Every finding on record at St Clare Manor Nursing and Rehabilitation

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles by failing to ensure:Resident rooms were free of loose and unlabeled pills for 1 (Resident #145's room) of 6 resident rooms observed during medication administration; andMedication carts were free of loose and unlabeled pills for 2 (Med Cart 1 and Med Cart 2) of 3 medication carts reviewed.Findings: Review of the facility's Storage of Medications policy, dated November 2020, revealed the following, in part:Policy:The facility stores all drugs and biologicals in a safe, secure, and orderly manner.2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 1.On 05/04/2026 at 10:12 a.m., an observation was made with S4LPN during medication administration of an unlabeled and oblong shaped white pill broken in half on the floor of Resident #145's room. On 05/04/2026 at 10:18 a.m., an interview was conducted with S4LPN. She confirmed the above unlabeled and oblong shaped white pill broken in half was on Resident #145's floor and should not have been. 2.On 05/04/2026 at 10:55 a.m., an observation was made of MedCart1 with S2LPN, which revealed five loose, and unlabeled, pills on the bottom of the cart's drawers. On 05/04/2026 at 10:59 a.m., an interview was conducted with S2LPN. S2LPN confirmed the above pills were loose, and unlabeled, in the cart and should not have been. On 05/04/2026 at 11:10 a.m., an observation was made of MedCart2 with S3LPN, which revealed one half of a white pill, loose and unlabeled, on the bottom of the cart's drawer. On 05/05/2026 at 3:48 p.m., an interview was conducted with S1DON. She was made aware of the above observation and confirmed medications should not be loose and unlabeled in the medication carts. She confirmed medications should not be unlabeled, loose on the floor of a resident's room.

Based on record review, observation, and interviews the facility failed to provide food that accommodated the resident's food preference for 1 (#9) of 9 of residents reviewed for food accommodations/preference. Findings: Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE]. Review of Resident #9's Quarterly MDS with an ARD of 02/25/2026 revealed a BIMS of 14, which indicated he was cognitively intact. Review of the May 2026 Menu revealed the following:Entree- Red BeansStarch- RiceWith a substitute alternative available. Review of the dietary system with RD (Registered Dietician) the following:Resident #9 disliked red beans and rice Review of the lunch dietary ticket dated 05/04/2026 for Lunch revealed the following:Entree- Entree substituteStarch- starch substitute On 05/04/2026 at 12:30 p.m., an observation and interview was conducted with Resident #9. Red beans and rice noted on Resident #9's food tray. Resident #9 stated he did not like red beans and rice. On 05/05/2026 at 12:54 p.m., an interview was conducted with S7RD. She stated residents provided their food dislikes and it was placed in the dietary system. She stated if a resident disliked the scheduled meal, the system would automatically request a substitution served on the dietary ticket. She reviewed the lunch dietary ticket, dated 05/04/2026 and confirmed it stated entree and starch substitution. She further confirmed Resident #9 should not have been served red beans and rice and should have been served the alternate meal. On 05/06/2026 at 4:00 p.m., an interview was conducted with S1DON. She confirmed residents should receive meals according to their preferences.

Based on observations, interviews and record reviews, the facility failed to communicate with hospice staff pertaining to residents current oxygen orders for 1 (#144) of 1 residents reviewed for oxygen therapy. Findings: Review of the Facility's Policy, Hospice Program, dated July 2017, revealed the following, in part:10. In general, it is the responsibility of the facility to meet the Resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include:d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; and Review of Resident #144's clinical record revealed he was admitted to the facility on [DATE] and admitted to hospice services on 04/29/2026. Review of the hospice binder for Resident #144 revealed standing orders for oxygen 2-5 liters via nasal cannula as needed. On 05/04/2026 at 9:13 a.m., an observation was made of Resident #144 supine in bed receiving oxygen at 6 liters per minute via nasal cannula. An interview was conducted with S2LPN on 05/04/2026 at 3:18 p.m. She confirmed Resident #144's current order was oxygen continuous at 2 liters via nasal cannula but the resident received hospice services. She stated the hospice agency had a standing order for oxygen 2-5 liters via nasal cannula. She stated she did not know what Resident #144's current oxygen rate was and only needed to check it once on her shift. An interview was conducted with the hospice agency nurse on 05/05/2026 at 1:46 p.m. She stated Resident #144 was admitted to the agency on 04/29/2026 and his oxygen was being administered at 2 liters via nasal cannula. She stated she completed a hospice visit on 04/30/2026 and his oxygen was being administered at 4 liters via nasal cannula. She confirmed the facility did not communicate to the hospice agency that Resident #144's oxygen was increased to 6 liters via nasal cannula and should have. An interview was conducted with S1DON on 05/06/2026 at 3:30 p.m. She confirmed the hospice orders included oxygen 2-5 liters via nasal cannula. She further confirmed the facility nurse should have notified the hospice agency when Resident #144 required 6 liters oxygen via nasal cannula for comfort.

Based on observations, interviews, and record review, the facility failed to ensure residents were offered a therapeutic diet when the health care provider ordered a nutritional supplement for 1 (#95) of 3 residents reviewed for nutrition. Findings: Resident #95Review of Resident #95's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Brain and Colostomy Status. Review of Resident #95's Quarterly MDS with an ARD of 03/11/2026, revealed a BIMS of 9, which indicated moderate cognitive impairment. Review of Resident #95's current Physician Orders revealed the following, in part:Start date 09/12/2025 -Mighty Shakes - with meals House supplement or equivalent with each meal Problem: I have the potential for weight loss/gain and altered nutrition related to my facility ordered diet.Interventions: Mighty Shakes with meals, house supplement or equivalent with each meal-date initiated-09/12/2025. On 05/05/2026 at 8:10 a.m., an observation was made of Resident #95 with breakfast tray at bedside. No mighty shake or equivalent noted on resident's breakfast tray. On 05/06/2026 at 8:24 a.m. observation made of S6CNA delivering Resident #95's breakfast tray. No Mighty Shake noted on resident's tray. CNA confirmed resident did not have a Mighty Shake or equivalent on his breakfast tray. On 05/06/2026 at 8:28 a.m., an interview was conducted with S5ADON. She reviewed Resident #95's orders and confirmed he should have a Mighty Shake or equivalent on his tray with all meals.

Based on interviews and record reviews, the facility failed to meet Hospice requirements by failing to maintain a system to ensure a hospice resident's Clinical Binder contained documentation of Hospice Nurse Visit Notes for 1 (#63) of 1 resident reviewed for hospice care. This deficient practice had the potential to affect any of the residents receiving hospice services in the facility. Findings: A review of Resident #63's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #63 was a patient of a local hospice agency with Certification Period of 01/24/2025 through 04/23/2025; and recertification on 04/14/2025 for current plan of care. A review of Resident #63's Hospice Nurse Visit Notes, performed on 05/28/2025 revealed, in part, the most recent Hospice Nurse Visit Note present in the Hospice Binder was created on 03/12/2025. On 05/28/2025 at 8:10 a.m., an interview was conducted with S9LPN. S9LPN reviewed the hospice binder and confirmed the last Hospice Nurse Visit Note was dated 03/12/2025. On 05/28/2025 at 8:10 a.m., an interview was conducted with S5MR. S5MR reviewed the hospice binder and confirmed the last Hospice Nurse Visit note was dated 03/12/2025. S5MR confirmed the Hospice Nurse Visit notes were not up to date and should have been. On 05/28/2025 at 9:25 a.m., an interview was conducted with Hospice Nurse. She confirmed she was the nurse caring for Resident #63. She stated Resident #63 was seen weekly. She stated she was not aware hospice staff should leave written communication related to the visit in the hospice binder. On 05/29/2025 at 1:20 p.m., an interview was conducted with S2DON. S2DON confirmed visit notes from the Hospice Nurse should have been placed in Resident #63's hospice binder, and were not.

Based on observations, interviews and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure a multi dose vial of insulin was dated upon opening. This deficient practice had the ability to affect any of the 129 residents who received medications in the facility. Findings: Review of the facility's policy titled, Medication Labeling and Storage with a revised date of February 2023, revealed the following, in part: Medication Labeling: 5. Multi-dose vials that have been opened or accessed are dated. An observation and interview was conducted on 05/27/2025 at 10:34 a.m., of refrigerator in Med Room A with S9LPN. Observed was an opened and undated multi-dose vial of Lispro Insulin for subcutaneous injection. S9LPN confirmed the insulin multi-dose vial was opened and undated, and stated it should have been dated upon opening. An interview was conducted on 05/28/2025 at 1:45 p.m., with S2DON and S1AA. S2DON and S1AA confirmed multi-dose insulin vials should be dated as soon as they are opened. S2DON confirmed the insulin in Med Room A refrigerator was not dated upon opening, and should have been.

Based on record review and interviews the facility failed to store food in accordance with professional standards for food service safety by failing to: 1. Properly document temperatures daily for Refrigeration units and; 2. Properly maintain and document chemical sanitation checks for the dishwasher at least once per shift. This deficient practice had the ability to affect 131 residents who consumed food from the facility. Findings: Review of Facility policy titled Food Receiving and Storage with a revised date of November 2022, revealed the following, in part: Refrigerated/ Frozen Storage: 5. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state specific requirements. 1. Review of the walk in Refrigerator Temperature Logs for May 2025 revealed no temperature checks documented for 5/24/2025 and 5/25/2025. 2. Review of the Dish Machine Log revealed no documented evidence the chemical solution was assessed and maintained at the correct concentration for the following dates and shifts: 05/03/2025- no breakfast, lunch or dinner chemical concentrations documented; 05/04/2025- no breakfast, lunch or dinner chemical concentrations documented; 05/10/2025- no breakfast, lunch or dinner chemical concentrations documented; 05/11/2025- no breakfast, lunch or dinner chemical concentrations documented; 05/20/2025- no dinner chemical concentrations documented; 05/21/2025- no lunch or dinner chemical concentrations documented; 05/23/2025- no lunch chemical concentrations documented; 05/25/2025- no lunch or dinner chemical concentrations documented; 05/26/2025- no lunch or dinner chemical concentrations documented An interview was conducted on 05/27/2025 at 11:00 a.m., with S13DMT and S14DDM. S13DMT and S14DDM reviewed May 2025 refrigerator temperature logs and dish machine logs and confirmed they were not completed as required. Both confirmed the kitchen should maintain daily documentation of refrigerator temperatures as well as documentation of chemical concentrations for the dishwasher each shift. An interview was conducted on 05/28/2025 at 1:45 p.m., with S17ADM. S17ADM confirmed the kitchen should maintain daily documentation of refrigerator temperatures as well as chemical concentrations for the dishwasher.

Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#7 and #72) of 5 (#7, #31, #41, #67, and #72) sampled residents reviewed for PASRR. Findings: Resident #7 Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses upon admit, which included Schizophrenia. Review of Resident #7's Level 1 PASRR dated 02/05/2025 revealed Section III: Mental Illness did not have Schizophrenia selected as a diagnosis. Resident #72 Review of the Clinical Record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses upon admit, which included Delusional Disorder. Review of Resident #72's Level 1 PASRR dated 02/17/2023 revealed Section III: Mental Illness did not have Delusional Disorder selected as a diagnosis. On 05/28/2025 at 11:55 a.m., an interview was conducted with S6SS. She stated she did not review admission paperwork to ensure accuracy of Level 1 PASRRs. She stated S7ADS reviewed admission paperwork for residents. She stated she would only submit paperwork to OBH for a Level II PASRR evaluation if told to do so. On 05/28/2025 at 12:20 p.m., an interview was conducted with S7ADS and S1AA. S7ADS stated she was not responsible for reviewing residents' Level 1 PASRR's upon admission to ensure mental illness diagnoses were accurate. S1AA stated there was not one staff member responsible for reviewing Level 1 PASRR's to ensure accuracy of the mental illness section. She reviewed Resident #7 and #72's Level 1 PASRRs and confirmed they indicated the residents did not have a mental illness, which was not accurate. She confirmed both Resident #7 and Resident #72's PASRR Level 1's had not been resubmitted to OBH with the accurate mental illness diagnoses selected for Level II evaluation. 47732

Based on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care-plan to meet the psychosocial needs for 1 (#67) of 2 (#18 and #67) residents reviewed for mood/behavior. Findings: Review of Resident #67's Clinical Record revealed he was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #67's Significant Change MDS with an ARD of 04/04/2025 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #67's most recent Care Plan revealed he was not care planned for triggers, behaviors, and interventions specific to his PTSD diagnosis. On 05/27/2025 at 10:50 a.m., an interview was conducted with Resident #67. He confirmed his diagnosis of PTSD, and stated he was triggered by acts of aggression due to the physical abuse he experienced during his childhood. On 05/29/2025 at 8:17 a.m., an interview was conducted with S11LPN. She stated she was aware of Resident #67's diagnosis of PTSD, but was unaware of his potential triggers, behaviors, and interventions to prevent re-traumatization. On 05/29/2025 at 10:33 a.m., an interview was conducted with S3MDS. She stated she was responsible for completing Resident #67's care plan assessments. She reviewed Resident #67's most recent care plan and confirmed Resident #67 was not care planned for triggers, behaviors, and interventions specific to his PTSD diagnosis. She stated she was unaware of the reasons for Resident #67's PTSD diagnosis and his associated triggers. On 05/29/2025 at 12:06 p.m., an interview was conducted S2DON. She confirmed Resident #67 was not care planned for his PTSD diagnosis. She further stated she expected care plans to feature resident-specific interventions for psychiatric behaviors.

Based on interviews and record reviews, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected the resident's status for 1 (#95) of 24 sampled residents by failing to ensure resident was coded correctly for Active Diagnosis. Review of Resident #95's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included in part: Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of Resident #95's Quarterly MDS, with ARD of 04/30/2025, revealed no BIMS due to severe cognitive impairment. Further review revealed Section I Active Diagnosis, Section I2500 Wound Infection other than foot - checked Yes. On 05/29/2025 at 9:05 a.m., an interview was conducted with S10CNA. S10CNA confirmed she provided ADL (Activities of Daily Living) care to Resident #95. She stated Resident #95 did not have a wound. On 05/29/2025 AT 9:07 a.m., an interview was conducted with S8LPN. S8LPN stated Resident #95 did not have a wound. On 05/29/2025 at 9:10 a.m., an interview was conducted with S18WC. S18WC stated Resident #95 is not receiving wound care services. She reviewed all of Resident #95's documentation from admission and stated the resident had never had a wound. On 05/29/2025 at 9:15 a.m., an interview was conducted with Wound Care Nurse Practitioner. He reviewed records for all wound care and stated they have not provided care for Resident #95. On 05/29/2025 at 9:45 a.m., an interview was conducted with S3MDS. She confirmed Resident #95's MDS was coded for I Active Diagnosis I2500 Wound Infection, and should not have been. On 05/292025 at 9:45 a.m., an interview was conducted with S2DON. She reviewed the MDS and confirmed Resident #95 was coded for I Active Diagnosis I2500 Wound Infection, and should not have been.

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#63) of 4 (#14, #18, #28, and #63) residents reviewed for infection control. The facility failed to ensure staff wore proper PPE (Personal Protective Equipment) while providing ADL (Activities of Daily Living) care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions revised 12/2024, revealed the following, in part: 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: b. Bathing/Showering Review of Resident #63's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, in part: Dementia and Colostomy Status. Review of Resident #63's current Physician Orders revealed the following, in part: EBP: Utilize gown and gloves during high contact activities for residents with chronic wounds or indwelling medical devices. An observation was made on 05/28/2025 at 9:00 a.m. of the EBP sign posted on Resident #63's door and above her bed. The sign revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. In addition to standard precautions, everyone must gown and glove for these resident care activities - Bathing/Showering. An observation was made on 05/28/2025 at 9:00 a.m. of Hospice CNA (Certified Nursing Assistant) providing bed bath to Resident #63. CNA did not wear a gown while providing bed bath to Resident #63. An interview was conducted on 05/28/2025 at 9:05 a.m. with Hospice CNA. Hospice CNA verified Resident #63 was on EBP. She confirmed she did not wear a gown when providing bed bath to Resident #63, and should have. An observation and interview was conducted on 05/28/2025 at 9:10 a.m. with S9LPN. S9LPN observed Hospice CNA bathing Resident #63 without wearing a gown, and confirmed Hospice CNA should have been wearing a gown. An interview was conducted on 05/28/2025 at 1:30 p.m. with S2DON. S2DON confirmed Resident #63 was on EBP due to colostomy. S2DON confirmed staff should wear a gown when bathing a resident on EBP.

Based on observations and interviews the facility failed to ensure a safe, sanitary environment. The facility failed to ensure Room B remained sanitary. Findings: Review of the facility's policy titled, Homelike Environment with a revised date of February 2021 revealed in part, the following: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. An observation was made on 05/27/2025 at 1:50 p.m. of Room B. The observation revealed the following: several soiled linen towels on the floor behind the door, one soiled blue glove on the shower gurney, a dried yellow substance on the shower gurney, a brown bug on the floor close to the shower drain, used paper towel on the floor closer to the shower, 1/2 bar used solid bar of soap on the floor in the shower, and multiple spots of dry yellow substance on the shower chair. An interview was conducted on 05/27/2025 at 2:00 p.m. with S15IP. She observed Room B and confirmed the above findings. She stated Room B was not appropriately sanitized after prior use and should have been. An observation and interview were conducted on 05/28/2025 at 10:10 a.m. with S16HS. She observed a used bar soap on the floor by the shower drain, shower chair with multiple spots of a dried yellow substance on the shower chair, and dried yellow substance on the shower gurney. She confirmed Room B was not properly sanitized after prior use and should have been. An interview was conducted on 05/28/2025 at 1:45 p.m. with S1AA and S17ADM informing them of the above observations made. S1AA and S17ADM stated the facility should always be maintained to promote a clean homelike and sanitary environment. S1AA and S17ADM confirmed the observations made were not considered sanitary to promote a safe, clean or homelike environment.

Based on observations, interviews, and record reviews, the facility failed to ensure menus were followed to meet the nutritional needs of residents by failing to ensure the correct portion sizes ordered were provided for 1 (#2) of 3 (#2,#5,#R1) residents reviewed for dining. This had the potential to affect 126 residents who received meals from the facility's kitchen. Findings: Review of the facility's policy, titled Tray Identification, dated 04/2007, revealed, in part: 3. Nursing staff shall check each food tray for the correct diet before serving the residents. Review of Resident #2's clinical record revealed an admitted [DATE], with diagnoses which included, Mild Protein-Calorie Malnutrition and Hypokalemia. Review of Resident #2's physician's orders dated 12/11/2024 to 02/17/2025 revealed: 1. Double Portions Diet-Regular texture, thin consistency, no rice, no grits. On 02/17/2025 at 11:36 a.m., an observation was made of Resident #2's lunch tray, revealed: 1 serving of mashed potatoes with gravy 1 serving of creole tomatoes 1 serving of red beans no rice 1 square of cornbread 1 frosted cake 1 cup of red juice 1 cup of water On 02/17/2025 at 11:37 a.m., an observation was made of Resident #2's tray ticket. The tray ticket revealed: Diet- Regular; Texture -Regular; Diet Intervention-Double Portions. On 02/17/2025 at 11:38 a.m., an interview was conducted with S7LPN. S7LPN observed the contents of Resident #2's lunch tray and confirmed the lunch tray served did not have double portions. On 02/17/2025 at 11:41 a.m., an interview was conducted with S6DTM. S6DTM observed the contents of Resident #2's lunch tray. S6DTM confirmed the lunch tray served did not have double portions. On 02/17/2025 at 11:44 a.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #2 should have double portions every meal and the lunch tray served on 02/17/2025 did not have double portions.

Based on observation, interviews, and record review, the facility failed to ensure a resident received meals to accommodate intolerances for 1 (#5) of 3 (#2, #5, and #R1) residents reviewed for dietary services. Findings: Review of the facility's undated policy titled, Tray Identification revealed the following, in part: Policy Interpretation and Implementation: 2. The food service manager or supervisor will check trays for corrects diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the resdients. Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Alert tab in her physical chart revealed the following: Allergies: Lactose Intolerance Review of Resident #5's current Care Plan revealed the following, in part: Focus: I am lactose intolerant Interventions: avoid allergen Review of Resident #5's Breakfast Meal Ticket dated 02/20/2025 revealed the following, in part: Beverage: 8 fluid ounces lactose free milk An observation was made of S9CNA feeding Resident #5 breakfast on 02/20/2025 at 10:03 a.m. Resident #5's meal ticket read lactose free milk. Resident #5 had an 8 ounce pre-packaged container of whole milk on her breakfast tray. S9CNA confirmed Resident #5 was served whole milk and should have been served lactose free milk. An interview was conducted with S4ADON on 02/20/2025 at 10:08 a.m. She reviewed Resident #5's breakfast meal ticket dated 02/20/2025 and confirmed it read lactose free milk. An interview was conducted with S3ADM on 02/20/2025 at 4:00 p.m. She confirmed a resident who was lactose intolerant and whose meal ticket read lactose free milk should not have been served whole milk.

Based on observation, record reviews, and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#2) of 5 (#2, #3, #4, #5, and #R2) residents sampled for pharmaceutical services. This had the potential to affect 126 residents residing in the facility. Findings: Review of the facility's policy, titled Documentation of Medication Administration, dated 11/2022, revealed, in part: 1. A nurse or certified medication aide documents all medications administered to each resident on the resident's MAR. 2. Administration of medication is documented immediately after it is given. Review of Resident #2's clinical record revealed an admitted [DATE], with diagnoses which included, Pain in Left Shoulder, Lymphedema, and Malignant Neoplasm of Breast. Review of Resident #2's physician's orders dated 12/11/2024 to 02/17/2025 revealed, in part: 1. Fentanyl Transdermal Patch 12 micrograms/hour (mcg/hr). Apply 1 patch transdermal in the morning every 3 days related to pain. On 02/19/2025 at 8:47 a.m., an observation was made of a Fentanyl patch to Resident #2's right chest wall. The patch revealed 2/16 KN. There were no other patches observed on Resident#2. On 02/19/2025 at 8:48 a.m., an interview was conducted with S10LPN, who confirmed the aforementioned observation. S10LPN stated the Fentanyl patch was applied on 02/16/2025. S10LPN confirmed the Fentanyl patch is ordered to be changed every 3 days, and a new patch should have been applied on 02/19/2025 at 6:00 a.m. Review of Resident #2's February MAR revealed the following: 1. 02/19/2025 at 5:59 a.m. Fentanyl patch removed, with a check mark, electronically signed by S8LPN. 2. 02/19/2025 at 6:00 a.m. Fentanyl patch applied, with a check mark, electronically signed by S8LPN. Upon further review, according to MAR Chart Codes, a check mark indicated the medication had been administered. On 02/19/2025 at 9:31 a.m., an interview was conducted with S8LPN, who stated she was the night nurse for Resident#2 on 02/18/2025. S8LPN stated, during medication administration for Resident #2 on 02/19/2025, at 6:00 a.m., she documented the Fentanyl patch was given, then was distracted by another situation and forgot to return to Resident #2 to apply the new Fentanyl patch. S8LPN stated the process is to give the medication first, then document medication as given on the MAR. S8LPN confirmed documenting medication as administered on the MAR when medication has not been administered is inaccurate documentation. On 02/19/2025 at 9:33 a.m., an interview was conducted with S2DON. S2DON confirmed all medications should be given according to physician orders, and all documentation of medication administration should be accurate. S2DON confirmed the documentation of Resident #2's Fentanyl patch was not accurate and should have been.

Based on interviews and record review, the facility failed to maintain accurate medical records for 1 (#1) of 5 (#1, #2, #3, #4 and #5) residents reviewed. S9LPN inaccurately transcribed the diagnosis for a new medication in Resident #1's clinical record. Findings: Review of Resident #1's Clinical Record revealed resident was admitted to the facility on [DATE] with diagnoses, which included Dementia with Behavioral Disturbance, Psychotic Disturbance, and Anxiety. Review of Resident #1's telephone order sheet dated 05/23/2024 revealed: Start Ativan 0.5 mg tablet; take one by mouth twice a day with diagnosis Dementia with Behavioral Disturbance. Review of Resident #1's Progress Note dated 05/23/2024 created by S6PNP revealed, in part: Resident #1 seen today for anxiety, pain, and follow up. Plan/orders-Anxiety Ativan sent to pharmacy. Review of Resident #1's May and June 2024 Medication Administration Record revealed Ativan 0.5 mg tablet one tablet by mouth twice a day was administered for Dementia with Behavioral Disturbance. On 07/03/2024 at 3:44 p.m., a telephone interview was conducted with S6PNP. S6PNP stated Ativan was started for Resident #1 to treat the diagnosis of Anxiety not Dementia. On 07/10/2024 at 10:12 a.m., a telephone interview was conducted with S7PSY. S7PSY stated Dementia was not an appropriate diagnosis for Ativan. On 07/11/2024 at 10:59 a.m., an interview was conducted with S2DON. S2DON verbalized it was expected that all physician telephone orders were accurately transcribed in the resident's Clinical Record.

Based on record review, observation, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff changed a resident's PICC (Peripherally Inserted Central Catheter) line dressing consistent with accepted standards of practice for 1of 1 (#4) sampled resident reviewed with a PICC line. Findings: Review of the facility's policy titled, Peripheral and Midline IV (Intravenous) Dressing Changes , dated 2001, revealed the following, in part: Purpose: The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. General Guidelines: 4. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for transparent semi-permeable membrane dressing. Review of Resident #4's Clinical Record revealed a readmitted [DATE] with diagnosis which included Sepsis, Unspecified Organism. Review of Resident #4's current Physician Orders revealed the following, in part: -Order date: 06/30/2024. Start date: 07/03/2024. Change PICC line dressing to left upper arm weekly and PRN (As needed). One time a day every Wednesday and every 12 hours as needed. Review of Resident #4's TAR (Treatment Administration Record) dated 06/30/2024 to 07/09/2024 revealed no documented evidence Resident #4's PICC line dressing was changed. Review of Resident #4's nurse's notes dated May 2024 through July2024 revealed the following, in part: 06/30/2024 PICC line, double lumen to left upper extremity placed on June 28, 2024. Further review revealed no documentation Resident #4's PICC line dressing was changed. An observation was made on 07/09/2024 at 12:10 p.m. of Resident #4, which revealed a PICC line located in her left upper extremity covered with a transparent dressing dated 06/28/2024. S2DON confirmed the aforementioned observation. An interview was conducted on 07/10/2024 at 10:38 a.m. with S10RN. S10RN confirmed RNs were responsible for changing PICC line dressings. S10RN stated she did not change Resident #4's PICC line dressing on 06/30/2024 and 07/03/2024. She stated a PICC line dressing dated 06/28 should be changed every seven days, which would have been due on 07/05/2024. S10RN confirmed no documented evidence of Resident #4's PICC line dressing change from 06/30/2024 to 07/09/2024 on the TAR meant the dressing change was not done. An interview was conducted on 07/10/2024 at 1:46 p.m., with S11RN. S11RN confirmed RNs were responsible for changing PICC line dressings. S11RN stated she did not change Resident #4's PICC line dressing on 07/04/2024. S11RN stated a PICC line dressing dated 06/28/2024 should be changed every seven days, which would have been due on 07/05/2024. An interview was conducted on 07/09/2024 at 4:37 p.m. with S2DON. S2DON stated Resident #4 returned from the hospital on 06/30/2024, and she expected the RNs to follow physician orders and facility policy to change the PICC line dressing every seven days and PRN for soiled dressing. S2DON stated she did not change Resident #4's PICC line dressing on 07/01/2024, 07/02/2024, 07/03/2024 or 07/05/2024. S2DON confirmed the aforementioned observation of Resident #4's PICC line dressing dated 06/28/2024. S2DON further confirmed there was no documented evidence of Resident #4's PICC line dressing change from 06/30/2024 to 07/09/2024 on the TAR, which meant the dressing change was not done.

Based on record review and interviews, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours after the incident, to the facility Administrator and to the State Survey Agency within the specified timeframe for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for accidents. Findings: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 09/2022, revealed the following, in part: Policy: All reports of resident abuse (including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) . Policy Interpretation and Implementation: Reporting Allegations to the Administrator . 1. If resident abuse .or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility. 3.Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia and Primary Generalized Osteoarthritis. Review of Resident #1's Quarterly MDS with ARD 04/03/2024, revealed she had a BIMS of 00, which indicated she was severely cognitively impaired. Review of Resident #1's Nurses Notes dated April 2024 revealed the following, in part: 04/19/2024 at 5:42 p.m. Resident #1 in bed, swelling and edema noted to left lower leg. On call Nurse Practitioner called, new orders noted to x-ray extremity to rule out fracture. Signed by S10LPN. 04/20/2024 at 3:54 a.m. Resident #1 x-ray results in, Resident #1 has a fracture to her left leg. On call Nurse Practitioner (NP) notified, order given to send Resident #1 to a local hospital. Resident #1's . results report called to Registered Nurse at 8:59 p.m. Resident #1 left facility via ambulance. Signed by S9LPN. Review of Resident #1's Mobile X-ray Report dated 04/19/2024 at 8:01 p.m. revealed the following, in part: Impression: The bones are osteopenic. Acute fracture of the distal tibia and proximal fibula. Further review revealed the mobile radiology company notified the nurse at the facility at 04/19/2024 at 8:07 p.m. Receipt of report was confirmed and read back was given. Review of Resident #1's Hospital Records dated 04/19/2024-04/22/2024 revealed the following, in part: Resident #1 was admitted to a local hospital on 04/19/2024 at 10:51 p.m. with chief complaint of left leg pain and had an x-ray obtained at the facility that showed a proximal fibular fracture and a distal tibia fracture. Repeat x-rays revealed a closed left tibia and fibula fracture. An interview was attempted with Resident #1 on 05/08/2024 at 1:00 p.m. Resident was unable to hold a conversation due to impaired cognitive status. An interview was conducted with S10LPN on 05/09/2024 at 10:25 a.m. She said Resident #1 had dementia, was nonverbal, and required total assistance with ADL's. She verified she worked on 04/19/2024 from 7:00 a.m. to 7:00 p.m. and was assigned to Resident #1. She said on the afternoon of 04/19/2024, S8CNA called her to Resident #1's room. She said S8CNA removed Resident #1's covers to reposition her in bed and noticed her left leg was swollen. She said she assessed Resident #1's left leg and observed discoloration and swelling. She stated she called the nurse practitioner on call and received an order for a left lower leg x-ray to rule out a fracture. She contacted the mobile radiology company, but did not receive the radiology report prior to the end of her shift. She said she reported her observations of Resident #1's left lower extremity to S9LPN during shift change. She said Resident #1 had no known falls or injuries that could have caused the injury to her left leg. A telephone interview was conducted with S8CNA on 05/09/2024 at 1:48 p.m. She said on 04/19/2024, she noticed Resident #1's left leg was swollen. She said she immediately notified S10LPN who came and assessed Resident #1's leg. She said an x-ray of Resident #1's left leg was done during her shift. She said Resident #1 was transferred to the hospital during her shift on 04/19/2024. She said she did not know how Resident #1 could have fractured her left leg. A telephone interview was conducted with S9LPN on 05/09/2024 at 2:00 p.m. She said on 04/19/2024 during shift change, S10LPN reported to her x-ray results were pending for Resident #1's left swollen leg. She said S10LPN reported it was unknown how Resident #1's left leg was injured. She said S4ADON called her with Resident #1's x-ray results which revealed a fracture to her left leg. She stated the physician was notified and Resident #1 was transferred to the hospital. An interview was conducted with S4ADON on 05/09/2024 at 2:17 p.m. She said on 04/19/2024, she was the on call nurse for the facility. She said she was aware Resident #1 had an injury of unknown origin and a mobile x-ray revealed a fracture to her left leg. She said Resident #1's fracture and injury of unknown origin should be reported to the State agency within 2 hours of the discovery. She said S1ADM was responsible for reporting injuries of unknown origin to the State agency. S4ADON confirmed she had not notified S1ADM on 04/19/2024 when Resident #1's fracture and injury of unknown origin was identified. An interview was conducted with S3DON on 05/09/2024 at 2:40 p.m. She said she received a phone call from S4ADON on 04/19/2024 around 9:00 p.m. that Resident #1's x-ray results revealed a fracture to her left leg and she was sent to the hospital. S3DON said she did not report Resident #1's fracture to S1ADM on 04/19/2024. An interview was conducted with S1ADM on 05/09/2024 at 3:20 p.m. He reviewed the facility's investigative report filed with the state dated 04/20/2024 at 9:43 a.m. for Resident #1. He said he was notified by S3DON on the morning of 04/20/2024, Resident #1 had a left leg fracture and was sent to the hospital. He said Resident #1 had a BIMS of 0 and was unable to tell staff what happened. He said he was not aware of Resident #1's injury of unknown origin and x-ray results until 04/20/2024.

Based on interviews and record review, the facility failed to ensure residents understood the binding arbitration agreement signed on admission or were given the right to rescind the agreement within 30 calendar days for 3 (#89, #101, and #267) of 3 (#89, #101, and #267) residents reviewed for arbitration. Findings: Review of the facility's form titled Admission Agreement on page 13 of 35 revealed an arbitration agreement was included in the Admission Agreement. This agreement revealed in part, the following: Binding Arbitration Provision. -If the parties to this agreement do not wish to include the following arbitration provision please indicate so by marking an X through the provision. -The parties expressly waive any right to jury trial and expressly waive any right to file a court action for any controversies, claims, or causes of action related to the Admission Agreement, or the breach thereof, or arising out of or related to the resident's stay, care, or rights at the facility. Further review revealed no documentation of the resident's right to rescind the agreement within 30 calendar days. Resident #89 Review of Resident #89's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #89's Clinical Record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #89's RP and S4AC on 02/15/2024. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:26 p.m. with Resident #89's RP. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. Resident #101 Review of Resident #101's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #101 was her own responsible party. Review of Resident #101's Quarterly MDS with an ARD of 01/23/2024 revealed the resident had a BIMS of 15, which indicated intact cognition. Review of Resident #101's Clinical Record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #101 and S4AC on 10/19/2023. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:24 p.m. with Resident #101. Resident #101 was able to answer questions appropriately, alert and oriented. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. Resident #267 Review of Resident #267's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #267's record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #267's RP and S4AC on 01/08/2024. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:27 p.m. with Resident #267's RP. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. An interview was conducted on 04/01/2024 at 12:17 p.m. with S4AC. She reviewed Resident #89, #101, and #267's signed Admission Agreements and confirmed all 3 residents' agreements included an arbitration agreement. She stated she did not know the Admission Agreement included an arbitration agreement if an X was not placed on the section in the Admission Agreements. She confirmed the residents or their RPs had not been educated on what an arbitration agreement was. She stated she was responsible for educating the residents and RPs of the Admission agreement upon admission. She stated she should have educated them on what an arbitration agreement was and did not.

Based on interviews and record review, the facility failed to ensure required components of an arbitration agreement were included for 3 (#89, #101, and #267) of 3 (#89, #101, and #267) residents reviewed for arbitration. Findings: Review of the facility's form titled Admission Agreement on page 13 of 35 revealed an arbitration agreement was included in the Admission Agreement. This agreement revealed in part, the following: Binding Arbitration Provision. -If the parties to this agreement do not wish to include the following arbitration provision please indicate so by marking an X through the provision. -The parties expressly waive any right to jury trial and expressly waive any right to file a court action for any controversies, claims, or causes of action related to the Admission Agreement, or the breach thereof, or arising out of or related to the resident's stay, care, or rights at the facility. Further review revealed no documentation for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue. Resident #89 Review of Resident #89's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #89's Clinical Record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #89's RP and the S4AC on 02/15/2024. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:26 p.m. with Resident #89's RP. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. Resident #101 Review of Resident #101's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #101 was her own responsible party. Review of Resident #101's Quarterly MDS with an ARD of 01/23/2024 revealed the resident had a BIMS of 15, which indicated intact cognition. Review of Resident #101's Clinical Record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #101 and S4AC on 10/19/2023. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:24 p.m. with Resident #101. Resident #101 was able to answer questions appropriately, alert and oriented. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. Resident #267 Review of Resident #267's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #267's record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #267's RP and S4AC on 01/08/2024. Further review revealed a binding arbitration agreement was included without an X marked through the provision. An interview was conducted on 04/01/2024 at 12:27 p.m. with Resident #267's RP. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated and understood what it meant. An interview was conducted on 04/01/2024 at 12:17 p.m. with S4AC. She reviewed Resident #89, #101, and #267's signed Admission Agreements and confirmed all 3 residents' agreements included an arbitration agreement. She stated she did not know the Admission Agreement included an arbitration agreement if an X was not placed on the section in the Admission Agreements. She confirmed the residents or their RPs had not been educated on their right for the selection of a neutral arbitrator agreed upon by both parties and the selection of a venue. She stated she was responsible for educating the residents and RPs of the Admission agreement upon admission.

Based on interviews and record reviews, the facility failed to ensure an allegation of possible sexual abuse was reported immediately, but not later than 2 hours after the allegation was made, to the facility Administrator and to the State Survey Agency for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for sexual abuse. S3NP and S5FMD failed to notify the facility's Administrator after a sexually transmitted disease was found in Resident #1's microscopic urine sample while residing in the hospital. This deficient practice resulted in an Immediate Jeopardy situation on 01/15/2024 when S3NP and S5FMD were made aware Resident #1, a nonverbal resident with Flaccid Hemiplegia, tested positive for Trichomonas, a sexually transmitted disease. S3NP and S5FMD failed to notify S1ADM and S4DON of Resident #1's positive Trichomonas urine test from 01/13/2024. The failure of notifying S1ADM and S4DON of a newly identified positive Trichomonas test result for Resident #1 prevented the facility from filing a report to the State Survey Agency and conducting a formal investigation to protect the remaining 120 residents residing in the facility from possible sexual abuse. The Immediate Jeopardy was removed on 02/08/2024 at 4:45 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. Findings: Review of the facility's policy titled, Reporting Suspicion of a Crime revealed the following, in part: Policy Statement: The Administrator, Director of Nursing, or any other designated individual will report (within the required time frames) any reasonable suspicion of a crime against a resident to the state survey agency and local law enforcement. Policy Interpretation and Implementation: 2. Once a year each covered individual is notified in writing of his or her obligation to report any reasonable suspicion of a crime to the state survey agency and at least one local law enforcement agency. a. A covered individual is defined as anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. 3. Each covered individual must report to the state survey agency and at least one local law enforcement agency any reasonable suspicion of a crime against a resident of the facility. d. Example of crimes that would be reportable in any jurisdiction include but are not limited to: 5. Sexual abuse Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Neurogenic Bladder with Chronic Foley Dependence with History of ESBL UTIs, Flaccid Hemiplegia, Aphasia, and PEG and Foley Dependence due to numerous CVA's. Further review of Resident #1's Clinical Record revealed she was transferred to a local hospital on 01/13/2024. Review of Resident #1's MDS with an ARD of 10/08/2023 revealed a BIMS of 99, which indicated Resident #1 was unable to complete the BIMS assessment. Review of the facility's Self-Reported Incident Reports dated August 2023 - January 2024 for Resident #1 revealed no entries for possible sexual abuse. Review of Resident #1's Physician Notes from a local hospital dated 01/13/2024 revealed the following, in part: Resident from a local nursing home with significant Past Medical History of CVA with residual Aphasia, PEG tube, Neurogenic Bladder with Chronic Indwelling Foley Catheter and history of ESBL UTI's was sent to Emergency Department for evaluation of Hypoxia with Suspected Aspiration Pneumonia. She is strictly PEG tube feedings. UA suggestive of UTI with 3+ leukocytes, WBC, moderate bacteria and Trichomonas. Review of Resident #1's Microscopic Urinalysis dated 01/13/2024 from a local hospital revealed the following, in part: Trichomonas = present Review of Resident #1's Discharge Summary from a local hospital dated 01/22/2024 revealed the following, in part: Hospital Course Note: Urinalysis showed Trichomonas present. Social Worker notified who will notify the Ombudsman. S3NP and S5FMD were notified. Of note, 10/2023, Urinalysis was negative for Trichomonas at a local hospital. The last microscopy of urine sent from the nursing home was on 09/27/2023 which was negative for Trichomonas. Resident was admitted to the hospital on 01/13/2024 where Trichomonas was found on urine microscopy. Resident's daughter knows Trichomonas is a sexually transmitted disease. Signed S6MD. An interview was conducted on 01/23/2024 at 11:45 a.m. with S3NP. He said he was a contracted provider with the facility. He verified he provided care to Resident #1 in the facility. S3NP said Resident #1 was admitted to the facility on [DATE] with diagnoses which included CVA, Aphasia, Neurogenic Bladder with Chronic Indwelling Foley Catheter and Paraplegia. He said Resident #1 was nonverbal, could not make her needs known, and required total assistance with ADL care. He said, on 01/15/2024, he was verbally informed by S6MD that Resident #1 had Trichomonas detected in her microscopic urine sample, which was found when she was admitted to a local hospital on 01/13/2024. He said on 01/15/2024, he and S5FMD discussed the possibilities in which Resident #1 could have been infected with Trichomonas. He stated Trichomonas was transmitted during sex, and there were a few cases of it being transmitted by contaminated linens, but that would be unlikely. He said he and S5FMD questioned whether sexual abuse happened at the facility. He said they speculated that she may have been assaulted; he said it was unlikely but possible. He said Resident #1 would not have been able to report if anyone had been in her room and assaulted her. He said he did not inform the facility's administrative staff of the positive Trichomonas result from Resident #1's microscopic urine test. He said he assumed it was the responsibility of the hospital to inform S1ADM or S4DON. He said he was unsure if S1ADM or S4DON were aware Resident #1's urine test was positive for Trichomonas. An interview was conducted on 01/23/2024 at 12:00 p.m. with S4DON. She said she knew Resident #1 well. She said Resident #1 had a diagnosis of Paraplegia, was unable to make her needs known, and she required total assistance with ADL care. She verified Resident #1 was in a local hospital at the present time. She said she was unaware Resident #1 had been recently treated for a sexually transmitted disease. She said if S3NP and S5FMD were aware Resident #1 had recently been treated for a sexually transmitted disease, she should have been made aware and had not been. An interview was conducted on 01/23/2024 at 12:30 p.m. with S2AA. She said she knew Resident #1 well. She said Resident #1 had a diagnosis of Paraplegia, was unable to make her needs known, and she required total assistance with ADL care. She verified Resident #1 was in a local hospital at the present time. She said she was unaware Resident #1 had been recently treated for Trichomonas, a sexually transmitted disease. She said no one informed her and she was unsure if S1ADM was aware. She said Resident #1 would not have been able to report if anyone had been in her room and sexually assaulted her. She said if S3NP and S5FMD were aware Resident #1 had recently been treated for a sexually transmitted disease, she and S1ADM should have been made aware and had not been. An interview was conducted on 01/23/2024 at 12:45 p.m. with S1ADM. He said he knew Resident #1 well. He said he was unaware Resident #1 had recently been treated for a sexually transmitted disease. S1ADM confirmed Resident #1 was not capable of consenting to any sexual acts or reporting any assault. He said Resident #1 testing positive for a sexually transmitted disease concerned him. He said a SIMS report should have been initiated and a full investigation completed regarding Resident #1 and had not been. He said he spoke with S5FMD on 01/22/2024 and she did not inform him of any issues regarding Resident #1's current medical condition. An interview was conducted on 01/24/2024 at 3:15 p.m. with S5FMD. She confirmed she was the Medical Director for the facility. She verified a microscopic urine test was performed for Resident #1 at a local hospital on 01/13/2024. She said the microscopic urine test revealed Resident #1 had Trichomonas in her urine. She confirmed Trichomonas was a sexually transmitted disease. She said she discussed Resident #1's positive results with S3NP on 01/15/2024. She said she did not have enough information to inform the facility of the positive urine results. She said she did not inform the facility of the positive Trichomonas result because Resident #1 was still in hospital and not under the facility's care. An interview was conducted on 01/24/2024 at 3:45 p.m. with S1ADM. He said on 01/23/2024, S3NP told him he did not disclose Resident #1's medical condition and treatment to him because it would have been a HIPAA violation. He said S3NP served as the facility's Nurse Practitioner under S5FMD, who was the facility's Medical Director. He confirmed he should have been informed by S3NP and S5FMD of this information in order to initiate a formal investigation since Resident #1 resided in the facility.

Based on interviews and record reviews, the Medical Director failed to fulfill her responsibility for the implementation of resident care policies by failing to notify S1ADM and S4DON after being made aware of a sexually transmitted disease for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for sexual abuse. This deficient practice resulted in an Immediate Jeopardy situation on 01/15/2024 when S3NP and S5FMD were made aware Resident #1, a nonverbal resident with Flaccid Hemiplegia, tested positive for Trichomonas, a sexually transmitted disease. S3NP and S5FMD failed to notify S1ADM and S4DON of Resident #1's positive Trichomonas urine test from 01/13/2024. The failure of notifying S1ADM and S4DON of a newly identified positive Trichomonas test result for Resident #1 prevented the facility from filing a report to the State Survey Agency and conducting a formal investigation to protect the remaining 120 residents residing in the facility from possible sexual abuse. The Immediate Jeopardy was removed on 02/08/2024 at 4:45 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. Findings: Review of the facility's policy titled, Reporting Suspicion of a Crime revealed the following, in part: Policy Statement: The Administrator, Director of Nursing, or any other designated individual will report (within the required time frames) any reasonable suspicion of a crime against a resident to the state survey agency and local law enforcement agency. Policy Interpretation and Implementation: 2. Once a year each covered individual is notified in writing of his or her obligation to report any reasonable suspicion of a crime to the state survey agency and at least one local law enforcement agency. a. A covered individual is defined as anyone who is an owner, operator, employee, manager, agent, or contractor of the facility. 3. Each covered individual must report to the state survey agency and at least one local law enforcement agency any reasonable suspicion of a crime against a resident of the facility. d. Example of crimes that would be reportable in any jurisdiction include but are not limited to: 5. Sexual abuse. Review of the facility's policy titled, Medical Director revealed the following, in part: Policy Statement: Physician services shall be under the supervision of the Medical Director. Policy Interpretation and Implementation: Physician services are under the general supervision of the Medical Director. 1. The Medical Director is a licensed physician in this state and is responsible for: b. Overseeing Physicians and those who perform physician-delegated tasks. d. Overseeing and helping develop and implement care-related policies and practices. e. Participating in efforts to improve quality of care and services. 3. Medical Director functions also include, but are not limited to: c. Helping assure that residents receive adequate services appropriate to meet their needs. g. Assuring Physician services comply with current rules, regulations and guidelines concerning long-term care. Review of the facility's policy titled, Attending Physician/PA/NP Responsibilities revealed the following, in part: Policy Statement: The attending Physicians shall be the primary practitioners responsible for providing medical services and coordinating the healthcare of each resident in the facility. Policy Interpretation and Implementation: Each Attending Physician will be responsible for the following: Accepting Responsibility for Resident Care 2. The Attending Physician will seek, provide, and analyze information regarding a resident's current status and treatment to enable safe, effective continuing care and to support facility compliance with regulations and care standards. Providing Appropriate Care 7. The Physician will respond to notification of and will access and manage acute and significant changes in resident condition. Providing Appropriate, Timely Medical Orders and Documentation 3. The Physician will help the facility comply with its legal and regulatory requirements. General Conduct and Compliance 1. The physician will abide by pertinent facility and medical policies and procedures, and will collaborate with the Medical Director to help the facility provide high- quality care. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Neurogenic Bladder with Chronic Foley Dependence with History of ESBL UTIs, Flaccid Hemiplegia, Aphasia, and PEG and Foley Dependence due to numerous CVA's. Further review of Resident #1's Clinical Record revealed she was transferred to a local hospital on 01/13/2024. Review of Resident #1's MDS with an ARD of 10/08/2023 revealed a BIMS of 99, which indicated Resident #1 was unable to complete the BIMS assessment. Review of the facility's Self-Reported Incident Reports dated August 2023 - January 2024 for Resident #1 revealed no entries for possible sexual abuse. Review of Resident #1's Physician Notes from a local hospital dated 01/13/2024 revealed the following, in part: Resident from a local nursing home with significant Past Medical History of CVA with residual Aphasia, PEG tube, Neurogenic Bladder with Chronic Indwelling Foley Catheter and history of ESBL UTI's was sent to Emergency Department for evaluation of Hypoxia with Suspected Aspiration Pneumonia. She is strictly PEG tube feedings. UA suggestive of UTI with 3+ leukocytes, WBC, moderate bacteria and Trichomonas. Review of Resident #1's Microscopic Urinalysis dated 01/13/2024 from a local hospital revealed the following, in part: Trichomonas = present Review of Resident #1's Discharge Summary from a local hospital dated 01/22/2024 revealed the following, in part: Hospital Course Note: Urinalysis showed Trichomonas present. Social Worker notified who will notify the Ombudsman. S3NP and S5FMD were notified. Of note, 10/2023, Urinalysis was negative for Trichomonas at a local hospital. The last microscopy of urine sent from the nursing home was on 09/27/2023 which was negative for Trichomonas. Resident was admitted to the hospital on 01/13/2024 where Trichomonas was found on urine microscopy. Resident's daughter knows Trichomonas is a sexually transmitted disease. Signed S6MD. An interview was conducted on 01/22/2024 at 10:15 a.m. with a Social Worker from a local hospital where Resident #1 was admitted . She said she was a mandated reporter. She said Resident #1 was nonverbal, could not make her needs known, and required total assistance with ADL care. She said Resident #1 was admitted to a local hospital on 01/13/2024 for Shortness of Breath, Possible Aspiration, and Suspected Sepsis from a Urinary Tract Infection. She said on 01/13/2024, Resident #1's microscopic urine sample tested positive for Trichomonas. She said S3NP and S5FMD were notified by S6MD of Resident #1's positive urine results. She said S6MD reviewed previous microscopic urinalysis results for Resident #1 from previous admissions at 2 local hospitals and no urine results revealed Resident #1 had Trichomonas prior to this hospitalization . She said she was unaware of a previous history of a sexually transmitted disease for Resident #1. She said the local police were notified. An interview was conducted on 01/22/2024 at 10:30 a.m. with S6MD. She said she provided care to Resident #1 at a local hospital. She said Resident #1 was admitted to the hospital on 01/13/2024. She said Resident #1 was nonverbal, could not make her needs known, and required total assistance with ADL care. She said on 01/13/2024, Resident #1's urine tested positive for Trichomonas. She said she reviewed previous microscopic urinalysis results for Resident #1 from previous admissions at 2 local hospitals and no urine results revealed Resident #1 had Trichomonas prior to this hospitalization . She confirmed Trichomonas was a sexually transmitted disease. She said she informed S3NP and S5FMD of Resident #1's positive Trichomonas results on 01/15/2024. An interview was conducted on 01/23/2024 at 11:45 a.m. with S3NP. He said he was a contracted provider with the facility. He verified he provided care to Resident #1 in the facility. S3NP said Resident #1 was admitted to the facility on [DATE] with diagnoses which included CVA, Aphasia, Neurogenic Bladder with Chronic Indwelling Foley Catheter and Paraplegia. He said Resident #1 was nonverbal, could not make her needs known, and required total assistance with ADL care. He said, on 01/15/2024, he was verbally informed by S6MD that Resident #1 had Trichomonas detected in her microscopic urine sample, which was found when she was admitted to a local hospital on 01/13/2024. He said on 01/15/2024, he and S5FMD discussed the possibilities in which Resident #1 could have been infected with Trichomonas. He stated Trichomonas was transmitted during sex, and there were a few cases of it being transmitted by contaminated linens, but that would be unlikely. He said he and S5FMD questioned whether sexual abuse happened at the facility. He said they speculated that she may have been assaulted; he said it was unlikely but possible. He said Resident #1 would not have been able to report if anyone had been in her room and assaulted her. He said he did not inform the facility's administrative staff of the positive Trichomonas result from Resident #1's microscopic urine test. He said he assumed it was the responsibility of the hospital to inform S1ADM or S4DON. He said he was unsure if S1ADM or S4DON were aware Resident #1's urine test was positive for Trichomonas. An interview was conducted on 01/23/2024 at 12:00 p.m. with S4DON. She said she knew Resident #1 well. She said Resident #1 had a diagnosis of Paraplegia, was unable to make her needs known, and she required total assistance with ADL care. She verified Resident #1 was in a local hospital at the present time. She said she was unaware Resident #1 had been recently treated for a sexually transmitted disease. She said if S3NP and S5FMD were aware Resident #1 had recently been treated for a sexually transmitted disease, she should have been made aware and had not been. An interview was conducted on 01/23/2024 at 12:30 p.m. with S2AA. She said she knew Resident #1 well. She said Resident #1 had a diagnosis of Paraplegia, was unable to make her needs known, and she required total assistance with ADL care. She verified Resident #1 was in a local hospital at the present time. She said she was unaware Resident #1 had been recently treated for Trichomonas, a sexually transmitted disease. She said no one informed her and she was unsure if S1ADM was aware. She said Resident #1 would not have been able to report if anyone had been in her room and sexually assaulted her. She said if S3NP and S5FMD were aware Resident #1 had recently been treated for a sexually transmitted disease, she and S1ADM should have been made aware and had not been. An interview was conducted on 01/23/2024 at 12:45 p.m. with S1ADM. He said he knew Resident #1 well. He said he was unaware Resident #1 had recently been treated for a sexually transmitted disease. S1ADM confirmed Resident #1 was not capable of consenting to any sexual acts or reporting any assault. He said Resident #1 testing positive for a sexually transmitted disease concerned him. He said a SIMS report should have been initiated and a full investigation completed regarding Resident #1 and had not been. He said he spoke with S5FMD on 01/22/2024 and she did not inform him of any issues regarding Resident #1's current medical condition. An interview was conducted on 01/24/2024 at 3:15 p.m. with S5FMD. She confirmed she was the Medical Director for the facility. She verified a microscopic urine test was performed for Resident #1 at a local hospital on 01/13/2024. She said the microscopic urine test revealed Resident #1 had Trichomonas in her urine. She confirmed Trichomonas was a sexually transmitted disease. She said she discussed Resident #1's positive results with S3NP on 01/15/2024. She said she did not have enough information to inform the facility of the positive urine results. She said she did not inform the facility of the positive Trichomonas result because Resident #1 was still in hospital and not under the facility's care. An interview was conducted on 01/24/2024 at 3:45 p.m. with S1ADM. He said on 01/23/2024, S3NP told him he did not disclose Resident #1's medical condition and treatment to him because it would have been a HIPAA violation. He said S3NP served as the facility's Nurse Practitioner under S5FMD, who was the facility's Medical Director. He confirmed he should have been informed by S3NP and S5FMD of this information in order to initiate a formal investigation since Resident #1 resided in the facility. On 02/08/2024 from 11:00 a.m. - 4:50 p.m., five requests were made to S2AA and S7CN of the need to interview S3NP and S5FMD. These attempts were unsuccessful. On 02/08/2024 at 4:55 p.m., two phone interviews were attempted with S5FMD without success. On 02/08/2024 at 5:00 p.m., S4DON and S2AA said S3NP and S5FMD were unavailable for interview. An interview was conducted on 02/08/2024 at 5:05 p.m. with S2AA. She said she was the acting Administrator at the present time in the absence of S1ADM. She said S5FMD had been the facility's Medical Director since 08/01/2023 and S3NP had been the facility Nurse Practitioner since 07/01/2023. She said S5FMD was involved in writing and approving the facility's policies. She said S3NP and S5FMD should have been aware of the facility's reporting policy and the timeframe an incident should be reported. She said S3NP and S5FMD had access to the facility's policies. She said S3NP and S5FMD had been educated on the Abuse/Neglect policy through the company which was contracted with the facility. She said she expected S3NP and S5FMD to follow the facility's reporting policies and had not. She said it was the facility's responsibility to ensure S3NP and S5FMD were aware of the facility's policies, including the reporting of potential sexual abuse.

Based on observations, interviews and record reviews, the facility failed to ensure each resident received: 1. Adequate supervision to prevent falls for a cognitively impaired resident with a known history of refusing to call staff for assistance with mobility, transfers and activities of daily living for 1 (#116) of 4 (#2, #3, #97, #116) residents reviewed for falls. 2. The required amount of transfer assistance for 2 (#97, #108) of 6 (#2, #3, #97, #108, #112, #116) residents reviewed for accidents. This deficient practice had the potential to affect all 64 residents identified by the facility as requiring two-person assistance for transfers, with or without the use of a mechanical lift. This deficient practice resulted in Resident #116 experiencing three actual harms; on 02/03/2019, 07/03/2019 and on 09/09/2019. On 02/03/2019, the resident was found in her room holding her right arm with a right swollen wrist and skin tears to the right elbow. The resident was taken to the hospital and diagnosed with [REDACTED]. The resident was taken to the hospital and diagnosed with [REDACTED]. On 09/09/2019, the resident was found on floor in the bathroom with large hematomas to the right side of the nose and to the middle of her forehead. The resident was taken to the hospital and diagnosed with [REDACTED]. The facility failed to increase supervision and to provide adequate assistance to prevent the resident from continuing to fall with injuries. This deficient practice resulted in an actual harm on 09/06/2019 for Resident #97 when S22CNA attempted to transfer the resident by herself from a Geri chair to the resident's bed. Resident #97 required two-person assistance with transfers. Resident #97's right leg made contact with an object during the transfer, which resulted in a right tibia fracture. Findings: Resident #116 Review of the record revealed Resident #116 had [DIAGNOSES REDACTED]. Review of the annual MDS with an ARD of 09/10/2019 revealed Resident #116 had a BIMS score of 12, which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #116 required limited/one person assistance with bed mobility, extensive/one person assist with transfers, limited/one person assist with locomotion on the unit, and used a wheelchair as a mobility device. Review of the current Care Plan revealed Resident #116 was cognitively impaired and at risk for increased confusion and memory loss, impaired decision making and mobility, speech impairment, and episodes of disorganized thinking. The resident was at risk for falls, needed assistance with transfers, bed mobility, and toileting, and refused care and activities of daily living. Further review of the resident's current Care Plan revealed the facility continued to add interventions such as: bed alarms, monitoring while in bed, maintenance of environment free of clutter and safety hazards, placement of frequently used items within easy reach, self-release seat belt while up in wheelchair, release of seat belt and repositioning every two hours and as needed, resident reeducation on asking for assistance with transfers and locking the wheelchair, position bars at head of bed for positioning and bed mobility, and bilateral arm supports for commode/toilet safety. Review of the Nurse's Notes revealed Resident #116 had fallen on the following days: 12/27/2018 At 9:35 a.m. fall in room resulting in a hematoma above her left eyebrow measuring 3.5 cm x 2.5 cm. a knot on the left upper eyelid and a skin tear to the left elbow measuring approximately 1.0 cm. 02/03/2019 10:59 a.m. fall in room with a bruise to right temple that extends upward to hairline. She had a right wrist swollen and two skin tears on right elbow. She has an old bruise under her left eye from a previous fall that is healing. 4:50 p.m. Resident #116 returned from the hospital with a [DIAGNOSES REDACTED]. 02/05/2019 Cast and right arm sling noted on Resident #116's right arm. 03/31/2019 Noted resident sitting on upright on buttocks on bathroom floor. Resident was trying to use toilet without assistance and had pulled emergency call light when she was trying to sit on the toilet and instead she landed on the floor. 06/30/2019 1:47 p.m.-Summoned to Hall B. Upon arrival, resident noted sitting on buttocks on floor with back against the wheelchair. Fall unwitnessed. 7/03/2019 At 7:45 p.m. informed by CNA that resident was on the floor in the bathroom. Left hand was swollen from earlier incident. X-ray results showed acute fracture ring finger metacarpal. 7/19/2019 6:58 p.m.: (Fall occurred at 6:15 p.m.) Resident #116 slid out of her wheelchair onto the floor. 8:56 p.m.: A (Fall occurred at 7:20 p.m.), Resident #116 was reported to have fallen a second time on another hall. 08/02/2019 9:58 a.m.: (noted in relation to fall at 9:15 a.m.) Resident's bed alarm went off. Care member (CNA) entered the room and Resident #116 was sitting on the floor. Resident reported back pain to the nurse. 1:49 p.m.: At 9:15 a.m., Resident #116 was sitting on the floor post fall. When she arrived to the room, Resident #116 was sitting upright on the floor on her buttocks, feet in front of her and shoes beside bed. She was attempting to put T.E.D. hose on. Resident #116 had no obvious injuries from the fall, but complained of a back ache. She stated her back hurt just below her shoulder blades and she rated her pain 9 on a 1-10 scale. Lumbar evaluation was negative for bumps or bruising. An x-ray was ordered by the physician. This fall was noted as an unwitnessed fall. 7:43 p.m.: X-ray findings revealed age-indeterminate compression fractures of L1 and L2 without prior exams to evaluate for chronicity. Correlate clinically. Received an order to send Resident #116 to the emergency room for evaluation and treatment. 08/23/2019 1:38 a.m.: Late entry for 08/22/2019 at 7:57 p.m.: Called to room by CN[NAME] Stated the Resident #116 was on the floor of the restroom. Entered the room to find resident sitting against bathroom wall in no obvious signs of distress. No obvious injuries noted. 09/09/2019 4:30 p.m., Resident #116's emergency light sounded. CNA entered the room and discovered Resident #116 on the bathroom floor. A large amount of bright red blood was noted on the floor. A hematoma was noted to the right side of her nose and the middle of her forehead. transported to the hospital. CT Scan of head revealed mild frontal scalp hematoma and probable acute right nasal bone fracture. Maxillofacial (sinus) CT Scan revealed probable acute minimally displaced right nasal bone fracture. Resident #116 was diagnosed with [REDACTED]. 09/10/2019 At 3:33 p.m.: Resident #116 returned from the hospital with a [DIAGNOSES REDACTED]. 09/21/2019 7:02 p.m. staff with reports the resident had a fall in her room. An abrasion with purple discoloration was noted to her right lower extremity and right knee. 11:27 p.m., an additional RN note was entered related to Resident #116's fall at 7:02 p.m. on 09/21/2019. Resident #116 noted to continue with one on one close monitoring through shift through the night. Her skin remained intact with old bruising continued to her face and bruising noted to right knee and right inner thigh. Resident #116 reported soreness to her face and buttocks. 09/21/2019. Resident #116 noted to continue with one on one close monitoring through shift through the night. Her skin remained intact with old bruising continued to her face and bruising noted to right knee and right inner thigh. Resident #116 reported soreness to her face and buttocks. An interview and observation was made of Resident #116 at 12:41 p.m. on 10/16/2019. She was observed self-propelling down the hall by herself in her wheelchair. Purplish-pink discoloration was observed extending across Resident #116's cheeks below both eyes. She stated she fell in her bathroom and hurt her face. She stated she knew she needed to call for help with transferring and toileting. An interview was conducted with S12LPN at 9:14 a.m. on 10/17/2019. She stated Resident #116 had a nasal fracture and another injury to her arm, which resulted in the need for a brace. She stated Resident #116 could not walk, but she could transfer herself. She stated it was unsafe for Resident #116 to transfer herself and she required assist x 1 person from staff with transfers. An interview was conducted with S17CNA at 9:22 a.m. on 10/17/2019. She stated Resident #116 liked to wander and was a fall risk. She stated Resident #116 required extensive/one person assist with transfers, but Resident #116 could do most of the transfer herself with standby assist. She stated Resident #116 had not fallen recently, but reported she fell sometime last month. She stated she (Resident #116) became one on one after that fall and that helped. She stated one on one consisted of being strictly with her and night staff should sit next to her door at all times and assist as needed. She stated day shift did not have to do this during the day. An interview was conducted with S12LPN at 1:27 p.m. on 10/17/2019. She stated Resident #116 had a fall on the night shift and was placed on one on one monitoring at night thereafter. She stated Resident #116 should be monitored every two hours when not one on one. An interview was conducted with S2DON at 1:47 p.m. on 10/17/2019. She stated Resident #116 was independent with self-propelling in her wheelchair and was noncompliant with calling for assistance. She stated staff should be rounding frequently or at least every two hours. She stated Resident #116 was noncompliant, and despite frequent rounding and increased supervision, Resident #116 continued to try to get out of bed without assistance and fell several times. An interview was conducted with S18CNA at 4:55 p.m. on 10/17/2019. She stated Resident #116 had fallen several times. She stated she did not have one on one during the day, but she did have one on one at night from 7:00 p.m. to 7:00 a.m. She stated she needed one on one monitoring in her room and someone should have been sitting in her room with her when she was in her room. An interview was conducted with S3ADON at 9:03 a.m. on 10/18/2019. She stated Resident #116 was alert to self, confused at times, and able to self-propel herself. She stated Resident #116 had a lot of falls recently. She stated the interdisciplinary team worked together to review incidents and implement changes, but she was responsible for reviewing and closing incident reports. She stated a fall prevention program started about one month and the team had one meeting regarding fall prevention; however, Resident #116 was not discussed in the meeting. She stated Resident #116 was placed on the falling star program as high risk for falls, but confirmed Resident #116 had been on the falling star program since (MONTH) (YEAR). She stated all residents were reassessed for falls risks and transfer status as part of the new falling star program. She stated CNAs should round on Resident #116 every other hour and the nurse should round in between. She confirmed this was routine for all residents as part of the new program. She confirmed a CNA was to be by Resident #116's room at night, but she was not sure when this was implemented. She stated the interventions that were implemented for Resident #116's fall prevention were for the most part ineffective. An interview was conducted with S5CPC at 8:51 a.m. on 10/18/2019. She stated staff should be rounding on Resident #116 to check her location every two hours. She stated all residents should be rounded on every two hours. She stated the new falling star program had not been completely initiated, but with the new program, CNAs round every two hours and the nurse rounds every hour in between. She confirmed Resident #116 wandered all over the facility. An interview was conducted with S31CNA at 9:16 a.m. on 10/18/2019. She stated Resident #116 had a history of [REDACTED].#116) and watch her at all times. An interview was conducted with S19CNA at 12:05 p.m. on 10/18/2019. She stated she was supposed to round on Resident #116 every two hours and toilet Resident #116 every one to two hours. She stated Resident #116 was a high risk for falls. She stated Resident #116 was injured in a fall on the night shift and bruised her face. She stated Resident #116 wandered off by herself when staff were busy, so it was hard to keep an eye on her when busy. An interview was conducted with S2DON at 1:36 p.m. on 10/18/2019. She verified that despite the interventions implemented by the facility, Resident #116 had continued to fall and sustain injuries. Resident #97 Review of Resident #97's Face Sheet and [DIAGNOSES REDACTED]. Review of Resident #97's Quarterly MDS with an ARD of 08/27/2019 revealed the resident did not have a BIMS score due to the resident being rarely/never understood. Section G - Functional Status revealed Resident #97 was totally dependent on full staff performance and required two plus person assistance with transfers. Review of Resident #97's Care Plan revealed the following, in part: Scheduled Care Tasks: Transfers with two-person assistance. Problem/Onset: Self-care deficit; require assistance with transfers secondary to cognitive impairment and physical mobility impairment (05/16/2019). Interventions: 08/28/2019 - Transfers with two-person assistance. Review of Resident #97's (MONTH) 2019 physician's orders [REDACTED]. 09/02/2019 - Transfers with a two-person assist. Review of Resident #97's ADL Assistance and Support documentation revealed the following: 09/06/2019 - Transfer: 4/2, which indicated the resident was totally dependent on staff and transferred by one-person physical assist. Signed by S22CN[NAME] Review of Resident #97's Nurse's Notes revealed the following, in part: 09/06/2019 at 6:45 p.m. - Approached by CNA after lunch stating that while putting the resident in bed, she bumped the resident's right leg against hers during the transfer and the resident was complaining of pain. During last med pass around 5:00 p.m., this nurse went in to the resident, and the resident stated, my leg hurt. Resident #97 pointed to her right leg. Assessed the resident's leg and noticed a small lump in the right lower leg. Due to the resident being in pain, an elderly care program was contacted for an X-Ray order. 09/06/2019 at 6:45 p.m. (Additional information was added into the Nurse's notes on 09/07/2019 at 9:55 p.m.), the resident was lying in bed with an abnormal bend to the lower front portion/shin area (9.5 cm x 7.5 cm). There was bluish discoloration, swelling and tenderness noted to the site. Foot drop noted to the right foot with redness and swelling. Facial grimacing and moaning noted with c/o pain to the right leg area. Resident #97 was asked how she hurt her right leg and responded, that girl trying to put me in bed, hit my leg on the chair. NP notified. At 8:55 p.m.: Right Tibia-Fibula X-Ray impression: [MEDICAL CONDITION]. Acute appearing non-displaced [MEDICAL CONDITION] third of the tibia. Review of an X-Ray of Resident #97's right leg, dated 09/06/2019 at 8:20 p.m., revealed an acute appearing oblique non-displaced non-angulated fracture involving the middle third of the tibia. The reason for the study was Pain. Review of a local Hospital's Record for Resident #97 for an encounter on 09/06/2019 revealed the resident was brought to the ER after she bumped her leg during a transfer. Denied falls or any other trauma. Found to have a right tibial shaft fracture. Physical Exam: Musculoskeletal: RLE splint. Visible deformity. X-Ray results, dated 09/07/2019 at 6:11 a.m., revealed a mid-tibial fracture. Review of documents provided by the facility contained a printed e-mail from S2DON to a previous administrator on 09/10/2019 at 1:52 p.m. The document revealed the following: On 09/06/2019, a phone interview was conducted with S22CNA in regards to an accident involving Resident #97. S22CNA stated she transferred the resident back to bed after lunch around 1:30 p.m. She stated while transferring the resident from the gerichair to the bed, she bumped the resident's foot. S22CNA admitted that resident was a two-person assist, but thought she could transfer the resident on her own. She positioned the resident in bed and told the nurse what had happened. On 10/17/2019 at 5:05 p.m., an interview was conducted with S1ADM and S2DON. S1ADM and S2DON confirmed there was no documentation of monitoring staff during resident transfers after Resident #97's incident. Resident #108 Review of Resident #108's Face Sheet with [DIAGNOSES REDACTED]. Review of Resident #108's Care Plan included: Scheduled Care Tasks: Transfer with two-person assistance. Problem/Onset: Potential for fall/injury, r/t impaired physical mobility secondary to poor safety awareness and medication side effects (06/05/2019). Interventions: Staff to get two-person assistance when transferring the resident due to increased weakness. Falling Star Program: High risk for falls. Review of the (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #108's Nurse's Notes revealed the following: 10/11/2019 at 5:15 a.m. - Called to Resident #108's room at 3:50 a.m. Resident was sitting in a wheelchair with her left pant leg raised and blood on her non-skid sock. S15CNA stated she was transferring Resident #108 with one-person assistance from her bed to the wheelchair. After transferring the resident, the resident stated her leg hurt (grimacing). Her pants were lifted and blood was present on her sock. Assessed the resident and a small amount of active bleeding was noted with a 2 cm x 2 cm skin tear with a torn flap and purple bruising underneath the skin. Resident #108 verbalizes she did not know how it happened and stated it was hurting. On 10/17/2019 at 5:05 p.m., an interview was conducted with S1ADM and S2DON. S1ADM stated Resident #108 suffered a skin tear on 10/11/2019 when S15CNA attempted to transfer the resident by herself. S1ADM stated Resident #108 required two-person transfer assistance. S2DON stated she did not know why S15CNA attempted to transfer the resident by herself.

Based on observations, interviews and record review, the facility failed to ensure a resident that was at high risk for falls received adequate supervision and interventions to prevent accidents for 1 (#4) of 5 (#1-#5) residents reviewed for incidents and accidents in the facility. This failed practice resulted in an actual harm for Resident #4 on 2/25/17 when the resident fell from a couch to the floor. Nursing staff found the resident on the floor bleeding from her forehead after they heard a scream in the dayroom. Resident #4, who was identified by the facility as a high risk for falls, sustained falls on 10/1/16, 12/3/16 and 12/15/16. There was no evidence that increased supervision or monitoring was done to prevent or decrease falls for the resident. The resident was transferred to the hospital on [DATE] where she had a CT (computerized tomography) scan that revealed she had a type 2 odontoid fracture (fracture in the neck). Findings: Review of the clinical record for Resident #4 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) for Resident #4 with an ARD (Assessment Reference Date) of 2/7/17 revealed the resident had BIMS (Brief interview for Mental Status) of 3 which indicated the resident was severely impaired for cognition. Further review of the MDS revealed the resident was coded to require total dependence for transfers with one person assist. Review of the incident/accident record provided by the facility revealed the following incidents for Resident #4- 2/25/17- Fall- Interventions included increase monitoring for safety, encourage resident to retire to her bed, transfer training with neck collar by therapy, Geri-chair, true low bed, edge definition mattress. 12/15/16- Fall- Ensure wheelchair alarm and bed alarm activated at all times 12/3/16- Fall- Do not leave resident's wheelchair next to bed when the resident is in bed 10/1/16- Fall- Increase observation Review of the care plan for Resident #4 revealed the following in part: 2/27/17- Potential for fall/injury related to impaired physical mobility, secondary to poor safety awareness, increased confusion, related to progression of dementia, medication side effects and shortness of breath upon exertion with oxygen use, 2/25/17- Actual fall, sustained fracture to the neck- admitted to the hospital. Interventions included 2/27/17-Position and range of motion to comfort, 2/27/17- Ensure resident can locate easily, reinforce how/why to use call light, 2/27/17- Falling star Program, 2/27/17- ½ side rail or positioning bars at head of bed for positioning, and bed mobility, release and reposition every 2 hours, 2/27/17- Observe for pain/stiffness during transfers, 2/27/17 Low bed, 3/8/17- Resident up in Geri-chair, monitor and reposition every hour, 2/27/17- bed against the wall for safety due to high risk related to poor safety awareness, 2/27/17, observe for side effects from meds, labs, appetite as cause for fall, Do not leave wheelchair next to bed when resident is in bed, 3/3/17- bed alarm while in bed at all times for safety due to poor safety awareness, and high risk for falls, monitor while in bed, 2/25/17- Increased monitoring for safety, encourage resident to retire to bed, 3/8/17- 2 person assist with transfers. Review of the hospital record for Resident #4 revealed the following- Chief complaint- Fall The patient presents with a history of severe Alzheimer's dementia, Congestive Heart Failure (CHF), Severe [DIAGNOSES REDACTED] and Depression who had an unwitnessed fall at the nursing home with significant facial trauma. Unknown Level of Consciousness, history unobtainable from patient due to her dementia. At present, she is awake and alert, oriented to name but nothing else. She complains of seeing rats coming out from underneath the bed, some flying. She was found to have an odontoid fracture that is being managed with an aspen collar by neuro surgery. Review of her nursing home records shows oxygen as needed. CT (computerized tomography) Scan revealed type 2 odontoid fracture (fracture in the neck) and chronic degenerative spondylosis (General term for age-related wear and tear of the spinal disks) appropriate for age. Resident discharged back to facility. Resident to have follow up with X-ray of Cervical Spine in 2 weeks (3/16/17) Review of the progress notes for Resident #4 revealed the following in part: 3/3/17- [AGE] year-old female recently hospitalized , presented to emergency room for evaluation following an unwitnessed fall at the nursing home, CT scan revealed 2 odontoid fracture with chronic degenerative spondylosis. She has a cervical collar in place, surgery was not indicated due to age, prior to hospital stay she was receiving hospice care with [DIAGNOSES REDACTED]. Physical Examination- Thin, frail appearing, diffuse ecchymosis to face, multiple facial lacerations, cervical collar to neck. 1) Cervical Fracture- surgery no indicated due to age, Aspen collar in place, continue meds for pain control. 2) CHF chronic- Continuous Oxygen therapy, Continue Ace (Blood Pressure Medication), diuretic, continue supportive care 3) Dementia Progression- more confused An observation was made of Resident #4 on 3/13/17 at 10:26 AM. Resident #4 was observed sitting reclined in a Geri-chair covered with a fleece blanket. The resident was connected to an oxygen concentrator with continuous oxygen flowing. Resident was observed to have generalized bruising to her face and forehead with a healing laceration noted to the right side of her forehead. C-Collar (Cervical collar/aspen collar) in place. Resident leaning to the right side of the Geri-chair. Attempted to interview resident at that time, resident lethargic, aroused with some difficulty. An interview was held with S6CNA on 3/13/17 at 12:30 PM. She stated she would round on the resident every 2 hours. She stated Resident #4 needed assistance with total care, she stated she would assist her with changing and the hospice aids would assist the resident as well 3 days a week. She stated she had returned back to work Resident #4 was in the hospital. She stated she was unsure as to why the resident was in the hospital. She stated nothing has changed for the resident regarding the care she needed since the resident had returned from the hospital. She stated she was not sure why the resident had bruising to her face and why she had the collar around her neck. She stated she was not aware of the resident having a history of falls. She stated she would find out about the residents by getting report from the previous shift or going to the nurse. An interview was held with S10LPN on 3/13/17 at 12:38 PM. She stated Resident #4 was total assistance for all ADLs (Activities of Daily Living). She stated when the resident was first admitted , she was fussy and would get agitated. She stated the resident's most recent fall happened on the night shift. She stated the resident fell off the sofa in the day area. Resident #4 would often state that it was too early for her to go to bed. She stated the resident would often ask for the staff to assist her with getting on the sofa. She stated the resident was sent out to the hospital when she had fallen off of the sofa. She stated since the accident, the resident was now in a Geri-Chair. She stated her need for assistance has increased more. She stated when the resident returned to the facility, she had been complaining of pain more frequently. She stated the resident had a new order to receive pain medication every 6 hours as needed. An observation was made of Resident #4 on 3/13/17 at 3:00 PM. She was observed in her bed. Resident was noted to have her collar removed from her neck. S5CNA was observed finishing getting the resident situated. Attempted to interview resident, but resident stated she was in some pain and displays signs of heavy breathing. An interview was held with S9LPN on 3/14/17 at 10:14 AM. She stated the resident's last fall happened during her shift. She stated Resident #4 reported to her that she did not want to lay in her bed because she was tired of it. She stated the resident proceeded to lay down on the couch. She said when she last saw the resident, the resident's wheelchair was within her reach, about midway right up against the sofa. She reported she saw S7CNA in the dayroom as she went to go complete her med pass on the rest of her residents. She stated she then went to the other end of the nurse's station to complete her med pass documentation. She said she was unable to see the resident when she was on the other end of the nurse's station. She stated that while she was charting, she heard a scream. She said ran over to find Resident #4 on the floor in front of the sofa, lying on her side and she was bleeding from her head. She stated she instructed the CNA to go grab some towels and they applied the towels to stop the bleeding. She stated she then notified the charge nurse and they called to have the resident sent out to the hospital. An interview was held with S7CNA on 3/14/17 at 11:51 AM. She stated when she first came on to her shift, the resident was in her wheelchair sitting in the dayroom. She stated she saw S13CNA assist the resident with getting on the couch and placed the resident on the sofa. She stated she was new and was not aware that Resident #4 was on her room assignment. She stated she was still training. She stated she went to go answer a call light and she told the nurse to watch the resident's in the dayroom while she answered the call light. She stated she returned back from checking the call light and she was talking to S13CNA in the dayroom. She stated she did not see the resident but they heard a scream. She stated she found the resident lying on her side and she was bleeding from a laceration on her forehead. When asked if she knew how the resident hit her head, she replied that there was nothing close by except for her wheelchair. She stated the resident's wheelchair was nearby for her to reach it but not close enough to where she could have hit her head on it. She stated she was not aware of the resident having a history of falls. She stated did not did get the full report on the resident when she started. An interview was held with S9LPN on 3/14/17 at 3:30 PM. When asked if she was ever told to observe Resident #4 while S7CNA answered a call light, she replied she was not told to watch the resident. An interview was held with S3ADON on 3/15/17 at 10:49 AM. She stated she was responsible for reviewing the incidents and accidents for the facility. She explained the interventions on the fall log were the interventions that were put in place to prevent the resident from having reoccurring falls. She stated it was a team effort to determine what interventions were appropriate for the resident's falls. She confirmed on 12/3/16 the resident was found next to the bed due to an attempt to transfer herself from the bed to the wheelchair and the intervention put in place was to keep the resident's wheelchair out of reach so she does not attempt to transfer self without assistance. She further reviewed the incident log and confirmed on 12/15/16 the resident was found next to her bed and she had soiled on the floor. She explained they had added a bed alarm and a wheelchair alarm as they were unsure if she fell out of the wheelchair or the bed. She stated every time she had seen the resident during the day she was always in her wheelchair or lying on the sofa. She stated the most recent fall that the resident had was when she had fallen off the sofa. She stated they obtained staff statements they had all reported that they heard the resident scream and she was found on the floor. When asked if staff had reported where the resident's wheelchair was, she explained the resident's wheelchair was in front of her and she was able to reach her wheelchair when she was on the sofa. She reviewed one of the interventions for one of the resident's falls and verified the resident's wheelchair was not to be within her reach to discourage her from getting up without assistance. She stated all staff had reported that they did not see the resident fall off of the sofa. She verified that the staff were not monitoring the resident at that time. She stated one of the staff members should have been watching the resident while she was lying on the sofa in the dayroom. An interview was held with S2DON on 3/15/17 at 1:20 PM. She stated Resident #4 was confused and she would often try to do for herself because she was used to being independent. She stated the resident had been confused for some time. She confirmed the resident had a fall when she was in the dayroom. She said staff were supposed to be monitoring the resident in the dayroom. She confirmed the resident's wheelchair should not have been placed next to the resident if they had identified as that as a risk for falls.

Based on observations, interviews and record reviews, the facility failed to provide care and services outlined in the Resident's plan of care for 2 (#1, #4) of 5 (#1-#5) residents reviewed for incidents and accidents. The facility failed to ensure interventions on the care plan were implemented by staff. This failed practice resulted in an actual harm for Resident #4 on 2/25/17 when the resident fell from a couch to the floor. Nursing staff found the resident on the floor bleeding from her forehead after they heard a scream in the dayroom. Resident #4, who was identified by the facility as a high risk for falls, sustained falls on 10/1/16, 12/3/16 and 12/15/16. There was no evidence that increased supervision or monitoring was done to prevent or decrease falls for the resident. The resident was sent to the hospital on [DATE] where she had a CT (computerized tomography) scan that revealed she had a type 2 odontoid fracture (fracture in the neck). Findings: Resident #4 Review of the clinical record for Resident #4 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) for Resident #4 with an ARD (Assessment Reference Date) of 2/7/17 revealed the resident had BIMS (Brief interview for Mental Status) of 3 which indicated the resident was severely impaired for cognition. Further review of the MDS revealed the resident was coded to require total dependence for transfers with one person assist. Review of the incident/accident record provided by the facility revealed the following incidents for Resident #4- 2/25/17- Fall- Interventions included increase monitoring for safety, encourage resident to retire to her bed, transfer training with neck collar by therapy, Geri-chair, true low bed, edge definition mattress. 12/15/16- Fall- Ensure wheelchair alarm and bed alarm activated at all times 12/3/16- Fall- Do not leave resident's wheelchair next to bed when the resident is in bed 10/1/16- Fall- Increase observation Review of the care plan for Resident #4 revealed the following in part: 2/27/17- Potential for fall/injury related to impaired physical mobility, secondary to poor safety awareness, increased confusion, related to progression of dementia, medication side effects and shortness of breath upon exertion with oxygen use, 2/25/17- Actual fall, sustained fracture to the neck- admitted to the hospital. Interventions included 2/27/17-Position and range of motion to comfort, 2/27/17- Ensure resident can locate easily, reinforce how/why to use call light, 2/27/17- Falling star Program, 2/27/17- ½ side rail or positioning bars at head of bed for positioning, and bed mobility, release and reposition every 2 hours, 2/27/17- Observe for pain/stiffness during transfers, 2/27/17 Low bed, 3/8/17- Resident up in Geri-chair, monitor and reposition every hour, 2/27/17- bed against the wall for safety due to high risk related to poor safety awareness, 2/27/17, observe for side effects from meds, labs, appetite as cause for fall, Do not leave wheelchair next to bed when resident is in bed, 3/3/17- bed alarm while in bed at all times for safety due to poor safety awareness, and high risk for falls, monitor while in bed, 2/25/17- Increased monitoring for safety, encourage resident to retire to bed, 3/8/17- 2 person assist with transfers. Review of the hospital record for Resident #4 revealed the following- Chief complaint- Fall The patient presents with a history of sever Alzheimer's dementia, [MEDICAL CONDITIONS], Severe [DIAGNOSES REDACTED], Depression who had an unwitnessed fall at the nursing home with significant facial trauma. Unknown Level of Consciousness, history unobtainable from patient due to her dementia. At present, she is awake and alert, oriented to name but nothing else. She complains of seeing rats coming out from underneath the bed, some flying. She was found to have an odontoid fracture that is being managed with an aspen collar by neuro surgery. Review of her nursing home records shows oxygen as needed. CT (computerized tomography) Scan revealed type 2 odontoid fracture (fracture in the neck) and chronic [MEDICAL CONDITION] spondylosis (General term for age-related wear and tear of the spinal disks) appropriate for age. Resident discharged back to facility. Resident to have follow up with X-ray of Cervical Spine in 2 weeks (3/16/17) Review of the progress notes for Resident #4 revealed the following in part: 3/3/17- [AGE] year-old female recently hospitalized , presented to emergency room for evaluation following an unwitnessed fall at the nursing home, CT scan revealed 2 odontoid fracture with chronic [MEDICAL CONDITION] spondylosis. She has a cervical collar in place, surgery was not indicated due to age, prior to hospital stay she was receiving hospice care with [DIAGNOSES REDACTED]. Physical Examination- Thin, frail appearing, diffuse ecchymosis to face, multiple facial lacerations, left forearm (LFA) laceration, cervical collar to neck. 1) Cervical Fracture- surgery no indicated due to age, Aspen collar in place, continue meds for pain control. 2) [MEDICAL CONDITION] chronic- Continuous oxygen therapy, Continue Ace (blood pressure medication), diuretic, continue supportive care 3) Dementia Progression- more confused An observation was made of Resident #4 on 3/13/17 at 10:26 AM. Resident #4 was observed sitting reclined in a Geri-chair covered with a fleece blanket. The resident was connected to an oxygen concentrator with continuous oxygen flowing. Resident was observed to have generalized bruising to her face and forehead with a healing laceration noted to her forehead. C-Collar in place. Attempted to interview the Resident at that time, resident was lethargic and aroused with some difficulty. An interview was held with S10LPN on 3/13/17 at 12:38 PM. She stated Resident #4 was total assistance for all ADLs. She stated the resident had fallen on the night shift the last fall she had. She stated the resident fell off the sofa in the day area. She stated a lot of times at night the resident did not want to go down for bed. Resident #4 would often state that it was too early for her to go to bed. She stated the resident would often ask for the staff to assist her with getting on the sofa. An observation was made of Resident #4 on 3/13/17 at 3:00 PM. She was observed in her bed. Resident was noted to have her collar removed from her neck. S5CNA was observed finishing getting the resident situated. Attempted to interview resident, but resident stated she was in some pain and displayed signs of heavy breathing. An interview was held with S9LPN on 3/14/17 at 10:14 AM. She stated the resident had her last fall during her shift. She stated the resident reported to her that she did not want to lay in her bed because she was tired of it. She stated the resident proceeded to lay down on the couch and she went to go complete her med pass. She said the resident's wheelchair was within her reach, about midway right up against the sofa. She reported she saw S7CNA in the dayroom as she went to go complete her med pass. She stated she then went to the other end of the nurse station to complete her med pass documentation. She said she was unable to see the resident when she was on the other end of the nurse's station. She stated while she was doing her charting, she heard a scream. She said ran over to find the Resident #4 on the floor in front of the sofa, lying on her side and bleeding from her head. An interview was held with S7CNA on 3/14/17 at 11:51 AM. She stated when she first came on to her shift, the resident was in her wheelchair sitting in the dayroom. She stated she saw S13CNA assist the resident with getting on the couch and placing the resident on the sofa. She stated she was new and was not aware that Resident #4 was on her room assignment. She stated she was still training. She stated she went to go answer a call light and she told the nurse to watch the residents in the dayroom while she answered the call light. She stated she returned back from checking the call light and was talking to S13CNA in the dayroom. She stated she did not see the resident, then they heard a yell. She stated the resident was lying on her side and she was bleeding because she had a laceration on her forehead. When asked if she knew how the resident hit her head, she replied that there was nothing close by except for her wheelchair. She stated the resident's wheelchair was nearby for her to reach it but not close enough to where she could have hit her head on it. An interview was held with S3ADON on 3/15/17 at 10:49 a.m. She confirmed on 12/3/16 the resident was found next to the bed due to an attempt to transfer herself from the bed to the wheelchair and the intervention put in place was to keep the resident's wheelchair out of reach so she does not attempt to transfer self without assistance. She further reviewed the incident log and confirmed on 12/15/16 the resident was found next to her bed and she had soiled on the floor. She explained they had added a bed alarm and a wheelchair alarm as they were unsure if she fell out of the wheelchair or the bed. She stated they obtained staff statements they had all reported that they heard the resident scream and she was found on the floor. When asked if staff had reported where the resident's wheelchair was, she explained the resident's wheelchair was in front of her and she was able to reach her wheelchair when she was on the sofa. She verified that the staff were not monitoring the resident at that time. She stated one of the staff members should have been watching the resident while she was lying on the sofa in the dayroom. An interview was held with S2DON on 3/15/17 at 1:20 PM. She said staff were supposed to be monitoring the resident in the dayroom. She confirmed the resident's wheelchair should not have been placed next to the resident if they had identified that as a risk for falls. Resident #1 Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) for Resident #1 with an Assessment Reference Date of 2/9/17 revealed the resident had a BIMS (Brief Interview for Mental Status) of 8, which indicated the resident was moderately impaired for cognition. An observation was made Resident #1 on 3/13/17 at 12:05 PM. Resident #1 was observed sitting in the dining room area attempting to eat her lunch. The resident required much verbal cueing by staff and was observed attempting to eat her lunch with a straw. An attempt was made at that time to interview the resident but the resident was not able to be interviewed. Review of the fall incident log for Resident #1 revealed the following in part: 2/28/17-Fall- Intervention-Frequent monitoring due to poor safety awareness, educate resident to call for assistance and not to attempt to reach for floor from her wheelchair. 1/15/17- Fall- Intervention-Resident to be monitored in main dining room area, redirect when indicated. 1/6/17- Fall- Intervention- Offer assistance with ADLs (Activities of Daily Living) 1/2/17- Fall- Intervention- Increase monitoring, assist with ADLs 12/25/16- Fall-Intervention-Frequent Monitoring of Resident, ensure safety precautions in place, encourage resident to call for assistance. 12/23/16- Fall-Intervention- Offer assistance with ADLs early in the AM 12/21/16- Fall-Intervention- Increase monitoring, ensure bed alarm is on and working properly 12/1/16- Fall-Intervention-Increase Observation An interview was held with S3ADON on 3/15/17 at 10:49 AM. She reviewed the fall log and confirmed the interventions for the resident were the ones identified on the log. She stated Resident #1 was occasionally cognitive. She stated the resident used to be able to do for herself. She stated the resident had frequent falls and interventions for the resident included to assist the resident with ADLs. She reviewed the incident log and confirmed the interventions for the last 4 falls were increase monitoring and offer assistance with ADLs. She reviewed the incident log and could not show how the increased monitoring. She agreed providing ADLs was something the CNAs were already doing and there was not a specific intervention for the resident. An interview was held with S2DON, on 3/15/17 at 2:00 PM. She stated Resident #1 was not cognitive. She stated the resident had been confused for the last 3-6 months. She stated she was not sure if the staff documented when they were to increase monitoring on a resident. She stated the resident would not remember to ask for assistance if you instructed her to. She confirmed an intervention to remind the resident to call for assistance was not appropriate for a confused resident.

Based on record review and interview , the facility failed to ensure a periodically accurate ongoing assessment was conducted for 1 of 5 sampled residents (#2). The facility failed to assess the resident for: 1. Signs and symptoms of dehydration (skin turgor, cracked lips, dry skin and mucous membranes) (#2) 2. Pocketing food in mouth (#2) 3. Loss of appetite/fluid intake (#2) 4. Laboratory test being performed to monitor therapeutic [MEDICATION NAME] levels (#2) 5. Ensure the Registered Dietician assessed resident for changes in nutritional parameters for a resident with weight loss(#2) Resident #2 was placed in actual harm when the facility failed to ensure the resident was reassessed for loss of appetite, signs and symptoms of dehydration, failure to monitor [MEDICATION NAME] levels which resulted in the resident being sent to the hospital on [DATE] at 12:29 p.m. On admission to the hospital the resident was diagnosed with [REDACTED]. Findings: Resident #2 was an [AGE] year old female admitted to the facility on [DATE]. She was readmitted to the facility on [DATE] after a Right Nephrectomy. Her cumulative [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was dependent on staff for all of her activities of daily living. Further review of the MDS under section J1550-Problem Conditions list the condition of Dehydrated- but it is not checked as a condition that existed for Resident #2. Review of the Physician order [REDACTED]. Diet--No Concentrated Sweets (NCS), No Added Salt (NAS), Mechanical Soft. Limit foods high in Potassium (no orange juice, potatoes, bananas. melon, tomatoes, greens and prune juice. Review of the Nurse's Notes revealed in part the following: 1) 11/28/10-6:35 p.m.-Resident's responsible party visited and stated "When she pockets food and doesn't eat, she usually has a urinary tract infection. 2) 11/28/10-8:26 p.m.-Appetite by mouth (po) intake remains poor. 3) 12/12/10-12:29 p.m.-Resident's responsible party visited and requested that she be sent to the hospital. States' she was not eating and does not look well. Order received to send resident to the hospital. There is no further documentation in the medical record that further assessments were done or followed through for the above documented incidents. An interview was conducted with S8CNA on 12/29/10 at 11:55 a.m. She stated that Resident #2 started pocketing food about one week prior to her hospitalization . She stated that there is no where on their ADL record to document such an incident for the resident; however, she stated that she did report it to the nurse. An interview was conducted with S3LPN on 12/30/10 at 9:45 a. m. She stated that she was aware that the resident was pocketing food and that sometimes that would indicate something else was going on with the resident. There is no documentation in the medication record to indicate the nurse did an assessment of the resident pocketing food and reported it to the nurse practitioner or physician. There is no documented assessment of the resident regarding po intake. Review of Resident #2's weight history revealed the following: 1) 11/17/10-120.50 lbs 2) 11/24/10-115.0 lbs 3) 12/1/10--113.50 lbs 4) 12/8/10-112 lbs Between the dates of 11/17/10 and 12/08/10 the resident sustained [REDACTED]. An interview was held with S4Registered Dietician on 12/30/10 at 11:50 a.m. She stated that when she received the weight list at the beginning of the month, there were several residents with weight loss to be addressed. She stated that Resident #2 was put on a re-weigh list because they were not sure if her weight loss was accurate. The re-weight was not documented on the medical record until 12/8/10. She further stated that by the time she got around to seeing the resident, she had been admitted to the hospital. An interview was conducted with S5Nutrition Coordinator on 12/30/10 at 12:10 p.m. She stated that the Registered Dietician visited the facility every Wednesday. She stated that if she encountered a problem with weight prior to the Registered Dietician's Wednesday visit, she would send a referral to her. She further stated that the Nurse Practitioner was made aware of Resident #2's weight loss. She also verified that Resident #2 had a significant weight loss that was not addressed prior to her hospitalization . An interview was conducted with S1DON on 12/30/10 at 12:30 p.m. She reviewed the computer for additional documentation of other assessments of the resident. She verified that no other assessment had been done and agreed that the resident should have been assessed more closely since she had been admitted to the hospital for dehydration before. Review of the facility's policy and procedure titled Hydration-Clinical Protocol revealed in part the following: Assessment and Recognition 1. As part of the initial assessment, the physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances) 2. The staff, with the physician's input will identify individuals with signs and symptoms (for example, [MEDICAL CONDITIONS], pre-renal azotemia, etc) from true dehydration (clinically significant loss of total body water) a. They will report this information promptly to the Attending Physician 3. The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. There was no documented risk assessment for Dehydration present in the medical record. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.125 mg-give one (1) 0.125mg tablet per PEG every day. Review of the medical record under labs section revealed no documented results of a [MEDICATION NAME] level for Resident #2. An interview was conducted with S3LPN on 12/30/10 at 9:45 a.m. When asked if a [MEDICATION NAME] level had ever been done on Resident #2, she stated she was not sure. The ward clerk reviewed the laboratory log. The ward clerk did not find a requested [MEDICATION NAME] level on the lab requests for 2010. An interview was conducted with S1DON on 12/20/2010 at 1:30 p.m. She also reviewed the medical record to determine if a [MEDICATION NAME] level had been done on Resident #2. She verified that a level had not been ordered or performed for the year 2010. She agreed that a [MEDICATION NAME] level should have been done, but she was verbally told that Resident #2's primary care physician did not allow routine labs to be drawn on his patients and that labs were done when the doctor deemed it necessary to order them. She admitted that she had not personally spoken to the primary care physician to verify this, but was told this was his preference. Review of the Emergency Physician Notes dated 12/12/10 at 12:29 p.m. revealed in part the following: History of Present Illness The patient presents with decreased responsiveness and not eating at nursing home. Physical Exam General: Alert, Moans when touched or moved. Skin: Warm, dry. Ears, nose, mouth, and throat: Oral mucosa and lips dry. Lab results: Na 135 LOW K 6.4 CRITICAL CO2 16 LOW Glucose 145 HI BUN level 226 CRITICAL Creatinine 6.40 HI Calcium 7.5 LOW Tot Protein 9.3 HI [MEDICATION NAME] 2.6 LOW Addendum per MD: Patient presents with weakened state. She has a UTI but she is also severely dehydrated with grossly elevated BUN/CREATININE and she is [MEDICATION NAME] toxic. She will be admitted to Intensive Care Unit. Her Potassium is high and she has been treated with Sodium [MEDICATION NAME] and Insulin therapy. Discharge summary in part: The patient was brought to the hospital emergency room from her nursing home due to increased somnolence. She has had multiple prior admissions for UTI, Dehydration, and Acute [MEDICAL CONDITION] which have present with altered mental status. Initial laboratory evaluation revealed WBC 16.9, BUN 224, Creatinine 6.40, K 6.4, [MEDICATION NAME] Level 4.8. She was admitted to the Intensive Care Unit and was given aggressive IV fluids and started on [MEDICATION NAME]. [MEDICATION NAME] was held for the duration of the hospitalization due to toxicity.

I. Based on record review, review of the facility's policy and procedure regarding hydration, and interview the facility failed to assess and use the results of the resident's assessment to develop and revise the resident's comprehensive plan of care that included measurable objectives and timetables to meet the medical, nursing and psychosocial needs for 1 of 5 sampled residents (#2) who had a history of [REDACTED]. The facility's failure to ensure that the comprehensive care plan was updated and revised with new measurable objectives and time tables resulted in an actual harm to a resident (#2) when she was admitted to the hospital on [DATE] for Dehydration. Findings: Resident #2 was an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a Right Nephrectomy. Her cumulative [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognitive status for decision making as Severely Impaired-rarely/never make decisions. The same MDS revealed the resident was dependent on staff for all of her activities of daily living. Review of the Comprehensive Plan of Care revealed no problem area designated for the [DIAGNOSES REDACTED]. Review of the Plan of Care dated October 2010 did not reveal an area related to dehydration. Review of the Resident #2's Weight History revealed the following: 1) 11/17/10--120.5 lbs 2) 11/24/10--115.0 lbs 3) 12/1/10--113.5 lbs 4) 12/8/10--112 lbs Review of the Comprehensive Plan of Care dated 10/8/10 revealed the following: Problem: Altered Nutrition: Less than body requirements, related to Dysphagia, and significant weight loss with peg tube placement. Tube Feeding as ordered if the resident consumes less than 50% of meals. Interventions: (10) Weigh weekly; Report Weight of loss/gain of 5% in 30 days or 10% or more in 180 day. Promptly report to MD/RD. Review of the Dietician assessment dated [DATE] revealed the following: Weight Change: 1 MO: -1.32 3 MO: -8.20 6 MO: -13.51 Additional Subjective/Objective Data: Tube Feeding changed to continue Glucerna 1.2 at 1 can 5 times /day. Flush with 150 cc's water 5 times per day. Weight loss occurred. Review of the Dietary Interdisciplinary Progress Notes dated 12/1/10 revealed that Resident #2's weight declined to 114 pounds from 115.0 pounds. The facility failed to update the Resident's care plan with interventions to address the weight loss problem. There is no documentation on the care plan after 10/8/10. II. Based on record review and interview the facility failed to review and revise a comprehensive plan of care with additional/new approaches for a resident with repeated Urinary Tract Infections to ensure the infection did not reoccur for 1 of 5 sampled residents (#2) from a total of 24 residents at the facility with Urinary Tract Infections. Findings: Review of the Plan of Care dated 1/9/10 revealed the following: Original Date: 7/12/10 Problem: Recent UTI Goals: 1) Resident will be free of s/s of UTI in 2 weeks. Negative U/A/C&S if ordered. 2) Absence discomfort upon urination, frequency, foul smelling, or discolored cloudy urine. 3) Will void in sufficient amounts with no palpable bladder distention Interventions: 1) Monitor urine for sediment, cloudiness, odor, blood, amount, abdominal pain, and increased mental confusion. Report abnormal findings promptly to MD. 2) Observe for color and characteristics of urine, and patient symptoms; notify MD if symptoms worsen or if not resolved after antibiotics complete. Review of the medical records revealed the resident had documented UTI's on 7/28/10, 10/15/10 and 11/28/10. The care plan was not updated with additional/new interventions to prevent reoccurring UTI's.

Based on interviews and review of the clinical record, the facility failed to : 1. ensure reweighs were done timely (#2) 2. ensure that all staff was aware that resident pocketed food (#2) 3. ensure pocketing of food was care planned (#2) 4. ensure that the resident's intake was monitored and an accurate record of resident's intake was documented (#2) 5. ensure the RD timely reevaluated the resident in order to recalculate nutritional needs calories, protein and fluid requirements) so that the resident maintained acceptable parameters of nutritional status to prevent weight loss. (#2) . This affected 1 of 5 sampled residents(#2) of a total of 23 residents on the facility's Roster Matrix listed with a weight loss. This resulted in actual harm to resident #2 when the resident sustained [REDACTED]. Findings: Resident #2 was an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was dependent on staff for all of her activities of daily living. Review of Resident #2's December 2010 physician's orders [REDACTED]. (1) No Concentrated Sweets (NCS), No Added Salt (NAS) Mechanical Soft. Limit foods high in potassium (No orange juice, potatoes, bananas, melon, tomatoes, greens and prune juice). (2) Glucerna 1.2-give one can 5 times per day per Percutaneous Endoscopic Gastrostomy (peg) tube. Review of the MDS dated [DATE] revealed the resident was on a mechanically altered diet therapeutic diet and required extensive assistance with meals. Review of Resident #2's weight history revealed the following: 1) 11/17/10-120.50 lbs 2) 11/24/10-115.0 lbs 3) 12/1/10--113.50 lbs 4) 12/8/10-112 lbs Review of the Nurse's Notes revealed in part the following: (1) 11/28/10-6:35 p.m.-Resident's responsible party visited and stated "When she pockets food and doesn't eat, she usually has a urinary tract infection. Could she be checked for that?" (2) 11/28/10-8:26 p.m.-Appetite by mouth (po) intake remains poor. Peg tube patent. Glucerna 1.2 given via peg...... (3) 12/12/10-12:29 p.m.-Resident's responsible party visited and requested that she be sent to the hospital. States' she was not eating and does not look well. Order received to send resident to the hospital. Review of the Meal Intake Exception for 11/28/10 and 12/12/10 revealed the following : 1) 11/28/10-51% to 75%-Dinner meal There is no documentation of the breakfast or lunch meal on the report. There is no evidence that the resident consumed any of either of these meals. 2) On 12/12/10, there is no documentation of any meal intake recorded. Resident was sent to the hospital on this day. Review of the Comprehensive Plan of Care dated October 8, 2010 revealed the following: Problems: Altered Nutrition: Less than body requirements, related to Dysphagia, and significant weight loss with peg tube placement. Tube Feeding as ordered if the resident consumes less than 50% of meals. Goals: 1) No complications from peg tube feeding: Aspiration, nausea/vomiting or diarrhea. 2) Hydration will be maintained as evidence by good skin turgor, and moist mucous membranes. Interventions: 1) Diet as Medical Director (MD) ordered; NCS, NAS, Mechanical Soft. Limit foods high in potassium (No orange juice, potatoes, bananas, melon, tomatoes, greens and prune juice). 2) Administer prescribed peg tube feedings. Glucerna 1.2-give 1 can per peg if resident consumes less than 50% of meal. 3) Flush peg tube with 100 cubic centimeters (cc) of water every (q) shift. 4) Head of bed (HOB) elevated 30 degrees at all times. 5) Check tube placement, patency, and residual q shift. Aspirate for stomach contents prior to feeding, and medication (med) administration. Chart number of cc's of stomach residual. 6) Administer good oral hygiene q shift and as needed (prn). 7) Administer peg tube care. 9) Monitor for complications such as n/v, diarrhea, aspirations. Feeding tolerated: 1=Tolerated well 2=Problem-see Nursing Notes. 10) Weigh weekly; Report Weight of loss/gain of 5% in 30 days or 10% or more in 180 day. Promptly report to MD/RD. Review of the current Physician order [REDACTED]. Glucerna 1.2-give one (1) can 5 times per day per PEG The Care Plan was not updated to reveal the current Glucerna order. Review of the Interdisciplinary Dietary Progress Notes dated 12/1/10 revealed the following: Resident weight report which showed a weight decline to 114 pounds (lb). Will refer to Registered Dietician (RD) for recommendations. Review of the Dietician Assessments revealed that Resident #2's IBW (Ideal Body Weight was: 117.19-124.44 Review of the assessment for 9/14/10 revealed the resident weighed 121.50 pounds. The RD made the following recommendations for Estimated Daily Needs: Calories: 1389.72, Protein: 55.23, Fluids: 1656.8 Review of the assessment for 11/3/10 revealed the resident weighed 112.00 pounds. The RD made the following recommendations for Estimated Daily Needs: Calories: 1335.83, Protein: 50.91, Fluids: 1527.27 These reports revealed even though the resident continued to lose weight, the caloric, protein and fluid needs were decreased. An interview was held with S4Registered Dietician on 12/30/10 at 11:50 a.m. She stated that when she received the weight list at the beginning of the month, there were several residents with weight loss to be addressed. She stated that Resident #2 was put on a re-weigh list because they were not sure if her weight loss was accurate. The re-weight was not documented on the medical record until 12/8/10. She further stated that by the time she got around to seeing the resident, she had been admitted to the hospital. An interview was conducted with S5Nutrition Coordinator on 12/30/10 at 12:10 p.m. She stated that the Registered Dietician visited the facility every Wednesday. She stated that if she encountered a problem with weight prior to the Registered Dietician's Wednesday visit, she would send a referral to her. She further stated that the Nurse Practitioner was made aware of Resident #2's weight loss. She also verified that Resident #2 had a significant weight loss that was not addressed prior to her hospitalization .

Based on record review and staff interview, the facility failed to assure that each resident would be provided with sufficient fluid intake to maintain proper hydration and health for 1 of 5 sampled residents (#2).The facility failed to: 1) ensure that the nurse's assess the resident's (#2) hydration status 2) ensure that dehydration was care planned for a resident (#2) with at history of dehydration 3) ensure that the resident's (#2) fluid intake was monitored and an accurate record of the resident's intake was documented. 4) notify the physician the resident's (#2) fluid intake had decreased. 5) ensure that staff followed the facility's hydration program. This resulted in actual harm when the resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Findings: Resident #2 was an [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was dependent on staff for all of her activities of daily living. Review of the medical record did not reveal documentation of a hydration risk assessment. Review of the Plan of Care dated October 2010 did not reveal an area related to dehydration. The resident was admitted to the hospital three times with the [DIAGNOSES REDACTED]. An interview was conducted with S1DON on 12/30/10 at 12:20 p.m. She reviewed the care plan in the medical record and verified that the problem of dehydration was not even listed on the care plan and there were no documented implementations to prevent reoccurrence. Review of the Point of Care ADL (Activities of Daily Living) History for Hydration for the month of December 2010 revealed the following: 12/1/10---Night Shift-----MLS Offered---2 MLS Consumed--0 12/1/10--Day Shift-------MLS Offered--200 MLS Consumed--200 There is no documentation of hydration for the Morning shift for 12/1/10. 12/2/10--Night Shift------MLS Offered--2 MLS Consumed--0 12/2/10--Morning Shift---MLS Offered--541 MLS Consumed--511 12/2/10--Day Shift-------MLS Offered----200 MLS Consumed--200 12/3/10--Night Shift------MLS Offered---2 MLS Consumed -0 There was only documentation for the Night shift for 12/3/10--no Morning or Day Shift documentation of hydration. 12/4/10--Night Shift------MLS Offered--2 MLS Consumed--0 There is no documentation for the Morning or Day Shift of hydration for 12/4/10. 12/5/10--Night Shift----- MLS Offered--2 MLS Consumed--0 12/5/10--Day Shift-------MLS Offered---100 MLS Consumed--25 There was no documentation for the Morning Shift of hydration for 12/5/10 12/6/10--Night Shift------MLS Offered---2 MLS Consumed--0 12/6/10--Morning Shift---MLS Offered---433 MLS Consumed--433 12/6/10--Day Shift-------MLS Offered---200 MLS Consumed--200 12/7/10--Night Shift------MLS Offered---0 MLS Consumed--0 12/7/10--Morning Shift---MLS Offered---720 MLS Consumed--0 12/7/10--Day Shift-------MLS Offered---200 MLS Consumed--200 12/8/10--Night Shift------MLS Offered--2 MLS Consumed--0 12/8/10---Morning Shift--MLS Offered---720 MLS Consumed--240 12/8/10---Day Shift------MLS Offered--100 MLS Consumed--50 12/9/10---Night Shift-----MLS Offered--2 MLS Consumed--0 There was no documentation of hydration for the Morning and Day Shifts for 12/9/10. 12/10/10--Night Shift-----MLS Offered--2 MLS Consumed--0 12/10/10--Morning Shift- -MLS Offered--500 MLS Consumed--0 12/10/10--Day Shift-------MLS Offered---325 MLS Consumed--325 12/11/10--Night Shift------MLS Offered---2 MLS Consumed--0 12/11/10---Morning Shift--MLS Offered---720 MLS Consumed--240 12/11/10---Day Shift------MLS Offered---474 MLS Consumed--474 12/12/10---Night Shift-----MLS Offered---0 MLS Consumed-0 There was no documentation in the medical record of any output for this resident. Review of the Dietician assessment dated [DATE] revealed the following estimated nutritional needs: Calories: 1335.83 Protein: 50.91 Fluids: 1527.27 The facility did not maintain complete records of fluid intake and did not take any action when the intake records showed that the resident was not consuming enough fluids to meet her nutritional needs. An interview was conducted with S1DON on 12/30/10 at 12:30 p.m. She reviewed the ADL hydration history and verified that there were shifts where documentation was incomplete or not done at all. She stated that the night shift was not documenting on the hydration sheet correctly. She stated that the amount offered and the amount consumed should have been in milliliters and not in number of times offered and in number of times consumed. She further stated that Resident #2 was not on Intake and Output even though she was receiving [MEDICATION NAME] tube feeding. She stated that the intake and output record had been discontinued in March 2010 and never reinstated. She agreed that the resident should have been monitored more closely, since she had been admitted to the hospital for dehydration before. She further stated that the facility had instituted a Hydration Program prior to Resident #2's last admission to the hospital. She stated that the hydration problem was discussed in the Quality meeting and it was decided that the CNA's would go between meals and offer fluids. Currently the CNA's make one round between breakfast and lunch-around 10:00 a.m. She said there was no evening hydration round and no way to monitor the fluid intake from the hydration cart. There was also no way of knowing which residents actually received hydration when the cart was passed. When asked about the evening shift hydration needs, she stated that the 3-11 shifts passed ice pitchers. There was no documentation in the medical record that the physician was notified regarding the resident's change in fluid consumption. An interview was conducted with S1DON on 12/30/10 at 12:30 p.m. She reviewed the medical record and verified that the resident's primary physician was not notified of the decreased fluid intake. Review of the Emergency Physician Notes dated 12/12/10 at 12:29 p.m. revealed in part the following: History of Present Illness The patient presents with decreased responsiveness and not eating at nursing home. Physical Exam Ears, nose, mouth, and throat: Oral mucosa and lips dry. Lab results: Na 135 LOW K 6.4 CRITICAL CO2 16 LOW Glucose 145 HI BUN level 226 CRITICAL Creatinine 6.40 HI Calcium 7.5 LOW Tot Protein 9.3 HI [MEDICATION NAME] 2.6 LOW Addendum per MD: Patient presents with weakened state. She has a UTI but she is also severely dehydrated with grossly elevated BUN/CREATININE... She will be admitted to Intensive Care Unit. Her Potassium is high and she has been treated with Sodium [MEDICATION NAME] and Insulin therapy. Discharge summary in part: The patient was brought to the hospital emergency room from her nursing home due to increased somnolence. She has had multiple prior admissions for UTI, Dehydration, ... Initial laboratory evaluation revealed WBC 16.9, BUN 224, Creatinine 6.40, K 6.4, [MEDICATION NAME] Level 4.8. She was admitted to the Intensive Care Unit and was given aggressive IV fluids.