Every finding on record at Sunset Estates of Purcell

Based on observation, record review, and interview the facility failed to ensure staff wore eye protection when entering residents' rooms who were COVID-19 positive. MDS Coordinator #1 identified 56 residents resided in the facility. The IP identified 16 residents had tested positive for COVID-19. Findings: An undated Sequence for Putting on Personal Protective Equipment form, documented goggles or faceshield were to be placed over face and eyes. Resident #13 had diagnoses which included COVID-19. A Progress Note, dated 11/11/24 at 4:01 a.m., documented Resident #50 was on isolation due to positive covid test. It documented the resident had a cough at times and was not feeling well. A Progress Note, dated 11/12/24 at 10:46 p.m., documented Resident #11 was covid positive. It documented the resident had fatigue, body aches, cough, and sore throat. A Progress Note, dated 11/12/24 at 10:35 p.m., documented Resident #34 was covid positive. It documented the resident had complaints of cough and congestion. A Progress Note, dated 11/13/24 at 4:43 a.m., documented Resident #16 was on isolation precautions for covid positive test. It documented the resident had a stuffy nose and cough. On 11/13/24 at 11:20 a.m., LPN #1 was observed to enter and perform a FSBS on Resident #13. They exited the room, prepared an insulin pen, and entered Resident #13's room again. LPN #1 was not observed to have worn eye protection either time they entered the resident's room. A Progress Note, dated 11/13/24 at 2:51 p.m., documented Resident #107 tested positive for covid. A Progress Note, dated 11/14/24 at 4:43 a.m., documented Resident #16 was on isolation precautions for a positive covid test. It documented the only symptoms were stuffy nose and cough. On 11/14/24 at 8:05 a.m., CNA #3 was observed to enter Resident #16's room without eye protection. On 11/14/24 at 12:31 p.m., CNA #1 was observed to enter Resident #50's room without eye protection. On 11/14/24 at 12:32 p.m., CNA #2 was observed to enter Resident #11's room without eye protection. On 11/14/24 at 12:35 p.m., CNA #2 was observed to enter Resident #34's room without eye protection. On 11/14/24 at 12:39 p.m., the IP stated staff should wear eye protection when entering residents' rooms who were positive for Covid. On 11/14/24 at 12:49 p.m., the speech therapist was observed to enter Resident #107's room without eye protection.

Based on observation and interview, the facility failed to ensure equipment was maintained in good repair in the laundry room. MDS Coordinator #1 identified 56 residents resided in the facility. Findings: On 11/14/24 at 11:21 a.m., a tour of the laundry room was conducted. Behind washing machine #2 water was observed on the floor coming out from under the machine. A blanket and a small rug were observed on the floor against the wall behind the washing machine. Both items were observed to be wet. On 11/14/24 at 12:04 p.m., Laundry #1 reported the washing machine had been leaking for about one week. They reported it happened about this time every year. They were asked about the blanket and rug on the floor behind the washing machine. They reported they did not know there was anything on the floor. On 11/14/24 at 1:25 p.m., the administrator reported they had not been told the washing machine was leaking.

Based on record review and interview, the facility failed to accurately complete a level I PASRR for one (#14) of one resident sampled for PASRR. MDS Coordinator #1 reported 56 residents resided in the facility. Findings: Res #14 admitted with diagnoses of major depressive disorder and delusional disorder. A PASRR level I, dated 11/01/19, documented the resident did not have a mental health diagnosis. On 11/14/24 at 10:33 a.m., the ADON was shown the level I PASRR and was asked if the form was filled out correctly. The ADON reported it was not filled out correctly.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food safety. The Resident Census and Conditions of Residents form, documented 52 residents resided in the facility. The dietary manager identified one resident did not receive nutrition from the kitchen. Findings: On 09/07/23 at 9:15 a.m., a brief initial tour of the kitchen was conducted. The following was observed in the walk in refrigerator during the tour: a. cooked hamburger patties in gallon Ziploc bag, dated 09/04/23, b. pre-cooked sausage patties in an opened box, dated 09/03/23, c. an open box below the pre-cooked sausage patties containing raw, uncooked bacon, dated 09/01/23, d. an unopened box below the raw bacon of pre-cooked sausage patties, dated 09/05/23. On 09/07/23 at 09:25 a.m., the dietary manager DM stated storage of leftovers is dependent on what the leftovers were. They stated the cooked hamburger patties should have been discarded. They stated the boxes should not have been stacked in that manner as it could cause cross-contamination.

Based on observation, record review, and interview, the facility failed to ensure a resident and/or resident representative was informed in advance of the risks and benefits of the use of a hypnotic medication and informed of, and participate in, their treatment plan for one (#9) of 24 sampled residents reviewed for medications. The Resident Census and Conditions of Residents form documented three residents received hypnotic medications. The MDS coordinator identified care plan meetings were conducted for 52 residents. Findings: A facility policy, revised December 2016, titled Resident Rights, read in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .e. self-determination .h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility .o. be notified of his or her medical condition and of any changes in his or her condition; p. be informed of, participate in his or her care planning and treatment . Res #9's physician order, dated 06/02/23, documented the facility was to administer 10 mg of Ambien (a hypnotic medication) at bedtime daily for a diagnosis of insomnia. A nursing note, dated 06/06/23 at 8:41 p.m., documented new order for Ambien begins on night shift tonight. On 09/06/23 at 12:38 p.m., Res #9 stated the nurses started them on Ambien (a hypnotic medication) for sleep. The resident stated they could not think straight on that medication. The resident also stated the first night they were given the sleeping medication the staff told them they were starting a new medication. The resident stated they asked the staff member what the medication was for and the staff member replied for sleep. The resident stated they wished the staff would have let them know what the name of the medication was and the side effects to be aware of prior to taking it. On 09/07/23 at 12:52 p.m., LPN #1 was asked what the facility protocol was when a resident began a new medication. They stated document every shift for 72-hour an observation assessing cognition, side effects, adverse reactions and notify the physician with any changes with the resident. LPN #1 was asked if the resident would be provided information regarding medication changes and the side effects and adverse reactions to be aware of. They stated they should be. LPN #1 was asked when a resident begins a hypnotic medication is the resident asked if they are experiencing any side effects or adverse reactions. They stated, they should be. \ An admission MDS assessment, dated 07/13/23, documented the resident was moderately impaired in cognition and required extensive assistance with most ADL's related their left leg AKA. On 09/12/23 at 1:11 p.m., the MDS coordinator was asked if they conducted care plan meetings. They stated they did. They were asked how often care plan meetings were conducted. They stated quarterly. The MDS coordinator was asked how they notified residents, responsible parties, and family members of an up coming care plan meeting. They stated they provided the resident with a letter and/or they mailed a letter to the responsible party and/or family member. The MDS coordinator was asked when was the last care plan meeting for Res #9. They stated I believe it was a couple of months ago. The MDS coordinator was asked for a copy of the care plan notification letter for Res #9. They stated they did not make copies of the letters. The MDS coordinator was asked who was present for Res #9 care plan meeting in July. They stated they would have to look. On 9/12/23 at 1:32 p.m., The MDS coordinator presented the care plan minutes for Res #9's care plan meeting held on 07/12/23. The minutes indicated Res #9 was not present for the care plan meeting nor was their POA. On 9/12/23 at 1:50 p.m., Res #9 was asked if they had been invited to the care plan meeting in July to review the care they were receiving. They stated they were not. On 09/12/23 at 1:58 p.m., the DON was asked what their expectation was of their staff when a resident began a new medication. They stated they should be documenting every shift for 72-hour an observation of the resident and any adverse reaction or side effects. The DON was asked if they expected the resident to be educated about the medication and any adverse reaction or side effects. They stated yes, they should do their best to educate the resident. The DON was asked if Res #9 was educated prior to beginning the Ambien. They stated the resident reported they were not.

Based on record review, observation, and interview, the facility failed to ensure a fall care plan was reviewed and revised for one (#9) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 52 residents resided in the facility. Findings: A facility policy, revised March 2018, titled Assessing Falls and Their Cause read in part: .Performing a Post-Fall Evaluation: 4. The intervention to prevent reoccurrence will be placed on the care plan. Res #9 was admitted to the facility on [DATE] and had diagnoses which included arthritis, right shoulder and arm fracture, and left AKA. A significant change MDS assessment, dated 05/23/23, documented Res #9's cognition was moderately impaired. The CAA documented cognitive loss, falls, psychotropic medication use, were triggered for care planning. The focus on the fall care plan, initiated 05/29/22, documented Res #9 was a low risk for falls r/t AKA. An incident report, dated 06/08/23 at 11:30 p.m., documented Res #9 experienced an unwitnessed fall without injury. The incident report, read in part, .resident noted to be on rt hip/stomach area with rt arm bent awkwardly behind him .small laceration noted to top of head with small knot .Rt arm noted to have bone misaligned near elbow. The incident report also documented the resident was lethargic and drowsy and had started on Ambien on 06/05/23 which was a new medication for Res #9. An admission MDS assessment, dated 07/13/23, documented Res #9's cognition was moderately impaired and required extensive to total dependence with most ADLs. The CAA documented cognitive loss, falls, and psychotropic medication use were triggered for care planning. On 09/06/23 at 12:45 p.m., Res #9 was asked if he had experienced any recent falls. They stated, Yes, that was how their arm got all messed up. On 09/07/23 at 12:38 p.m., LPN #1 was asked how fall interventions were communicated to the staff. They stated through communication between staff, communications slips, and the 24-hour report sheet. LPN #1 was asked who was responsible for updating care plans. They stated the MDS coordinator. A nurse note, dated 06/19/23 at 4:39 a.m., documented resident had refused Ambien for two nights. The note documented it made them too confused. A nurse note, dated 06/19/23 at 11:56 p.m., documented resident notified this nurse that they no longer wish to receive Ambien. The note documented they have their mind about them but not when they take that medication. On 09/12/23 at 11:00 a.m., the MDS coordinator was asked if they were responsible for developing, reviewing, and revising of care plans. They stated Yes, they were. The MDS coordinator was asked when they reviewed and revised care plans. They stated quarterly, and as needed. The MDS coordinator was asked if they were familiar with Res #9. They stated, Yes. They were asked if the resident had experienced any falls. They stated, Yes on 06/08/23 due to starting Ambien a few days prior. The Ambien caused the resident to become lethargic and confused. The MDS coordinator was asked what Res #9's fall risk score was according to their current fall care plan. They stated it says low risk. They were asked if the care plan should have been revised to reflect the resident's current fall risk score of high risk for falls. They stated yes it should have been. The MDS coordinator was asked if Res. #9's fall care plan was revised to include a fall mat. They stated it was not but should have been. On 09/12/23 at 11:17 a.m., the DON was asked to review Res #9's fall risk assessment dated , 05/27/23 and their fall care plan. The DON was asked what the resident's fall risk score was. They stated they are a high risk for falls. The DON was asked what fall risk score was indicated on the resident's fall care plan. They stated it says low risk. The DON was asked if Res #9 had a fall mat in their room. The DON stated they did. The DON was asked if the fall matt was on the resident's fall care plan. They stated it was not.

Based on observation, record review, and interview, the facility failed to implement interventions to prevent weight loss for one (#17) of two sampled residents reviewed for nutrition. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 52 residents resided in the facility. Findings: Res #17 had diagnoses which included Alzheimer's disease, dementia, GERD, diabetes, and adult failure to thrive. A vital sign record, dated 03/03/23, documented the resident weighed 186.2 lbs. A physician order, dated 03/28/23, documented the resident received a mechanical soft diet with nectar thick liquids for dysphagia. A vital sign record, dated 04/01/23, documented the resident weighed 182.6 lbs. A vital sign record, dated 05/03/23, documented the resident weighed 176.6 lbs. A vital sign record, dated 06/01/23, documented the resident weighed 177.6 lbs. A vital sign record, dated 07/01/23, documented the resident weighed 187.4 lbs. An annual MDS, dated [DATE], documented the resident was severely cognitively impaired, required set-up assistance of one staff with meals, and received a mechanically altered diet. A vital sign record, dated 08/03/23, documented the resident weighed 171.9 lbs. (8% weight loss in one month) A care plan, reviewed 08/24/23, documented Res #17 had a nutritional problem related to vitamin deficiency. The interventions documented included to monitor for weight loss, and to monitor, document and report any incidences of refusing to eat, or appearing concerned during meals. A nutrition/dietary note, dated 08/28/23, documented a request from the dietitian for a reweigh of the resident to confirm significant weight loss. A vital sign record, dated 08/29/23, documented the resident weighed 165.8 lbs, which reflected a weight loss of 11.24% in six months. The resident's record did not document orders for supplements for weight loss. On 09/07/23 at 11:49 p.m., Res #17 was observed seated at a table in the dining room. The resident's plate was in front of him within reach. The resident was observed until 12:20 p.m. The resident had made no attempts to feed self, and staff had not intervened or attempted to help resident with meal. No supplements were offered to resident. On 09/07/23 at 12:42 p.m., the resident was observed still seated in the dining room. The plate was pushed away from resident to the side. The plate did not appear to have been touched since last observation. CNA #4 was observed approaching the resident and pushing them away from the table in their wheelchair. On 09/07/23 at 1:26 p.m., Res #17 was observed in bed with eyes open. The resident was asked about their lunch meal, but was not cognitively able to respond to questions. On 09/07/23 at 3:45 p.m., CNA #2 was asked about documentation for resident meal intake. They stated there was a reference form near the door to the kitchen. On 09/07/23 at 3:51 p.m., the DON was asked about Res #17's dietary status. They stated the resident had a recent weight loss related to diarrhea. They stated tests were ordered related to the diarrhea and had returned negative. They stated there were no additional orders from the physician after the test results were received. They stated the dietitian had requested a reweigh of the resident but had not been contacted regarding the reweigh since it was obtained two weeks ago. The DON was asked if the resident was receiving supplements, they stated there were none ordered and they would contact the dietitian. On 9/11/23 at 12:18 p.m., CNA #1 was asked how it was communicated to the nursing staff when a resident was losing weight. CNA #1 stated change of shift report and by how the resident's meal intake was and if they were refusing meals. On 09/11/23 at 12:22 p.m., LPN #1 was asked how it was communicated to the nursing staff when a resident was losing weight. They stated the staff receive communication slips from the DON and from the 24-hour report sheet. On 09/11/23 at 12:26 p.m., the MDS coordinator was asked how are interventions related to residents experiencing weight loss was communicated to the nursing staff. They stated through communication slips. The MDS coordinator was asked how they were made aware of a resident with weight loss. They stated in morning meetings, weight loss/gain meeting monthly, and the DON will complete a communication slip for the department heads. The MDS coordinator was asked what interventions were in place to prevent Res #17 from further weight loss. They stated, through encouragement, cueing, and providing mighty shakes or magic cups. The MDS coordinator was asked to review the resident's care plan for the last date a revision which was made to their nutrition care plan. They stated 03/24/23 for a swallow study. On 09/11/23 at 12:40 p.m., the dietary manager stated she had not received notification Res #17 had a significant weight loss.

Based on record review, observation, and interview, the facility failed to review the risks and benefits of side rails with the resident or resident representative; and obtain an informed consent prior to installation for one (#9) of one sampled resident reviewed for side rails. The corporate nurse consultant #1 identified 10 residents had grab bars and six residents had side rails. Findings: Res #9 was admitted to the facility on [DATE] and had diagnoses which included arthritis, right shoulder and arm fracture, and left AKA. A facility policy, revised December 2016, titled Proper Use of Side Rails, read in part, .5. consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol .7. documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails . A facility policy, revised August 2022, titled Bed Safety and Bed Rail, read in part, The use of bed rails is prohibited unless the criteria for use of bed rails have been met .Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of sizes, shapes, and sizes ranging from full to one-half, one quarter, or one-eighth lengths .For the purpose of this policy bed-rails include: a. side rails; b. safety rails; and c. grab/assist bars .3. The use of bed rails (including temporarily raising the side rail for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives .and resident informed consent. 4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers .use of concave mattresses to reduce rolling off the bed .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent . A care plan, dated 05/29/22, documented the resident was a low risk for falls related to AKA. An admission MDS assessment, dated 07/13/23, documented Res #9 was cognitively intact and required extensive to total dependence with ADLs. The assessment also documented Res #9 stated it was very important to them to have family or a close friend involved in discussions about their care during their interview for daily preferences. On 09/07/23 at 10:58 a.m., CNA #2 was asked the reason Res #9 had bed rails. They stated the resident experienced a fall a couple of months ago due to the addition of Ambien to their medication regime. CNA #2 stated they were also a CMA when needed. CNA #2 stated the Ambien caused Res# 9 to become confused and have vivid dreams and one night the resident dreamt he was riding a horse and fell off. A night CNA found them in the floor in their room. On 09/07/23 at 12:15 p.m., Res #9 was asked about their bed rails. They stated, I do not need them. Res #9 was asked if the facility staff reviewed the risks and benefits of the bed rails with them and obtain an informed consent prior to installation. They stated, No, they did not. On 09/12/23 at 11:04 a.m., the MDS coordinator was asked if they had reviewed the risks and benefits of the bed rails with Res #9 and obtain a signed informed consent from them prior to installation of the bed rails. They stated they were not aware a consent was required prior to bed rail installation. They also stated, if that is the case, none of the residents who have bed rails were informed of the risks and benefits of their bed rails and no signed consent was obtained from them prior to installation. On 09/12/23 at 11:23 a.m., the DON was asked if the risks and benefits of the bed rails were reviewed with Res #9, and was a signed informed consent obtained from the resident prior to installation of the bed rails. They stated it was not.

Based on record review and interview, the facility failed to ensure blood pressure medications were not administered when a resident's blood pressure was below parameters for one (#6) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, dated 09/06/23, documented 52 residents resided in the facility. Findings: Res #6 had diagnoses which included HTN, heart failure, and chest pain. A physician order, dated 02/08/23, documented to administer lisinopril 2.5 mg one time per day for HTN. The order documented to hold the medication when the systolic blood pressure was below 110. A July 2023 MAR, documented the resident received the lisinopril when systolic blood pressure was below 110 six times. A physician order, dated 08/02/23, documented to administer isosorbide mononitrate 10 mg one time per day for heart failure and chest pain. The order documented to hold the medication if systolic blood pressure was below 110. A physician order, dated 08/02/23, documented to administer lisinopril 2.5 mg one time per day for HTN. The order documented to hold the medication when the systolic blood pressure was below 110. An August 2023 MAR, documented the resident received isosorbide mononitrate when systolic blood pressure was below 110 four times, and An August 2023 MAR, documented the resident received lisinopril when systolic blood pressure was below 110 five times. On 09/08/23 at 9:15 a.m., CMA #1 stated if a resident's blood pressure was below parameters, the medication should be held and the blood pressure re-checked in 30 minutes. The CMA stated if the blood pressure is still below parameters at the re-check they would notify the nurse and document the medication as held. The CMA was shown the instances on Res #6's MAR in which the medication was given with a systolic blood pressure above 110. They stated the medication should have been held for those instances. On 09/08/23 at 9:33 a.m., RN #1 was asked what the process for a resident with blood pressure under parameter was. They stated the nurse should retake the blood pressure manually and notify the physician. They stated a progress note should be documented that included notification of physician and any new orders if received. When shown the instances of the medication being given for Res #6 when the parameters were not met, they stated the medication should have been held and the nurse notified. On 09/08/23 at 9:36 a.m., the DON was asked what the process for a blood pressure below parameter was. They stated the CMA should re-take the blood pressure manually and notify the nurse if it is still below parameter. They stated the nurse should retake the blood pressure and then notify the provider if the blood pressure was below parameters. The DON stated in the instances for Res #6 the medication should have been held.

Based on record review and interview, the facility failed to ensure a hospital physician discharge order was followed for one (#4) of four residents whose physician orders were reviewed. The Resident Census and Conditions of Residents form documented 41 residents resided in the facility. Findings: Res #4 had diagnoses which included coronary artery disease, hyperlipidemia, peripheral vascular disease, COPD, hypertension, congestive heart failure, and edema. A nurse progress note, dated 01/18/23, documented Res #4 was sent to the ER for a heart rate of 36 that was irregular. The note documented the physician ordered to send Res #4 for an EKG and workups. An after visit summary, dated 01/29/23, documented an echocardiogram scheduled for 01/23/23 at the local hospital. The record did not document an order in Res #4's EHR for the echocardiogram. On 02/01/23 at 2:45 p.m., the DON stated the discharge order from the hospital was missed, so Res #4 did not receive an echocardiogram. She stated the nurse who entered the discharge orders should have put an order for the procedure into the EHR, so the facility would know to transport the resident.

Based on record review and interview, the facility failed to collect labs as ordered by the physician for one (#10) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 10/18/22, documented 42 residents resided in the facility. Findings: Res #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/22 at 11:31 a.m., the DON was asked to provide the lab results. On 10/19/22 at 11:56 a.m., the DON stated they missed collecting the labs. The DON stated they should have been collected.

Based on record review and interview, the facility failed to correctly identify an individual with a mental disorder for two (#16 and #33) of two residents sampled for PASRR level I screening. The Resident Census and Conditions of Residents form documented 18 residents had documented psychiatric diagnoses. Findings: 1. Res #33 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR I screening, completed on 11/01/19, documented, No to all questions regarding mental illness. A quarterly assessment, dated 09/10/22, documented the resident was moderately impaired with cognition and had no behaviors during the look back period. A care plan, last reviewed 09/18/22, documented to monitor, document, and report a change in behavior, mood, cognition, hallucinations, delusions, social isolation, suicidal thoughts, and withdrawal. On 10/18/22 at 10:45 a.m., the DON stated she was not here when the PASRR was filled out for the resident. She stated the PASRR level I should have included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Res #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A level I PASRR, dated 04/20/21, documented the resident had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation the OHCA had been contacted to see if a level II PASRR was required. On 10/17/22 at 3:58 p.m., the DON was shown Res #16's level I PASRR and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked to provide documentation the OHCA was notified to see if a level II PASRR was required. On 10/18/22 at 10:41 a.m., the DON stated they had no documentation the OHCA was notified of the diagnosis. They stated the OHCA should have been contacted.

Based on record review, observation and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents form documented two residents had ordered tube feedings. Findings: Res #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A admission assessment, dated 10/07/22, documented the resident was moderately impaired with cognition, required extensive to total assistance with activities of daily living, and had a feeding tube. A physician order, dated 08/01/22, documented start enteral feed at 50 ml per hour in the afternoon related to encounter for attention to gastrostomy. There was no documentation on the order for the type, strength, or time frame for the feeding to be administered to the resident. A dietitian note, dated 09/08/22 documented a goal for weight stabilization and recommended to increase [MEDICATION(S)] 1.5 to 55 ml/hr continuous. A physician order, dated 09/13/22, documented enteral feed every shift for peg tube at 55 ml/hr with 100 ml water flush every three hours and turn feeding off from 2:00 pm to 4:00 pm. There was no documentation on the order for the type and strength of feeding the resident was to receive. A nurse note, dated 9/13/22, documented to change [MEDICATION(S)] to 55 ml/hr by physician. A care plan, updated on 9/13/22, documented enteral feeding order every shift for peg tube 55 ml/hr with 100 ml water flush, turn off from 2:00 pm to 4:00 pm, see TAR. A nurse note, dated 9/19/2022, documented the resident had refused to have his feeding pump hooked up. The note documented the resident was feeling full and on coming nurse was notified. A fax to the physician, dated 09/19/22 at 6:48 a.m., documented the physician was notified of the resident feeling full and uncomfortable. The fax documented residual of 50 cc and a request for gas drops. The physician did not decrease the feeding at that time. On 10/17/22 at 11:01 a.m., surveyor observed Isosourse running at 50 ml /hr, with flush of 200 ml. Resident #42 stated he was only feed by the tube feeding. On 10/17/22 at 3:31 p.m., the tube feeding was not running at this time. Res #42 stated they shut it off to let him rest a little and then turn the feeding back on. The October TAR was reviewed related to the above orders. Both orders were being documented they had been completed. Documentation for 55 ml/hr was each shift, day, evening, and night. Documentation for 50 ml/hr was at 4:00 p.m. The TAR did not identify how long the feeding was to be administered. On 10/19/22 at 4:00 p.m., LPN #1 stated they keep changing the resident's feeding amount. She stated the last time she took care of the resident, she got 200 ml of residual. She stated he was tolerating the feeding well at 50 ml. She stated she only worked evening shift and had been running his feedings at 50 ml/hr. On 10/19/22 at 4:10 p.m., the DON stated he was having a hard time tolerating the feeding at 55 ml/hr. She stated we were running it at 50 ml. She stated as of yesterday there were two orders for his feeding. On 10/19/22 at 4:25 p.m., the DON stated she did not get an order clarification until yesterday. She stated the dietitian wanted to try the feeding at 55 ml/hr. She stated the 50 ml/hr order from August should have been discontinued when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and interview, the facility failed to assess the need and risk of using bed rails for one (#29) of one sampled resident reviewed for bed rail usage. The administrator reported the facility had six residents with bed rails and one resident with an assist bar. Findings: Res #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 08/27/22, documented the resident was severly impaired with cognition and required extensive to total care with activities of daily living. A care plan, last reviewed 09/08/22, did not document the resident had bed rails. A review of the resident's EHR did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/22 10:57 a.m., the resident was observed in bed on an air mattress with quarter rails up on the bed and a fall mat on the floor. On 10/20/22 at 09:58 a.m., the DON stated the resident did not have a bed rail assessment. She stated he used the rail for positioning and helping the staff when turning. On 10/20/22 at 10:08 a.m., the MDS coordinator stated she stated the bed rails were not care planned. She stated there was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, it was determined the facility failed to ensure: a. written rationales were provided describing the reason the medications were clinically contraindicated, and b. the physician addressed recommendations in a timely manner for MRRs for two (#5 and #35) of five sampled residents who were reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 10/18/22, documented 42 residents resided in the facility. Findings: The Medication Monitoring policy, effective 10/01/18, read in parts, .the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident .If the Attending Physician declines or otherwise rejects the Consultant Pharmacist's recommendation, an explanation as to the rationale for the rejection shall be documented in the resident's medical record . 1. A MRR, dated 08/08/22, documented Res #5 received [MEDICATION(S)] 30 mg daily. It documented the pharmacist made a recommendation to consider a dose reduction for the medication to 20 mg daily. It documented to provide a written rationale describing the reason the dose reduction for the medication was clinically contraindicated. The physician disagreed, provided a signature, and documented no changes. There was no date when the physician responded to the recommendation. The recommendation was noted by the DON on 08/18/22. There was no written rationale provided. A MRR, dated 09/16/22, documented Res #5 received [MEDICATION(S)] 7.5 mg HS. It was documented the pharmacist made a recommendation to consider a trial discontinuation if appropriate. The physician disagreed, provided a signature, and documented already at minimum. There was no date when the physician responded to the recommendation. The recommendation was noted by the DON on 10/18/22. On 10/18/22 at 2:48 p.m., the corporate nurse consultant was asked if the physician had responded to the 09/16/22 recommendation and if the rationale from the physician on the 08/08/22 pharmacy recommendation was an acceptable rationale. She stated there was no rationale provided. On 10/18/22 at 3:32 p.m., the DON stated the MRRs were taken to the physician and a rationale was added to continue the antidepressant as is for the 08/08/22 MRR and the 09/16/22 MRR was signed and a rationale provided. 2. Res #35 had diagnoses which included anxiety disorder, conduct disorder, mood disorder, and major depressive disorder. A physician order, dated 02/11/20, documented [MEDICATION(S)] 20 mg ([MEDICATION(S)]) administer one every 48 hours related to major depressive disorder. A physician order, dated 02/11/20, documented [MEDICATION(S)] (an antipsychotic medication) 0.25 mg give at bed time for major depressive disorder. A physician order, dated 06/15/21, documented [MEDICATION(S)] 7.5 mg ([MEDICATION(S)]) administer at bedtime for [CONDITION(S)]. A pharmacy MRR, dated 03/07/22, documented this resident currently takes [MEDICATION(S)] 0.25 mg at HS. Please assess and if appropriate, consider a trial discontinuation. If no reduction, please provide written rationale below describing why a dose reduction for this medication is clinically contraindicated. The physician documented disagree and no changes. A pharmacy MRR, dated 04/06/22, documented this resident currently takes [MEDICATION(S)] 7.5 mg at HS. Please assess and if appropriate, consider a trial discontinuation. If no reduction, please provide written rationale below describing why a dose reduction for this medication is clinically contraindicated. The physician signed and dated the form with no rationale provided. A quarterly assessment, dated 09/13/22, documented the resident was moderately impaired with cognition and performed most ADLs independently. The assessment documented the resident had received an antipsychotic, an antidepressant, and a hypnotic medication during the look back period. A pharmacy MRR, dated 09/15/22, documented this resident currently takes [MEDICATION(S)] 0.25 mg at HS. Please assess and if appropriate, consider a trial discontinuation. If no reduction, please provide written rationale below describing why a dose reduction for this medication is clinically contraindicated. The physician signed and dated the MRR 10/18/22 which was not in the time frame per facility policy. On 10/19/22 at 7:30 a.m., Res # 35 was observed in the dining room for breakfast. On 10/19/22 at 11:58 a.m., the DON stated the physician did not give a rationale for the April recommendation. The physicain wrote no changes on the other recommendations. On 10/19/22 at 12:25 p.m., the DON stated the pharmacist was in the facility on friday October 14th for the October recommendations. She stated the physician did not sign the September recommendations until 10/18/22. So the policy was not followed.

Based on record review and interview, the facility failed to ensure a resident with a new serious mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Census and Conditions of Residents report, dated 10/18/22, documented 42 residents resided in the facility. Findings: A level I PASRR, dated 04/20/21, documented Res #16 did not have a serious mental illness. On 05/06/22, Res #16 had a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation the OHCA had been contacted to see if a level II PASRR was required. On 10/17/22 at 3:58 p.m., the DON was shown Res #16's level I PASRR and new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They were asked to provide documentation the OHCA was notified to see if a level II PASRR was required. On 10/18/22 at 10:41 a.m., the DON stated they had no documentation the OHCA was notified of the diagnosis. They stated the OHCA should have been contacted.

Based on record review, observation and interview, the facility failed to accurately complete assessments for two (#33 and #35) of 12 residents whose assessments were reviewed. The ''Resident Census and Conditions of Residents'' form documented 42 residents resided in the facility. Findings: 1. Res #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 11/07/19, documented [MEDICATION(S)] (an antidepressant medication) administer 15 mg by mouth at bed time for appetite stimulant. An annual assessment, dated 12/08/21, documented the resident was severely impaired with cognition and was taking an antianxiety and an opioid medication. The assessment did not document the resident was taking an antidepressant medication. A quarterly assessment, dated 09/10/22, documented the resident was moderately impaired in cognition and was not taking an antidepressant medication. A care plan, last reviewed 09/18/22, documented the resident was taking a sedative, antianxiety, and an antidepressant medication. On 10/18/22 at 11:12 a.m., the MDS coordinator stated she had not been capturing the [MEDICATION(S)] as an antidepressant on the MDS. She stated it had been being given as an appetite stimulant. She looked back at the quarterly and annual assessments and stated she had not captured the antidepressant on either assessment. 2. Res #35 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 02/11/20, documented [MEDICATION(S)] (an antipsychotic medication) 0.25 mg give at bed time for major depressive disorder. A pharmacy MRR, dated 03/07/22, documented this resident currently takes [MEDICATION(S)] 0.25 mg at HS. Please assess and if appropriate, consider a trial discontinuation. If no reduction, please provide written rationale below describing why a dose reduction for this medication is clinically contraindicated. The physician documented disagree and no changes. A quarterly assessment, dated 09/13/22, documented the resident was moderately impaired with cognition and performed most ADLs independently. The assessment documented the resident had received an antipsychotic, an antidepressant, and a hypnotic medication during the look back period. The assessment documented a GDR was clinically contraindicated on 09/01/22. On 10/19/22 at 7:30 a.m., Res # 35 was observed in the dining room for breakfast. On 10/19/22 at 12:12 p.m., the MDS coordinator stated she had the wrong date on the MDS for the GDR date. She had looked at the date for when the next evaluation was due.

Based on observation and interview, the facility failed to post daily nurse staffing information in a prominent area where it could be readily viewed by residents and visitors. The Resident Census and Conditions of Residents form documented 42 residents resided in the facility. Findings: On 10/17/22 at 10:00 a.m., the nurse staffing information was not posted. On 10/18/22 at 2:23 p.m., the nurse staffing information was not posted. On 10/18/22 at 2:25 p.m., the DON stated a paper printout of the monthly nurse staff schedule enclosed in a glass bulletin board case on the southwest hall served as the daily staffing board. The DON stated not having been aware of the requirement to post daily staffing and census in an area available to residents and visitors. On 10/18/22 at 2:58 p.m., the corporate nurse consultant reported daily staffing information and census was written on a clipboard kept at the nurses' station and not in view for residents or visitors but it should have been.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM met the State requirement for DM and complete/maintain certification as the DM. The DM identified 40 residents received services from the kitchen. Findings: An employee hire date list documented the DM was hired [DATE]. There was no documentation the DM was certified as a dietary manager. On [DATE] at 9:20 a.m., the DM was asked if she was certified as a DM. She stated she had been certified. The DM stated their certification expired in 2020.

Based on record review and staff interviews, it was determined the facility failed to ensure neurological (neuro) checks were conducted after residents had an unwitnessed fall and/or were assessed following a fall for three (#1, 2 and #3) of three sampled residents reviewed for falls. The facility identified 43 residents who resided in the facility. Findings: An undated facility policy titled, Response to Resident Fall, documented, .Purpose .To avoid or minimize injury and ensure appropriate treatment and prevention methods. Procedure .Following a fall, the resident should be assessed at least every shift for 72 hours. Website; Lippincott Nursing Center, https://www.nursingcenter.com/journalarticle?Article_ID= 8&Journal_ID= &Issue_ID= 7, Source: AJN, American Journal of Nursing November 2007, Volume :107 Number 11, Article: When a Fall Occurs Four steps to take in response to a fall, Author: Ann [NAME], MSN (master's of science in nursing), RN (registered nurse), FAAN (fell ow of the American Academy of Nursing,) documented the following: .Step three: monitoring and reassessment. After the patient returns to bed, perform frequent neurologic and vital sign checks, including orthostatic vital signs. Fall victims who appear fine have been found dead in their beds a few hours after a fall. .Step four: documentation. Follow your facility's policies and procedures for documenting a fall. Thorough documentation helps ensure that appropriate nursing care and medical attention are given. Whether it's written on the patient's chart or entered in the hospital's electronic medical record, documentation for a fall should include .all observations. .assessments. .evaluation . 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 02/15/21 at 7:52 a.m., documented, .Un-witnessed .At 4:10 a.m., she was found sitting in floor at the foot of her bed, closet door was open and clothes were [at] the end of her bed, she stated she did not hit her head she was getting clothes out, denies pain or discomforts .Has non skid socks in place and hourly checks are done, staff helps her dress and takes her to theE [sic] BR [bathroom] .No Injuries observed at time of incident . There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ 02/15/21 - 11:00 p.m. - 7:00 a.m., and ~ 02/17/21 - 7:00 a.m. - 3:00 p.m. and 11:00 p.m. - 7:00 a.m. There was no documentation neurological checks had been conducted for 72 hours following the resident's unwitnessed fall. A quarterly assessment, dated 02/21/21, documented the resident had severe impairment of cognition. The assessment documented she had no falls since the prior assessment. An incident report, dated 04/17/21 at 8:13 p.m., documented, .Un-witnessed .CMA [certified medication aide] .notified that res [resident] was on the ground in her bathroom, sitting on her bottom. Upon entering room, res is on her bottom c/ [with] her back against the toilet. No facial grimacing noted .Resident Unable to give Description .CMA .said that the resident claimed to have 'slipped off' the toilet seat .No s/s [signs or symptoms] of injuries noted. Denies pain/complaints. VS [vital signs] WNL [within normal limits]. No acute distress noted .educated aides to have light on in bathroom at all times . An incident report, dated 04/18/21 at 7:45 a.m., documented, .Un-witnessed .@ [at] 0745 [7:45 a.m.], CNA [certified nursing assistant] .reported that res had a wound on her R [right] temple. Upon entering room, res is resting in bed c/eyes open. Upon her moving her neck, she grimaced and groaned in pain. 2 x [by] 1 cm [centimeter] shear noted to R temple. Res was able to vocalize the pain was around her neck .Unable to give Description .LPN [licensed practical nurse] .stated she never witnessed her leaving her room, or going into other residents [sic] rooms. Transferred res to .ER [emergency room ]. VS [vital signs] WNL [within normal limits]. Neuros WNL. Per family request, will initiate body/bed alarm for fall prevention .body alarm placed to alert staff when she is trying to get up in an attempt to prevent recurrence . There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her falls on the following shifts: ~ 04/19/21 - 11:00 p.m. - 7:00 a.m., and ~ 04/20/21 - 7:00 a.m. - 3:00 p.m. and 11:00 p.m. - 7:00 a.m. An incident report, dated 05/03/21 at 7:49 a.m., documented, .Un-witnessed .Resident in DR [dining room] for breakfast sitting in W/C [wheelchair] at 708am [7:08 a.m.] .heard a resident yell out .resident was laying in the floor on her back, resident began to cry .Resident Unable to give Description .resident verbalized pain and showed non verbal symptoms of pain with movement at the pelvic area .Resident Taken to Hospital? Y [yes] . There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ 05/03/21 - 11:00 p.m. - 7:00 a.m., ~ 05/04/21 - 11:00 p.m. - 7:00 a.m., and ~ 05/05/21 - 3:00 p.m. - 11:00 p.m. and 11:00 p.m. - 7:00 a.m. There was no documentation neurological checks had been conducted for 72 hours following the resident's unwitnessed fall. An incident report, dated 05/10/21 at 7:51 a.m., documented, .Witnessed .heard her alarms sounding, went to her room she was standing by her roommates chair holding on to it with her pants and brief down starting to squat then she sat down, stated she was in the bathroom on the toilet, she then realized that she was not .No Injuries observed at time of incident . There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ 05/10/21 - 11:00 p.m. - 7:00 a.m., ~ 05/11/21 - 11:00 p.m. - 7:00 a.m., and ~ 05/12/21 - all three shifts. On 06/16/21 at 9:05 a.m., the corporate registered nurse (RN) was asked if a resident with severe cognitive impairment should have had neuro checks done for an unwitnessed fall. She stated according to the facility's policy neuro checks would be done at the nurses' discretion if a head injury was suspected. At 12:40 p.m., LPN #1 was asked what her responsibilities were when a resident had a fall. She stated when a fall was unwitnessed, if the resident was not cognitive enough to trust them stating they had not hit their head, then they initiated neuro checks according to their policy. LPN #1 was asked if resident #2 was cognitive enough to tell them if she hit her head or not. She stated, [Resident #2's name deleted] was not cognitive enough to take her word for not hitting [her] head. 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An incident report, dated 02/07/21, documented, .Nursing Description .called to resident's room by CNA, resident slid to the floor from recliner no injury noted .CNA was passing in hallway and witnessed resident sliding from chair. CNA stated she was scooting and attempting to get up but slid before she could get to her. assessed ROM [range of motion] .VS obtained, systolic slightly elevated other VS WNL. denies pain. Resident Description .Resident Unable to give description .Injury Type .No Injuries observed at time of incident .People Notified .Physician .14:21 [2:21 p.m.] Family Member .14:20 [2:20 p.m.] . There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ on 02/08/21 during the 7:00 a.m. to 3:00 p.m. shift, there was no documentation the resident had a fall and was being monitored, vital signs obtained or if she was assessed for pain, ~ on 02/09/21 during the 7:00 a.m. to 3:00 p.m. shift, there was no documentation the resident had a fall and was being monitored or vital signs obtained; during the 11:00 p.m. to 7:00 a.m. shift there was no documentation the resident had a fall and was being monitored, and ~ on 02/10/21 during the 7:00 a.m. to 3:00 p.m. shift, there was no documentation the resident had a fall and was being monitored or vital signs obtained. A quarterly resident assessment, dated 03/25/21, documented the resident's cognition was severely impaired. An incident report, dated 05/19/21, documented, .Nursing Description .summoned to dining room where resident was lying on floor on left side, Resident Description .Resident Unable to give Description .Description .assessment was done, rom wnl for her, got up and sat in wc, vs were taken .skin tear to area between second and third fingers of left hand, and 1.5cm bruise to left elbow .was crying out in a fearful manner, no s/s injuries to her head, no other injuries noted at this time .Other Info [information] tried to get out of wheel chair without assist, was not wearing fall alarm at time of incident .Witnesses .No Witnesses found .People Notified .Physician .20:16 [8:16 p.m.] Family Member .19:16 [7:16 p.m.] . There was no documentation neurological checks had been conducted for 72 hours following the resident's unwitnessed fall. There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ on 05/20/21 during the 7:00 a.m. to 3:00 p.m. shift there were no vital signs obtained, and ~ on 05/21/21 during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift there were no vital signs obtained. 3. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly resident assessment, dated 12/03/20, documented the resident's cognition was severely impaired. An incident report, dated 01/01/21, documented, .Nursing Description .found lying on back on fall matt at bedside Resident Description .I was going to bed .Immediate Action Taken .assessment was done, rom wnl, noted 0.5cm bruise to right elbow, and 3cm abrasion to mid spine .denies pain .Witnesses .No Witnesses found .People Notified .Family Member .20:49 [8:49 p.m.] .Physician .20:48 [8:48 p.m.] . There was no documentation neurological checks had been conducted for 72 hours following the resident's unwitnessed fall. There was no documentation the resident had been thoroughly assessed every shift for 72 hours after her fall on the following shifts: ~ on 01/02/21 during the 11:00 p.m. to 7:00 a.m. shift there were no vital signs obtained; during the 7:00 a.m. to 3:00 p.m. shift there was no documentation the resident had a fall and was being monitored; and during the 3:00 p.m. to 11:00 p.m. shift there was no documentation the resident had a fall and was being monitored, vital signs obtained or if she was assessed for pain, and ~ on 01/04/21 during the 7:00 a.m. to 3:00 p.m. shift, there was no documentation the resident had a fall and was being monitored, vital signs obtained or if she was assessed for pain. On 06/15/21 at 10:45 a.m., the corporate RN was asked to provide documentation resident #1 and resident #3 were assessed following the above falls. She was asked what the procedure was when a resident had an unwitnessed fall due to the residents having had unwitnessed falls. At 11:07 a.m., the corporate RN stated if a resident had an unwitnessed fall neurological checks would be conducted at the nurses' discretion if there was a suspected head injury. At 11:40 a.m. the corporate RN provided a policy which documented residents' were to be assessed every shift for 72 hours following a fall. She stated the 72 hour fall monitoring would be documented in the residents' electronic medical record. At 2:13 p.m. the corporate RN was asked what was to be included in the assessment conducted every shift after a resident had a fall. She stated there should be documentation in the nurses' notes every shift with information relating to the fall, vital signs and pain assessed. She was made aware of the missing assessments for resident #1 and resident #3 and acknowledged the findings.

Based on interview and record review the facility failed to ensure a comprehensive assessment of one (R1) of two residents (R 1, R 2) records reviewed which was symptomatic and tested COVID 19 positive received appropriate medical intervention and care in a timely manner and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices provided. This failed practice resulted in an Immediate Jeopardy for one (R1) expired residents which had the potential for serious harm, negative outcome and death for 13 residents who were not currently positive for COVID-19. The Administrator was informed of the Immediate Jeopardy condition on [DATE] at 9:29 a.m. The census was 47 Findings: An interview conducted on [DATE] at 9:45 a.m. with the Adm. when asked if there were any COVID positive or presumptive COVID cases currently in the facility stated, Yes, we have 21 residents who have tested positive for COVID and 34 staff that tested positive for COVID. The Adm. further stated there were 2 resident deaths due to COVID, we received the first COVID positive test on [DATE]. The resident had fever and shortness of breath. The Administrator was asked how are residents and/or staff handled if they exhibited symptoms of COVID (fever, chills, SOB), stated, They were sent to the ER. The Adm. also stated all residents and employees were tested on [DATE], and that she also contracted COVID 19 as well as the DON, We were out sick for 3 weeks with COVID. An interview conducted on [DATE] at 10:10 a.m. with DS1 when asked if any dietary staff were COVID symptomatic or called in sick stated, Two staff that were recently on duty tested positive and were quarantined. During an interview conducted on [DATE] at 8:00 a.m. with the Adm., stated the DON is the facility Infection Control Preventionist began work at the facility in April. An interview conducted with the DON-ICP on [DATE] at 3:15 p.m. when asked why R1 was not sent to the emergency room when the resident began exhibiting early, consistent signs and symptoms of COVID 19 (fever, chills, decreased O2 levels) stated, I wasn't going to send her out until I received a doctor's order. The DON-ICP further stated when asked if the physician came in to the facility to evaluate the resident stated, No, he may have done a telehealth visit but I'm not sure. I was out sick myself with COVID for 3 weeks. The DON-ICP further stated, R1 was the first COVID positive resident and then it was a domino effect. An interview conducted with the Clinical Director (CD) on [DATE] at 4:50 p.m. regarding R1 exhibiting early symptoms of COVID beginning on [DATE] and not being sent to the hospital for further treatment stated, The outcome would not have been any different. The CD further stated, We were taught to not send residents to the hospital until their O2 Sat drops. This writer discussed high risk factors associated with contracting COVID 19 (age, nursing home resident and comorbidities) as rationale to send the resident to hospital for further treatment and symptom management. The CD stated, I understand. Resident #1 Review of the resident Admission Record revealed the resident was a [AGE] year old female resident admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the following: [DATE] 1927 Orders Administration Note: Gave Tylenol Tablet 325 mg 2 tabs due to fever of 102.2 charge nurse aware. [DATE] 1938 [MEDICATION NAME] Tablet 4 mg. Give 1 tablet by mouth every 6 hrs as needed for N/V Health Status Note [DATE] 0147 O2 90% RA documented in the Vital Sign electronic note. (Normal oximeter readings usually range form ,[DATE]%. [DATE] 0149 Upon entering room, res is resting in bed with eyes closed. Tremors note to BUE and jaw. I asked if this is normal for her, she says, It's just that I'm really, really cold. This is the coldest I've ever been. VS WNL [DATE] 0300 Temp @ 102.4 Admin. PRN Tylenol 325 mg x2 PO elevated temp. [DATE] 0419 Temp @ 100.8. Tremors noted to jaw when res attempts to speak. Physician notified. [DATE] 0730 O2 Sat 83% (Values under 90% are considered low. Mayo Clinic) [DATE] 0903 Resident complains of feeling cold. T 100.0 Tylenol given per orders O2 Sat 94% on room air very talkative, denies wanting to eat. [DATE] 1340 Resident complained of feeling cold Temp. 101.3, Tylenol given per orders. [DATE] 1624 O2 sat 84% [DATE] 1658 resident noted with temperature 100, v/s taken wnl. Denies headaches at the moment but c/o chills, awaiting for UA results, notified dr. for new orders for labs for resident, still awaiting for doctors response , Resident has no medication for fever for the moment last prn dose of Tylenol was provided at 1330 , waiting for doctor to give new orders .t 100.0 O2 sat 91%. [DATE] 1703 I called doctor's office back and got the service exchange, spoke to (staff) and left a message for doctor to call me back, still waiting for doctor to call me back. [DATE] 1729 Orders- Administration Note: PRN Administration was: Ineffective Health Status Note 23:45 Resident noted with fever during shift and chills, O2 was to be initiated because resident O2 Sat were ,[DATE]% doctor made aware, gave new orders for cbc to be done in the morning, resident refused dinner .c/o chills , fevers are 100.8, resident takes her prn Tylenol q6hrs but seems to be ineffective, doctor made aware. [DATE] 23:54 b/p ,[DATE] p 102 t 101.7 r 18 O2 Sat 85% [DATE] 02:22 Tylenol 325 mg 2 tablets by mouth every 6 hrs as needed for knee pain; med given for temp [DATE] 4:43 at 2 am temp 101.7 prn Tylenol was given 4 am temp rechecked and was 99.5 [DATE] 08:33 Tylenol 325 mg T 101.1 [DATE] 09:30 Administration Note: PRN was: Effective T 99.0 [DATE] 10:30 Administration Note: [MEDICATION NAME] 800 mg by mouth every 4 hours as needed for pain/elevated temp. T 101.0 [DATE] 11:07 Health Status Note: Resident temp at 0744 101. Administered Tylenol and [MEDICATION NAME] at alternating times , Resident has productive cough, sputum is yellow tinged. Lungs with wheezes in bilateral lower lobes. CXR obtained report indicates multi-focal bilateral infiltrates. Dr. made aware of findings via telephone call to office. CXR results faxed. Awaiting further instructions at this time , Labs drawn and [DATE] 11:24 Administration Note: [MEDICATION NAME]. 800 mg given [DATE] 12:34 Health Status Note: SPO2 85% O2 @ 3.5L/NC Dr. notified and ordered resident be sent to (sic) hospital. [DATE] 22:21 Health Status Note: call received from PMH with an update, Resident is not expected to make it through the night [DATE] 06:18 Health Status Note: Call from (sic) with PMH stating resident passed away at 5:40 am this morning. Review of the Facility Listing Report dated [DATE] revealed resident list of 45 annotated with the letter P (positive) and N (negative) for the COVID test results. Thirty-one of forty-seven residents were listed as P and 13 listed as N. Review of the Facility Pandemic COVID-19 (formerly Novel [MEDICAL CONDITION]) Plan dated [DATE] revealed in part; Monitoring Activities: If a resident requires a higher level of care or the facility cannot fully implement the recommended precautions, the resident should be transferred to another facility that is capable if implementation; Direct care providers will receive additional education to include but not limited to identification of residents /staff ill with acute respiratory symptoms and fever, prevention and transmission According to the Centers for Disease Control and Prevention ([DATE]), anyone can have mild to severe symptoms. Older adults and people who have underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID 19 illness. CDC further states the symptoms of COVID 19 may appear ,[DATE] days after exposure to [MEDICAL CONDITION] and people with the following symptoms may have COVID 19: Cough Shortness of breath or difficulty breathing *Fever *Chills Muscle pain Sore throat New loss of taste or smell Other less common symptoms have been reported, including gastrointestinal symptoms like *nausea, *vomiting, diarrhea Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html [DATE] At 11:44 a.m., an acceptable plan of removal was provided by the administrator. The plan of removal documented, Plan of Removal [DATE] 10:36 am Failure to accurately assess and take action to seek immediate medical attention 1. In-service/Educate nurses, CMA and CNA's on S/S of COVID-19 including but not limited to cough, shortness of breath, elevated temperature, chills, muscle pain, sore throat, loss of taste or smell, decreased appetite, and gastrointestinal symptoms (nausea, vomiting, and diarrhea). 2. In-service/educate licensed nurses when a change of condition occurs (including elevated temperature and decreased oxygen saturation levels) to notify physician and document correspondence on the clinical record. 3. Re-educate/re-inservice licensed nursing staff on completing respiratory assessments/screens on every resident every shift including but not limited to obtaining a oxygen saturation level, temperature, and listening to lung sounds. 4. Re-educate/re-inservice licensed nursing staff to contact the Director of Nursing and/or Administrator in the event that the residents physician or Medical Director does not wish to transfer a resident to the hospital with a worsening of symptoms and/or signs and symptoms of distress. The education/in-servicing will be completed no later than [DATE] at 3:00pm. On [DATE], interviews were conducted with a total of seven direct care and licensed nursing staff who worked different shifts. The staff verified they had been in-serviced regarding the components documented in the plan of removal and they understood the information provided. The IJ was removed as of [DATE] at 3:00 p.m., when all components of the plan of removal had been completed.

Based on record review and interview, it was determined the facility failed to ensure the physician was notified of a change in condition with the development of [MEDICAL CONDITION] for one (#1) of four sampled residents whose clinical records were reviewed. The facility identified five residents who received diuretics. The faciliy failed to notify the physician for the new onset of [MEDICAL CONDITION] and the resident being admitted to the hospital two times for respiratory distress. Findings: A facility policy, dated 09/19/02, documented, Purpose: The nursing personnel of this facility are responsible for notification of the physician of the below information. All attempts to notify physicians will be noted in the resident's health record including the time and method of communication. If the physician is not contacted, the individual acknowledging contact, if any, will be documented .Procedure: Physicians will be promptly notified of: .Any sudden and/or marked adverse change in signs, symptoms or behaviors exhibited by a resident .An unusual occurrence involving a resident .A change of weight of five pounds or more within a 30-day period, unless the attending physician has stipulated otherwise in writing, or a significant change in weight over a period of time .If the attending physician or his designee is not readily available, emergency medical care will be provided and emergency physicians contacted. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A physician order, dated 04/08/16, documented [MEDICATION NAME] (a diuretic) 40 milligrams (mg) one time day. A quarterly assessment, dated 09/23/16, documented the resident's cognition was intact. The assessment documented the resident was independent with transfers, eating, hygiene, toilet use and ambulation. It further documented she required extensive assistance with dressing and physical help with bathing. The clinical records were reviewed from 10/2016 - 01/2017. There was no documentation to indicate the resident had the presence of [MEDICAL CONDITION] until 11/06/17. A nurse's note, dated 11/06/16 and 11/07/16, documented the resident had developed a new onset of 2+ [MEDICAL CONDITION] in her lower extremities. There was no documentation to indicate the physician had been notified the resident had developed [MEDICAL CONDITION]. An incident report, dated 11/09/16 at 10:15 a.m., documented the resident had a fall, with a head and hip injury. It further documented an x-ray had been ordered and a fracture was observed to the right femoral head. The resident was transported to the emergency room via ambulance. A nursing admission screening/history note, dated 11/15/16 at 4:43 p.m., documented the resident returned from the hospital with the [DIAGNOSES REDACTED]. A skilled nurse's note, dated 11/15/16 at 8:10 p.m., documented the resident had 1+ [MEDICAL CONDITION] to the right leg. A skilled nurse's note, dated 11/16/16 at 12:10 p.m., documented the resident had 2+ [MEDICAL CONDITION] to both lower extremities. A skilled nurse's note, dated 11/17/16 at 7:24 p.m., documented the resident had 3+ [MEDICAL CONDITION] to the right leg. It further documented the resident's right leg was very swollen, tight and shiny. A skilled nurse's note, dated 11/18/16 at 2:24 a.m., documented the resident had 3+ [MEDICAL CONDITION] and Right leg very swollen, tight, and shiney. A skilled nurse's notes, dated 11/19/16 through 12/06/16, documented lower extremity [MEDICAL CONDITION] varied from [MEDICAL CONDITION] to 3+ [MEDICAL CONDITION]. There was no documentation to indicate the physician had been notified the resident had continued or worsening [MEDICAL CONDITION]. A nurse note, dated 12/06/16, documented the resident had .large dark purple area noted to left lower ext. (extremety) . .verbal order to send to (name of hospital deleted) E.R. (emergency room ) for eval. (evaluation) . An emergency medical services (EMS) prehospital care report, dated 12/06/16, documented, EMS called to sunset estates for an elderly female with a hematoma to her left leg. Upon arrival the LPN (licensed practical nurse) gave report and noted concern of the hematoma, upon assessment patient was noted to be in severe respiratory distress with 1-2 word dyspnea and audible wheezing. Patient was on O2 (oxygen) via nasal cannula but the oxygen concentrator was not turned on and functioning. Patient was lifted and secured to stretcher and placed on nebulizer treatment with improvement noted. IV (intravenous) access was established and 125mg (milligram) solu-[MEDICATION NAME] was administered. Patient was noted to improve and was transported to local municipal hospital ER (emergency room ). Patient care was transferred to receiving nurse with report. The EMS report documented vital signs were taken at 7:13 p.m. It documented the blood pressure was 138/88, pulse 120, respiration 30, and an oxygen saturation level of 80% (a normal level is at or above 90%). It documented a breathing treatment was administered. Vital signs taken at 7:30 p.m. documented the blood pressure was 124/76, pulse 110, respirations 18 and oxygen saturation was at 94%. The resident was placed on continuous positive airway pressure during transport. The local hospital emergency room note, dated 12/06/16 at 9:38 p.m. documented the resident was oriented to person, place and time, appeared sickly, ill and in distress (respiratory). The note further documented, .Accessory muscle usage present. Tachypnea noted. She is in respiratory distress. She has decreased breath sounds. She has wheezes. She has no rhonchi. She has no rales. She exhibits retraction. Patient in respiratory distress breathing 30+ times per minute on 10 L (liters) via non rebreather. She has diffuse retractions from intercostals, suprasternal, infra and supraclavicular. Patient is splinting and has labored breathing with prolonged expiratory phase .She exhibits [MEDICAL CONDITION] (3+ bilateral lower extremity [MEDICAL CONDITION] with the left leg having one area of weeping [MEDICAL CONDITION] overlying a large superficial hematoma) . The local hospital emergency room discharge summery documented the resident was discharged to another hospital with a [DIAGNOSES REDACTED]. A skilled nurse's note, dated 12/13/16 at 9:24 p.m., documented the resident had 4+ [MEDICAL CONDITION] to both lower extremities, 1+ [MEDICAL CONDITION] to the upper thighs and a dark purple area to the left shin with an eraser sized opening. A nursing admission screening/history note, dated 12/14/16 at 10:59 a.m., documented 4+, very deep pitting of 8mm (millimeters), [MEDICATION NAME] two-five minutes, dependent extremity grossly distorted. The note further document 1+ [MEDICAL CONDITION] to both thighs. A skilled nurse's note, dated 12/14/16 at 1:20 p.m., documented the resident had 3+ [MEDICAL CONDITION] to both lower extremities. A skilled nurse's note, dated 12/15/16 at 5:45 p.m., documented the resident had 4+ [MEDICAL CONDITION] to the lower extremities. Skilled nurse's notes, dated 12/18/16 through 12/20/16, documented the resident had [MEDICAL CONDITION] of 3+ [MEDICAL CONDITION] to the lower extremities. A telephone order, dated 12/19/16, documented to increase [MEDICATION NAME] 40mg bid (twice a day). There was no documentation to indicate the physician had been notified the resident's [MEDICAL CONDITION]. A nurse's progress note, dated 12/23/16 at 12:02 p.m., documented the resident had respiratory difficulty, diaphoretic, labored respirations at 24 breaths per minute. The note documented the oxygen saturation was at 86%, EMS was notified and the resident was transferred to the emergency room by ambulance. A local hospital history and physical, dated 12/23/16 at 8:00 p.m., documented an impression which included, acute [MEDICAL CONDITION] with hypercapnia, improved with the [MEDICAL CONDITION], bilateral pleural effusion, right more than left, and pneumonia cannot be excluded. A hospital diagnostic report, dated 12/27/16, documented the resident underwent [REDACTED]. A hospital diagnostic report, dated 12/29/16, documented the resident underwent [REDACTED]. A local hospital discharge summary, dated 12/30/16, documented a discharge [DIAGNOSES REDACTED]. It documented the resident continued to be in respiratory distress and [MEDICAL CONDITION] and did not improve at all in her respiratory status. It was discussed with her as well as with her son who decided to make her comfort care and put her on hospice, so today she will be discharged on hospice. On 02/02/17 at 3:55 p.m., licensed practical nurse (LPN) #1 was asked when a physician would be notified for a change in a residents condition. She stated when a resident had a change in condition such as with skin conditions, mental status changes, had an injury, vital sign changes, and anything that was different for that resident. She was asked if a physician would be notified if a resident developed [MEDICAL CONDITION]. She stated yes. She was asked how a physician was contacted if there was a change in their condition. She stated if it was an emergency situation then the physician would be called and if it was not an emergency situation the physician would be faxed. She was asked if a physician was faxed, how would she know if the physician received the fax. She stated that if the physician does not send a fax back within 24 hours, the physician would be contacted. At 4:47 p.m., LPN #2 was asked when a physician would be notified. She stated when a resident had a change in condition in skin conditions, mental status changes, had an injury, vital sign changes, and anything that was different for that resident. She was asked if a physician would be notified if a resident developed [MEDICAL CONDITION]. She stated yes. She was asked how a physician was contacted if there was a change in their condition. She stated if it was an emergency situation then the physician would be called and if it was not an emergency situation the physician would be faxed. She was asked if a physician was faxed, how would she know if they physician received the fax. She stated that if the physician does not send a fax back within 24 hours, the physician would be contacted. At 6:22 p.m., the director of nurses (DON) was asked if a resident developed [MEDICAL CONDITION] if the facility should notify the physician. She stated they should. She was shown the resident's clinical record and was asked if there was documentation to indicate the resident's physician had been notified when the resident developed [MEDICAL CONDITION]. She stated it does not look like they were notified and they should have been.

Based on record review and interview, it was determined the facility failed to assess monitor and intervene for the new onset of [MEDICAL CONDITION] for one (#1) of four sampled residents whose clinical records were reviewed. This had the potential to affect five resident who received diuretics identified by facility. The resident was admitted to the hospital two times for respiratory distress. Findings: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A care plan, initiated on 03/25/16, documented, Resident is at risk for cardiac dysfunction r/t (related to) [MEDICAL CONDITION]. Interventions included, chest pain, [MEDICAL CONDITION], cough, cyanosis, cold/clammy skin etc.) alert charge nurse and if unrelieved by rest notify physician as needed. A quarterly assessment, dated 09/23/16, documented the resident's cognition was intact. The assessment documented the resident was independent with transfers, eating, hygiene, toilet use and ambulation. It further documented she required extensive assistance with dressing and physical help with bathing. There was no documentation in the clinical record to indicate the resident had [MEDICAL CONDITION] between 10/20/16 and 11/05/16. A nurse's note, dated 11/06/16 and 11/07/16, documented the resident had 2+ [MEDICAL CONDITION] in her lower extremities. An incident report, dated 11/09/16 at 10:15 a.m., documented the resident had a fall, with head and hip injury. It further documented an x-ray had been ordered and a fracture was observed to the right femoral head. The resident was transported to the emergency room via ambulance. A nursing admission screening/history note, dated 11/15/16 at 4:43 p.m., documented the resident's return from the hospital for a right [MEDICAL CONDITION] and the presence of [MEDICAL CONDITION]. A skilled nurse's note, dated 11/15/16 at 8:10 p.m., documented the resident had 1+ [MEDICAL CONDITION] to the right leg. A skilled nurse's note, dated 11/16/16 at 12:10 p.m., documented the resident had 2+ [MEDICAL CONDITION] to both lower extremities. A skilled nurse's note, dated 11/17/16 at 7:24 p.m., documented the resident had 3+ [MEDICAL CONDITION] to the right leg. It further documented the resident's right leg was very swollen, tight and shiny. A skilled nurse's note, dated 11/18/16 at 2:24 a.m., documented the resident had 3+ [MEDICAL CONDITION] and Right leg very swollen, tight, and shiny. Skilled nurse's note, dated 11/19/16 through 12/06/16, documented lower extremity [MEDICAL CONDITION] varied from [MEDICAL CONDITION] to 3+ [MEDICAL CONDITION]. There was no documentation to indicate the physician had responded to the notification of the new onset of [MEDICAL CONDITION], An emergency medical services (EMS) prehospital care report, dated 12/06/16, documented, EMS called to sunset estates for an elderly female with a hematoma to her left leg. Upon arrival the LPN (licensed practical nurse) gave report and noted concern of the hematoma, upon assessment patient was noted to be in severe respiratory distress with 1-2 word dyspnea and audible wheezing. Patient was on o2 via nasal cannula but the oxygen concentrator was not turned on and functioning. Patient was lifted and secured to stretcher and placed on nebulizer treatment with improvement noted. IV access was established and 125mg (milligram) solu-[MEDICATION NAME] was administered. Patient was noted to improve and was transported to local municipal hospital ER (emergency room ). Patient care was transferred to receiving nurse with report. The report documented vital signs were taken at 7:13 p.m. There results documented the blood pressure was 138/88, pulse 120, respiration 30, oxygen saturation 80%. The note documented a breathing treatment was administered. Vital signs taken at 7:30 p.m. documented the blood pressure was 124/76, pulse 110, respirations 18 and oxygen saturation was at 94%. The resident was placed on continuous positive airway pressure during transport. A local hospital emergency room note, dated 12/06/16 9:38 p.m. documented the resident was oriented to person, place and time, appeared sickly, ill and in distress (respiratory). The note further documented, Accessory muscle usage present. Tachypnea noted. She is in respiratory distress. She has decreased breath sounds. She has wheezes. She has no rhonchi. She has no rales. She exhibits retraction. Patient in respiratory distress breathing 30+ times per minute on 10 L (liters) via non rebreather. She has diffuse retractions from intercostals, suprasternal, infra and supraclavicular. Patient is splinting and has labored breathing with prolonged expiratory phase .She exhibits [MEDICAL CONDITION] (3+ bilateral lower extremity [MEDICAL CONDITION] with the left leg having one area of weeping [MEDICAL CONDITION] overlying a large superficial hematoma). The local hospital emergency room discharge summery documented the resident was discharged to another hospital with a [DIAGNOSES REDACTED]. A skilled nurse's note, dated 12/13/16 at 9:24 p.m., documented the resident had 4+ [MEDICAL CONDITION] to both lower extremities, 1+ [MEDICAL CONDITION] to the upper thighs and a dark purple area to the left shin with an eraser sized opening. A nursing admission screening/history note, dated 12/14/16 at 10:59 a.m., documented 4+, very deep pitting of 8mm (millimeters), [MEDICATION NAME] two-five minutes, dependent extremity grossly distorted. The note further document 1+ [MEDICAL CONDITION] to both thighs. A skilled nurse's note, dated 12/14/16 at 1:20 p.m., documented the resident had 3+ [MEDICAL CONDITION] to both lower extremities. A skilled nurse's note, dated 12/15/16 at 5:45 p.m., documented the resident had 4+ [MEDICAL CONDITION] to the lower extremities. Skilled nurse's notes, dated 12/18/16 through 12/20/16, documented the resident had [MEDICAL CONDITION] of 3+ [MEDICAL CONDITION] to the lower extremities. There was no documentation to indicate the physician had been notified the resident's [MEDICAL CONDITION]. A nurse's progress note, dated 12/23/16 at 12:02 p.m., documented the resident had respiratory difficulty, diaphoretic, labored respirations at 24 breaths per minute. The note documented the oxygen saturation was at 86%, EMS (emergency medical services) was notified and the resident was transferred to the emergency room by ambulance. A hospital diagnostic report, dated 12/27/16, documented the resident underwent [REDACTED]. A hospital diagnostic report, dated 12/29/16, documented the resident underwent [REDACTED]. A local hospital discharge summary, dated 12/30/16, documented a discharge [DIAGNOSES REDACTED]. It documented the resident continued to be in respiratory distress and [MEDICAL CONDITION], did not improve at all in her respiratory status. We discussed with her as well as with her son who decided to make her comfort care and put her on hospice, so today she will be discharged on hospice. On 02/02/17 at 3:55 p.m., LPN #1 was asked when a physician would be notified for a change in a residents condition. She stated when a resident had a change in condition such as with skin conditions, mental status changes, had an injury, vital sign changes, and anything that was different for that resident. She was asked if a physician would be notified if a resident developed [MEDICAL CONDITION]. She stated yes. She was asked if the physician for resident #1 had been notified concerning the resident's development and continued presence of [MEDICAL CONDITION]. She stated she could not find any documentation the physician had been notified. At 4:47 p.m., LPN #2 was asked when a physician would be notified. She stated when a resident had a change in condition in skin conditions, mental status changes, had an injury, vital sign changes, and anything that was different for that resident. She was asked if a physician would be notified if a resident developed [MEDICAL CONDITION]. She stated yes. At 6:22 p.m., the director of nurses (DON) was asked if a resident developed [MEDICAL CONDITION], should the physician be notified. She stated they should. She was shown the resident's clinical record and was asked if the resident's physician had been notified when the resident developed [MEDICAL CONDITION]. She stated it does not look like they were notified and they should have been.

Based on record review and staff/resident/family interviews, it was determined the facility failed to ensure care plan interventions were implemented to prevent the occurrence of fecal impaction for one (#5) of 10 sampled residents who had a [DIAGNOSES REDACTED]. The resident was referred to Hospice on 10/31/12, for failure to thrive. The facility 'Care Tracker' documented the resident had 3 bowel movements during an 11 day period from 10/24/12 through 11/03/12. This resulted in the digital removal of a fecal impaction on 11/04/12, causing actual harm to the resident. The DON identified an additional 29 residents in the facility with a [DIAGNOSES REDACTED]. Findings: The facility policy for "Resident Care Plan" documented, "...Approach/Plan... Coordinate all care to be provided to the resident for the most effective, efficient utilization of resources. Individualize care for the unique needs of the resident. Communicate vital information to all staff providing direct resident care... " Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A facility "Bladder and Bowel Report" beginning 10/11/12 through 10/17/12, documented the resident had one bowel movement on 10/14/12. The resident's MAR for the same dates documented the resident received MOM (laxative) one time on 10/12/12, [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]-pain medication) 5/500 mg, 21 times during the same time period. The resident's PRN Ex-Lax, for constipation, was not administered. A facility "Bladder and Bowel Report" dated 10/25/12 through 10/30/12, documented the resident did not have a bowel movement during the 6 day time period. The resident's PRN Ex-Lax, for constipation, was not administered. The resident's MAR for the above time period indicated the resident had received 11 doses of [MEDICATION NAME] (A constipating pain medication). A quarterly assessment dated [DATE], documented the resident required supervision and set up help only for bed mobility, ambulation in the room, and was continent of stool. A physician's orders [REDACTED]. Ex-Lax 2 sq daily PO PRN constipation give 2 squares PO daily." A physician's telephone order dated 10/31/12, documented, "Refer to (name withheld) Hospice. A care plan last updated 10/31/12, documented: "Problem: risk for constipation D/T S/E of meds. goal met-cont w goal & approaches x 3 months. Goal: (Resident) will have soft, formed stool at least Q 3 days x 3 months. Approach: medicate as ordered...monitor and record all BMs, check BM report on CT (Care Tracker) dly. Problem: (Resident) is in need of Hospice care r/t failure to thrive. Goal: needs will be met. approach: open visitation without restrictions to afford emotional support for (Resident)." A physician's telephone order dated 11/03/12, documented, "[MEDICATION NAME] Supp 10 mg R Q day PRN constipation." A facility "Bladder and Bowel Report" dated 10/31/12 through 11/06/12, documented the resident had two bowel movements during the seven day period. One on 11/01/12 and one on 11/04/12. The resident's MAR for the same time period documented the resident received 11 doses of [MEDICATION NAME] and one [MEDICATION NAME] suppository on 11/03/12. The nurses' notes did not contain any documentation between the dates of 10/27/12 through 11/02/12. A nurse's note dated 11/03/12, documented, "Called hospice w res inability to have B.M.-was given [MEDICATION NAME] supp s/ results, 0 acute distress. Hospice called stated will have someone come out to do enemas." The resident's MAR indicated [REDACTED]. The resident was not administered the [MEDICATION NAME] which was ordered on [DATE]. A nurse's note dated 11/04/12 at 12:30 a.m., documented, "...hospice RN is here at this time. Digitally removed impaction from resident..." On 11/07/12 at 4:15 p.m., the resident was interviewed in her room. When asked if she had any further problems with constipation, she stated, "No." She further stated she got plenty of water now that she felt better and was able to get it for herself. When asked about the Hospice visit to remove the fecal impaction, she stated, "That was awful, painful, and humiliating." The resident also complained that she was awakened at 1:00 a.m., to have the impaction removed. A family member was interviewed and asked about the Hospice visit. She stated, "We agreed to place her on hospice because she was so ill. We were very afraid for her. I'm glad its over." At 4:30 p.m., CNA #3 was interviewed. She was asked how she communicated a resident's activities, baths and bathroom visits for her shift on a daily basis. She stated,"We chart it on the CareTracker system." The surveyor asked for clarification of the CareTracker system. The CNA pointed to the computer monitor mounted on the wall in the hallway. The CNA was then asked how the resident's bowel movements were monitored. She stated,"We chart every two hours whether they have a BM or not, in the system." The surveyor then asked the CNA at what point would she report to her charge nurse that a resident has not had a BM. She stated she reported daily to the oncoming shift but did not have the authority to look at a resident's weekly bowel pattern on the Care Tracker system. At 4:45 p.m., CMA #1 was interviewed. She was asked how she knew when a resident required a PRN medication. She stated, "They (resident) or the CNA tells me." She was then asked what if the medication was for constipation? She stated, "The resident will ask or the CNA will tell me the resident hasn't had a BM in 3 to 4 days or something like that." The surveyor asked the CMA how would the CNA know if the resident had not had a BM in 3 to 4 days. She stated, "Oh, that's right. I don't know, we can't see that either. We only chart their fluid intake in the kiosk (Care Tracker)." At 4:45 p.m., LPN #2 was interviewed and asked what the facility policy was for monitoring a resident's bowel movements. She stated towards the end of her shift she pulled the bowel/bladder information from her kiosk. If the resident had not had a BM in 3 to 4 days, she would request medication be given by the CMA. She was then asked how she followed up on the medication administration. She stated, "The CMAs usually let me know when the meds are given and the next shift should see the results when they check the system again." The LPN stated she only worked Wednesdays and Saturdays so was unable to do a follow-up on the medication given for constipation. The LPN was asked if it was a facility policy for the nurses to monitor their residents for frequency of bowel movements during their shifts. She stated, "They are supposed to..." At 4:50 p.m., the ADON was interviewed. She was asked what the facility policy was for monitoring residents' bowel movements and frequency. She stated, "I don't think we have a policy, but when a resident has a BM it's entered into the kiosk's (Care Tracker) by the CNA." She was then asked to explain how the kiosk information was processed. She stated, "I pull a report from the kiosk. Other nurses can pull it also, but I typically pull it for Hospice." She was asked how often the reports were pulled. She stated, "They are pulled at least three times a week and typically that's the only time I pull it up." The surveyor asked the ADON if she thought this was an effective practice. She stated, "No, if I take two weeks off work, I can see how that would be a problem and if Hospice doesn't ask for the list, it isn't generated. We wouldn't know." The surveyor then asked the ADON how she knew which residents were at risk for constipation and fecal impaction. She stated, "The staff knows, and generally it's the ones receiving pain medication routinely." The resident's MAR indicated [REDACTED]. The resident only had eight bowel movements in a 37 day period. The ADON further stated, "I don't like the new system. We still have problems like this to work out and I can see how this could happen." On 11/08/12 at 9:00 a.m., the DON and MDS coordinator were interviewed regarding the resident's care plan not being implemented. They were asked how they planned on monitoring residents at risk for constipation and fecal impaction to prevent this from recurring. The DON stated they are now going to have the charge nurse of each shift generate a report two hours before the end of their shift to let them know which resident had not had a BM in a three day period. The DON was asked if this had been implemented prior to the resident's fecal impaction. She stated the plan had not been implemented at that time. The surveyor asked the staff members if this could have been avoidable. The DON stated, "Yes, I can see how this could have been prevented."

Based on record review and staff/resident/family interviews, it was determined the facility failed to assess, monitor and intervene, for constipation for one (#5) of 10 sampled residents who had a [DIAGNOSES REDACTED]. The facility also failed to assess and monitor the resident's bowel status on a weekly basis, and failed to administer PRN laxative when the resident did not have a bowel movement and complained of constipation. The resident was referred to Hospice on 10/31/12, for failure to thrive. The facility 'Care Tracker' documented the resident had 3 bowel movements during an 11 day period from 10/24/12 through 11/03/12. This resulted in the digital removal of a fecal impaction on 11/04/12, causing actual harm to the resident. The DON identified an additional 27 residents in the facility with a [DIAGNOSES REDACTED]. Findings: A facility policy for "Constipation" documented, "The purpose of a routine bowel protocol is to facilitate early identification of constipation (as indicated by individual resident bowel patterns and as documented) and reduce episodes of constipation. ... Evaluate resident's response thru a bowel record (electronic or paper). Frequency,character, amount, bowel movement pattern, episodes of constipation/fecal soiling and use of oral and rectal laxatives should be monitored and charted. ..Evaluate the success of preventive measures by using the bowel record." Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A facility "Bladder and Bowel Report" beginning 10/11/12 through 10/17/12, documented the resident had one bowel movement on 10/14/12, and constipation was present. The resident's MAR for the same dates documented the resident received MOM (laxative) one time on 10/12/12, [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]-pain medication) 5/500 mg, 21 times during the same time period. The resident's PRN Ex-Lax, for constipation, was not administered. A facility "Bladder and Bowel Report" dated 10/25/12 through 10/30/12, documented the resident did not have a bowel movement during the 6 day time period. The resident's PRN Ex-Lax, for constipation, was not administered. The resident's MAR for the above time period indicated the resident had received 11 doses of [MEDICATION NAME] (A constipating pain medication). A quarterly assessment dated [DATE], documented the resident required supervision and set up help only for bed mobility, ambulation in the room, and was continent of stool. A physician's orders [REDACTED]. Ex-Lax 2 sq daily PO PRN constipation give 2 squares PO daily." A physician's telephone order dated 10/31/12, documented, "Refer to (Name withheld) Hospice. A care plan last updated 10/31/12, documented: "Problem: risk for constipation D/T S/E of meds. goal met-cont w goal & approaches x 3 months. Goal: (Resident) will have soft, formed stool at least Q 3 days x 3 months. Approach: medicate as ordered...monitor and record all BMs, check BM report on CT (Care Tracker) dly. Problem: (Resident) is in need of Hospice care r/t failure to thrive. Goal: needs will be met. approach: open visitation without restrictions to afford emotional support for (Resident)." A physician's telephone order dated 11/03/12, documented, "[MEDICATION NAME] Supp 10 mg R Q day PRN constipation." A facility "Bladder and Bowel Report" dated 10/31/12 through 11/06/12, documented the resident had two bowel movements during the seven day period. One on 11/01/12 and one on 11/04/12. The form documented constipation was present. The resident's MAR for the same time period documented the resident received 11 doses of [MEDICATION NAME] and one [MEDICATION NAME] suppository on 11/03/12. The nurses' notes did not contain any documentation between the dates of 10/27/12 through 11/02/12. A nurse's note dated 11/03/12, documented, "Called hospice w res inability to have B.M.-was given [MEDICATION NAME] supp s/ results, 0 acute distress. Hospice called stated will have someone come out to do enemas." The resident's MAR indicated [REDACTED]. The resident was not administered the [MEDICATION NAME] which was ordered on [DATE]. A nurse's note dated 11/04/12 at 12:30 a.m., documented, "...hospice RN is here at this time. Digitally removed impaction from resident..." On 11/07/12 at 4:15 p.m., the resident was interviewed in her room. When asked if she had any further problems with constipation, she stated, "No." She further stated she got plenty of water now that she felt better and was able to get it for herself. When asked about the Hospice visit to remove the fecal impaction, she stated, "That was awful, painful, and humiliating." The resident also complained that she was awakened at 1:00 a.m. to have the impaction removed. A family member was interviewed and asked about the Hospice visit. She stated, "We agreed to place her on hospice because she was so ill. We were very afraid for her. I'm glad its over." At 4:30 p.m., CNA #3 was interviewed. She was asked how she communicated a resident's activities, baths and bathroom visits for her shift on a daily basis. She stated,"We chart it on the CareTracker system." The surveyor asked for clarification of the CareTracker system. The CNA pointed to the computer monitor mounted on the wall in the hallway. The CNA was then asked how the resident's bowel movements were monitored. She stated,"We chart every two hours whether they have a BM or not, in the system." The surveyor then asked the CNA at what point would she report to her charge nurse that a resident has not had a BM. She stated she reported daily to the oncoming shift but did not have the authority to look at a resident's weekly bowel pattern on the Care Tracker system. At 4:45 p.m., CMA #1 was interviewed. She was asked how she knew when a resident required a PRN medication. She stated, "They (resident) or the CNA tells me." She was then asked what if the medication was for constipation? She stated, "The resident will ask or the CNA will tell me the resident hasn't had a BM in 3 to 4 days or something like that." The surveyor asked the CMA how would the CNA know if the resident had not had a BM in 3 to 4 days. She stated, "Oh, that's right. I don't know. We can't see that either. We only chart their fluid intake in the kiosk (Care Tracker)." At 4:45 p.m., LPN #2 was interviewed and asked what the facility policy was for monitoring a resident's bowel movements. She stated towards the end of her shift she pulled the bowel/bladder information from her kiosk. If the resident had not had a BM in 3 to 4 days, she would request medication be given by the CMA. She was then asked how she followed up on the medication administration. She stated, "The CMAs usually let me know when the meds are given and the next shift should see the results when they check the system again." The LPN stated she only worked Wednesdays and Saturdays so was unable to do a follow-up on the medication given for constipation. The LPN was asked if it was a facility policy for the nurses to monitor their residents for frequency of bowel movements during their shifts. She stated, "They are supposed to..." At 4:50 p.m., the ADON was interviewed. She was asked what the facility policy was for monitoring residents' bowel movements and frequency. She stated, "I don't think we have a policy, but when a resident has a BM it's entered into the kiosk's (Care Tracker) by the CNA." She was then asked to explain how the kiosk information was processed. She stated, "I pull a report from the kiosk. Other nurses can pull it also, but I typically pull it for Hospice." She was asked how often the reports were pulled. She stated, "They are pulled at least three times a week and typically that's the only time I pull it up." The surveyor asked the ADON if she thought this was an effective practice. She stated, "No. If I take two weeks off work, I can see how that would be a problem and if Hospice doesn't ask for the list, it isn't generated. We wouldn't know." The surveyor then asked the ADON how she knew which residents were at risk for constipation and fecal impaction. She stated, "The staff knows, and generally it's the ones receiving pain medication routinely." The resident's MAR indicated [REDACTED]. The resident only had eight bowel movements in a 37 day period. The ADON further stated, "I don't like the new system. We still have problems like this to work out and I can see how this could happen." On 11/08/12 at 9:00 a.m., the DON and MDS coordinator were interviewed regarding the resident's care plan not being implemented. They were asked how they planned on monitoring residents at risk for constipation and fecal impaction to prevent this from recurring. The DON stated they are now going to have the charge nurse of each shift generate a report two hours before the end of their shift to let them know which resident had not had a BM in a three day period. The DON was asked if this had been implemented prior to the resident's fecal impaction. She stated the plan had not been implemented at that time. The surveyor asked the staff members if this could have been avoidable. The DON stated, "Yes, I can see how this could have been prevented."