmed that R10 did not have a comprehensive care plan addressing R10's ROM limitation. 2. On 11/14/22 at 11:26 AM, R68 was alert sitting up in her recliner. R68 had an indwelling urinary catheter drainage bag hooked to her walker that contained dark amber urine. R68's Physician's orders, dated 11/15/22, document an order for R68 to have a indwelling urinary catheter 16 French/10 ml (milliliters) balloon to be changed every four weeks for the diagnosis of urinary retention. R68's care plan has no documentation of a comprehensive care plan addressing R68's indwelling urinary catheter. On 11/16/22 at 1:24 p.m., V7 (MDS Coordinator) confirmed that R68 did not have a comprehensive care plan addressing R68's indwelling urinary catheter. 31682 3. R47's Physician's Order Sheets dated 11-15-22 document, Eliquis (anticoagulant/blood thinner) 2.5 mg (milligrams) one tablet by mouth two times a day for the diagnosis of Atrial Fibrillation. R47's current Care Plan does not include a comprehensive plan of care for the use of R47's anticoagulant medication (Eliquis). On 11/15/22 at 01:54 PM V2 (Director of Nursing) stated, (R47) has not had a care plan developed to address (R47's) anticoagulant use.

Based on observation, interview, and record review, the facility failed to provided ROM (Range of Motion) programming for a resident with limited ROM for one of one resident (R10) reviewed for limited ROM in the sample of 36. Findings include: The facility's Contracture Prevention Program policy, dated 1/15/11, documents, Objective: To maintain residents at the highest level of physical functioning possible. To stimulate circulation and prevent edema. To prevent fixation of a joint for long periods of time. To prevent atrophy of muscles. Procedure: The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing contracture may include goals, positioning aids, treatment plans and potential for improvement. Those individuals having limited range of motion and fair to good potential for resolution may be placed in therapy or restorative/rehabilitation program. On 11/14/22 at 11:51 AM, R10 was alert leaning over to her right side in her recliner. R10 stated that she has no function on her left side due to her diagnosis of Cerebral Palsy. R10 also stated that staff do not help her with exercises, but she would really like them to. R10's Contracture Risk Evaluation, dated 9/6/22, documents, ROM limited on left related to Cerebral Palsy. R10's MDS (Minimum Data Set), dated 9/6/22, documents in Section G Functional Status that R10 has functional limitation in range of motion on one side of her upper and lower extremities. R10's current care plan has no documentation of R10 receiving any type of ROM programming. R10's CNA (Certified Nursing Assistant) Task list, dated 11/15/22, has no documentation of CNAs providing ROM programming to R10. On 11/16/22 at 12:05 PM, V2 (Director of Nurses) confirmed that R10 does not have any restorative ROM programming.

Based on record review and interview the facility failed to develop a comprehensive plan of care to address Dementia needs and treatments for three of three residents (R5, R56,R63) reviewed for Dementia Care in the sample of 36. Findings include: R5, R56, and R63's Electronic Health Record Diagnoses Listings document R5, R56, and R63 have a diagnosis of unspecified Dementia without Behavioral Disturbance. R5, R56, R63's current Care Plans do not include a Comprehensive Care Plan of R5, R56, R63's goals and treatments to address R5, R56, R63's diagnosis of Dementia. 34118 On 11/15/22 at 01:42 PM, V2 (Director of Nursing) stated, The facility has not comprehensively assessed (R5, R56, and R63's) physical, mental, and psychosocial needs associated with (R5, R56, and R63's) Dementia and has not developed a person-centered plan of care with goals and treatments to address (R5, R56, and R63's) diagnosis of Dementia.

Based on observation, interview, and record review, the facility failed to document appropriate diagnoses/condition to warrant the use of an antipsychotic medication, have documented behaviors to justify the use of an antipsychotic medication, implement an individualized care plan for the use of antipsychotics, perform a gradual dose reduction of an antipsychotic medication for two of three residents (R63 and R56) reviewed for antipsychotic medications in the sample of 36. Findings include: The Facility's Psychotropic Medication Policy dated 11/28/17, documents, Intent: Residents are free from unnecessary psychotropic medication use. These medications are to be given to treat specific condition/medical symptoms that is diagnosed and documented in the clinical record. Additionally, Antipsychotic medication may be indicated for use if: 1) Behavioral symptoms present a danger to the resident or others; 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; 4) GDR (Gradual Dose Reduction) was attempted, but clinical symptoms returned. Gradual Dose Reduction: 1) Resident's should receive the lowest effective dose of psychotropic medication for the resident's physical, mental, and psychosocial well-being. 2) GDR is to be attempted within the first year in two separate quarters, (with at least one month between attempts), unless clinically contraindicated. 3) If treating expression or indications of distress related to dementia, the GDR may be contraindicated for the following reasons: a) Target symptoms returned or worsened after attempt of GDR, and b) Physician has documented rationale why a reduction would impair residents' function or increase distressed behavior. R63's current POS/Physician Order Sheet documents, Quetiapine Fumarate (antipsychotic) 25 mg (milligrams) three times a day related to Unspecified Dementia with Behavioral Disturbance. R63's current Care Plan and Behavior Monitoring Logs dated 8-1-22 through 11-16-22 do not include an individualized anti-psychotic care plan addressing R63's specific behavioral signs/symptoms with interventions for the use of Quetiapine. R63's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 10/11/22 documents under Reduction Attempts: Specify current drug order: Quetiapine 25 mg three times daily. Date of most recent reduction attempted 7/25/22. Response to reduction attempts: Medication increased 7/28/22 per POA (Power of Attorney) request. R63's medical records do not include any behaviors after the reduction of Quetiapine to 25 mg twice daily to justify the increase back to Quetiapine 25 mg three times daily. On 11/14/22 at 10:15 am., R63 was laying in her chair in her room. R63 was confused and had no behaviors. On 11/16/22 at 11:15 am., R63 was resting in her room in her chair. R63 made conversation and was pleasant at this time and showed no behaviors. On 11/16/22 at 9:50 am, V1 (Administrator) stated, No, (R63) is not a threat to herself or to other residents. She has behaviors towards staff only. On 11/16/22, at 10:00 am., V2 (DON/Director of Nursing) stated, (R63) is not a threat to herself or other residents. (R63) seldom comes out of her room. (R63) has issues with African American staff. (R63's) POA is set on not reducing (R63's) Quetiapine so (R63's) Quetiapine was increased back three days after the reduction. There were no behaviors exhibited to increase the Quetiapine back. 31682 2. R56's Physician's Order Sheets dated 11-15-22 document R56 has the diagnoses of Dementia without Behaviors, Mood Disorder, Bipolar Disorder, Anxiety, and Depression. R56's Physician's Order dated 10-5-21 and signed by V5 (R56's Psychiatrist) document, Abilify (antipsychotic)10 mg (milligrams) daily for the diagnosis of Major Depression. R56's Physician's Order Sheets dated 10-5-21 through 11-16-22 do not include a GDR attempt of R56's Abilify. R56's Health Status Note dated 9/2/22 documents, (R56) is very confused. (R56) keeps saying that she is able to walk and keeps attempting to get up on her own. (R56) keeps wanting to go to the other house down the way to get her things. Call placed to (V4's/R56's Primary Physician) office. Awaiting return call. R56's Physician's Order dated 9-3-22 an signed by V4 (R56's Primary Physician) documents, (Increase) Abilify to 15 mg by mouth at bedtime for mood. R56's MDS (Minimum Data Set) Assessments dated 3-30-22, 6-21-22, and 9-20-22 document R56 has had no behavioral symptoms and is not a danger to herself or others. R56's MDS Assessments dated 6-21-22 and 9-20-22 document R56 has not had a GDR (Gradual Dose Reduction) attempt of R56's Abilify and a GDR has not been documented by a physician as clinically contraindicated. R56's current Care Plan and Behavior Monitoring Logs dated 8-1-22 through 11-16-22 do not include an individualized anti-psychotic care plan addressing R56's specific behavioral signs/symptoms with interventions for the use the Abilify. On 11/14/22 at 11:04 AM V6 (Registered Nurse) stated, (R56) does not have any behaviors except for trying to get up unassisted. 11/16/22 10:30 AM V2 (Director of Nursing) stated, It looks like (R56's) Abilify was increased to 15 mg every night on 9-3-22 by (V4/R56's Primary Physician) due to (R56) attempting to get out of bed unassisted. (R56) knows she cannot walk. (R56's) current Care Plan and Behavior Tracking Reports do not document the specific behavior signs/symptoms (R56) has for the use of Abilify. The staff should have contacted (V5/R56's Psychiatrist) to manage (R56's) Abilify dose. (R56) was originally ordered Abilify for Depression and somehow throughout the medical record the use of Abilify got changed to Mood Disorder. (R56) has not had a GDR attempt of the Abilify within the last year and the physician had not documented why a GDR is clinically contraindicated.

Based on observation, interview, and record review the facility failed to post nurse staffing hours. This failure had the potential to affect all 91 residents within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 11-14-22 and signed by V7 (MDS/Minimum Data Set Coordinator) documents 91 residents reside within the facility. On 11-14-22 from 9:30 AM through 11:15 AM, a tour of the facility was conducted. During the tour the nurse staffing hours information was not posted. On 11/15/22 at 09:23 AM V2 (Director of Nursing) stated, Nurse staffing information has not been posted since at least July 2022. The ball got dropped.

Based on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands and acknowledge if the resident and their representative understood the agreement. This had the potential to affect all 91 residents residing in the facility. Findings include: The facility's Contract between resident and select facility has no documentation in the arbitration agreement that the agreement can be rescinded within 30 days of signing it, nor that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. R68's Contract Between Resident and Facility, dated 5/6/20, documents that R68 signed the binding arbitration. On 11/16/22 at 01:05 PM, R68 stated that she was unaware of what the arbitration agreement meant when she signed it, and no one explained it to her. She also stated she wasn't aware of giving up her rights to litigation. R143's Contract Between Resident and Facility, dated 10/21/22, documents that V10 (R143's family member) signed the binding arbitration. On 11/16/22 at 01:02 PM, V10 stated, The admission process was very rushed. They just kept pushing papers in front of me to sign. I didn't know exactly what I was signing. I surely didn't know I was signing to give up my right to litigation in a court. This would have been nice to know before I signed everything. On 11/16/22 at 01:37 PM, V8 (Social Services Director) stated that both V8 and V9 (Social Services Assistant) do the admission contract with residents when they are admitted to the facility. V8 and V9 both confirmed that they were unaware of the full meaning of agreeing to an arbitration agreement, and during the admission process all they explained was that if a lawsuit was filed it would go through mediation. On 11/14/22 at 02:45 PM V1 (Administrator) stated, All of our admissions sign the full contract including the arbitration section. The facility's CMS (Centers for Medicare and Medicaid Services) Form 672 dated 11-14-22 and signed by V7 (MDS/Minimum Data Set Coordinator) documents 91 residents reside within the facility.

Based on observation, interview, and record review, the facility neglected to provide R1 with a thorough assessment, medical assistance, pain control and pain assessment, and timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 being left in excruciating pain from an acute left hip fracture, without Physician or power of attorney notification or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-26-22, the facility remains out of compliance at a severity Level II as the facility continues to provide in-servicing to all staff, including new hires and agency staff, prior to working their first shift on the facility's Fall Assessment and Management Policy, Pain Management Policy, Guidelines for Physician Notification of Change in Resident Condition, Resident Rights Policy, Abuse Policy, Resident Care Policy, and Safe Handling Program Policy, and while the facility continues to monitor residents for abuse and neglect, changes in condition, resident rights, pain, and post-fall interventions. Findings include: Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media policy dated 3-15-18 documents, Subject: Abuse prohibition. Abuse and Neglect is prohibited. All residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. An owner, licensee, administrator, employee, or agent of a facility shall not abuse or neglect a resident. Neglect means a failure in a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility's Management of Pain policy dated 4-4-12 documents, Policy: Our mission is to facilitate resident independence, promote resident comfort, and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain. A standard format for assessing, monitoring, and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign of the facility. For purposes of this policy, pain is defined as 'whatever the experiencing person says it is, existing whenever the experiencing person say it does.' Procedure: Physician Communication and Involvement-Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The Physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the Physician. Thorough communication with the Physician will ensure an appropriate pain management plan. Nursing Involvement: Pain Screening-Upon change in condition or when new pain or an exacerbation of pain is suspected, the Pain Questionnaire will be filled out with input from the resident, family member, or responsible party. If the resident scores a five or above on the Pain Questionnaire, the Comprehensive Pain Assessment must be completed. Comprehensive Pain Assessment measures the impact of pain on the resident's function, assessing the resident's physical condition, history, mental status, and ADLs (Activities of Daily Living). The assessment will cover the following areas: intensity, location, onset, type, frequency, description, change, treatment, effect, and what makes it better or worse. A licensed nurse will initiate the Comprehensive Pain Assessment under the following circumstances: A change in resident condition occurs to requires pain control and new pain is reported. Nursing Observation is an important part of the pain assessment, especially in the non-verbal resident. Using the chart provided with the pain assessment, nursing will observe behaviors that may indicate pain in the non-verbal or cognitively impaired resident. Pain may be indicated when there are changes in the following: Facial expression, vocal behaviors, body movements, routines, mental status. Physical Examination: The nurse will complete a physical evaluation of the resident that include the following: Vitals, bowel sounds, lung sounds, and objective observation of the painful area. Plan of Care-Initiate an interdisciplinary plan of care based on the initial assessment, the choice of a pain rating scale, and the development of pain-relieving strategies. Include both pharmacological and complementary interventions in the care plan. An immediate care plan will be initiated upon admission for any resident with orders for pain management, with reports of pain/injury or exhibiting common pain behaviors and reviewed at each care plan conference. Pain flow sheet-Initiate a pain flow sheet for all resident reporting pain regardless of the treatment. The pain flow sheet is completed each shift. The effectiveness of pain interventions should be measured one to two hours after administration of treatment using the pain scale chosen by the resident or the behavioral indicators. Documentation-Document interventions and responses in the medical record as appropriate and on the pain flow sheet. The facility's Fall Assessment and Management policy dated 04-2019 documents, It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned. Post fall assessment-immediately after fall: After a fall, the resident will not be moved from their position until a licensed nurse determines it is safe to do so. A licensed nurse will immediately assess the resident after a fall. Assessment parameters may include level of consciousness, complaints of pain, decreased range of motion, vital signs, and presence or absence of obvious injuries (lacerations, bruises, obvious fractures, bleeding, etc.) Assessment parameters also may include: A description of how the resident was observed and circumstances surrounding the fall, such as what the resident was doing at the time. Unusual signs or symptoms. The Physician will be notified immediately when an accident involving a resident, results in injury and has the potential for requiring Physician intervention. The responsible party will be notified promptly. The facility's Guidelines for Physician Notification of Change in Resident Condition policy dated 04/2019 documents, Purpose: To define resident care situations that require Physician notification. Change in condition may include Redness or swelling of any body part, newly defined deformity of any body part, new or increased complaints of pain, and accidents or occurrences. CNAs (Certified Nursing Assistants) are responsible for reporting any changes they observe to their charge nurse. It is the responsibility of each nurse to notify the Physician of a significant change in condition before the end of the shift. R1's Admission Face Sheet dated 6-26-20 documents R1 is a [AGE] year-old with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Annual MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively intact, exhibits no behaviors, has had no pain, and has had no falls since the prior MDS assessment on 3-31-22. This same MDS assessment documents R1 requires a walker for mobility and supervision of one staff physical assistance for transfers and walking on/off the corridor and in his room. R1's Progress Notes dated 7-7-22 at 8:15 PM and signed by V3 (LPN/Licensed Practical Nurse) document, (R1) states to staff that he fell in the hallway going towards the cafe area. (R1) has told four different stories to five different staff members. (R1) was seen up walking down hallway after he stated that he fell . (R1) states that he has broken his right hip and then stated that he broke his left hip. (R1) was able to stand and pivot without difficulties. There is no external rotation to either leg. R1's Medical Record does not include any further documentation regarding R1's fall, an assessment of R1's verbalization of having a left hip fracture and pain, a comprehensive pain assessment, Physician notification regarding R1's complaints of injury to the left hip, or power of attorney notification of R1's complaints of injury to the left hip after the Progress Note entered by V3 on 7-7-22 at 8:15 PM, until 7-8-22 at 6:15 AM when V5 (LPN) documented regarding R1's fall. R1's Progress Notes dated 7-8-22 at 6:15 AM and signed by V5 (LPN) document, After receiving report from night nurse (V3 LPN), this nurse went to (R1's) room to assess (R1). Upon entering (R1's) room, nurse observed (R1) laying on right side of body while aides were performing care on (R1). Nurse observed (R1) yelling out in pain at slightest movement in body when aides attempted to reposition (R1). Nurse had aides reposition (R1) on to his back to perform assessment. Nurse palpated left hip area due to (R1's) complaint of pain in that area. (R1) yelled out in pain. (R1) unable to lift left leg. Unable to perform flexion/extension motion or rotate left foot outward or inward. Nurse also observed (R1) sweating profusely. (R1) informed nurse pain level at 10. VS (Vital Signs) BP (Blood Pressure) 149/84, Pulse 104, Oxygen Saturation at 96 percent at room air, temperature 99.1 (degrees Fahrenheit), respirations 20. R1's Progress Notes dated 7-8-22 at 6:55 AM and signed by V5 document, At 6:20 AM (R1) informed nurse of unwitnessed fall on 07/07/2022 near cafe area by entrance/exit doors. (R1) informed nurse he fell on tile flooring. Complaint of left hip pain. (R1) cried out in pain to touch and when aides attempted to change his depends. (R1) requested to be sent to emergency room . 6:42 AM: 911 called. 6:53 AM: (R1) transported to (Local Hospital) emergency room via stretcher. 6:53 AM: Power of attorney called. Left voicemail. Awaiting call back. 7:01 AM: manager on call notified. R1's Hospital Clinical Report dated 7-8-22 at 7:04 AM documents, Chief complaint: Injury to left hip. The injury happened last night. (R1) presents to the emergency room with complaints of left hip pain after he fell last night. (R1) states he had his walker but slipped on something on the ground when he was walking, causing him to fall. (R1) states he landed on his left hip. (R1) states he was unable to put weight on that hip, so they had to get him into a wheelchair. However, they (the facility staff) did not send him over for evaluation until this morning when he told the staff he was having a lot of hip pain. Physical Exam: Left hip: deformity and mild tenderness. The left leg is shortened. Significant pain when moving (R1) around. Updated (R1) on results of x-ray and that he broke his hip. Discussed need to be transferred out of this hospital for surgery. R1's Left Hip Radiology Report dated 7-8-22 documents, Findings: There is an acute impacted fracture of the mid-left neck (left hip) without significant displacement or angulation. R1's Surgical Report dated 7-9-22 documents R1 required a surgical hemiarthroplasty (replacement of half of the hip joint/screw fixation of the left hip to repair R1's left hip fracture. R1's Care Plan dated 7-12-22 does not include a pain plan of care with interventions to treat R1's pain sustained after the fracture on 7-7-22. V3's (LPN) Disciplinary Action Form dated 7-11-22 and signed by V3 and V2 (Director of Nursing/DON) document, Type of Documentation: Written. Type of Violation: Unsatisfactory job performance, or substandard quality or quantity of work. Description of Violation: Failed to follow fall policy when a resident (R1) self-reported a fall to her. V3's (LPN) Disciplinary Action Form dated 7-15-22 and signed by V3 and V2 (Director of Nursing) documents, Type of Documentation: Last Chance. Type of Violation: Violation of established safety rules or standard operating procedures, including failure to report personal injuries or resident injuries in a timely manner. Description of Violation: Failed to notify the Physician of a change in condition of a resident (R1). V9's (CNA) Disciplinary Action Form dated 7-15-22 and signed by V9 and V2 documents, Type of Documentation: Last Chance. Type of Violation: Violation of established safety rules or standard operating procedures, including failure to report personal injuries or resident injuries in a timely manner. Description of Violation: Failure to contact supervisor regarding a resident (R1) that she felt needed to be sent to the emergency room and the nurse (V3) was not taking action. V4's (CNA) Disciplinary Action Form dated 7-15-22 and signed by V4 and V2 documents, Type of Documentation: Last Chance. Type of Violation: Violation of established safety rules or standard operating procedures, including failure to report personal injuries or resident (R1) injuries in a timely manner. Unsatisfactory job performance, or substandard quality or quantity of work. Description of Violation: Failed to contact supervisor regarding a resident (R1) that she felt needed to be sent to the emergency room and the nurse (V3) was not taking action. Failed to follow fall protocol, transferring a resident, that self-reported a fall, before the nurse had examined him. V5's (LPN) undated written statement documents, (Around 6:00 am 7-8-22) Received report from the night nurse (V3 LPN) that (R1) has been ringing call light and yelling all night. Per night nurse, (R1) complaining of left hip pain due to fall on 7-7-22. V6's (CNA) undated written statement documents, On Thursday 7-7-22, I was working on rehab (rehabilitation hallway) 6:00 PM-10:00 PM. (V11/LPN) was the nurse on rehab. Several visitors and other employees came over to rehab to let us know that a resident (R1) is sitting in a chair by the doors saying he fell and needs an ambulance. After the second person came to tell us, I decided to go down there to see what was going on. When I walked down to the seating area by the doors, I saw (R1) sitting there. I asked what happened and (R1) said he fell on the curve of birch/oak in front of the plants, and then said he used his walker as a crutch to get off the floor and walked to the seating area. (R1) then asked me to call an ambulance. (R1) was clearly in pain and was sweating. I went to go talk with the nurse and other CNAs on birch/oak (hallways) about (R1) to see what was going on, and they said (R1) was having a behavior and the CNAs said the nurse (V3 LPN) told them to leave (R1) there until his behavior issues are over. After that, I went back to my hall. The nurse for rehab (V11) went on break and when she came back, she told me that (R1) was still there asking for an ambulance. V7's (CNA) undated written statement documents V7 was working 2:00 PM to 10:00 PM on 7-7-22 and witnessed R1 sitting in a wheelchair in front of the nurse's desk, sweating like he was in pain, however everyone (facility) staff was saying R1 was fine, and it was behavioral. V8's undated interview with V2 (Director of Nursing) documents, On 7-7-22 at 8:15 PM, (R1) was sitting in a chair up at the front saying that he does not know what he did and that he could not move because he broke his hip. (V8) said she got (R1) a wheelchair, transferred (R1) to the chair, and took him to the nurse (V3). The nurse told (V8) that (R1) does that all the time. V9's (CNA) written statement dated 7-8-22 documents, At 8:00 PM (7-7-22) I walked down to birch/oak (hallways) to get fingernail clippers for my resident on maple/walnut (hallways). On my way, I saw (R1) sitting in a blue sofa chair by (V2's/Director of Nursing) office. (R1) said he needs help and needs to go to the hospital. I asked the girls on birch/oak what was going on with (R1) and they said (R1) won't get out of the chair and needs to get back up but is saying he won't unless it is by a stretcher. (V8 and V4/CNAs) were on their way down to get (R1) with a wheelchair. I walked over 15 to 30 minutes later, and they were trying to get (R1) to stand by talking to (R1). (R1) had told me when I originally walked by that he had fallen. The fall was unseen. I was told (R1) had stood and walked, however I did not see him stand or walk. At 10:15 PM, the nurse (V3) told me and (V4 CNA) that we need to get (R1) into bed. We changed (R1) and (V3) assessed him. When we finished changing (R1), I told both of them (V3 LPN and V4 CNA) that they should send (R1) out in case something did actually happen. V12's (CNA) written statement dated 7-11-22 documents, It was 8:01 PM when I and (V4) came back in from our lunch break where we had found (R1) sitting in the foyer in front of birch/oak entrance. We proceed to stop and ask (R1) how he was, and he responded by saying not very good, I need some help. I came to the left side of the chair noticing the left side of (R1's) pants was off his hip, seeing an old scar. I then asked him what was wrong, and he told me he had (fallen) coming from around the corner of birch/oak (hallways) where he proceeded to use the railing on the wall to get himself up from the floor and came to the foyer and sat, and that it where he had been until we had showed up. V13's (CNA) written statement dated 7-8-22 documents, I received report from (V9/CNA). (V9) stated that (R1) at the beginning of the shift stated that he fell and fractured his hip. (V9) informed me that (R1) had been hollering all night and pushing his call light. His light was ringing when I arrived (6:00 am). We proceeded in to tend to his light, I walked into a brown ring underneath (R1) with a soaked (adult brief) and soaked shirt. On 7-22-22 at 9:15 AM, R1 was lying in bed. R1 had a gauze dressing to his left hip. R1 stated, On 7-7-22 around 7:30 PM, I fell going around the corner from this hallway towards the administration offices. I had my walker and it got caught when I lost my balance and fell . I just went down and landed on my left hip. My hip hurt so bad. No staff was around, so I was able to get myself up and I wobbled about 60 feet to a chair in the front lobby. Staff did not find me until 8:00 PM. The nurse that night (V3/Licensed Practical Nurse/LPN) made me sit in the chair and would not send me to the emergency room . I kept telling her I wanted to go to the emergency room . I knew my left hip was broke. The nurse had staff put me in a wheelchair about two hours later. I could not even stand. The staff lifted me under my arms and put me in a wheelchair. It hurt so bad. I was crying and screaming in pain. The staff wheeled me to an area by the desk and left me there for hours. The nurse never did ask me if I needed anything for pain. I kept telling every staff member that walked by that I needed to go to the emergency room , but no one would listen. Later on, the nurse made me go to my room and get into bed. I was still screaming in pain. The staff picked me up again and slammed me into my bed. It hurt so bad. I suffered until the next morning. No one did anything for me, until the next morning. The morning nurse came in and sent me straight to the hospital. I was sent to another hospital and had to have surgery on my left hip. The morning nurse was my guardian angel. I have never felt so neglected in my life and that night nurse should not be taking care of anyone. On 7-22-22 at 9:32 AM V3 (LPN) stated, On 7-7-22 around 8:00 PM, a CNA came and got me and said that (R1) had fallen. (R1) was sitting in the lobby in a chair. I did range of motion with (R1), and it was fine. I do not recall all of the events the rest of that night. I was too busy. I know (R1) was on his call light all night saying his hip was broken. (R1) has behaviors. I did not call the doctor and report (R1's) fall. I let the day shift nurse know when she came on shift around 6:00 AM. (V5/LPN) sent (R1) right to the emergency room and (R1) had a broken hip. On 7-22-22 at 10:00 AM V4 (CNA/Certified Nursing Assistant) stated, I came in from my lunch break around 8:02 PM and saw (R1) sitting on the chair in the front lobby. (R1) told me he had fallen. (R1) said he was walking around the corner, off of the unit, lost his balance and fell . I went to tell the nurse (V3 LPN) that (R1) fell . (V3) yelled at me, 'I do not have time for this tonight. I feel like calling (V10/Scheduler/CNA) and telling her I need to go home.' I then saw his CNA (V8) coming up the hallway and told her (R1) needed vital signs and had fallen. Me, (V3 LPN) and (V8 CNA) then went back up to the lobby where (R1) was sitting. (R1) told us he needed to go to the emergency room . (V3) told us to transfer (R1) into the wheelchair and take him into his room. Me and (V8) tried to stand (R1) to get him to transfer to the wheelchair. (R1) started screaming he needed to go to the hospital and wanted us to call 911. (R1) said the only way he was leaving that chair was on a stretcher. (V8) said, 'I am not doing this.' We sat (R1) back down in the chair and (V8) went back to the unit (V8) was working on. I left (R1) in the chair in the lobby and went and told (V3 LPN) that (R1) could not transfer to the wheelchair because he was in too much pain. (V3) continued to pass medications to other residents and said to leave (R1) in the chair. A little later, (V6/CNA) from a different hallway came over and told us that (R1) had told her he had fallen and needs to go to the hospital. (V8) told (V6) that she already knows (R1) fell . (V8) said to me, 'I am tired of staff coming over here telling us about (R1). Let's go get him up into the wheelchair.' Me and (V8) went back up to the lobby where (R1) was sitting. (V8) told (R1) he had to get up in the wheelchair because the EMTs (Emergency Medical Technicians) could not get him in the front lobby and (V3) needed to examine him in his room. (R1) agreed to get in the wheelchair when (V8) told him EMTs could not pick him up in the lobby. Me and (V8) lifted (R1) from the chair to the wheelchair. (R1) could not bear weight on his left leg and was yelling out in pain during the transfer. (R1) could not pick up his left leg, so I placed his left foot on top of his right foot, turned his wheelchair backwards, and (V8) wheeled him to the nurse's station. Nobody had examined him yet. It was shift change and I was trying to finish charting. (R1) continued to moan. (R1) sat in the wheelchair for a long time, while (V3) finished her medication pass and treatments. (V3) then told me and (V9/CNA), we all need to get (R1) into bed. I wheeled (R1) backwards in the chair again to his room. (V3 and V9) lifted (R1) from his wheelchair into his bed. While transferring, (R1) was screaming, 'Wait. Wait. Wait.' (R1) was sitting on the side of the bed. (V3 and V9) went to grab (R1's) legs to lift them up into the bed and noticed (R1's adult brief) was wet and soiled. (V9) made (R1) turn from side to side to change his (adult brief). (R1) was screaming in pain and was trying to get (V9) to stop. (V9 CNA) said, '(R1) is too much!' (V9) continued to pull (R1's) brief down. (R1's) left hip was bulging and there was obviously something wrong with it. I told (V3 LPN) to look at (R1's) left hip. (V3) never did look at (R1's) hip. We positioned (R1) in bed and left the room. I could hear (R1) screaming out in pain clear up the hallway. (V9 CNA) complained about (R1) the entire night. (R1) was left in his room, in pain, until the next morning around 6:00 AM when another nurse came in and sent (R1) to the emergency room . (R1) was definitely neglected. Last Friday, (7-15-22), (V1/Administrator) and (V2/Director of Nursing) gave me a write-up because I did not call my supervisor to let them know that I did not think (V3 LPN) was taking adequate care of (R1) after (R1) fell . On 7-22-22 at 10:45 AM V5 (LPN) stated, I came in at 6:00 AM on 7-8-22. (R1) told me he had fell on the tile by the lobby the night before and was able to get himself up and walk to the chair in the lobby. (R1) was in a lot of pain and had a lump on his left hip. (R1) said he was in pain all night and had told the night staff he wanted to go to the hospital because he thought he had broken something. I immediately sent him to the emergency room . Later that day, (V2 Director of Nursing) had called the hospital and got report. The hospital told (V2) that (R1's) left hip was fractured. On 7-22-22 at 11:25 AM V6 (CNA) stated, I was working a different hallway on 7-7-22 from 6:00 PM to 10:00 PM. I saw (R1) in the lobby sitting in a chair around 8:15 PM. (R1) said he had fell and was waiting on an ambulance. (R1) was sitting crooked in the chair and was very sweaty. I went and told (V8 CNA) that (R1) said he had fell and was in pain. (V8) told me (V3 LPN) had said (R1) needs to sit there until his behavior stops. A little later, (R1) was sitting in a wheelchair and was sweaty from head to toe and requesting to get an ambulance. I knew something was wrong with (R1) because (R1) never wants to go to the hospital. (R1) was definitely in pain. (R1) would not yell out in pain unless he was hurting really bad. (V4 CNA) came over to my hallway a little later and told me (R1) had been sitting in pain for over two hours and (V3) still had not assessed him. I left at 10:00 PM that night and do not know what happened after that. On 7-22-22 at 12:00 PM V7 (CNA) stated, On 7-7-22 at 8:45 PM, I was sitting at the nurse's desk and (R1) was sitting in a wheelchair in front of the desk. (R1) was sweating a lot and saying he was in pain. (R1) kept repeating he needed to go to the emergency room because he fell , and his hip was hurting. (V3 LPN) never did assess him while I was there. (V3) kept saying (R1) was having behaviors. I have never seen (R1) have behaviors like that. I know (R1) was in a lot of pain. On 7-22-22 at 12:30 PM, V2 (Director of Nursing) stated, (V3 LPN) was disciplined because she did not call or report to (R1's) physician or (R1's) power of attorney after (R1) fell and was complaining of pain on 7-7-22. (V3) did not do a thorough fall assessment or pain assessment and should have. (V4 CNA) and (V9 CNA) were disciplined because they did not report to their supervisor when they felt like (R1) was not getting the cares he needed, and felt like (V3) should have sent (R1) to the emergency room for complaints of pain and a hip fracture and (V3) refused to send (R1) in. On 7-23-22 at 6:20 PM V11 (LPN) stated, I worked 6:00 PM to 6:00 AM on 7-7-22 through 7-8-22. On 7-7-22 around 8:15 PM me and (V6 CNA) went up to the front lobby to check on (R1). (R1) was sitting in a chair and said he had fallen and broke his hip. (R1) said he needed an ambulance. (V6) went and told (V3) that (R1) was in a chair and was saying he broke his hip and needed and ambulance. (V3) told (V6) that (R1) did not fall and (R1) was just having a behavior. Later on, I was coming in from my lunch break around 1:30 AM, and (V3) was outside. (V3) said (R1) is still having behaviors and has been screaming all night. Around 5:00 AM, (V9/CNA) came over to my hallway to see her dad who is also a resident at the facility. (V9) said to me (R1) has been up screaming all night and on his call light. (V9) said (V3) told her to just let (R1's) call light go off. (V13/CNA) came into work at 6:00 AM that morning (7-8-22) and was (R1's) CNA. (V13) told me when she came in (R1) was screaming bloody murder in pain and was grabbing his left hip saying it was broken. On 7-23-22 at 8:30 PM V8 (CNA) stated, (V4 CNA) came and got me and said (R1) had fallen and was sitting up in a chair in the lobby. I went and told (V3 LPN) and she said to check his vital signs. (R1) said he could not move and could not get up. (R1) said something about his left hip. I told (V3) that (R1) was unable to move, or get up, and she said to transfer him into a wheelchair. Me and (V4) had to pick (R1) up under the arms and transfer him to a wheelchair. (R1) was unable to pick his left leg up so I had to wheel his wheelchair backwards. I wheeled him in front of the nurse's desk. (R1) was shaking and saying he could not move. (V3 LPN) kept saying (R1) was just having behaviors. I was off work at 10:00 PM and did not see (R1) after that. On 7-24-22 at 7:30 AM, V12 (CNA) stated, Me and (V4 CNA) came in from break on 7-7-22 around 8:01 PM and found (R1) sitting in a chair in the lobby. (R1) said he had fallen, gotten himself back up, and walked to the chair. (R1) had his pants pulled down on the left side and said he was in pain, his left hip hurt, and he needed an ambulance. (V4) was his CNA that night and went to get (R1's) nurse. I did not take care of (R1) the rest of the night. On 7-25-22 at 7:30 AM V13 (CNA) stated, I came in at 6:00 AM on 7-8-22 and (R1) had his call light was on. I answered the call light and (R1) was yelling 'bloody murder' in pain. (R1) was soaked in urine and there was a brown urine ring under (R1). (R1) was drenched in sweat and you could tell (R1) was in excruciating pain. I asked (V9/CNA) why (R1) was soaked in urine and (V9) said they thought (R1) could change himself. (V9) also reported to me that (R1) had been on his call light screaming all night and the nurse (V3) told (V9) to just shut the call light off. The day shift nurse (V5 LPN) came in and assessed him and knew (R1) was in pain and broke his hip. (V5) sent him to the emergency room . The Immediate Jeopardy was identified on July 25, 2022 at 8:21 AM. The Immediate Jeopardy began on July 7 2022, when the facility neglected to provide R1 with a thorough assessment, medical assistance, pain control and pain assessment, and timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on July 26, 2022 at 8:45 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Corrective actions were initiated immediately following the incident with R1 that occurred on 7/08/2022 when V2 (Director of Nursing) and V1 (Administrator) became aware. 2. On 7-26-22, all nursing staff and therapy staff were in-serviced by V14 (Assistant Director of Nursing/ADON) on the facility's Fall Assessment and Management Policy. 3. On 7-26-22, all nursing staff and therapy staff were in-serviced by V14 on the facility's Resident Care Policy. 4. On 7-26-22, all nursing staff were in-serviced by V14 on the facility's Guidelines for Physician's Notification of Change in Resident Condition Policy. 5. On 7-26-22, all nursing staff were in-serviced by V14 on the facility's Resident Rights policy. 6. On 7-26-22, all staff were in-serviced by V14 on the facility's Abuse Policy, recognizing neglect and know to report any observance of neglect to the administrator immediately. 7. On 7-26-22, all nursing staff and therapy staff were in-serviced by V14 on the facility's Pain Management Policy and Safe Handling Policy. 8. On 7-26-22, all staff were in-serviced [TRUNCATED]

Based on interview and record review, the facility failed to ensure staff appropriately monitored enteral feedings for one (R1) resident reviewed for Gastrostomy Tube/G-Tube feeding in a sample of four. This failure resulted in R1 experiencing an emesis subsequently leading to an aspiration pneumonia requiring antibiotics. Findings include: The facility's Enteral/Tube Feeding Policy, (Revised 2/26/15) documents: It is the policy of this facility that all residents receive basic nutrition while in the facility and that no resident will have nutrition withheld in the absence of formulated advanced care plan/advanced directive directing such care. Objective: To maintain a consistent plan of care for residents who require tube feeding due to the inability to eat orally or the inability to eat enough to sustain life. R1's current Care Plan documents: (R1) requires tube feeding related to NPO (Nothing by Mouth) status. R1's Minimum Data Set Assessment (MDS) documents R1 has a BIMS (Brief Interview of Mental Status) score of 13. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R1's Order Summary Report (Dated 4/2022) documents: (Nothing by Mouth) diet, (Nutrients) 1.2 for (Gastrostomy Tube/G-Tube); intake every shift for G-Tube. Give 1300 ml via G-Tube every 24 hours for tube feeding to infuse over 20 hours at 65 ml. R1's Progress Note (Dated 4/18/22, 12:15 am) documents: (R1) was (complaining of) upset stomach. When nurse went into room, feeding bottle was hanging, but was empty. Nurse noted that part of feeding tube was not connected to the pump. R1's X-ray results (Dated 4/18/22) documents: Impressions: No acute intrathoracic disease process; and R1's X-ray results (Dated 4/20/22) documents: Impressions: Right lower lobe atelectasis/infiltrate. Facility's Final Report to (State Agency) (Dated 4/25/22) for R1 documents: It was determined that (R1's) tube placement became dislodged causing the pump sensor to allow the feeding to flow quickly. On 4/28/22 at 10:25 am, V5 Family Member to R1 stated that on 4/17/22, (R1's) (G-Tube Nutrients) were infused too fast, R1 vomited, and R1 had aspiration and developed pneumonia. V5 stated that R1 called her on 4/17/22 and stated that (R1's) stomach was upset. V5 stated that (V7 Licensed Practical Nurse, LPN) was in R1's room at that time. On 4/28/22 at 12:45pm, V2 Director of Nursing (DON) stated that R1's (G-Tube nutrients) went quickly into R1, R1 had an upset stomach, and R1 developed pneumonia per her chest X-ray. V2 stated that R1 was currently on an antibiotics for pneumonia. On 4/29/22 at 11:15 am, V6 Licensed Practical Nurse (Agency/LPN) stated that on 4/17/22 she connected R1's G-Tube to the feeding pump at the scheduled 4:00pm time; that occasionally, the pump would beep requiring her to check it. V6 stated that she had worked with feeding pumps before but was unfamiliar with R1's feeding pump and was unsure why the pump beeped. V6 stated that at 8:15pm, she checked the feeding pump and about 600 ml of fluid remained. Stated that she secured the tubing in place on the pump but it still beeped at times; stated that she turned the feeding pump off; clamped the tubing so it would not flow and also clamped R1's G-Tube tubing so the fluids would not infuse into R1. V6 stated that she does not know what happened to the feeding pump after she left at 10:00pm. V6 stated that prior to this 4/17/22 feeding pump incident involving R1's G-Tube, that she had no orientation or training on the feeding pump. On 4/28/22 at 2:00pm, V7 Licensed Practical Nurse (LPN) stated that on 4/17/22, that she was the oncoming nurse after V6 LPN. V7 stated that V6 reported she had trouble with R1's feeding pump, had turned it off, and that R1 did not feel well and her stomach hurt. V7 stated that she checked on R1 and R1's feeding pump tubing was not secured in the pump chambers, and felt that V6 had not properly connected the tubing. V7 stated that the (G-Tube nutrient fluid) container was empty but should not have been as it was hung at 4pm that day to infuse at 65 ml per hour. V7 Stated that the fluids may have drained by gravity and infused very quickly into R1's stomach. V7 stated that R1's stomach was distended and it was normally flat. V7 stated that R1 had an emesis (vomit) soon after V7 checked on her; and that R1 also now had pneumonia per R1's X-ray report. On 4/28/22 at 3:10pm, V3 Assistant Director of Nursing (ADON)/Registered Nurse (RN) stated that V6 LPN had not been trained or orientated on R1's (G-Tube) feeding pump but should have been; stated that staff were encouraged to find out what to do if they did not know how to do tasks. V3 stated that V6 did not follow the policy for enteral feeding; and stated that the feeding Pump Brochure was available at the nursing station for reference also.

Based on record review and interview, the facility failed to provide life sustaining medical interventions for a resident who was choking and became unresponsive and failed to ensure staff were certified to perform CPR (Cardio-Pulmonary Resuscitation, if required. These failures resulted in staff not providing proper chest compressions, oxygen or suctioning to R1 while R1 was choking, resulting in R1's death from choking. Findings include: The American Red Cross CPR/AED (Automated External Defibrillator) for Professional Rescuers and Health Care Providers handbook documents, Unconscious choking: If a ventilation attempt does not make the chest clearly rise: 1. Re-tilt the head and give another ventilation. 2. If the chest still does not rise clearly, give 30 chest compressions. 3. Look for an object inside the mouth. 4. If you see an object, remove it. 5. Give two ventilations. Provide care as needed: If the ventilations still do not make the chest clearly rise, repeat steps ,d+[DATE]. If the ventilations make the chest clearly rise, check for breathing and a pulse for no more than 10 seconds: If unconscious but breathing, place in a recovery position; If unconscious and no breathing but there is a pulse, give ventilations; If unconscious and no breathing or pulse, begin CPR. The facility's Emergency Care for Choking policy, no date available provided by V1 (Administrator) on [DATE], documents, Unconscious victim: Give 30 compressions pushing down at least two inches on the center of the chest. Place one hand on top of the other. Push hard. Open the airway and check the mouth for objects. Remove the obstructing object only if you see it. With the airway open attempt to give two breaths. If unsuccessful, return to compression. Repeat steps until victim starts breathing or until emergency medical help arrives. The facility Assessment, dated ,d+[DATE], documents, The facility must have sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. R1's POLST (Practitioner order for Life-Sustaining Treatment) form, dated [DATE], documents, Cardiopulmonary Resuscitation (CPR): If patient has no pulse and is not breathing. Do not attempt Resuscitation/DNR; When not in cardiopulmonary arrest: Medical interventions (If patient is found with a pulse and/or breathing): Comfort-focused Treatment: Primary goal of maximizing comfort: Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Speech Therapy Evaluation and Plan of Treatment, dated [DATE], documents, Definite risk for: choking, frequently coughing up food during swallow, aspiration, delayed or slow swallow reflex and wet or gurgly voice quality after swallowing liquids. The Facility's report to the State Agency, dated [DATE], documents, (On [DATE]), (R1) was experiencing an acute respiratory illness. CNA (Certified Nursing Assistant) was assisting (R1) at mealtime, (R1) began to cough expelling food and phlegm. Nursing assessment done. [MEDICATION(S)] maneuver was initiated. 911 was called and ambulance arrived. (R1) assessed. (R1) was without vital signs. (R1) was a DNR (Do Not Resuscitate). Family was present at the time of the occurrence and requested no further treatment. Coroner notified, arrived at facility and released body to funeral home. Local ambulance report, dated [DATE], documents, Chief complaint: arrest secondary to choking incident. Dispatched by 911 to facility, for (R1) who is choking and facility staff are attempting to give the [MEDICATION(S)] maneuver. Facility staff reports that (R1) was eating in the common area, visiting with family, when he began to choke on food. Staff report they attempted to give the [MEDICATION(S)] maneuver but were unsuccessful. Staff reports they moved (R1) from the common eating area to his room. It is unclear the timeline of events provided by facility staff and what was done in the dining area versus (R1's) room prior to ambulance arrival. (R1) is found laying supine in his bedroom. There is no chest rise and fall, eyes are open and face is cyanotic and mottled around he sides. (R1) has secretions with green baby pea pieces in his mouth, on his clothes and on the floor. No radial pulses nor carotid pulse found upon multiple palpations by both paramedics. (R1) chest is auscultated and there are no heart sounds nor breath sounds. Paramedic prepares to cut (R1) shirt open to apply fast patches and paramedics asks facility staff is (R1) has a DNR. Staff provides (R1's) paperwork and here is a signed and valid DNR in (R1's) records. EKG (Electrocardiogram) patches applied to (R1) and a 4 lead is obtained showing PEA (Pulseless Electrical Activity). Pulses checked again and still none are found. EKG printed off to give to coroner. Paramedic contacts 911 dispatch and requests that the coroner be notified. (R1's) family members are still present in the hallway and verify that they do not want resuscitation efforts made. (R1's) eyes are assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) disconnected from monitor and a blanket is placed across (R1) for privacy. The report also documents, Estimated time of collapse to 911: 5 minutes. Estimated time of arrest: ,d+[DATE] minutes. Call received: 5:22 p.m. Dispatched 5:24 p.m. On scene: 5:26 p.m. At patient: 5:28 p.m. In field pronouncement: 5:37 p.m. On [DATE] at 1:55 p.m., V26 (LPN-Licensed Practical Nurse) stated, (V27 CNA-Certified Nursing Assistant) started feeding (R1). He coughed a little bit and was spitting the food out. (V27) would prompt him to spit it out when he was coughing so he didn't choke. I was in that area for approximately 10 minutes because I was giving other residents in that area medicine as well. When I left, he was still occasionally coughing. I went around the corner, but I was still able to visualize him. I gave medications to two residents, on that hall when (V27) came to get me because she thought (R1) was choking. I got to (R1) and his face was red, and he had both hands on his chest clutching his chest. When I got to him he was unresponsive, leaning back in his chair. I moved his hands and performed the [MEDICATION(S)]. While he was sitting in the chair I was standing on his right sided and using my right hand only I thrust under his ribs three times. He didn't bring anything up. When nothing came up, we (V26, V27, V28-CNA) took him to his room in the wheelchair, and lowered him to the floor. We had (R1) on his left side. I tried three thrusts with my right hand from sitting beside him and still didn't bring anything up. Other nurse (V29,LPN) came with backboard and we rolled him onto his back. I thrust under his ribs using both hands while he was laying on his back. The girls (V27 & V28) stayed with him and I called 911. The girls asked if they needed to start CPR while I was gone and I told them no, as long as he had a pulse, not do CPR. When I returned (V27) said she still felt his pulse. I felt and it was weak,but it was still there. The paramedics appeared after I got back to the room. The paramedics took over. They hooked (R1) up to the monitor. He did have a heartbeat when he was hooked up, but it was very low. The male paramedic asked the code status. The paramedic asked to see the DNR paper I got it for him he said ok and handed it back to me. Shortly after that, one paramedic listened to his chest and shook her head so the other one listened and shook his head and pronounced (R1) expired. On [DATE] at 10:23 a.m., V27 CNA stated, I took (R1) out to the dining area. The nurse asked me to assist (R1) with his meal. Prior to feeding him, he was coughing. I asked the nurse about the coughing and she stated it was because of pneumonia. It was concerning that he was coughing and coughing. He took the first bite and he wasn't chewing well. So I gave him time to chew. By the third bite he didn't want to eat any more. I stopped feeding him. He was speaking with his family. (R1) started coughing up phlegm. Then he stopped coughing entirely. I was sitting there, talking with daughter, when all of a sudden (R1) started coughing uncontrollably. He was holding his chest. I got the nurse (V26). She came and he was trying to talk but couldn't talk. The nurse started to attempt to do the [MEDICATION(S)] maneuver using one arm and nothing came up. We took him to his room and laid him on the floor on his left side and we were doing back slaps. The nurse stood over him and did thrusts as well. A little bit of food came up with the back slaps. The crash cart was in the room. (V26) tried to do a mouth sweep, then (V29) brought the crash cart into the room. They did not put oxygen on him or use the suction machine. I felt a pulse, but I went to start CPR. (V26) saw me, said he is a DNR, and told me to stop CPR. Then, (V26) left the room. The whole time (V26) was out of the room we (V27 & V28 CNA) were doing back slaps until the ambulance got there and took over. On [DATE] at 11:30 a.m. V28 stated, (R1) started choking in the dining room. We took him to his room and laid him down on the floor. He was not responding. Once we got him on the floor, we turned him on to his side and continued the [MEDICATION(S)] by doing back slaps. The nurse (V26) left the room, and we (V27 & V28) just continued the back slaps. (V27) attempted to start CPR, but before she could start compressions, (V26) came back in and told her to stop because (R1) was a DNR. We were checking him for a pulse the whole time, and he still had a pulse. (R1) did not have oxygen on, and they never tried to suction him. Not long after the nurse got back, the ambulance came and said (R1) had passed away. V28 also stated, If a resident is unresponsive and choking you continue to do the [MEDICATION(S)] with the back slaps or getting your arms around them if you're able to. On [DATE] at 2:10 p.m., V26 stated, I did not instruct the CNAs (V27 & V28) to continue the [MEDICATION(S)]. They asked about doing CPR and I said no. They should have continued the [MEDICATION(S)]. When I got back to the room, I had just enough time to check for a pulse, and he still had one. During this incident no suctioning was done on (R1). The machine had not been set up. V26 verified that R1's POLST documented, Comfort-focused Treatment: Primary goal of maximizing comfort: Relieve pain and suffering through the use of medication by any route as needed; use oxygen, suctioning and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 12:35 p.m., V29, LPN stated, I was working in the area of where (R1) started choking, and I could hear what was going on. So, I immediately grabbed the crash cart, and checked (R1's) chart for his code status. (R1) was a DNR. I took the crash cart to the room even though (R1) was a DNR, and I knew we wouldn't need to use the crash cart for any reason because of the DNR. (R1) did not have oxygen on nor did anyone suction him at any time. V29 also stated, If a resident is choking and unresponsive, I would call for help, get the person in a [MEDICATION(S)] position and attempt thrusts. I would keep attempting this until the paramedics got there to take over. I don't think you do chest compressions on a choking person especially if they are a DNR. The facility's daily assignment sheet, dated [DATE], documents that six nurses and 11 CNAs were working when R1's incident occurred. Of those staff members three CNAs', V15, V18, and V20, CPR certifications were expired. On [DATE] at 1:30 p.m., V2 (Director of Nursing) stated, (V15, V18, and V20) are not up to date on their CPR certification. On [DATE] at 9:50 a.m., V2 (Director of Nursing) stated, All of our nursing staff should be CPR certified. On [DATE] at 12:55 p.m., V2 provided a list of all nursing staff. V2 marked off employees that are no longer working here. V2 provided copies of current CPR certifications, and confirmed that the following staff members CPR certifications had expired and were not renewed: CNAs: V6-V8, V11-V18, V20, V21, V23, V24; RNs: V9, V19; LPNs: V10, V22, V25. V2 also stated that V13 is the facility's primary transporter of residents. On [DATE] at 2:22 p.m., V18 (CNA) confirmed that her CPR certification was not up to date. V18 stated, If a resident was choking I would do [MEDICATION(S)] maneuver. If the person was unconscious, I would do CPR if they didn't have a pulse. If they had a pulse, and they are unconscious I would call 911 and do nothing else until the ambulance gets here. On [DATE] at 1:45 p.m., V31 LPN stated, If a resident was choking and unresponsive I'd check their airway and see if something is lodged. If they are unresponsive and lodged. I would start CPR. If you tried the [MEDICATION(S)] and mouth sweep and nothing was successful, I would continue with CPR. However, if the resident is a DNR you can't do CPR because they are a DNR. So we would stop and wait for 911 to get here. We should apply oxygen though and attempt to suction the resident to see if that would remove the object. On [DATE] at 2:10 p.m. V32, CNA stated, If a resident was unresponsive and heart was still beating, I would continue with [MEDICATION(S)]. I don't start CPR unless their heart stops beating. On [DATE] at 2:20 p.m. V23, CNA stated she wasn't sure if her CPR certification was expired or not. On [DATE] at 2:25 p.m., V14, CNA stated, My CPR certification is expired and I haven't renewed it. If a resident is unresponsive and choking, I just keep doing the [MEDICATION(S)] until its dislodged or CPR if their heart stops beating. On [DATE] at 12:55 p.m., V2 stated, R1's POLST states for comfort measures to provide oxygen, suctioning and manual treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . I believe they were attempting to set up suctioning, but never suctioned him. They said (R1) had a pulse, and they did the [MEDICATION(S)]. I do not know if they did any chest compressions. On [DATE] at 1:00 p.m., V3 (Assistant Director of Nursing) confirmed that R1 was not suctioned after choking. V3 stated, I would need more guidance regarding whether to do chest compressions. I'm not able to answer if chest compressions on a unconscious choking resident should be started if they are a DNR, even if their heart is still beating. On [DATE] at 11:15 a.m., V30 (R1's Physician and acting Medical Director) stated, (R1) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was a big guy so there was no way to get your arms around him. Putting him on the floor and doing abdominal thrusts while lying on his back was the best option. V30 also stated, The important thing is to keep attempting to dislodge the object. I would expect that the facility nursing staff would all be up to date on their CPR certification. I presume that (R1) passed away due to aspiration and choking. R1's Certificate of Death Worksheet (dated [DATE]) documents R1's Cause of Death as Aspiration and documents R1's Manner of Death was Accidental.

Based on interview and record review the facility failed to ensure a resident was safely transferred for one of three residents (R2) reviewed for transfers in a sample of three. This failure resulted in R2 being improperly transferred and subsequently sustaining a left ankle fracture. Findings include: The facility's Safe Handling Program Policy revised 3-18-18, documents The Safe Handling Program exits to ensure a safe working environment for resident handlers. Initial Screening will be performed on all residents to assess transfer and ambulating status. Resident transfer status will be reviewed via care plan time frame and on an as needed basis. R2's current POS (Physician Order Sheet) documents R2 has Diagnoses of [CONDITION(S)], [CONDITION(S)], Shortness of breath, Diabetes Mellitus, [CONDITION(S)], and Unsteadiness on Feet. This same POS documents orders for Physical Therapy three times a week for: Therapeutic Exercise, Mobility Training, Gait Training, and Safety Awareness, started 4/29/21 for 12 weeks. R2's Minimum Data Set assessment dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) of 15 (cognitively intact). This same assessment documents R2 requires extensive assist of two for bed mobility and transfers. R2's Current Functional Performance plan of care dated 3/2/21, documents Transfer-Extensive Assist/two-person physical assist with slide board. R2's progress notes dated 6/24/21, document a call to R2's physician (V12) regarding complaint of pain in left knee and left anterior leg and Left ankle. This same note documents (R2) said she twisted this leg during transfer. Progress notes dated 6/24/21 document orders for X-ray of left knee and left ankle and an order for Tylenol. R2's X-ray report dated 6/24/21, documents, X-ray of Left Ankle. A fracture of the distal aspect of the medial malleolus is identified. R2's State Reportable Final Report dated 6/30/21 and signed by V1 (Administrator), documents, (R2) stated (V11 CNA/Certified Nursing Assistant) was standing (R2) up so she could transfer from her wheelchair to her bed. (R2) thought her leg was going to slide, but instead it planted on the ground and when (V11) went to turn (R2) to sit, her body turned and her leg did not. (R2's) care plan was updated with new transfer status. There is a fracture of the tip of the medial malleolus of the tibia. On 7/7/21 at 1:00 pm, R2 stated, V11 transferred me from my wheelchair to my bed by himself. My leg moved but my foot didn't. They always have two people and use a slide board to transfer me but (V11) said he was strong enough to do it himself. I broke my ankle during the transfer. On 7/7/21 at 1:15 pm, V1 (Administrator) and V2 (ADON/Assistive Director of Nursing) both stated R2 was suppose to be transferred with two person assist and a slide board.