Every finding on record at Sunset Villa Healthcare

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #3 and R #37) of 5 (R #1, R #3, R #15, R #37, and R #48) residents reviewed for unnecessary medications, when staff failed to:1. Ensure that as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #3 and R #37.2. Ensure monitoring for possible side effects of an anti-psychotic medication for the duration of the order for R #3.These deficient practices could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #3 A. Record review of R #3's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Anxiety (feelings of fear or apprehension), 2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly), 4. Cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). B. Record review of physician orders dated 02/17/26 revealed an order for hydroxyzine 50 milligrams (mg) every eight hours as needed for anxiety. No stop date listed. C. On 04/23/26 at 12:25 pm, during an interview with the Director of Nursing (DON), she confirmed that the order for the hydroxyzine did not have a stop date and it should. R #37 D. Record review of R #37's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Depression, 2. Anxiety, 3. Cerebral infarction, 4. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 5. Impulse disorder (type of mental health condition where a person has a strong, uncontrollable urge or impulse to do something that is harmful, dangerous, or against the law). E. Record review of physician orders dated 12/24/26 revealed an order for Ativan one mg every four hours as needed for agitation and restlessness. F. On 04/23/26 at 12:25 pm, during an interview, the DON confirmed that the Ativan order did not contain a stop date. She stated the medication should have had a 14 day renewal date or should have been discontinued but it was not.

Based on record reviews and interviews, the facility failed to ensure that the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment accurately reflected residents' clinical status for 2 (R #2 and R #31) of 4 (R #2, R #4, R #9, and R #31) residents reviewed for assessments. This deficient practice could likely result in the residents' needs not being met. The findings are: R #2 A. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Type two diabetes mellitus (DM2, a metabolic disorder leading to elevated blood glucose), 2. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), 3. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #2's physician order dated 12/25/25 revealed amitriptyline (antidepressant medication) 100 milligram (mg) to be given daily at bedtime for depressive symptoms. C. Record review of R #2's MDS assessment dated [DATE] revealed 1. R #2 does not take antidepressant medications. 2. R #2 received schedule pain medications. D. On 04/23/26 at 11:57 am during an interview with the MDS coordinator, he confirmed: 1. R #2 does take antidepressant medications, 2. R #2 has not taken any pain medications, 3. The MDS assessment for R #2 is inaccurate. R #31 E. Record review of R #31's admission Record revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Spondylolysis (natural wear and tear of the cushiony discs in the spine over time with age), 2. Low Back Pain, 3. Hypertension (HTN; high blood pressure), 4. Anxiety disorder (feelings of fear or apprehension). F. Record review of physician orders dated 01/05/26 revealed an order for tramadol (an opioid pain medication) for low back pain. G. Record review of MDS assessment dated [DATE] revealed R #31 does not take opioid medication. H. On 04/23/26 at 11:55 am during an interview with MDS coordinator, he confirmed R #31's MDS assessment is not accurate because it does not indicate R #31's use of an opioid medication and it should.

Based on record review and interview, the facility failed to ensure each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring residents receiving diuretic therapy were appropriately monitored for edema for 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for unnecessary medication. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are:A. Record review of R #48's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of:1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Long-term use of anticoagulants (blood thinner),3. Edema (swelling caused by excess fluid).B. On 04/20/26 at 11:00 am an observation and interview of R #48 revealed him socializing in the dining room with other residents. Both of his lower legs had visible redness and swelling. R #48 stated that he has swelling daily and does take medication to help it.C. Record review of R #48's Physician Orders revealed no monitoring in place for edema.D. Record review of R #48's Pharmacy Medication Review (MRR) dated 01/07/26, revealed a new recommendation to monitor resident for increased edema and notify physician if present.E. On 04/26/26 at 12:54 pm during an interview with the Director or Nursing (DON) she confirmed R #48's care plan was not updated to reveal management of his edema while on a diuretic and it should have been.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #48's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Anxiety (feelings of fear or apprehension),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Cardiac arrhythmia (irregular heartbeat).B. Record review of R #48's physician's orders revealed the following:1. An order dated 07/17/25 for Lorazepam (anti-anxiety medication), 0.5 milligrams (mg) to be given by mouth two times a day for anxiety.2. An order dated 01/08/26 for Zoloft (anti-anxiety/anti-depressant medication), 25 mg to be given by mouth one time a day for anxiety.C. Record review of R #48's electronic health record (EHR) revealed no consent was obtained before the Lorazepam and Zoloft medications were started.D. On 04/23/26 at 1:00 pm, during an interview with the Director of Nursing (DON), she confirmed staff did not obtain the consent forms prior to starting the Lorazepam and Zoloft. The DON stated this does not meet her expectations because the consent forms are to be obtained prior to the start of the medications and these were not.

Based on observation, record review and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 2 (R #5 and R #48) of 5 (R #3, R #5, R #15, R #43 and R #48) residents reviewed for care plans when staff failed to develop: 1. A care plan with goals and interventions for R #5's diagnosis of type 2 diabetes mellitus (DM2, a condition results from insufficient production of insulin, causing high blood sugar). 2. A care plan with goals and interventions for R #48's:-Use of an anticoagulant (medication that prevents blood from clotting) medication,-Diagnosis of edema (swelling caused by excess fluid). This deficient practice could likely result in proper care not being provided to residents.The findings are:R #5A. Record review of R #5's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar).B. Record review of R #5's physician orders revealed the following:1. An order dated 04/13/26 for 20 units of Lantus (long-lasting insulin used to lower blood sugar levels) to be administered in the morning.2. An order dated 11/15/25 for Insulin Aspart (short-acting insulin used to lower blood sugar level) to be administered before meals and at bedtime.3. An order dated 12/26/25 for ten units of Insulin Glargine (long-acting insulin) to be administered at bedtime.C. Record review of R #5's care plan last revised on 04/29/26, revealed no care plan for diabetes mellitus.D. On 04/22/26 at 9:00 am during an interview with Registered Nurse (RN) #1 she confirmed R #5 has diabetes mellitus.E. On 04/26/26 at 12:54 pm during an interview with the Director of Nursing (DON) she confirmed R #5 has a diagnosis of diabetes mellitus. The DON confirmed the facility should have developed a care plan to address R #5's diabetes mellitus but failed to do so. R #48F. Record review of R #48's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Type 2 diabetes mellitus,2. Long-term use of anticoagulant medications.3. EdemaG. On 04/20/26 at 11:00 am, an interview and observation with R #48 in his dining room revealed both of his lower legs had visible redness and swelling. R #48 stated that he has redness and swelling daily and confirmed he takes a diuretic medication (a medication that helps reduce swelling through removing salt and water through urine).H. Record review of R #48's physician orders revealed an order for furosemide, 20 milligrams (mg) to be given in the morning for edema.I. On 04/26/26 at 12:54 pm during an interview with the DON, she confirmed R #48 does have edema. The DON confirmed the facility should have developed a care plan to address R #48's use of anticoagulant medication and his edema and failed to do so.

Based on record review and interview, the facility failed to provide quality of care when staff failed to monitor 1 (R #48) of 5 (R #3, R #5, R #15, R #43, and R #48) residents reviewed for edema. These deficient practices could likely result in residents not getting the treatment needed and/or potentially worsening conditions. The findings are: A. Record review of R #48's admission Record revealed he was admitted to the facility on [DATE] with diagnoses of:1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Long-term use of anticoagulants (blood thinner),3. Edema (swelling caused by excess fluid).B. Record review of R #48's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment dated [DATE], revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.2. R #48 is on a diuretic (a medication that helps reduce swelling through removing salt and water through urine).C. Record review of R #48's Nursing Summary Report dated 01/07/26, revealed a new recommendation to monitor #48 for increased edema and to notify the physician if present.D. On 04/20/26 at 11:00 am, an interview and observation with R #48 in the dining room revealed both of his lower legs had visible redness and swelling. R #48 stated that he has redness and swelling daily and confirmed he takes a diuretic medication.E. Record review of R #48's physician orders revealed the following:1. An order for furosemide, 20 milligrams (mg) to be given in the morning for edema,2. No monitoring in place for edema.F. On 04/26/26 at 12:54 pm during an interview with the Director of Nursing (DON), she confirmed R #48 does have edema. The DON confirmed the facility should have been monitoring R #48's edema and failed to do so.

Based on observation and interview, the facility failed to ensure the call light was in working order for 1 (R #4) of 3 (R #2, R #4, and R #8) residents reviewed during random observation of the facility. If the facility is not ensuring a working call light system, then residents and staff are unable to request immediate assistance when needed. The findings are:A. On 04/20/26 at 9:29 am, during an observation and interview with R #4, she stated she needed help and pushed her call light. She stated nobody was coming. There was no light outside of R #4's room.B. On 04/20/26 at 9:34 am, during an interview with the Director of Nursing (DON), she confirmed the call light was not working. The DON stated the light bulb must have burnt out.

Based on record review and interview, the facility failed to report allegations of abuse and neglect to the State Agency within twenty-four hours for 3 (R #1, R #2, and R #3) of 5 (R #1, R #2, R #3, R #4, and R #6) residents reviewed for abuse and neglect. If the facility fails to report allegations of abuse and neglect to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect. The findings are: A. Record review of the facility's Initial Incident Report dated 10/06/25 revealed that on 10/03/25 CNA #1 yanked (pulled) R #1 by her left arm while assisting her into a sitting position and made fun of her financial situation by telling her the driver was going to take her to another facility because she couldn't afford her bills. B. Record review of the facility's Initial Incident Report dated 09/30/25, received by the State Agency on 10/01/25, revealed the following:1. An allegation of neglect where CNA #2 assisted R #2 to bed with a dirty (urine and bowel movement) adult brief on and did not assist with personal care that occurred on 09/30/25.2. An allegation of neglect where CNA #2 said R #3 refused his meal, but she never offered it to him on 09/30/25.C. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM), she confirmed that CNA #2 last worked at the facility on 09/28/25, indicating the date of incident was 09/28/25, not 09/30/25. The ADM confirmed both Initial Incident Reports (dated 10/06/25 and 09/30/25) were not submitted to the State Agency within the required timeframe.

Based on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 3 (R #1, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:A. Record review of the facility's Initial Incident Report dated 10/06/25 revealed an alleged incident of abuse where Certified Nurse Aide (CNA) yanked (pulled) R #1 by her left arm while assisting her into a sitting position which occurred on 10/03/25.B. Record review of the facility's investigation summary, no date, revealed the summary report was submitted to the State Survey Agency on 10/13/25 (six working days after the incident).C. Record review of the facility's Initial Incident Report dated 10/02/25 revealed a resident-to-resident altercation where R #5 physically assaulted R #6. D. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM), she confirmed the following:1. The facility's investigation summary for the incident regarding R #1 was not submitted within five working days.2. The facility failed to submit the investigation summary for the altercation between R #5 and R #6.

Based on record review and interview, the facility failed to keep residents free from abuse for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for abuse when Certified Nurse Aide (CNA) #1 was verbally abusive to R #1. This deficient practice led to R #1 feeling embarrassed. The findings are: A. Record review of the facility's Initial Incident Report dated 10/06/25 revealed that on 10/03/25 CNA #1 yanked (pulled) R #1 by her left arm while assisting her into a sitting position and made fun of her financial situation by telling her the driver was going to take her to another facility because she couldn't afford her bills.B. On 11/20/25 at 1:15 pm, during an interview with R #, she stated she does not feel like CNA #1 meant to hurt her, but she does not like to be rushed, and he was rushing her. R #1 stated he made her feel embarrassed because he was laughing at her financial situation by telling her the driver was going to take her to another facility since she couldn't pay her bills.C. Record review of CNA #1's training file revealed CNA #1 received training on abuse, neglect, and exploitation and training on resident rights on 07/04/25.D. Record review of CNA #1's termination form dated 10/06/25 revealed that CNA #1's employment at the facility was terminated due to abuse.E. On 11/21/25 at 9:20 am during an interview with the Administrator (ADM), she confirmed CNA #1's employment with the facility was terminated on 10/06/25 due to abuse.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of pelvis (a basin-shaped complex of bones that connects the trunk of a person's body to the legs),2. Fracture of left pubis (the lower, left part of the hip bone). B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 08/16/25, revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact.2. R #1 requires substantial to maximal assistance to shower or bathe. C. On 09/02/25 at 9:51 am during an interview with R #1, she stated she has not had a shower or a bath since she was admitted to the facility. R #1 stated she remembers being offered a bath one time, but she had just finished therapy and was tired, so she refused (date unknown). D. Record review of the facility's shower schedule, no date, revealed R #1 is scheduled for a shower on Mondays, Wednesdays, and Fridays. E. Record review of R #1's survey documentation report for the month of August 2025 revealed the following: 1. R #1 refused to be showered on 08/20/24 and on 08/22/25. 2. R #1 was showered with one-person physical assistance on 08/27/25. 3. The survey documentation report did not contain any documentation to show R #1 was offered or assisted with a bath or shower for six days from 08/14/25 (admission) to 08/20/24. 4. The survey documentation report did not contain any documentation to show R #1 was offered or assisted with a bath or shower for five days from 08/22/25 to 08/27/25. F. Record review of R #1's shower sheet dated 08/14/25 revealed R #1 refused to be showered. G. On 09/02/25 at 11:15 am during a follow-up interview with R #1, she stated she does not remember being assisted with a shower since being admitted to the facility. R #1 stated that if they did assist her with one shower, that is still not enough because she likes to shower every day but understood that three times a week while at the facility would be sufficient. H. On 09/02/25 at 11:02 am during an interview with the Administrator (ADM), she confirmed according to the facility's documentation, R #1 has only received one shower since being admitted to the facility. The ADM stated that she expects the shower schedule to be followed. R #2 I. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Acute and chronic combined systolic and diastolic heart failure (a condition where the heart's ability to pump blood is compromised),2. Muscle wasting and atrophy (loss of muscle mass and strength) of left ankle, right thigh, left thigh, right lower leg, left lower leg, right ankle, and right foot, 3. Need for assistance with personal care.J. Record review of R #2's quarterly Minimum Data Set, dated [DATE], revealed the following: 1. BIMS score of 15, cognitively intact.2. R #2 requires substantial to maximal assistance to shower or bathe. K. On 09/02/25 at 10:04 am during an interview with R #2, she stated there are times where she doesn't get showered as scheduled. L. Record review of the facility's shower schedule, no date, revealed R #2 is scheduled for a shower on Tuesdays, Thursdays, and Saturdays. M. Record review of R #2's survey documentation report for the month of August 2025 revealed the following: 1. R #2 was showered 08/02/25, 08/05/25, 08/12/25, 08/17/25, 08/19/25, 08/28/25, and 08/30/25. 2. R #2 refused to be showered on 08/14/25 and 08/21/25. 3. The survey documentation report did not contain any documentation to show R #2 was assisted with a bath or shower for seven days from 08/05/25 to 08/12/25. 4. The survey documentation report did not contain any documentation to show R #2 was assisted with a bath or shower for seven days from 08/21/25 to 08/28/25. R #3N. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified dementia2. Adult failure to thrive3. Need for assistance with personal careO. Record review of R #3's quarterly Minimum Data Set, dated [DATE], revealed the following: 1. BIM score of 07, severe impairment.2. R #3 requires partial to moderate assistance to shower or bathe. P. Record review of the facility's shower schedule, no date, revealed R #3 is scheduled for a shower on Mondays, Wednesdays, and Fridays.Q. Record review of R #3's survey documentation report for the month of August 2025 revealed the following: 1. R #3 was showered on 08/04/25, 08/11/25, and 08/21/25. 2. R #3 refused to be showered on 08/09/25, 08/18/25, 08/21/25, 08/28/25, 08/30/25, and 08/31/25. 3.The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for five days from 08/04/25 to 08/29/25. 4. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for seven days from 08/11/25 to 08/18/25. R. On 09/02/25 at 11:02 am during an interview with the Administrator (ADM), she stated her expectation is for the shower schedule to be followed and confirmed it was not.

Past Non-Compliance Based on record review, and interview, the facility failed to prevent neglect for 1 (R #24) of 1 (R #24) resident reviewed for abuse and neglect when staff failed to complete rounds (process where nursing staff checks on the status or condition of each resident) timely. This deficient practice likely resulted in R #24 laying on the floor in his room after a fall for approximately three hours. The findings are: A. Record review of R #24's Admission Record revealed R #24 was admitted to the facility on [DATE] with the following multiple diagnoses: 1. Alzheimer's disease, unspecified, 2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), moderate, 3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe with behavioral disturbance. 4. Cognitive Communication deficit (a communication difficulty that's caused by a cognitive impairment), 5. Essential Hypertension (HTN; high blood pressure). B. Record review of R #24's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/29/25 revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not completed because [Name of R #24] is rarely or never understood. C. Record review of R #24's progress note dated 07/05/24 revealed R #24's daughter called the facility at 12:09 am to advise them that she was watching the camera that she had installed in R #24's room and saw her father on the floor. D. On 02/03/25 at 10:40 am, during an interview with R #24's daughter and Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) she confirmed she did have a camera installed in her father's room so she would be able to check on him. She stated on the morning of 07/05/24 a little after midnight, she turned the video on to check in on him and saw that he was lying on the floor in his room, so she called the facility and notified them. She stated staff went into the room a few moments later and assisted her father off the floor. R #24's daughter stated she watched the video from 07/04/24 and saw that her father fell at approximately 8:45 pm. She stated that nobody entered her father's room until she called the facility to notify them that he was on the floor. She stated that her father was not physically injured due to the fall, but would be mortified if he was able to remember having to lie on the floor for over three hours because nobody checked on him. E. Record review of the POA's video of R #24's room from 07/04/24 through 07/05/24 revealed the door to R #24's room was closed, and R #24 stood by his bed at 8:42 pm, when R #24 leaned forward and fell backwards, landed on the floor. The video revealed R #24 laid on the floor in his room yelling out for help and staff did not enter the room until after R #24's daughter called the facility at 12:09 am on 07/05/24. F. Record review of R #24's Change of Condition form dated 07/05/24 revealed Residents daughter [name of R #24's daughter] called (as there is a camera in resident's room) and advised us that her father got up out of his bed and fell . G. Record review of R #24 Care Plan dated 06/07/24, revealed R #24 was at risk for falls due to confusion, deconditioning, and poor safety awareness. H. Record review of the facility's Nursing Policy and Procedure revealed nursing staff are to .participate in resident rounds at least every two hours, more often if condition of resident requires. I. On 02/06/25 at 12:23 pm, during an interview with the Director of Nursing (DON), she stated R #24 laying on the floor after a fall for over three hours does not meet her expectations because staff should have checked on him at least every two hours. Based on the facility's investigation of staff not completing rounds resulting in R #24 lying on the floor for approximately three hours after a fall, the following action steps were implemented prior to the survey investigation completed on 02/06/25: 1. The care team was in-serviced on hourly rounding for R #24. Completed 07/05/24. 2. An order dated 07/31/24 was entered for R #24 to be checked on for incontinence, positioning, and other needs every hour, was entered to ensure staff complete and document hourly checks. Completed 07/31/24. 3. All staff were reeducated on resident rounding, meeting resident needs, fall prevention, along with abuse and neglect. Completed 07/05/24. 4. The facility completed Safe Surveys with every resident in the facility which indicated no additional concerns. Completed 07/05/24. 5. Administrator audited ambassador rounds, stand up and down meetings, and clinical meetings weekly for four weeks and then monthly thereafter. The first monthly audit completed 08/02/24. 6. The DON completed a fall audit on all residents residing at the facility to determine if falls were documented correctly and change of conditions were completed. Completed 07/09/24. 7. The nurse in charge of resident care on 07/04/24 chose to resign instead of accepting the corrective action that was presented to him by the Administrator. -On 02/06/25 at 1:43 pm, during an interview with CNA #1, she confirmed that rounds are required to be completed with R #24 hourly.

Based on observation, record review, and interview, the facility failed to develop and implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections). This failed practice has the potential to affect all 96 residents living in the facility as identified by the census provided by the Administrator on 12/08/24. This deficient practice could likely result in the spread of infectious diseases. A. On 02/03/25 at 6:00 am, during a random observation of the facility, signs indicated enhanced barrier precautions were on the doorways of rooms 102, 109, 110, and 120. B. Record review of the facility's Infection Prevention and Control Program Policy and Process Surveillance and Reporting policy, revision date of 06/2020, revealed the following: 1. The Infection Preventionist coordinates the development and monitoring of the facility's established infection control policies and procedures. 2. Reporting information related to compliance with the facility's established infection control policies and procedures to the Administrator and the Infection Control Committee. C. On 02/05/25 at 2:30 pm during an interview with the Infection Preventionist (IP), he confirmed he does not have any ongoing documentation or evidence to support an annual review of the of infection monitoring to submit to surveyors for review on the infection prevention and control program. The IP confirmed the facility failed to continuously implement an ongoing infection prevention and control program prior to October 2024 due to the previous IP not completing these duties.

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect all 45 residents in the facility. Residents identified on the matrix provided by the Administrator on 02/03/25. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record review of the facility's Antibiotic Stewardship policy, revision date of 06/20 revealed The Infection Control Committee (ICC) will review infections and monitor antibiotic usage patterns on a regular basis. In addition, the ICC will obtain and review results from microbial cultures, resistant organisms, alerts and antibiograms from the lab for tends of resistance. B. On 02/05/25 at 2:30 pm during an interview with the Infection Preventionist (IP), he confirmed he does not have ongoing monitoring documentation for antibiotic usage patterns or evidence to support an annual review of the Antibiotic Stewardship Program had been completed to submit to surveyors for review on the antibiotic stewardship program. The IP confirmed that the facility failed to continuously implement an ongoing antibiotic stewardship program prior to October 2024 due to the previous IP not completing these duties. This is not clear, since October 2024 has the IP monitored and documented for antibiotic usage patterns since he became the IP? Are you looking for non compliance in October or now? They are supposed to be able to provide documentation of monitoring since last survey, they only monitored for infection for 4 months since last survey. They did not maintain or continuously implement or review their program for 8 months. I added they did not provide evidence of annual review that is required by the regulation. 51616

Based on record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 3 (R #5, R #24, and R #34) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #5 A. Record review of R #5's Admission Record revealed R #5 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Diabetes Mellitus with Hyperglycemia (a chronic metabolic disorder characterized by high blood sugar), 2. Heart failure, 3. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of unspecified part of limb, 5. Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe with other behavioral disturbance. B. Record review of R #5's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/13/25 revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 12, moderately impaired. C. Record review of R #5's medical orders revealed an order dated 11/05/24 for R #5 to have a wander guard (wearable technology used to keep residents from wandering or eloping (leaving) from the facility unattended) attached to his wheelchair daily. D. Record review of R #5's care plan revised 01/31/25 revealed the care plan did not contain the following: 1. Interventions to include the use of a wander guard. 2. Interventions to include R #5's diagnosis of severe dementia or the care he required regarding the dementia diagnosis. E. On 02/06/25 at 12:20 pm, during an interview with the Director of Nursing (DON), she confirmed R #5's care plan does not include the use of a wander guard and the care R #5 requires regarding his dementia. R #24 F. Record review of R #24's Admission Record revealed R #24 was admitted to the facility on [DATE] and has multiple diagnoses including: 1. Alzheimer's disease, unspecified, 2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), moderate, 3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe with behavioral disturbance. 4. Cognitive Communication deficit (difficulties with communication and cognitive function that can arise due to diabetes), 5. Essential Hypertension (HTN; high blood pressure). G. Record review of R #24's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/29/25 revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not completed because R #24 is rarely or never understood. 2. Section GG revealed R #24 is dependent (the MDS form states dependent means a helper does all of the effort. Resident does none of the effort to complete the activity) on staff for all self-care (eating, hygiene, bathing, dressing). H. On 02/03/25 at 10:40 am, during an interview with R #24's daughter and Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) she stated R #24 does not get enough fluids. She stated that staff at the facility had told her that they will offer her father a drink every time they enter his room but she sees through the camera that does not happen. R #24's daughter confirmed that she has a camera placed in R #24's room. She stated that she can log in and view R #24 live and the camera also records video. I. Record review of R #24's medical orders revealed an active order for hospice services through Interim Hospice dated 07/19/24. J. Record review of R #24's care plan dated 10/23/24 revealed the following: 1. There is no care plan or interventions in place regarding hydration supports. 2. There was no care plan or intervention that included R #24's diagnosis of severe dementia or the care he required regarding the dementia diagnosis. 3. There was no care plan or interventions in place regarding R #24's hospice services. K. On 02/06/25 at 12:20 pm, during an interview with the DON, she confirmed R #24's care plan does not include hydration support, dementia care or hospice services. She stated R #24's care plan does not meet her expectations because it is not comprehensive. R #34 L. Record review of R #34's Admission Record revealed R #34 was admitted to the facility on [DATE] with multiple diagnoses including the following: 1. Acute Respiratory Failure with Hypoxia (when the lungs are unable to adequately provide oxygen to the body, resulting in low blood oxygen levels (hypoxia) that occur suddenly and require immediate medical attention), 2. Urinary Tract Infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra), site not specified, 3. Bladder-neck obstruction (a blockage in the bladder neck that prevents the bladder from emptying properly), 4. Benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urinary difficulty) with lower urinary tract symptoms, M. On 02/04/25 at 8:36 am, during an interview with R #34, he stated he utilizes a catheter (a device that drains urine from the bladder) and stated he was admitted to the facility with it in place. N. Record review of R #34's hospital discharge paperwork dated 12/24/24 revealed R #34 arrived at the hospital on 12/09/24 with a catheter in place. O. Record review of R #34's care plan dated 02/03/25 revealed the care plan for his catheter care was not developed or implemented until 02/03/25 (38 days after admission). P. On 02/06/25 at 12:20 pm during an interview with the Director of Nursing (DON) she confirmed R #34's care plan for catheter care was not developed or implemented until 02/03/25. She stated R $#34's care plan does not meet her expectations. 51616

Based on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #5 and R #24) of 6 (R #1, R #5, R #17, R #24, R #34, and R #39) residents reviewed for pain medication management. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #5 A. Record review of R #5's Admission Record revealed R #5 was admitted to the facility on [DATE]. B. Record review of R #5's electronic files revealed a physician order for oxycodone (pain medication) dated 01/29/25 to be administered every six (6) hours as needed for pain. C. Record review of R #5's Medication Administration Record (MAR) for the month of February 2025, revealed R #5 was not administer oxycodone but has an active order that is available to be administered. D. Record review of R #5's comprehensive care plan revised on 01/31/25 revealed the comprehensive care plan did not include the use of pain medications and interventions for the following: 1. Monitoring for Pain. 2. Non-pharmacological interventions (strategies used to relieve symptoms without use of medication). 3. Effectiveness of pain medication use. E. On 02/06/25 at 12:20 pm, during an interview with the Director of Nursing (DON), she confirmed R #5 had an active order for oxycodone. The DON confirmed the revision of the comprehensive care plan for R #5 was last revised on 01/21/25. The care plan was not revised to include pain medication management and should have been. R #24: F. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE]. G. Record review of R #24's electronic files revealed a physician order dated 11/07/24 for fentanyl transdermal patch (pain medication patch to be placed on the skin) to be administered every three (3) days. H. Record review of R #24's MAR for the month of February 2025, revealed R #24 was administered fentanyl on 02/02/25. I. Record review of R #5's comprehensive care plan last revised on 10/23/24 revealed the comprehensive care plan was not revised to include the order of fentanyl transdermal patch and interventions for the following: 1. Monitoring for Pain. 2. Non-pharmacological interventions (strategies used to relieve symptoms without use of medication). 3. Effectiveness of pain medication use. J. On 02/06/25 at 12:20 pm, during an interview with the Director of Nursing (DON), she confirmed R #5 had an active order for Fentanyl. The DON confirmed there was not a revision of the comprehensive care plan for R #24 to include pain medication management and should have been.

Based on record review and interview, the facility failed to ensure residents who had completed and signed a consent form for influenza (flu, infection of the nose, throat and lungs caused by a virus) vaccine actually received the vaccination for 1 (R #9) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for immunizations. If residents are not vaccinated appropriately for influenza, then they have a higher likelihood of contracting the illness and spreading the flu to other residents in the facility. The findings are: A. Record review of R #9's Electronic Health Record (EHR) revealed the following: 1. The last influenza vaccine was received on 09/21/22. 2. History of vaccinations indicated the last flu shot was given on 09/21/22. 3. R #9 signed a consent for the influenza vaccine on 11/28/24. The EHR did not indicate the resident received the vaccination. B. On 02/06/2025 at 12:40 pm, during an interview with the Director of Nursing (DON), she confirmed R #9 had not yet received influenza vaccination after consenting for the vaccination. She was unable to confirm why the vaccination had not been given.

Based on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations to 4 (R #7, R #9, R #10, and R #14) of 5 (R #7, R #9, R #10, R #14, and R #27) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19. The findings are: R #7 A. Record review of R #7's Electronic Health Record (EHR) revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the COVID-19 vaccine to the resident. B. On 02/06/24 at 12:40 pm, during an interview with the Director of Nursing (DON), she confirmed R #7's EHR does not contain any evidence that the facility offered the COVID-19 vaccination to R #7. R #9 C. Record review of R #9's EHR revealed the last COVID-19 vaccination that R #9 received was on September 21, 2022. D. On 02/06/24 at 12:40 pm, during an interview with the DON, she confirmed R #9's EHR did not contain any evidence that the facility offered the COVID-19 vaccination to R #7 since September, 2022. R #10 E. Record review of R #10's EHR revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the COVID-19 vaccine to the resident. F. On 02/06/2025 at 12:40 pm, during an interview with the DON, she confirmed R #10's EHR does not contain any evidence that the facility offered the COVID-19 vaccination. R #14 G. Record review of R #14's EHR revealed the last COVID-19 vaccination that R #14 received was November 18, 2022. H. On 02/06/24 at 12:40 pm, during an interview with the DON, she confirmed R #14's EHR does not contain any evidence that the facility offered the COVID-19 vaccination to R #14 since November, 2022. I. Record review of the facility's COVID-19 Program Policy, revision date of 05/20/21 revealed Purpose .This infection control/prevention program is desinged to prevent the spread of COVID-19 in this facility. Keys to an effective Control Program: Following Center for Disease Control (CDC) recommendations for COVID-19. J. Record review of the Center for Disease Control and Prevention's website, https://www.cdc.gov/covid/vaccines/long-term-care-residents.html, stated the following: 1. CDC recommends everyone ages 5-[AGE] years, including people who live and work in long-term care (LTC) settings, get 1 dose of a 2024-2025 COVID-19 vaccine. 2. CDC recommends everyone ages [AGE] years and older, including people who live and work in LTC settings, get 2 doses of a 2024-2025 COVID-19 vaccine 6 months apart.

Based on observation and record review, the facility failed to ensure privacy was provided for 1 (R #1) of 1 (R #1) residents reviewed when they failed to ensure personal privacy while dressing in her room. This deficient practice is likely to cause residents to feel exposed and unimportant. The findings are: A. Record review of R #1's Admission Record revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: 1. Type 2 Diabetes Mellitus (a chronic disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels), 2. Degenerative disease of nervous system, unspecified (a condition that causes nerve cells in the brain or spinal cord to die with no known reason), 3. Altered mental status, unspecified (a significant change in a person's mental function, affecting their awareness, cognition, and behavior with no known reason), 4. Need for assistance with personal care. B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/06/25 revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 08, moderately impaired. C. On 02/03/25 at 7:30 am, during a dining observation in the main dining area, R #1 was seen standing in her room, by her bed. R #1 was wearing a disposable adult brief and a t-shirt while she was pulling her pants up. R #1 was in full view of the dining area where staff and residents, including R #14, R #25, and R #33 were able to see her dress. D. Record review of R #1's care plan dated 02/03/25 revealed R #1 has an Activities of Daily Living (ADL) self-care performance deficit and requires supervision and touching assistance while dressing the upper body and partial moderate assistance while dressing the lower body.

Based on observation and interview, the facility failed to provide a comfortable and homelike environment that was in good condition for 1 (R #5) of 1 (R #5) resident reviewed for a homelike environment by not repairing the wall and the blinds in his room. Failure to maintain and provide a comfortable environment is likely to result in residents feeling unimportant and undervalued. The findings are: A. On 02/03/25 at 7:54 am, during an interview with R #5 he pointed to the sliding glass door in his room which had several broken and missing blinds and stated he has asked maintenance to fix them but hasn't heard anything. R #5 stated the blinds have been broken and missing for months, but could not remember exactly how long. B. On 02/05/25 at 3:16 pm, an observation of R #5's room revealed the following: 1. A section of the wall by the bed measuring approximately six feet by three feet had paint that was scrapped and was peeled. 2. The sliding glass door had several broken and missing blinds. C. On 02/05/25 at 3:46 pm, during an interview with the Maintenance Director (MD), he confirmed R #5's room was not in good condition by stating [Name of R #5's]'s room is in need of repairs. The MD stated that he will look into ordering blinds.

Based on record review and interview, the facility failed to prevent an accident for 2 (R #1 and #6) of 2 (R #1 and #6) residents reviewed for falls: 1. When the facility failed to ensure R #1, who was a fall hazard, was not left alone while in the restroom. 2. When therapy failed to use a gait belt for R #6. 3. When the facility failed to immediately assess R #6 following the fall to check for injuries. These deficient practices likely resulted in R #1 and R #6 having falls with injuries that required treatment at the hospital. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Myelodysplastic Syndrome (a group of disorders caused by blood cells that are poorly formed or do not work properly). 2. Unsteadiness on feet. 3. Repeated falls. B. B. Record review of R #1's fall risk assessment, dated [DATE], revealed R #1's fall risk score was a 7, moderate fall risk, and required activities of daily living (ADL; fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) assistance from staff. C. Record review of R #1 medical record did not include a care plan or any other direction to staff regarding R #1's fall risk. D. Record review of R #1's nursing progress notes, dated [DATE], revealed R #1 had an unwitnessed fall in the bathroom trying to transfer himself off of the toilet. The resident hit his head and received a laceration to back of his head that bled. R #1 had a history of six to seven falls recently at home. E. Record review of R #1's hospital documentation, dated [DATE], revealed the resident sustained an injury to the head. Patient presented to the Emergency Department (ED) via Emergency Medical Services (EMS) after an unwitnessed fall. Patient complained of head, shoulder, and neck pain. R #1 expired on [DATE]. F. Record review of R #1's nursing progress notes, dated [DATE],revealed R #1 was placed on the toilet and was alert and oriented (A&O; a way of measuring the extent of a person's awareness) at the time. The Certified Nursing Assistant (CNA) went back into the bathroom, and the resident was on the floor on his back with his head tilted toward the wall by the door. The resident was unresponsive. R #1's daughter wanted her father transferred to the emergency room (ER) for further evaluation. Upon arrival a computerized tomography scan (CT scan; uses a computer that takes data from several X-ray images of structures inside a human or animal body and converts them into pictures on a monitor) was performed, and R #1's results were a brain bleed. G. On [DATE] at 2:17 pm during an interview with R #1's Power of Attorney (POA; The authority to act for another person), she stated R #1 was left unsupervised at the facility, and he fell . The POA stated staff should not have left R #1 alone. She said R #1 fell because he was left unsupervised, and he got a brain bleed. The POA stated hospice did not want R #1 at home prior to being admitted at the facility, because he was a fall risk. She stated that was why he went to the facility in the first place. H. On [DATE] at 3:21 pm during an interview with R #1's Hospice Registered Nurse (HRN), she stated she thought the resident fell on the day he arrived at the facility, [DATE]. She stated she got to the facility at 7:35 am on [DATE]; and the staff reported to her that R #1 was assisted to the toilet, left alone on the toilet for an undisclosed period of time, and another CNA found him unresponsive on the floor. The HRN stated R #1 had a history of falls, and the facility knew that. She stated the facility staff never should leave someone who was a fall risk on the toilet alone. I. On [DATE] at 4:10 pm during an interview with R #1's daughter, she stated the facility staff left R #1 alone in the bathroom so the staff could attend to other tasks while the resident used the bathroom. She stated the facility staff said R #1 was unconscious for about four minutes. The daughter stated the facility sent R #1 to the hospital, and the hospital found a brain bleed. The daughter stated when the resident was admitted to the facility, she told the staff not to leave the resident alone, because he was a fall risk. J. On [DATE] at 4:44 pm during an interview with CNA #1, she stated they did not leave residents alone when toileting if the resident was a fall risk. She stated she would put them on the toilet and wait by the bathroom door. CNA #1 stated they were given the information on who was a fall risk at shift change, and it was also in their care plan. CNA #1 stated she was aware that R #1 was a fall risk. K. On [DATE] at 4:53 pm during an interview, CNA #2 stated residents who are considered a fall risk should not be left alone when using the toilet. CNA #2 also stated sometimes she will perform other tasks and briefly leave a resident who is a fall risk alone on the toilet to complete the task. She stated she will return right away to the resident. CNA #2 was aware R #1 was a fall risk. L. On [DATE] at 5:13 pm during an interview with Registered Nurse (RN) #1, she stated R #1 was a fall a risk. She stated her expectation was for the CNAs to stay with the resident. RN #1 stated the CNAs were trained as to who was a fall risk, and the information was also in the residents' care plans. M. On [DATE] at 5:51 pm during an interview with the Director of Nursing (DON), the DON stated staff should not leave residents who are considered a fall risk alone while using the toilet. N. On [DATE] at 6:05 pm during an interview with the Regional Clinical Consultant (RCC), she stated she did not know who the CNA was that found R #1 or left R #1, but R #1 should not have been left alone to use the toilet when he was considered a moderate fall risk. O. On [DATE] at 9:46 am during an interview with the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) Coordinator (MDSC), he stated R #1 was admitted into the facility because R #1 was a fall risk. The MDSC also stated staff should not leave anybody who was at risk for falls alone on the toilet, in his professional opinion as a Registered Nurse. 47031 R #6: P. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE] with the following diagnoses: 1. Cognitive communication deficit. 2. Muscle weakness. 3. Other lack of coordination. 4. Need for assistance with personal care. Q. Record review of the facility fall policy, dated ,d+[DATE], revealed the following guidelines after a resident experienced a fall: - Evaluate the resident promptly in order to identify and treat injuries. - The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. - The evaluation should include vital signs and neurological status. R. Record review of R #6's fall risk assessment, dated [DATE], revealed R #6's fall risk score was a 10, high fall risk, and required assistance (standby, walker, cane, gait belt, hands-on) from staff. S. Record review of R #6's nursing progress notes, dated [DATE], revealed R #6 fell outside during a therapy session. The Occupational Therapy Aide (OTA) witness the resident's fall. R #6 was assisted off the ground without notification to the nurse for a fall assessment, per facility protocol. The OTA assisted the resident into the building and to the dining table for lunch. R #6 requested Tylenol for general discomfort, and staff administered a dose to the resident T. Record review of nurses note, dated [DATE], the resident was sent to the ED because of emesis (the forceful ejection of some or all of the contents of the stomach through mouth) with headache. R#6 was assessed and given medication at the ED and was sent back to the facility on [DATE]. U. On [DATE] at 9:30 am during interview with Regional Corporate Therapy Consultant (RCTC), she stated staff did not follow facility protocol and use a gait belt with the resident. She stated it was expected staff would follow protocol. V. On [DATE] at 10:00 am during an interview with the OTA, she stated R #6 had a fall, and she did not follow facility protocol. The OTA stated she did not put a gait belt on the resident. She stated R #6's strength, balance, and everything was getting better; and she did not think about the gait belt. She stated she knew better and usually used one. The OTA also stated R #6 did not hit her head when she fell so she assisted R #6 up without having her assessed by a nurse. W. On [DATE] at 10:25 am during an interview with the MDS Coordinator, he stated staff should follow facility protocol for all residents. X. On [DATE] at 5:39 pm during interview with LPN #1, she stated she was not made aware of R #6's fall until after lunch. LPN #1 stated the OTA should have called a nurse to assess the resident after the fall, but the OTA did not. LPN #1 stated she assessed the resident when she gave the resident Tylenol.

Based on record review and interview, the facility failed to ensure 3 (R #'s 3, 43, and 51) of 3 (R #'s 3, 43, and 51) residents reviewed for behavioral health concerns received necessary behavioral health care to meet residents needs when staff failed to: 1. Refer R #3 for psychiatric services when staff observed depressive symptoms and R #3 verbalized feelings of depression. 2. Ensure R #43 was receiving psychiatric service to include psychotherapy (talk therapy) to manage depressive symptoms. 3. Refer R #51 for behavioral health services when he was exhibiting disruptive behaviors which resulted in R #51 being transferred to the hospital and not allowed to return to the facility. 4. Document and monitor for depressive symptoms on the Treatment Administration Record (TAR) for R #3 and R #43 despite staff being aware that these residents had depressive symptoms. These deficient practices likely resulted in behaviors worsening and not receiving the behavioral or mental health care needed to improve mood and reduce depression and anxiety. The findings are: R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: 1. Other specified depressive episodes. 2. Other specified anxiety disorders. B. Record review of R #3's care plan, dated 05/24/23, revealed the following: - Focus: R #3 had depression. - Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/document/report as needed (PRN) any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/document/report PRN any signs and symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. C. Record review of R #3's physician orders, dated 12/03/23, revealed an order for Psychiatric Services Provider to evaluate and treat psychiatric and psychological health. D. Record review of R #3's progress notes, dated 01/22/24, revealed R #3's Patient Health Questionnaire (PHQ) Evaluation (Depression Screening Tool) was a score of 10 (10-14 is moderate depression). Further review of the record revealed the facility did not send a referral for psychiatric services to the Psychiatric Services Provider. E. Record review of R #3's TAR, dated January 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness and loneliness. Further review of the record revealed staff documented two days as Yes for R #3 experiencing sadness/loneliness (01/17/24 and 01/21/24), and staff documented 29 days as no behaviors. F. Record review of R #3's TAR, dated February 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness and loneliness. Further review of the record revealed staff documented 29 days as no behaviors. G. Record review of R #3's TAR, dated March 1 through 4, 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness, and loneliness. Further review of the record revealed staff documented four days as no behaviors. H. Record review of the psychiatric service provider resident list (list of residents receiving psychiatric services) provided by the facility on 03/05/24 revealed a psychiatric service provider did not see R #3. I. On 03/04/24 at 3:35 pm during an interview with R #3, she stated she asked to talk to a psychiatric service provider, and the facility staff did not do anything. She further stated she just need someone to talk to and let it out. J. On 03/04/24 at 4:00 pm during an interview with the Social Worker (SW), the SW stated she was not aware R #3 had depression. K. On 03/04/24 at 5:59 pm during an interview with Licensed Practical Nurse (LPN) #2, he stated R #3 had depression, and she had showed signs of depression since he met R #3 (longer than a few weeks). LPN #2 stated he did not report it to the nursing administration. L. On 03/05/24 at 11:25 am during an interview with LPN #3, she stated R #3 was always negative, and it was hard for her to tell the difference between the resident's depression, sadness, and anger. LPN #3 stated R #3 showed signs of depression every time she worked with the resident, which has been for several months, but she did not report R #3's signs of depression due to this being a consistent behavior for R #3. LPN #3 also confirmed nursing staff documents signs of depression in R #3's TAR. LPN #3 stated she always marked no for signs of depression, because those signs and symptoms were R #3's baseline behaviors. M. On 03/05/24 at 11:46 am during an interview with Certified Nursing Assistant (CNA) #1, she stated R #3 had depression and showed signs of depression often. CNA #1 stated she reported it to nursing staff. CNA #1 stated R #3 did not get out of bed, and R #3 began to eat more due to R #3 feeling depressed. The CNA stated she reported R #3's depression symptoms to nursing staff due to how often R #3 showed signs of depression . N. On 03/05/24 at 4:36 pm during an interview with LPN #4, she stated R #3 had depression and showed signs of depression for a long time. LPN #4 stated the facility was aware of it. O. On 03/05/24 at 5:18 pm during an interview with the Regional Social Worker (RSW), she stated it was the responsibility of the facility staff to bring any psychiatric concerns to the Social Worker's attention. The RSW stated talk therapy should be offered to the residents and psychiatric provider notes should be uploaded immediately in the residents' Electronic Health Record (EHR). The RSW also stated it was expected the staff members would inform the SW of R #3's depression symptoms. The RSW stated R #3 should receive psychiatric services if R #3 experienced frequent depression symptoms. P. On 03/06/24 at 9:48 am during an interview with the Psychiatric Nurse Practitioner (PNP), she stated signs of depression would include residents not eating like they normally eat, being withdrawn, not socializing, and not expressing emotion. The PNP confirmed she did not offer talk therapy to residents in the facility and only focused on psychiatric medication management. The PNP also stated she wanted to be notified of R #3's moderate depression symptoms. The PNP stated she would have expected R #3 to be referred for services and she was not. Q. On 03/06/24 at 11:37 am during an interview with the Director of Nursing (DON), she stated the facility nursing staff did not tell her that R #3 was depressed. The DON stated the facility nursing staff needed to tell her that. The DON stated R #3 did not receive psychiatric services for depression symptoms and should have. R #43: R. Record review of R #43's face sheet revealed R #43 was admitted into the facility on [DATE] with the following diagnoses: 1. Major depressive disorder. 2. Schizoaffective disorder. 3. Insomnia. S. Record review of R #43's physician orders, dated 12/05/23, revealed an order for Psychiatric Service Provider to evaluate and treat psychiatric and psychological health. T. Record review of R #43's TAR, dated January 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness and loneliness. Further review of the record revealed staff documented 31 days as no behaviors. U. Record review of R #43's psychiatric provider progress notes, dated 01/11/24, revealed R #43 said his mood was fair, he had quite a bit of anxiety, and some days are worse than others. Treatment Plan of Care: Patient could benefit and had the capacity to participate in treatment. Patient was compliant. Future visits were recommended two times a month Treatment was recommended for six months. V. Record review of R #43's TAR, dated February 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness and loneliness. Further review of the record revealed staff documented 29 days as no behaviors. W. Record review of R #43's psychiatric provider progress notes, dated 02/07/24, revealed R #43 reported he still felt sad about two days a week. X. Record review of R #43's psychiatric provider progress notes, dated 02/19/24, revealed R #43 reported he was sleeping okay and added, I only get a few hours of sleep, but it's not straight sleep. It's like two hours here and two hours there. Y. Record review of R #43's care plan, dated 02/28/24, revealed the following: - Focus: Resident on psychotropic medication related to depression, insomnia, and antidepressant. - Interventions: Encourage to verbalize his feelings. Respond to resident concern and feelings, listen and reassure. Z. Record review of R #43's TAR, dated March 1 through 5, 2024, revealed staff to monitor behaviors of depression mood/behavior, sadness and loneliness. Further review of the record revealed staff documented five days as no behaviors. AA. On 03/04/24 at 3:38 pm during an interview with R #43, he stated, They [facility] don't have any mental health here. Two weeks ago, I got depressed, and I was thinking about killing myself. I was thinking about taking all my medications and trying to take them all at once. This [suicidal ideation] was two weeks ago, and I've told them [facility staff] that I wanted to talk to someone, but they never let me know. R #43 stated he experienced depression often, and the staff was aware he felt that way. BB. On 03/04/24 at 4:04 pm during an interview with the SW, she stated the resident communicated to her (SW) that he used to go to mental health therapy, and he wanted to see someone for talk therapy. The SW thought the resident already saw the psych provider for talk therapy, and she assumed talk therapy was a service they psych provider offered. The SW confirmed she did not ask if talk therapy services were provided. CC. On 03/05/24 at 11:49 am during an interview with CNA #1, she stated R #43 secluded himself, would shut down, and hide in his room. CNA #1 stated R #43 has experienced depression since he was admitted into the facility, and the facility nursing staff were aware of R #43's depression symptoms. DD. On 03/05/24 at 5:25 pm during an interview with the RSW, she stated the psychiatric service provider said they were offering talk therapy. The RSW stated her expectation was for the psychiatric provider to offer psychotropic medication management and talk therapy services to residents. The RSW also stated R #43 should receive talk therapy services. EE. On 03/06/24 at 9:57 am during an interview with the PNP, she stated R #43 could benefit from talk therapy, and she expected staff to notify her of R #43's depression symptoms. The PNP confirmed she saw R #43 for psychotropic medication management and not for talk therapy services. FF On 03/06/24 at 11:40 am during an interview with the DON, she stated she asked for communication from the psychiatric service provider, but they did not communicate with the facility. The DON stated if a resident needed to talk to someone for talk therapy services then they needed to have that option. The DON stated R #43 should have talk therapy services if he wanted it. The DON confirmed she thought talk therapy services were offered by the current psychiatric provider. 47031 R #51: GG. Record review of R #51's face sheet revealed R #51 was admitted to facility on 05/06/2023 with the following diagnoses: 1. Muscle wasting and atrophy, multiple sites [the wasting (thinning) or loss of muscle tissue]. 2. Dysphasia, oropharyngeal phase (transferring a food bolus posteriorly to the epiglottis and then to the upper esophageal sphincter). 3. Other symptoms and signs involving cognitive functions and awareness (problems remembering, difficulty speaking and difficulty understanding). 4. Mixed receptive-expressive language disorder (a disorder that, as its name implies, affects both receptive and expressive areas of communication). 5. Cerebral palsy, unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture). 6. Diverticulosis of large intestine without perforation or abscess without bleeding ( little pouches form in the inside lining of your colon). 7. Other intervertebral disc degeneration, lumbar region (the wear and tear of lumbar intervertebral disc). 8. Muscle weakness (generalized; decreased strength of the muscles, affecting both distal and proximal musculature). 9. Inflammatory disease of prostated, unspecified (a frequently painful condition that involves inflammation of the prostate and sometimes the areas around the prostate). 10. Cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions). 11. COVID-19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death). 12. Unspecified protein-calorie malnutrition (a disorder caused by a lack of. proper nutrition or an inability. to absorb nutrients from food). HH. Record review of R #51's care plan, dated 05/20/23, revealed the following: - Focus: R #51 was potential to be verbally aggressive (yelling at staff, talking down to staff, stating staff members are servants to him) related to ineffective coping skills and poor impulse control. - Interventions: Administer medications as ordered. Monitor and document for side effects and effectiveness. - Focus: R #51 had behavioral issues. - Interventions: One-to-one therapeutic conversation. Encourage socialization with residents of similar interests. Monitor every shift for episodes described behavior and record on mediation sheet. II. Record review of R #51's progress notes, dated 09/05/2023, revealed R #51's Patient Health Questionnaire (PHQ; a depression screening tool) revealed the following: - A score of 1 through 4 meant the resident did not have depression, 5 through 9 meant mild depression. - R#51's score was 2. - The staff did not send a referral to psychiatric services, and there were no other assessments conducted to identify any psychiatric issues. JJ. Record review of R #51's TAR, dated December 2023, revealed staff to monitor patient for behaviors of making accusations of others. Further review of the record revealed staff documented one as yes, experienced issues of making accusations of others, and staff documented four days as no behaviors. KK. Record review of R #51's medical record revealed R #51 was sent to the local hospital on 12/05/23 for a psychiatric evaluation due to harm to himself and others, and the facility did not allow the resident to return to facility due to his behaviors. Further review revealed the medical record did not identify that R #51 was referred for psychiatric services during his admission. LL. Record review of the psychiatric service provider resident list provided by the facility on 03/05/24 revealed a psychiatric service provider did not see R #51 during his stay. MM. On 03/06/24 at 11:37 am during an interview with the DON, she stated she did not think the psychiatric provider saw R #51. The DON further stated R #51 had many behavior issues such as urinating on the floors, being rude to other residents and staff, not being compliant with medication administration, and not allowing staff to assist with personal hygiene. DON confirmed that R#51 was not referred for psychiatric services.

Based on record review and interview, the facility failed to ensure that 1(R #1) of 4 (R #,d+[DATE]) residents reviewed received treatment and care in a timely manner and in accordance with professional standards of practice when the facility failed to identify a change in condition and adequately assess R #1 when she informed the nurse that she thought she was having a stroke and then demonstrated unexplained significant weakness during transfer. Several hours later, R #1 became unresponsive and hypoxic (low oxygen in blood). This deficient practice likely resulted in R #1 experiencing a delay in treatment. The findings are: A. Record review of R #1 face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: 1. Acute and chronic respiratory failure, with hypoxia (low oxygen) or hypercapnia (too much carbon dioxide in blood). 2. Type 2 Diabetes Mellitus with hyperglycemia (a group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness, and pain in hands and feet). 3. Morbid obesity. 4. Hyperlipidemia (high levels of fats in the blood). 5. Depression. 6. Sleep apnea. 7. Nicotine dependence. 8. Essential hypertension (high blood pressure). 9. Myocardial infarction type 2 (condition contributes to imbalance between oxygen supply and demand) 10. Paroxysmal Atrial fibrillation 11. Chronic obstructive pulmonary disease (COPD: a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). 12. Displaced fracture of surgical neck of left humerus (closed fracture). 13. Need for assistance with personal care. B. Record review of R #1's nursing progress notes revealed the following: 1. On [DATE] at 5:30 pm: Pt (patient) came in from facility transport in a wheelchair accompanied by her husband. Her speech is clear, she can stand and walk some with one person assist and uses a cane but mostly in a wheelchair, cheeks are pink, eyes are 2 mm (millimeters) bilateral, she has lower dentures only, she has a broken left should [shoulder] that is a closed fracture and she said they cannot do surgery. She has CHF (Congested Heart Failure), COPD,on O2 (oxygen) NC (nasal cannula) at ,d+[DATE] liters, with edema on heart and lungs, skin is clear with each lower leg having a healed veinous ulcer. 2. On [DATE] at 12:03 pm: Pt was sitting at the dining room table and said she thought she was having strokes [sic] (damage to brain from interruption of its blood supply). I asked if she had them before and she said yes. I asked how many and she said all of the time. I asked again, how many, which she could not give a number. Her vs (vital signs) are ,d+[DATE]; 98.0;85% on 4 L (liters) (she said she gets low in the 70s at home) I asked if she wanted me to call an ambulance and her go to the hospital and she said she wanted a paramedic to tell her if she needed to go or not and I said they cannot legally tell you what to do because it is your decision. There are no signs of a stroke or TIA (transient ischemic attack: brief stroke). She has no weak movement in her arms, no slurred speech, no blurry vision. The nursing note did not contain documentation staff contacted the physician. 3. On [DATE] at 3:30 pm: Resident requested to go to bed from wheelchair. CNA attempted to transfer resident, resident was unable to stand and help with transfer. This nurse came to assist resident. Unable to stand resident for transfer, so resident was assisted into the floor and then transferred to bed via hoyer lift (a mobility tool used to transfer). 4. On [DATE] at 5:44 pm: Situation: The Change In Condition (CIC) reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Unresponsiveness. At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] -[DATE] 17:20 Position: Lying r (right)/arm - Pulse: P 65 - [DATE] 17:20 (5:20 pm) PulseType: Regular - RR: R 20.0 - [DATE] 17:20 - Temp: T 97.6 - [DATE] 17:20, Route: Forehead (non-contact) - Weight: W 244.0 lb - [DATE] 16:13 (4:13 pm) Scale: Wheelchair - Pulse Oximetry: O2 65.0 % - [DATE] 17:20, Method: Oxygen via Nasal Cannula - Blood Glucose: BS 95.0 - [DATE] 17:20. C. Record review of the Patient Care Report, dated [DATE], revealed, Responded emergency with Engine -5 crew re: (regarding) unresponsive 63 YOF (year old female). Upon our arrival, the nursing staff reports the pt was fine about an hour and a half ago and when she went to check on her, she was not responsive, she was breathing inadequately, and her blood pressure was very high; that she placed a high flow oxygen non-rebreather mask on the pt and called for ems. We found the pt lying supine (face up) on her bed in her room, her husband was also present. D. Record review of R #1's hospital emergency note, dated [DATE], revealed R #1 presented to the emergency department with acute hypoxemic respiratory failure (hypoxia of hypercapnia) and unresponsive. R #1 was intubated and sedated on presentation. R #1 on 100 percent (%) oxygen on ventilator was in the low 80s (Normal range is 95% or higher), and R #1 was in acute renal failure and hypotensive. R #1's spouse and son were at bedside and emergency room physician spoke with them about R #1's code status [do not resuscitate]. Spouse and son were in agreement to stop the sedation and to extubate (remove tube). emergency room physician proceeded with extubating, and R #1 expired at 9:55 pm [on [DATE]]. E. On [DATE] at 10:00 am and [DATE] at 3:41 pm during interview, R #1's spouse stated he spoke with R #1 around 11:00 am on [DATE], and she stated she was going to get a shower. He stated he tried calling R #1 later, and there was no answer. After work at around 3:30 pm, he went to the facility and found her unresponsive. He stated, she was blue, unconscious, and cold. He stated R #1 was not wearing her oxygen, and he called out for the charge nurse [License Practical Nurse LPN #1]. He stated the charge nurse was handling medications outside R #1's room door. He stated LPN #1 took R #1's vitals and called the paramedics. He stated it took 30 to 40 minutes for the paramedics to arrive. R #1's spouse stated an unknown staff member spewed out that R #1 almost passed out in the shower. R #1's spouse stated, I think they worked the hell out of her in therapy and she loss consciousness and they put her in the room and left her like that. F. On [DATE] at 9:30 am and [DATE] at 315 pm during interview with Certified Nurse Aide (CNA) #1, she stated she was R #1's CNA on [DATE], and R #1 was fine earlier in the day; laughing, talking, excited about getting a shower, talking on the phone and had breakfast. CNA #1 also reported she observed R #1 walking in her room independently [without her walker] in the morning. CNA #1 confirmed R #1 was a one person assist. CNA #1 stated she gave R #1 a shower with no issues and later in the day she observed the resident sleeping in her chair. CNA #1 stated, she looked like she was going to fall over. CNA #1 stated she woke R #1 up and offered to transfer her to bed. She stated R #1 was talking and responding, but R #1 reported she was tired. CNA #1 stated many residents get tired after lunch, and she thought R #1 was exhausted from therapy [at 10:00 am] and the shower. CNA #1 stated the resident was dead weight when she transferred R #1 from her wheelchair to the bed, and she called for LPN #1 to assist with the transfer. CNA #1 reported she told LPN #1, I said something is wrong with her. [Name of LPN #1] said it was probably her oxygen. CNA #1 confirmed R #1 wore her oxygen during the shower. CNA #1 stated the resident was connected to the in room oxygen concentrator [via nasal cannula] and after she was transferred to bed. G. On [DATE] at 11:30 am and [DATE] at 2:32 pm and at 4:52 pm during interview with LPN #1, she stated that [DATE] was the only day she took care of R #1. She stated R #1 was alert and oriented, took her medication, and went to the therapy that day. LPN #1 stated earlier in the day she saw R #1 wheeling (in wheelchair) herself in the hallway. LPN #1 stated she heard from therapy the resident was a one person transfer. LPN #1 stated she was in the resident's room after lunch and assisted R #1's roommate when CNA #1 asked her to assist in transferring R #1. LPN #1 stated that R #1 had scooted herself to the edge of the wheelchair and was too weak to assist CNA #1 with the transfer. LPN #1 stated she came over to assist. LPN #1 stated CNA #1 was trying to hold up R #1 but due to R #1 being lower than the wheelchair seat, it was easier to assist her to the floor than to pick her back up to sit in the wheelchair, so they [LPN and CNA] assisted R #1 to the ground. LPN #1 stated they used a hoyer lift to move the resident from the floor to the bed. LPN #1 stated R #1 stated she was tired, but LPN #1 did not check the resident's vitals. LPN #1 stated R #1 did not hit her head. LPN #1 stated she was passing medications outside of R #1's room and could hear her sleeping/snoring. LPN #1 stated the resident did not appear to be in any distress. LPN #1 stated a couple hours after putting R #1 in bed, her husband came to visit. She said the husband tried to talk to the resident and wake her up, but R #1 did not respond. LPN #1 said the husband called for assistance. LPN #1 said she checked the resident's vitals and could see that her oxygen saturation (blood oxygen level) was 65%. LPN #1 stated, All her (the resident's) vitals were okay, but she wasn't responding to him (her husband). LPN #1 confirmed R #1 wore her oxygen cannula when she was found unresponsive, but she pulled the oxygen from the crash cart so that she could push more oxygen. LPN #1 stated she called 911. LPN #1 stated the paramedics arrived shortly afterwards. LPN #1 confirmed she was aware R #1 passed after being transferred to the hospital. LPN #1 stated she was now aware that R #1's weakness during transfer should have been considered a change in condition. H. On [DATE] at 4:50 pm interview with Physical Therapy Director (PTD), he stated therapy saw R #1 the morning of [DATE], before her shower; and they did extended stretches with her for her shoulder. He stated R #1 seemed like a good therapy candidate, and it was determined she only needed one person to assist with transfers. The PTD did not identify any concerns during her session on [DATE]. I. On [DATE] at 11:30 am interview with Director of Nursing (DON), she stated it was expected staff would complete a change of condition when R #1 was unresponsive. The DON confirmed that staff did not complete the change of condition documentation or notification to the Medical Doctor. J. On [DATE] at 9:42 am during interview with the Assistant Director of Nursing (ADON) regarding R #1, she stated staff should have sent R #1 to the hospital for evaluation when the resident told the nurse she thought she was having a stroke ([DATE]), even though the resident's vital were okay. The ADON stated the staff also should have notified the Physician due to R #1's history and diagnosis. Regarding R #1 being weak during transfer on [DATE] and needing the use of a hoyer, ADON stated this is considered a fall and the nurse should have assessed the resident, including taking her vitals. The ADON stated both incidents, the one on [DATE] [telling nurse she was having a stroke] and the one on [DATE] [being weak and needing hoyer transfer], would be considered change in conditions prior to the R #1 being found unresponsive. 48960

Based on record review and interview, the facility failed to effectively manage pain for 1 (R #3) of 2 (R #'s 3 and 57) residents reviewed for pain when staff did not assess for pain and provide pain treatment. This deficient practice likely resulted in R #3 experiencing long periods of pain without sufficient relief. A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: 1. Pain. 2. Osteoarthritis (Inflammation of one or more joints). 3. Muscle wasting and atrophy (A progressive and degeneration or shrinkage of muscles or nerve tissues). B. Record review of R #3's pain summary, dated January 2024, revealed R #3 experienced the following pain levels: - A score of 0 to 1 means the resident had no pain; 2 to 3 means mild pain; 4 to 5 means discomforting, moderate pain; 6 to 7 means distressing, severe pain; 8 to 9 means intense, very severe pain; and 10 means unbearable pain. - R #3's pain scale rating was a five out of 10, four times during the month of January. - R #3's pain scale rating was a six out of 10, fifteen times during the month of January. - R #3's pain scale rating was a seven out of 10, nineteen times during the month of January. - R #3's pain scale rating was a eight out of 10, twelve times during the month of January. - R #3's pain scale rating was a nine out of 10, four times during the month of January. - R #3's pain scale rating was a ten out of 10, one time during the month of January. C. Record review of R #3's Medication Administration Record (MAR), dated January 2024, revealed staff administered R #3 the following pain medications: 1. Duloxetine HCl oral capsule delayed release particles, 30 milligrams (mg). Give one capsule by mouth in the morning for depression or pain. Start date 01/20/24. 2. Lidocaine external gel 4 percent (%). Apply to most painful area topically in the morning related to pain. Start date 01/07/24. 3. Acetaminophen oral tablet, 500 mg. Give two tablets by mouth, three times a day for chronic osteoarthritis pain. Start date 01/20/24. 4. Gabapentin tablet, 600 mg. Give one tablet by mouth, three times a day for pain. Start date 04/13/23. 5. Tylenol oral tablet, 325 mg. Give two tablets by mouth, every six hours as needed for pain. Start date 03/09/23 and discontinue date 01/20/24. Documentation in the MAR revealed, Tylenol was administered 4 times, 1 was documented as ineffective and 3 were documented as unknown D. Record review of R #3's nursing progress notes, dated 01/17/24, revealed a Provider encounter. The resident was teary and somewhat agitated due to frustration over her situation and beliefs that she has chronic pain that no one is really addressing. E. Record review of R #3's nursing progress notes, dated 01/18/24 revealed the resident declined to shower related to chronic right hip pain. The resident became verbally aggressive, screamed, and cried. P. Record review of R #3's physician orders revealed the following: 1. Order dated 01/20/24 for a non-contrast magnetic resonance imaging (MRI; a non-invasive imaging technology that produces three dimensional detailed anatomical images) of right hip for severe pain to rule out right hip avascular necrosis (death of bone tissue due to temporary or permanent loss of blood supply to the bones). 2. Order dated 02/27/24 for a non-contrast MRI of right hip for severe pain to rule out right hip avascular necrosis Q. Record review of R #3's Electronic Health Record (EHR) revealed R #3 did not go to an MRI appointment as ordered. F. Record review of R #3's pain summary, dated February 2024, revealed R #3 experienced the following pain levels: - A score of 0 to 1 means the resident had no pain; 2 to 3 means mild pain; 4 to 5 means discomforting, moderate pain; 6 to 7 means distressing, severe pain; 8 to 9 means intense, very severe pain; and 10 means unbearable pain. - R #3's pain scale rating was a five out of 10, seven times during the month of February. - R #3's pain scale rating was a six out of 10, twelve times during the month of February. - R #3's pain scale rating was a seven out of 10, thirty-nine times during the month of February. - R #3's pain scale rating was a eight out of 10, twelve times during the month of February. - R #3's pain scale rating was a nine out of 10, five times during the month of February. - R #3's pain scale rating was a ten out of 10, one time during the month of February. G. Record review of R #3's MAR, dated February 2024, revealed staff administered R #3 the following pain medications: 1. Duloxetine HCl oral capsule delayed release particles, 30 milligrams (mg). Give one capsule by mouth in the morning for depression or pain. Start date 01/20/24. 2. Lidocaine external gel 4 percent (%). Apply to most painful area topically in the morning related to pain. Start date 01/07/24. 3. Acetaminophen oral tablet, 500 mg. Give two tablets by mouth, three times a day for chronic osteoarthritis pain. Start date 01/26/24. 4. Gabapentin tablet, 600 mg. Give one tablet by mouth, three times a day for pain. Start date 04/13/23. 5. Tramadol HCl oral tablet, 50 mg. Give one tablet by mouth every eight hours as needed for pain, for 14 days. Start date 02/28/24. Further review showed staff did not administer Tramadol to the resident in February 2024, and R #3 experience pain on 02/28/24 and 02/29/24. H. Record review of R #3's pain summary, dated March 1 through 4, 2024, revealed R #3 experienced the following pain levels: - R #3's pain scale rating was a five out of 10, six times during the month of March. - R #3's pain scale rating was a six out of 10, two times during the month of March. - R #3's pain scale rating was a seven out of 10, two times during the month of March. - R #3's pain scale rating was a eight out of 10, eight times during the month of March. - R #3's pain scale rating was a nine out of 10, one time during the month of March. I. Record review of R #3's MAR, dated March 1 through 4, 2024, staff administered R #3 the following pain medications: 1. Duloxetine HCl oral capsule delayed release particles, 30 milligrams (mg). Give one capsule by mouth in the morning for depression or pain. Start date 01/20/24. 2. Lidocaine external gel 4 percent (%). Apply to most painful area topically in the morning related to pain. Start date 01/07/24. 3. Acetaminophen oral tablet, 500 mg. Give two tablets by mouth, three times a day for chronic osteoarthritis pain. Start date 01/26/24. 4. Gabapentin tablet, 600 mg. Give one tablet by mouth, three times a day for pain. Start date 04/13/23. 5. Tramadol HCl oral tablet, 50 mg. Give one tablet by mouth every eight hours as needed for pain, for 14 days. Start date 02/28/24. Further review showed staff documented tramadol as ineffective two times (initial doses on 03/02/24 and 03/03/24). J. Record review of R #3's nursing progress notes, dated 03/05/24, revealed staff offered R #3 pain medication, but the resident refused stating it doesn't help. Staff notified the doctor the tramadol was ineffective. The record did not contain any other progress notes that staff notified the physician that the pain medication was not effective. K. On 03/04/24 at 3:29 pm during an interview with R #3, she stated she was in constant pain, and the medications prescribed did not help her pain. She further state she was waiting for an MRI that she was supposed to get over a year ago. She stated it was upsetting and frustrating because she should have had it [MRI] by now. Resident was was grimacing during the interview. L. On 03/05/24 at 11:27 am during an interview with Licensed Practical Nurse (LPN) #3, the LPN stated that for as long as she can remember R #3 was in constant pain, and the medications did not work. LPN #3 further stated R #3 experienced frequent pain, because her pain was not managed well. LPN #3 stated she was not sure if the Physician had been notified. M. On 03/05/24 at 4:38 pm during an interview with LPN #4, she stated R #3 did not get out of bed because of the pain. LPN #4 stated R #3 experienced frequent pain that was not managed well enough, and she had that pain for awhile. LPN #3 could not recall if the physician had been notified. LPN #4 stated if staff notified the physician then there would be a note in the resident's medical record. N. On 03/05/24 at 4:45 pm during an interview with Certified Nursing Assistant (CNA) #2, she stated R #3 was always in a lot of pain. CNA #2 stated she reported R #3's frequent pain to the nursing staff. O. On 03/04/24 at 6:06 pm and 03/06/24 at 11:36 am during an interview with the Director of Nursing (DON), she stated R #3 had not gone to get an MRI as ordered by Physician on 01/20/24 and on 02/27/24, but she should have went. The DON stated the facility should initiate something else for pain management if the pain medication was not working. The DON stated that she was unaware that R #3's pain was not being managed and the nurses should have told her about the resident's pain or brought it to her attention so they could try something else for the resident's pain management.

The facility failed to identify a pressure ulcer to R #24s heal until it was unstageable (full thickness skin or tissue loss with unknown depth) - 4.0 cm X 7.0 cm - on 08/25/20. On 10/27/20 the resident was sent to the emergency room with a fever. He was diagnosed with [REDACTED]. On 11/09/20 a left [MEDICAL CONDITION] was performed. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being identified on 12/09/20. The facility was notified on 12/09/20 at 12:30 pm. The facility took corrective action by providing a Plan of Removal on 12/09/20 at 4:05 pm, and was accepted on 12/09/20 at 4:10 pm. Based on the Plan of Removal the interventions included: 1. A skin sweep using a current census will be completed by members of nursing management beginning on 12/09/20 to identify concerns regarding skin integrity. The physician will be notified of any new area identified for treatment orders. 2. Current pressure ulcers were re-assessed by the Registered Nurse on 12/09/20 to evaluate and identify any wound infection and documented on the Wound Treatment and Progress Record. The physician will be contacted for further orders if a concern is identified by the registered nurse. 3. Care Plans will be updated by members of nursing management to reflect current wound status by 12/10/20. 4. The Registered Nurse (Acting Director of Nursing) was re-educated by the Clinical Consultant on 12/0920 on expectations of over-site on the skin processes. This included: a. validating that weekly skin audits are completed as scheduled by a weekly review b. Making weekly wound rounds to stage, measure and evaluate the wound bed and if stage has increased greater than a stage 2 or if signs and symptoms of infection are identified the physician will be notified and a referral will be made to the Nurse Practitioner (NP). The NP assess wounds that are stage 3 and above weekly. 5. Validate that there are no signs and symptoms of wound infection, odor, increased drainage, puss or blood, redness around the wound bed, warmth 6. Random audits of wound dressings weekly to validate the date of dressing correlates with order 7. Rounding daily (The act of seeing patients in the facility) Monday through Friday to validate skin prevention measures are in place/occurring and on week-ends by charge nurse The Registered Nurse (Acting Director of Nursing) was able to verbalize education given indicating understanding in order to educate the licensed nurses on the following beginning 12/09/20: a. That the licensed nurse is expected to perform weekly skin audit on resident identifying areas of skin impairment and notifying physician of any area identified for orders for treatments. b. Observing wound characteristics and signs and symptoms of infection with every treatment, notifying the physician and acting Director of Nursing/designee if any changes, worsening are identified. c. Updating the comprehensive care plan, to include approaches to prevent further skin breakdown or worsening of inherited pressure injury. d. If a C.N.A (Certified Nursing Assistant) provides the information that a skin integrity concern has been identified, the nurse is to sign the shower sheet and address as indicated and the C.N.A. will make a copy and give to Director of Nursing. If not in facility will slide under door. e The Certified Nursing Assistants were re-educated starting on 12/09/20 on the expectation of reporting to the nurse any skin integrity issue for intervention. If a C.N.A. provides information that a skin integrity concern has been identified, the nurse is to act upon the information by evaluating the area of concern and notifying the physician for treatment. This re-education will be completed by 12/10/20. Any clinical staff member not receiving by this date will receive prior to next scheduled shift. This will be presented to agency staff and new hires. Anyone not receiving will be presented prior to next scheduled shift. The Registered Nurse (Acting Director of Nursing)/designee will be reviewing the body audits completed each day Monday through Friday and the charge nurse on week-ends to validate that any skin integrity concerns identified was addressed and the MD notification and order are obtained and implemented. The Registered Nurse (Acting Director of Nursing)/designee will make rounds weekly to assess, stage and evaluate that there are no signs or symptoms of infection. The Medical Director was notified of the Immediate Jeopardy on 12/09/20. Based upon verification of the implementation of the approved Plan of Removal, the IJ was lifted on 12/09/20 at 4:10 pm. This resulted in the scope and severity being reduced from level J to a level G. Based on record review and interview, the facility failed to ensure 1 (R #24) of 1 (R #24) resident reviewed for wound care, received care: 1. To prevent the development of multiple pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin). 2. To identify a pressure ulcer prior to becoming unstageable. This deficient practice likely resulted in R #24 developing an infection from unstageable pressure wound to the heal resulting in a [MEDICAL CONDITION] (surgical removal of the leg below the knee). The findings are: A. Record review of facility face sheet revealed R #24 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, Unspecified intracellular (within the capsule of the hip joint) fracture of left femur, subsequent encounter for closed fracture with routine healing, Complete traumatic amputation (surgical removal of the leg below the knee) at level between knee and ankle, left lower leg, sequel ( the consequence of a previous disease or injury), Cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit), Limitation of activities due to disability, Muscle wasting and atrophy (is the partial or complete wasting away of a part of the body), not elsewhere classified, right shoulder, Muscle wasting and atrophy, not elsewhere classified, left shoulder, Muscle weakness (generalized), Other reduced mobility, Unsteadiness on feet, Difficulty in walking, not elsewhere classified, Muscle wasting and atrophy, not elsewhere classified, right upper arm, Repeated falls, Altered mental status, unspecified, Presence of artificial hip joint, bilateral (both sides), Unspecified dementia (A type of brain disorder that causes problems with memory, thinking and behavior) without behavioral disturbance, Type 2 diabetes mellitus (high blood sugar) without complications, Pain in right hip, Anxiety disorder, unspecified. B. Record review of an untitled document (Assistant Director of Nursing states this is a Wound Care Report) for R #24 revealed documentation of wound care on the following dates: 06/02/20 - redness buttocks - zinc oxide after each brief change - no change to treatment 06/08/20 - redness buttocks - zinc oxide after each incontinent episode - no change to treatment 06/16/20 - redness buttocks - zinc oxide after each brief change - no change to treatment 06/23/20 - redness buttocks - zinc oxide after each brief change - no change to treatment 07/14/20 - skin tear below left buttock - 1 centimeter (cm) X 0.5 cm X 0.1 cm - [MEDICATION NAME] ((medication is used to treat and prevent minor skin irritations) to site every brief change - no change to treatment 07/28/20 - skin tear below left buttock - 0.5 cm X 0.8 cm - [MEDICATION NAME] to site every brief change - no change to treatment 08/04/20 - left lower buttock - no measurements - [MEDICATION NAME] to site every brief change - no change to treatment 08/11/20 - redness buttocks - [MEDICATION NAME] to site every brief change - no change to treatment, right forearm - skin tear - 5.0 cm X 0.1 cm WC, [MEDICATION NAME] (is used to cover and protect low to non-exudating (cells and fluid that has seeped out of blood vessel) wounds, [MEDICATION NAME] (a soft foam dressing that is indicated for use on pressure ulcers) T/Th/Sat -no change to treatment 08/25/20 - #1 - left (?) hip D/C'd closed, #2 - Left heel - unstageable (full thickness skin or tissue loss with unknown depth) - 4.0 cm X 7.0 cm - [MEDICATION NAME] (Antiseptic for Minor Cuts, Scrapes, Burns, Helping to Prevent Infections) daily, #3 - Multiple abrasions buttocks and peri-area - [MEDICATION NAME] to site every brief change 09/01/20 - #1 - redness buttocks - [MEDICATION NAME] to site every brief change - no change to treatment, #2 - left heel - unstageable - 4.0 cm X 6.5 cm -[MEDICATION NAME] daily - no change to treatment 09/08/20 - #1 - left heel - unstageable - 7.0 cm X 5.0 cm - [MEDICATION NAME] daily - no change to treatment, #2 Buttocks - Stage 2 (partial-thickness skin loss into but no deeper than the dermis (second layer of the skin)) - 6.0 cm X 4.5 cm X 0.2 cm - [MEDICATION NAME] to site every brief change - no change to treatment 09/15/20 - #1 - buttocks - stage 2 - 4 cm X 2 cm - [MEDICATION NAME] to site every brief change - no change to treatment - #2 - left heel - stage 2 - 8 cm X 4 cm - [MEDICATION NAME] daily - no change to treatment 09/22/20 - #1 - buttocks - stage 2 - 3.0 cm X 0.5 cm X 0.1 cm - [MEDICATION NAME] to site every brief change - no change to treatment, #2 - Left heel - unstageable - 3.5 cm X 6.5 cm - [MEDICATION NAME] daily - no change to treatment 09/28/20 - #1 - buttocks - abrasion - 1.0 cm X 0.5 cm - [MEDICATION NAME] to site every brief change - no change to treatment, #2 - left heel - unstageable - 3.5 cm X 6.4 cm - [MEDICATION NAME] daily - no change to treatment 10/20/20 - #1 - left heel - unstageable - 3.0 cm X 3.0 cm - Wound Cleanser (WC), Exuderm (protective, translucent barrier) T/Th/Sat & PRN - no change to treatment - #2 - buttocks - rash - [MEDICATION NAME] to site every brief change - no change to treatment 10/27/20 - #1 - left heel - unstageable - 6.0 cm X 3.0 cm - cover with Dakins (an antibiotic that fights bacteria) soaked gauze wrap with Kerlix (a bandage) and Allwrap (used for wound coverage and nerve or tendon protection)- no change to treatment - #2 - excoriation - buttocks - [MEDICATION NAME] to site every brief change - no change to treatment 11/17/20 - #1 - Left BKA - staples in place suture line well approximated - WC, Xeroderm (medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations), wrap with gauze QD (every day) - #2 - left arm - skin tear - 2 cm X 2 cm - WC, [MEDICATION NAME] T/TH/Sat & PRN - no change to treatment 11/24/20 - #1 - buttocks - excoriation (damage or remove part of the surface of (the skin)) - [MEDICATION NAME] to site every brief change - #2 - left BKA - 13 cm incision sutures in place - WC, [MEDICATION NAME], Kerlix Daily and as needed - #3 - left arm - skin tear - 1 cm X 0.5 cm - WC, [MEDICATION NAME] T/TH/Sat & PRN - no change to treatment, #4 - right inner knee - scab - 2.5 cm X 1 cm - [MEDICATION NAME] daily 12/01/20 - #1 - left inner knee - unstageable - 2.0 cm X 0.7 cm - [MEDICATION NAME] daily - #2 - buttocks - excoriation - 1.0 cm X 0.2 cm X 0.1 cm [MEDICATION NAME] to site every brief change - #3 - left arm - closed, #4 - left BKA - closed - WC, [MEDICATION NAME], Kerlix daily and as needed, #5 - left knee - unstageable - 1.5 cm X 2.0 cm - [MEDICATION NAME] daily - #6 - left medial/BKA - 5.0 cm X 3.0 cm - [MEDICATION NAME] daily. C. Record review of Nurse's Notes or Daily Skilled Nurse's Notes revealed no evidence that the Physician (Medical Director) was notified by nursing staff of the residents pressure ulcer. D. Record review of Hospital Records for R #24 with dates as indicated revealed, 11/02/20 - From Discharge Summary - .Incision and drainage ( minor surgical procedures to release pus or pressure built up under the skin) of left ankle/heel abscess (an area under the skin where pus (infected fluid) collects). Wound Vac (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal) application. 11/05/20 - Summary: Assessment: 1. Left heel infection with fever and leukopenia (is a decrease in the number of white blood cells), currently on [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic). Plan: 1. Admit the patient to Medical Floor 3. Get (name of physician) to see the patient with regard to his infected left heel. 7. Bedside debridement of his left heel eschar. Post-Operative Plan: .Plan for serial debridement and return to operating room in 2 days. Same date a Groshong catheter (a type of central venous (vein) catheter) was surgically placed for antibiotic therapy use. Operative Findings: Unstageable posterior calcaneal (heel bone) pressure ulcer with eschar (piece of dead tissue that is cast off from the surface of the skin) necrotic (Death of cells in an organ or tissue) base, Necrotic and infected epidermis, subcutaneous tissue, fascia and Achilles tendon sheath. No evidence of involvement of the nerve, artery, bone or joint, No Involucrum or sequestrum. 11/09/20 - Operative Report Summary: Left [MEDICAL CONDITION] was performed. E. On 12/09/20 at 8:50 am during a phone interview the Acting Director of Nursing (A-DON), he was unable to explain how R #24's left heel pressure ulcer developed without being noticed until it was unstageable and the how the wound increased from 3.0 cm X 3.0 cm on 10/20/20 to a unstageable pressure ulcer measuring 6.0 cm X 3.0 cm on 10/27/20. F. Record review of Care Plans with Problem, measurable Goal and Approaches with dates as indicated include: 11/25/20 - R #24 has redness to buttocks related to (R/T) immobility and incontinence, 11/25/20 - R #24 has an open area to right inner knee, 11/22/20 -R #24 is at risk for dehydration R/T dementia, 11/22/20 - R #24 requires an indwelling urinary catheter R/T pressure ulcers, 09/10/20 - R #24 will be in a geri-chair R/T immobility from hip dislocation evidenced by (E/B) stage 2 pressure ulcer on buttocks, 11/22/20 - R #24 has complaints of pain R/T Left [MEDICAL CONDITION] (BKA) E/B shouting when he is hurting, 08/13/20 - R #24 is limited in ability to transfer self s/p Left BKA, 08/13/20 - R #24 has abrasions on buttocks, 08/05/20 - R #24 has complaints of acute pain R/T history (HX) of bilateral (both sides) hip replacement E/B verbal complaint of (c/o) pain, 06/10/20 - R #24 is limited in ability to transfer self R/T [MEDICAL CONDITION], 06/01/20 - R #24 has complaints of acute pain R/T fracture with right femur E/B vocalization of pain, 06/01/20 - R #24 requires a therapeutic diet R/T diabetes (high blood sugar), 06/01/20 - R #24 is at risk for falling R/T confusion and Left BKA, 06/01/20 - R #24 is at risk for pressure ulcers R/T incontinence E/B redness on coccyx (tail bone), 05/26/20 - R #24 has impaired decision making R/T dementia, as well as recent surgery with anesthesia. G. Record review of Weekly Skin Integrity Review for R #24 revealed, skin reviews were done on 05/23/20, 05/28/20, 06/04/20, 06/11/20 and 06/18/20. No other Weekly Skin Integrity Reviews were found. H. Record review of the Medical Record of R #24 did not identify that pressure wound prevention methods were implemented, including no evidence that R #24 was repositioned/turned to relieve pressure. Note: Due to COVID 19 diagnosis, Nursing and Certified Nursing Assistant's (CNA's) with knowledge of this resident were unavailable for interview.

Based on record review and interview the facility failed to prevent avoidable accidents, 1.) by not repairing an automatic door closer allowing the door to close with enough force to likely result in injury (R #1), 2.) by failing to use a mechanical lift to transfer the resident (R #1) and, 3.) improper use of an wheelchair likely resulting in an injury to the right lower leg (R #2) for two (R #1 and R #2) of two (R #1 and R #2) residents reviewed for injuries. This deficient practice likely caused R #1 to sustain a fracture to her right arm when struck by the door and a fracture to the left leg likely caused of not using a mechanical lift to transfer the resident and R #2 likely having a fracture to the right leg from improper use of a wheelchair. If automatic doors are not operating properly, a mechanical lift is not used as ordered and a wheelchair is not used properly residents have the potential to suffer further injuries. The findings are: Resident #1 - Arm fracture - A. Record review of R #1 facesheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED].), type 2 diabetes, generalized muscle weakness, abnormalities of gait and mobility, lack of coordination . Assessments include, Nursing data collection tool, joint mobility screen, evaluation for use of side rails, urinary continence evaluation, risk of elopement/wandering review, fall risk evaluation. B. Record review of R #1 Nurse's Notes dated 07/23/17 at 5:20 pm revealed, .Noted [MEDICAL CONDITION] with discoloration to R (right) inner elbow, resident continues to guard arm and refuses to let nurse fully assess her. When questioned resident is able to provide yes or no answers. Resident frequently exits the building into courtyard area by pushing the exit door open with her power w/c (wheelchair). When asked if that door hit her arm anytime recently she stated, 'Yes'. Spoke with her some more about her pain, which she denies at this time, as she is not moving around at all. Asked her again about the door hitting her arm and again she stated, 'Yeah' . C. Record review of Facility Incident Detail Report (Incident log) for R #1 dated 07/23/17 revealed, (name of resident) had an injury of unknown origin resulting in a fracture to the right arm. D. Record review of Patient/Resident Incident/Accident Investigation Worksheet for R #1 dated 07/23/17 revealed, .12:00 pm, CNA (Certified Nursing Assistant) reported to nurse that res'd (resident) c/o (complains of) R (right) arm pain. Nurse noted [MEDICAL CONDITION] (swelling) with some discoloration to right inner elbow. Res'd non-compliant with further assessment D/T (due to) pain, guarding (minimize motion or agitation of sites) R arm. POA (power of attorney) and MD (Medical Doctor) notified N.O. (new order) for x-rays to R/O (rule out) fracture . E. Record review of Radiology Report from (name of hospital) for R #1 dated 07/23/17 revealed, .Conclusion: Distracted (separation of the two parts of a bone) angle [MEDICAL CONDITION] (away from the center of the body) shaft of the right humerus (a break in the lower end of the upper arm bone) . F. On 11/20/17 at 9:50 am during an interview Licensed Practical Nurse (LPN) #1, stated, It did not appear to be an obvious fracture. There was [MEDICAL CONDITION], bruising and we got an order for [REDACTED]. it open. (Name of resident) stated twice, in single word answers, that yes the door had hit her arm. At this time, she appeared to be alert and oriented . G. On 11/21/17 at 8:10 am during an interview the Administrator (ADM) stated, I was unaware of the issue with the courtyard automatic door not staying open and could have caused the injury to (name of resident). H. On 11/21/17 at 3:30 pm during an interview the Maintenance Director stated, The automatic door to courtyard has not been working since approximately (MONTH) (YEAR) and is still not functioning correctly. So, the door rapidly closing could have closed on a resident causing an injury. Resident #1 - Leg fracture - I. Record review of Facility Incident Detail Report dated 10/21/17 revealed (name of resident) had an injury of unknown cause resulting in a fracture to her left femur. J. Record review of Patient/Resident Incident/Accident Investigation Worksheet for R #1 dated 10/21/17 at 10:00 am revealed, .Called to shower room by CNA to observe apparent Fx (fracture) to L (left) femur (large bone of the upper leg). Unknown how or when accident occurred as resident has HX (history) of fractures with [MEDICAL CONDITION] . K. Record review of Nurse's Notes for R #1 dated 10/24/17 at 10:00 am revealed, (Family Member #1) here wants x-rays of L femur to rule out fracture . Received orders (from the physician) for non-emergent ambulance to transport to (name of local hospital) for x-rays 3 views left femur . L. Record review of Radiology (X-ray) report for R #1 dated 10/24/17 revealed, .Conclusion: Displaced and angulated [MEDICAL CONDITION] femur . M. Record review of Care Plan for R #1 dated 04/24/17 revealed, Problem: Falls, 1. (name of resident) is at risk for falls related to (r/t or R/T) decreased mobility s/p (status [REDACTED]. 2. (name of resident) uses electric scooter to get around in facility. 3. (name of resident) is at risk for injury R/T [MEDICAL CONDITION]. Short Term Goal Target Date: 07/24/17 1. (name of resident) will have no falls thru next review. 2. (name of resident) will remain safe in facility thru next review. 3. (name of resident) will sustain no injury R/T falls or [MEDICAL CONDITION] thru next review. Approach Start Date: 04/24/17 Keep (name of resident) call light within easy reach when she is in her room. Make sure (name of resident) electric scooter gets plugged in to charge when she is in bed. (name of resident) knows she cannot walk and makes no attempts to get up or transfer herself. (name of resident) prefers her electric scooter to a w/c (wheelchair). Notify (name of resident) family of any problems with scooter. Staff to be aware of risk for injury with falls because of (name of resident) [MEDICAL CONDITION]. Use two staff and Hoyer lift for transfers. N. On 11/20/17 at 3:05 pm during an interview the Assistant Director of Nursing (ADON) stated, When I interviewed (name of CNA), he said that she had not transferred (name of resident) with the mechanical lift but picked her up and placed her in the shower chair. Not long after this was when the fracture was discovered. I can not say with any certainty that this transfer cause the fracture but with (name of resident) history of pathological fractures that is when it could have happened. O. On 11/21/17 at 8:50 am during an interview the Administrator (ADM) stated, After investigating the incident with (name of resident's) broken femur the CNA involved was terminated for placing the resident at risk by not properly following the care plan for transfers. Resident #2 - Leg fracture - P. Record review of facility facesheet for R #2 dated 05/30/17 revealed, R #2 was admitted to the facility on this date. Admission [DIAGNOSES REDACTED].), contracture (a permanent shortening of a muscle or joint) of the left and right knees, [MEDICAL CONDITION] (disease that weakens bones) with current pathological fracture (fx) (a bone fracture caused by disease that led to weakness of the bone structure) of the lower leg, generalized muscle weakness, abnormalities of gait and mobility, dysphagia (difficulty swallowing), cognitive communication deficit. Q. Record Review of Assessments include, Nursing data collection tool, joint mobility screen, pain evaluation, risk of elopement/wandering review, fall risk evaluation. Joint Mobility Screen dated 05/30/17 revealed, form was present in chart but was not completed. R. Record review of Nursing Data Collection Tool for R #2 dated 05/30/17 revealed, Section 8: Physical Evaluation - Musculoskeletal - 1.) Modes of Locomotion block for Wheelchair is checked. 2.) Functional Limitation in ROM (range of motion), does the resident have any limitation that interferes with daily functions or places resident at risk of injury? Block for upper and lower extremities are checked and further indicates impairment to both sides. S. Record review of the Activities of Daily Living (ADL) Care Area Assessment (CAA) Detail Report for R #2 dated 06/06/17 revealed, under section titled, [DIAGNOSES REDACTED]. Locomotion - Wheelchair Use there are 2 choices uses wheelchair or Does not use wheelchair neither block is checked. Care Plan decision is marked as yes. T. Record review of the Falls CAA Detail Report for R #2 dated 06/06/17 revealed, under section titled, [DIAGNOSES REDACTED]. Under section titled: Analysis of Findings: (name of resident) is at high risk for falls, with a fall risk score of 18 (a fall risk score of 10 or greater is considered high risk). She is not steady, and only able to stabilize with staff assistance. Care Plan decision is marked as yes. U. Record review of Care Plan for R #2 dated 06/15/17 revealed, Problem: Falls, (name of resident) at risk for falling R/T requiring extensive assist with toileting, transfers and bed mobility. Goal: (name of resident) will remain free from injury. Approach: Give (name of resident) verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Observe frequently and place in supervised area when out of bed. Occupy (name of resident) with meaningful distractions: watching the birds out the windows, music. V. Record review of Facility Incident Detail Report for R #2 dated 08/20/17 revealed, resident sustained [REDACTED]. W. Record review of the Patient/Resident Incident/Accident Investigation Worksheet dated 08/20/17 revealed, it was reported to (LPN #3) by (CNA # 5) that (name of resident) right foot was swollen with some discoloration. The foot was examined and was noted as hot to touch, swollen with +2-3 [MEDICAL CONDITION] (swelling) going up her ankle. (name of resident) also showed signs of pain when her right foot was manipulated. The family informed LPN #3 that while pushing (name of resident), her right foot would get caught under her wheelchair. X. Record review of Nurse's Notes for R #2 dated 08/20/17 at 8:00 am revealed, .At start of shift night CNA informed me that patients right foot was hot, red, swollen. Observed right foot with +2-3 [MEDICAL CONDITION] (swelling) warm to touch with redness with pain to touch, unable to move . (Family Member) stated that even when she was pushing her (the resident) in chair (wheelchair) the right foot dragged the floor due to contraction. Notified (name of physician), family decided to take resident to (Name of hospital emergency room ) left around 8:30 am. Returned around 2:20 pm [DIAGNOSES REDACTED]. Y. Record review of Radiology Report from (name of hospital) for R #2 dated 08/20/17 revealed, .Impression: Acute displaced [MEDICAL CONDITION] (away from the center of the body) tibia (bone in the lower leg) is present. Severe osteopenia (a condition in which bone mineral density is lower than normal) [MEDICAL CONDITION] joint disease . Z. On 11/21/17 at 2:50 pm during an interview the ADM stated, We really don't know how the ankle was fractured. Did the resident turn wrong in bed and fracture it, did the family pushing her in her wheelchair cause her foot to get caught on something causing it to fracture. During the investigation the then ADON, who no longer works here, stated that the daughter had transferred the resident from the wheelchair to the bed and that the residents contracted right foot would drag on the floor when she was pushed in the wheelchair. AA. On 11/29/17 at 11:15 am during an interview the MDS Coordinator stated, There are no care plans for (name of resident) use of a wheelchair nor for her contractures. BB. On 11/22/17 at 1:15 pm during an interview (name of resident) did not respond when attempting to talk with her.

The facility failed to monitor the effects of a blood thinning medication, [MEDICATION NAME], with laboratory monitoring from 07/20/11 to 06/07/12 for Resident #1. This resulted in an Immediate Jeopardy being called on 06/07/12 at 5:02 pm. The Administrator, Director of Nursing, and Assistant Director of Nursing were informed. The facility provided an acceptable plan of removal on 06/07/12 at 6:40 pm. Acceptance of the plan of removal lowered the scope and severity to level E. The Plan of Removal included: a. A stat (urgent) [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) test for Resident #1, a laboratory test that measures the balance in the blood between preventing clots and causing excessive bleeding, b. A Physician's Order for therapeutic monitoring for Resident #1 on a monthly basis, c. Licensed staff in-servicing related to therapeutic monitoring of [MEDICATION NAME], d. Implementation of a plan that if the Primary Care Physician does not respond within 24 hours of requested lab work the Medical Director will be notified to act on behalf of the facility, e. An audit of all residents taking [MEDICATION NAME] for monitoring of therapeutic levels, f. Notification of the Consulting Pharmacist for failure to identify and request labs for [MEDICATION NAME] therapeutic monitoring. g. Resident #1's stat PT/INR results were obtained and the Medical Director's Certified Nurse Practitioner adjusted the medication. Based on record review and interview, the facility failed to monitor the effects of a blood thinning medication with laboratory monitoring from 07/20/11 to 06/07/12 for 1 (#1) of 10 (#1, 3, 6, 19, 24, 29, 30, 41, 43, 60) residents reviewed for unnecessary medications. This failure was likely to cause severe injury or death from bleeding or blood clot formation. The findings are: A. Record review for Resident #1 revealed the following: 1. A Physician's Order dated 02/18/11 revealed, "[MEDICATION NAME] (blood thinner) 3 mg (milligrams) 1 time a day, Monday, Wednesday, Friday, and Saturday," and "[MEDICATION NAME] 5 mg 1 time a day, Sunday, Tuesday, and Thursday." 2. Review revealed that there were no Physician's Orders for PT/INR lab work from 01/01/12 to 06/07/2012. 3. Review of the laboratory section of the chart revealed no results related to the [MEDICATION NAME] for therapeutic monitoring. 4. A physician progress notes [REDACTED].[DIAGNOSES REDACTED]." 5. Review of the Pharmacist Consultation Reports dated January 2012, February 2012, March 2012, April 2012, and May 2012 contained reviews for Resident #1 with no recommendations for therapeutic monitoring for [MEDICATION NAME]. B. On 06/07/12 at 2:47 pm, the Assistant Director of Nursing (ADON) was interviewed. The ADON was asked if there was a Physician's Order for the lab work to monitor the [MEDICATION NAME]. The ADON looked in the current medical record and the thinned chart and did not find Physician's Orders for a PT/INR. The ADON reviewed the Pharmacy Consultant's Records and stated, "The pharmacist had not made a recommendation for lab work." The ADON was asked to find laboratory results. C. On 06/07/12 at 4:20 pm, the ADON stated that she called the local hospital laboratory and they did not have any PT/INR results for Resident #1. The ADON stated that she called another local laboratory and they did not have any PT/INR results since 2011. The ADON stated that she called Resident #1's Physician and could not get an answer from the Physician's office because they did not answer the telephone. The ADON produced 1 lab result from the thinned record, dated 07/20/11, which revealed [MEDICATION NAME] (PT) 22.3, with normal ranges 11.1-15.2. The INR was 1.94 with a normal range of 0.80-1.20. The ADON was asked if there had been any monitoring for the [MEDICATION NAME]. The ADON stated, "There is no monitoring."

The facility failed to ensure that the Primary Care Physician reviewed the Resident's total program of care including medications that required therapeutic monitoring for Resident #1. Resident #1's physician failed to order [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) results, a laboratory test that measures the balance in the blood between preventing clots and causing excessive bleeding, for the use of [MEDICATION NAME] (a blood thinning medication),from 12/1/11 to 06/07/12. This resulted in an Immediate Jeopardy being called on 06/07/12 at 5:02 pm. The Administrator, Director of Nursing, and Assistant Director of Nursing were informed. The facility provided an acceptable plan of removal on 06/07/12 at 6:40 pm. Acceptance of the plan of removal lowered the scope and severity to level E. The Plan of Removal included: a. A stat (urgent) PT/INR test for Resident #1. b. A Physician's Order for therapeutic monitoring for Resident #1 on a monthly basis. c. Licensed staff in-servicing related to therapeutic monitoring of [MEDICATION NAME]. d. Implementation of a plan that if the Primary Care Physician does not respond within 24 hours of requested lab work the Medical Director will be notified to act on behalf of the facility. e. An audit of all residents taking [MEDICATION NAME] for monitoring of therapeutic levels. f. Notification of the Consulting Pharmacist for failure to identify and request labs for [MEDICATION NAME] therapeutic monitoring. g. Resident #1's stat PT/INR results were obtained and the Medical Director's Certified Nurse Practitioner adjusted the medication. Based on record review and interview, the facility failed to ensure that 1 (#1) of 1 (#1) residents Primary Care Physician reviewed the Resident's total program of care including medications that required therapeutic monitoring. Resident #1's Physician failed to order PT/INRs for the use of [MEDICATION NAME]. This failure was likely to cause severe injury or death from bleeding or blood clots. The findings are: A. Record review for Resident #1 revealed the following: 1. A Physician's Order dated 02/18/11 revealed, "[MEDICATION NAME] 3 mg (milligrams) 1 time a day, Monday, Wednesday, Friday, and Saturday," and "[MEDICATION NAME] 5 mg 1 time a day, Sunday, Tuesday, and Thursday." 2. Review revealed that there were no Physician's Orders for PT/INR lab work from 01/01/12 to 06/07/2012. 3. Review of the laboratory section of the chart revealed no results related to the [MEDICATION NAME] for therapeutic monitoring. 4. A physician progress notes [REDACTED].[DIAGNOSES REDACTED]." 5. Physician's Progress Notes dated 02/08/12 revealed no PT/INR results. There were no additional progress notes after 02/08/12. B. On 06/07/12 at 2:47 pm, the Assistant Director of Nursing (ADON) was interviewed. The ADON was asked if there was a Physician's Order for the lab work to monitor the [MEDICATION NAME]. The ADON looked in the current medical record and the thinned chart and did not find Physician's Orders for a PT/INR. The ADON was asked to find laboratory results. C. On 06/07/12 at 4:20 pm, the ADON stated that she called the local hospital laboratory and they did not have any PT/INR results for Resident #1. The ADON stated that she called another local laboratory and they did not have any PT/INR results since 2011. The ADON stated that she called Resident #1's Physician and could not get an answer from the Physician's office because they did not answer the telephone. The ADON produced 1 lab result from the thinned record, dated 07/20/11, which revealed [MEDICATION NAME] (PT) 22.3, with normal ranges 11.1-15.2. The INR was 1.94 with a normal range of 0.80-1.20. The ADON was asked if there had been any monitoring for the [MEDICATION NAME]. The ADON stated, "There is no monitoring."

The facility's Monthly Pharmacy Review failed to identify the necessity of monitoring for the effects of a blood thinning medication, warfarin, from January 2012 to May 2012 for Resident #1. This resulted in an Immediate Jeopardy being called on 06/07/12 at 5:02 pm. The Administrator, Director of Nursing, and Assistant Director of Nursing were informed. The facility provided an acceptable plan of removal on 06/07/12 at 6:40 pm. Acceptance of the plan of removal lowered the scope and severity to level E. The Plan of Removal included: a. A stat (urgent) Prothrombin Time/International Normalized Ratio (PT/INR) test for Resident #1, a laboratory test that measures the balance in the blood between preventing clots and causing excessive bleeding, b. A Physician's Order for therapeutic monitoring for Resident #1 on a monthly basis, c. Licensed staff in-servicing related to therapeutic monitoring of warfarin, d. Implementation of a plan that if the Primary Care Physician does not respond within 24 hours of requested lab work the Medical Director will be notified to act on behalf of the facility, e. An audit of all residents taking warfarin for monitoring of therapeutic levels, f. Notification of the Consulting Pharmacist for failure to identify and request labs for warfarin therapeutic monitoring. g. Resident #1's stat PT/INR results were obtained and the Medical Director's Certified Nurse Practitioner adjusted the medication. Based on record review and interview, the facility's Monthly Pharmacy Review failed to identify the necessity of monitoring for the effects of a blood thinning medication, warfarin, from January 2012 to May 2012 for 1 (#1) of 10 ( #1, 3, 6, 19, 24, 29, 30, 41, 43, 60) residents reviewed for unnecessary medications. This failure was likely to cause severe injury or death from bleeding or blood clot formation. The findings are: A. Record review for Resident #1 revealed the following: 1. A Physician's Order dated 02/18/11 revealed, "warfarin (blood thinner) 3 mg (milligrams) 1 time a day, Monday, Wednesday, Friday, and Saturday," and "warfarin 5 mg 1 time a day, Sunday, Tuesday, and Thursday." 2. Review revealed that there were no Physician's Orders for PT/INR lab work from 01/01/12 to 06/07/2012. 3. Review of the laboratory section of the chart revealed no results related to the warfarin for therapeutic monitoring. 4. A physician progress notes [REDACTED].[DIAGNOSES REDACTED]." 5. Review of the Pharmacist Consultation Reports dated January 2012, February 2012, March 2012, April 2012, and May 2012 contained reviews for Resident #1 with no recommendations for therapeutic monitoring for warfarin. B. On 06/07/12 at 2:47 pm, the Assistant Director of Nursing (ADON) was interviewed. The ADON was asked if there was a Physician's Order for the lab work to monitor the warfarin. The ADON looked in the current medical record and the thinned chart and did not find Physician's Orders for a PT/INR. The ADON reviewed the Pharmacy Consultant's Records and stated, "The pharmacist had not made a recommendation for lab work." The ADON was asked to find laboratory results. C. On 06/07/12 at 4:20 pm, the ADON stated that she called the local hospital laboratory and they did not have any PT/INR results for Resident #1. The ADON stated that she called another local laboratory and they did not have any PT/INR results since 2011. The ADON stated that she called Resident #1's Physician and could not get an answer from the Physician's office because they did not answer the telephone. The ADON produced 1 lab result from the thinned record, dated 07/20/11, which revealed protime (PT) 22.3, with normal ranges 11.1-15.2. The INR was 1.94 with a normal range of 0.80-1.20. The ADON was asked if there had been any monitoring for the warfarin. The ADON stated, "There is no monitoring."