Every finding on record at The Bradford Skilled Nursing and Rehabilitation

Based on record review and interviews the facility failed to ensure residents plan of care was revised after a change in condition for 1 (#4) of 5 residents whose plan of care was reviewed. The facility failed to revise Resident #4's plan of care after an elopement and after the development of a diabetic ulcer. Based on record review and interviews the facility failed to ensure residents plan of care was revised after a change in condition for 1 (#4) of 5 residents whose plan of care was reviewed. The facility failed to revise Resident #4's plan of care after an elopement and after the development of a diabetic ulcer. Findings: Review of Resident #4's medical record revealed an admit date of 01/09/2026 with a diagnosis of but not limited to, type 2 diabetes mellitus, cognitive communication deficit; aphasia; muscle wasting and atrophy, not elsewhere classified, multiple sites; other abnormalities of gait and mobility, disorientation, unspecified; unspecified dementia, unspecified severity, with anxiety, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, and essential (primary) hypertension. Review of Resident #4's progress notes revealed on 02/08/2026 at 6:06 p.m. Resident #4 was found outside of the facility in the flower bed in the front of the facility bent over with her hands in the dirt by an oncoming nurse. Further review of Resident #4's progress notes revealed a diabetic ulcer was found on Resident #4's right heel on 02/09/2026. Review of Resident #4's comprehensive plan failed to reveal a revision had been made to reflect Resident #4's elopement from the facility and development of a diabetic ulcer on the right heel. During an interview on 03/24/2026 at 12:10 p.m. S4 MDS Coordinator confirmed Resident #4's plan of care should have been revised to reflect an actual elopement and to reflect Resident #4's development of a diabetic ulcer.

Based on record review and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive plan of care for 1 (#4) of 5 sampled residents. The facility failed to develop and implement approaches addressing Resident #4's risk of developing a diabetic foot ulcer. Findings: Review of Resident #4's medical record revealed an admit date of 01/09/2026 with a diagnosis of but not limited to, type 2 diabetes mellitus, cognitive communication deficit; aphasia; muscle wasting and atrophy, not elsewhere classified, multiple sites; other abnormalities of gait and mobility, disorientation, unspecified; unspecified dementia, unspecified severity, with anxiety, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, and essential (primary) hypertension.Review of Resident #4's admission MDS dated [DATE] revealed Resident #4 t was assessed to have a deep tissue injury on the rigth heel.Review of Resident #4's skin assessment dated [DATE] revealed Resident #4 had a deep tissue injury on the right heel. Review of Resident #4's progress note by S6 Nurse Practitioner dated 01/12/2026 revealed:Deep tissue injury on right heel which is being treated with gentian violet and foam. Right heel is tender to touch. Review of Resident #4's January and February 2026 Physicians Orders failed to reveal any wound care treatment orders between 01/09/2026 and 02/08/2026.Review of Resident #4's January and February 2026 Treatment Administration Record failed to reveal any wound care treatments were provided between 01/09/2026 and 2/8/2026. Review of Resident #4's progress note by S5 Wound Care Nurse dated 02/09/2026 at 11:59 a.m. revealed a diabetic ulcer on resident #4's right heel was identified, right heel was tender and spongy to touch. Applied gentian violet soaked gauze and a foam dressing applied for protection. Review of Residents #4's skin assessment dated [DATE] revealed:Skin not intact-existing, treatment in place-diabetic ulcer to right heel.'Review of Resident #4's Plan of care for diabetes initiated 01/0920/26 revealed these approaches; Check all of body for breaks in skin and treat promptly as ordered by doctor.Review of Resident #4's February 2026 Physician's Order revealed an order for:Diabetic area to right heel, monitor skin integrity to area, apply gentian violet dampened gauze and protective dressing on Monday and Thursday dated 02/09/2026. Review of Resident #4's February 2026 Treatment Administration Record revealed documentation of treatment as ordered above on the right heel on Monday 02/09/2026, Thursday 02/12/2026 and 02/16/2026 only. During an interview on 03/23/2026 at 10:00 a.m. Resident #4's responsible party reported Resident #4 was discharged from the facility on 02/16/2026 and had to be seen in the local emergency department for treatment of an infected diabetic ulcer on the right heel that required antibiotics. Review of Resident #4's emergency room Visit Notes dated 02/17/2026 revealed Resident #4 was treated for cellulitis due to a diabetic ulcer on the right heel and discharged home with antibiotics. During an interview on 03/25/2026 at 9:00 a.m. S5 Wound Care nurse confirmed the documentation of a deep tissue injury on Resident #4's 01/09/2025 skin assessment without any physicians orders for treatment. S5 Wound care nurse also confirmed Resident #4 developed a diabetic ulcer that was not identified until 02/09/2026 on Resident #4's right heel. During an interview on 03/25/2026 at 9:00 a.m. S6 Nurse Practitioner confirmed his documentation of Resident #4's right heel deep tissue injury in his notes dated 01/12/2026. S6 Nurse Practitioner confirmed he had only examined Resident #4's right heel on 01/12/2026.

Based on record review and interview, the facility failed to report a resident's elopement to the State Survey Agency in accordance with State law, for 1 (#4) of 5(#1, #2, #3, #4, #5) sampled residents.Based on record review and interview, the facility failed to report a resident's elopement to the State Survey Agency in accordance with State law, for 1 (#4) of 5(#1, #2, #3, #4, #5) sampled residents.Findings:Review of the facility's Wandering and Elopement Policy dated 11/15/2023 revealed the following: 3. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse Shall. Examine the resident for injuries; Notify the Attending Physician and report findings and conditions of the resident: Complete and file Report of Incident/Accident; and Document the event in the resident's medical record; Notify regulatory agencies per state guidelines indicated.Review of Resident #4's medical record revealed an admit date of 01/09/2026 with a diagnosis of but not limited to, type 2 diabetes mellitus, cognitive communication deficit; aphasia; muscle wasting and atrophy, not elsewhere classified, multiple sites; other abnormalities of gait and mobility, disorientation, unspecified; unspecified dementia, unspecified severity, with anxiety, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, and essential (primary) hypertension.Review of resident #4's Quarterly Minimum Data Set, dated [DATE] revealed Resident #4 was assessed to have a Brief Interview Mental Status score of 4 indicating severely impaired cognition.Review of Resident #4's medical record revealed Resident #4 was assessed to be an elopement risk at a level of 3 due to a history of attempted elopement at home, wandering with a purpose in the facility and exit seeking behavior. During a phone interview on 03/23/2026 10:00 a.m. Resident #4's nephew/responsible party reported Resident #4 was found outside in the front of the facility alone on 02/08/2026. Review of Resident #4's progress notes revealed on 02/08/2026 at 6:06 p.m. Resident #4 was found outside of the facility in the flower bed in the front of the facility bent over with her hands in the dirt by an oncoming nurse. During a telephone interview on 03/25/2026 at 2:17 p.m. S3 licensed practical nurse confirmed on 02/08/2026 at approximately 6:00 p.m. she observed Resident #4 outside of the facility bent over in the flower bed in the front of the facility near the front door when she arrived for her scheduled shift. S3 licensed practical nurse further reported she parked her car and went to assist Resident #4 and alerted the staff inside the facility that Resident #4 was outside alone on 02/08/2026.During an interview on 03/24/2026 at 9:00 a.m. S1 Administrator confirmed on 02/08/2026 Resident #4 was found outside in the flower bed in the front of the facility and although Resident #4 had diagnosis of dementia and a BIMS score of 4 he did not report this incident to the State Survey Agency.

Based on record review, observation and interview, the facility failed to provide appropriate treatment and services for 1(#1) of 1(#1) resident reviewed for tube feedings. The facility failed to ensure Resident #1's tube feeding bag and water flush bag were changed daily.Findings:Review of Resident #1's medical record revealed an admit date of 07/30/2025 with the following diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction and gastrostomy status. Review of Resident #1's Physician's orders revealed an order dated 07/30/2025 - Enteral Feed one time a day related to dysphagia following cerebral infarction and gastrostomy status - Enteral Nutrition Isosource at 40 ml (milliliter) per hour for 12 hours via pump. Start infusion at 2000 and continue until 0800. Further review revealed an order dated 07/30/2025 - Enteral Feed every 6 hours Enteral: Flush feeding tube with 100 ml of water per hour every 6 hours.Observation on 09/22/2025 at 8:40 a.m. revealed Resident #1's continuous tube feeding of Isosource 1.5 infusing via pump at 40 ml/hr (hour) and water flush infusing at 100ml/hr. Further observation revealed tube feeding bag dated 09/20/2025 and water flush bag dated 09/20/2025. During an interview on 09/22/2025 at 8:50 a.m. S8 ADON (Assistant Director of Nursing) acknowledged Resident #1's tube feeding bag and water flush bag were dated 09/20/2025 and should have been changed daily.

Based on record reviews, observations and interviews, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain nail care for 2 (#35, #86) of 3 (#5, #35, #86) residents reviewed for ADLs.Findings:Review of Facility's Care of Fingernails/Toenails Policy revised October 2010 revealed: Purpose: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming.Resident #35Review of Resident #35's medical record revealed an admit date of 07/25/2024 with diagnoses that include in part muscle wasting and atrophy, lack of coordination, and legally blind. Review of Resident #35's MDS (Minimum Data Set) dated 09/10/2025 revealed in part Resident #35 was dependent for bathing, toileting, dressing, and personal hygiene. Observation on 09/22/2025 at 9:30 a.m. revealed Resident #35's fingernails were long, past fingertips, some jagged, with brown substance underneath. During an interview on 09/22/2025 at 9:30 a.m. Resident #35 reported he would like to have his fingernails cut because they scratch him. Resident #35 further reported he is not able to see to do it himself and does not have anything to clean or clip his fingernails. During an interview on 09/22/2025 at 3:15 p.m. S3 Corporate Nurse confirmed Resident #35's fingernails were long and jagged with brown substance underneath and should have been cut and cleaned and were not. Resident #86 Review of Resident #86's medical records revealed an admit date of 08/27/2025 with the following diagnoses, including in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #86's MDS assessment dated [DATE] revealed in part: impairment on one side of upper extremity and dependent for personal hygiene and shower/bath.Observation on 09/22/2025 at 1:00 p.m. revealed Resident #86's fingernails on both hands were long and jagged with a dark brown substance noted underneath fingernails. During an interview on 09/22/2025 at 2:40 p.m. S7 CNA (Certified Nurse Assistant) reported fingernails are trimmed as needed. S7 CNA confirmed Resident #86's fingernails were long, jagged and dirty and needed trimming.

Based on record review and interview, the facility failed to ensure residents were free of unnecessary medications for 1 (#1) of 5 (#1, #2, #3, #4, #11) residents reviewed for unnecessary medications. The facility failed to monitor behaviors for Resident #1 while receiving an antidepressant.Findings: Review of Resident #1's medical record revealed an admit date of 07/30/2025 with the following diagnoses, including in part: depression unspecified.Review of Resident #1's Comprehensive Care Plan revealed, in part: The resident uses antidepressant medication related to diagnosis of depression - .change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, and withdrawal. Review of Resident #1's Physician's orders revealed the following orders:08/14/2025 for Trazadone HCl (Hydrochloride) tablet 100 mg (milligram) give 1 tablet via (by way of) PEG (percutaneous endoscopic gastrostomy)-tube at bedtime for major depressive disorder (MDD). 08/07/2025 - Prozac Oral Capsule 20 mg (Fluoxetine HCl) give 1 capsule via PEG-Tube in the morning for MDD.Review of Resident #1's September 2025 Medication Administration Record failed to reveal behaviors were monitored while receiving an antidepressant medication.During an interview on 09/24/2025 at 9:00 a.m. S4 ADON (Assistant Director of Nursing) reported Resident #1 has not been monitored for behaviors because he has not received a psychotropic but acknowledged resident currently takes an antidepressant medication.

Based on record reviews, observations and interviews, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice for 4 (#18, #19, #44, #75) of 4 (#18, #19, #44, #75) residents reviewed for respiratory therapy. The facility failed to ensure respiratory supplies were changed weekly and stored in a covered device.Findings: Review of the facility's Oxygen Administration policy revised February 2025 revealed in part:Purpose: The Purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention associated with respiratory therapy tasks,Steps in the Procedure: 4. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and /or nasal catheter).5. Oxygen cannula and tubing will be changed within 7-10 days or if visibly soiled. Store in a covered device (i.e., plastic bag, kangaroo pouch) between uses. Resident #18 Review of Resident #18's medical record revealed an admit date of 05/19/2023 with diagnoses that include in part chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease. Review of Resident #18's physician orders revealed an order dated 03/06/2025 Oxygen: Change Mask, 02 (oxygen) tubing, water bottle and clean concentrator filter every night shift every Sunday change tubing and respiratory bags and as needed for contamination. Observation on 09/22/2025 at 10:00 a.m. revealed Resident #18 with oxygen in use via nasal cannula and failed to reveal the oxygen tubing was dated indicating when it had been changed. Observation on 09/22/2025 at 2:45 p.m. revealed Resident #18 with oxygen in use via nasal cannula and failed to reveal the oxygen tubing was dated indicating when it had been changed. Observation on 09/22/2025 at 3:15 p.m. with S3 Corporate Nurse revealed resident #18 lying in bed, oxygen in use via nasal cannula and no date on the oxygen tubing. During an interview on 09/22/2025 at 3:15 p.m. S3 Corporate Nurse confirmed the oxygen tubing should have been dated and was not. Resident #19Review of Resident #19's medical records revealed an admit date of 07/25/2025 with the following diagnoses, including in part: chronic respiratory failure with hypoxia.Review of Resident #19's Physician's orders revealed an order dated 08/22/2025 for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram)/3ml (milliliter) 1 vial inhale orally every 6 hours as needed for shortness of breath.Observation on 09/22/2025 at 8:15 a.m. revealed Resident #19's hand held nebulizer mask and tubing dated 09/0/08/2025 lying on corner shelf and not stored in a covered device.During an interview on 09/22/2025 at 8:15 a.m. Resident #19 reported he received breathing treatments.Observation on 09/22/2025 at 11:30 a.m. revealed Resident #19's hand held nebulizer mask and tubing dated 09/0/08/2025 lying on corner shelf and not stored in a covered device.Observation on 09/22/2025 at 2:30 p.m. revealed Resident #19's hand held nebulizer mask and tubing dated 09/0/08/2025 lying on corner shelf and not stored in a covered device.During an interview on 09/22/2025 at 2:30 p.m. S6 LPN (Licensed Practical Nurse) confirmed hand held nebulizer mask and tubing should be changed every week and acknowledged Resident #19's hand held nebulizer tubing and mask was not changed. Resident #44Review of Resident #44's medical record revealed an admit date of 10/03/2018 with diagnoses that include in part cough, anxiety disorder, chronic obstructive pulmonary disease, and chronic sinusitis. Review of Resident #44's physician orders revealed in part:05/23/2025 Nebulizer: Assess after administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales 3=Congested 4=Crackles 5=Rhonchi 6=Rubs 7=Wheezing 8=Diminished three times a day.05/23/2025 Nebulizer: Assess prior to administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales 3=Congested 4=Crackles 5=Rhonchi 6=Rubs 7=Wheezing 8=Diminished three times a day03/01/2024 Albuterol Sulfate Inhalation Nebulization Solution (2.5 mg/3 ml) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally via nebulizer three times a day for Bronchospasms related to chronic obstructive pulmonary disease.Observation on 09/22/2025 at 9:20 a.m. revealed Resident #44's nebulizer machine sitting on his bedside table with the mask uncovered. During an interview on 09/22/2025 at 2:45 p.m. S3 Corporate nurse confirmed Resident #44's nebulizer mask was not bagged and should have been. Resident #75Review of Resident #75's medical record revealed an admit date of 01/17/2025 with a diagnosis of but not limited to muscle wasting and atrophy, other chronic pain, anxiety disorder, unspecified, atherosclerotic heart disease of native coronary artery without angina pectoris, and chronic obstructive pulmonary disease. Review of Resident #75's September 2025 Physician's Orders revealed orders for:1. Nebulizer: tubing and mask change every night shift every Friday related to chronic obstructive pulmonary disease, change bag every 30 days dated 08/09/2024. 2. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)mg/3ml (Ipratropium-Albuterol) 1 vial, inhale orally every six hours as needed for shortness of breath related to chronic obstructive pulmonary disease, dated 08/09/2024. Observation on 09/22/2025 at 3:51 p.m. revealed Resident #75's nebulizer mask with a date of 09/08/2025 was lying uncovered on Resident #75's roommate's night stand. Observation on 09/23/2025 at 9:00 a.m. with S10 LPN revealed Resident #75's nebulizer mask with a date of 09/08/2025 was lying uncovered on Resident #75's roommates' night stand. During an interview on 09/23/2025 at 9:00 a.m. S10 LPN confirmed Resident #75's nebulizer mask should have been in a black bag labeled with the resident's name.

Based on record review, observations and interviews the facility failed to ensure residents' plans of care were developed and implemented for 2 (#5, #44) of 2 (#5, #44) residents out of a total sample of 37 residents. The facility failed to provide a palm roll for Resident #5 and failed to develop a plan of care for nebulizer treatments for Resident #44. Finding: Resident #5Review of Resident #5's medical record revealed an admit date of 05/20/2024 with a diagnosis of but not limited to muscle wasting and atrophy, lack of coordination, contractures, encephalopathy, atrial fibrillation, essential hypertension, cerebral infarct, and idiopathic progressive neuropathy.Review of Resident #5's annual MDS (Minimum Data Set) dated 08/20/2025 revealed Resident #5's BIMS (brief interview mental status) score was 00 indicating Resident #5 was rarely understood. Further review revealed Resident #5 was totally dependent on facility staff for all ADLs (activities of daily living). Review of Resident #5's comprehensive care plan revealed Resident #5 had an ADL self-care performance deficit related to a cardiovascular accident with left-sided hemiparesis and a contracture of the left upper and lower extremity. Approaches included; nurse to apply palm roll to left hand daily in the a.m. and nurse to remove palm roll in the p.m. daily. Review of Resident #5's September 2025 physicians orders revealed these orders:1. May apply hand roll/palm roll to left hand for 8 hours for contracture management as tolerated. May be applied and removed by certified nursing staff every shift2. Nurse to apply palm roll to left hand daily at 9:00 a.m.3. Nurse to remove palm roll at 5:00 p.m. daily one time a day for therapyObservation on 09/22/2025 at 8:00 a.m. failed to reveal a palm roll in Resident #5's left contracted hand.Observation on 09/23/2025 at 10:00 a.m. failed to reveal a palm roll in Resident #5's left contracted hand.During an interview on 09/24/2025 at 10:00 a.m. S9 OT (occupational therapist) reported the treatment for Resident #5's left hand contracture was for the nurses to apply a small palm roll daily for 8 hours and remove the palm roll in the evening.During an interview on 09/24/2025 at 9:20 a.m. S10 LPN (licensed practical nurse) confirmed Resident #5's left hand was contracted and did not have a palm roll in use as ordered.Resident #44Review of Resident #44's medical record revealed an admit date of 10/03/2018 with diagnoses that include in part cough, chronic obstructive pulmonary disease (COPD), and chronic sinusitis.Review of Resident #44's physician orders revealed in part:03/01/2024 Albuterol Sulfate Inhalation Nebulization Solution (2.5 milligrams (mg)/3milliliters) 0.083% (Albuterol Sulfate) 2.5 mg inhale orally via nebulizer three times a day for bronchospasms related to chronic obstructive pulmonary disease.Review of Resident #44's quarterly MDS dated [DATE] revealed in part: active diagnoses include asthma (COPD) chronic lung disease with health conditions that include shortness of breath at rest, with exertion, or lying flat. Review of Resident #44's comprehensive care plan failed to reveal Resident #44 had been care planned for nebulizer treatments.Observation on 09/22/2025 at 9:20 a.m. revealed Resident #44's nebulizer machine sitting on his bedside table. Observation on 09/22/2025 at 2:45 p.m. with S3 Corporate Nurse revealed Resident #44's nebulizer machine sitting on his bedside table. During an interview on 09/23/2025 at 2:35 p.m. S5 MDS Nurse reviewed Resident #44's comprehensive care plan and confirmed Resident #44 had not been care planned for the care and use of his nebulizer and should have been.

Based on record review, observations, and interviews, the facility failed to obtain informed consent for side rail use and failed to assess resident for the risk of entrapment from side rails quarterly for 1(#3) of 3(#1, #2, and #3) sampled residents. Findings: Review of the facility's Proper Use of Side Rails policy (revised August 2024) revealed in part: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General Guidelines 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (Prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or to assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS (Minimum Date Set) and PRN(As Needed), therapy nursing designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. Bed mobility. b. Ability to change positions, transfer to side of bed and from bed or chair, and to stand and toilet, c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks. Review of Resident #3's medical record revealed an admission date of 05/19/2023 with diagnoses included, in part: muscle wasting and atrophy, not elsewhere classified, left shoulder, chronic pain, unspecified osteoarthritis, and morbid obesity due to excess calories. Review of Resident #3's physician orders revealed: 09/10/2024 may have (bilateral) assist rails to promote independence and bed mobility. Check for placement and functioning every shift; every shift related to muscle wasting and atrophy, not elsewhere classified, multiple sites. Review of Resident #3's 04/25/2025 Annual MDS revealed Resident #3 had a BIMS (Brief Interview Mental Status) Score of 15, which indicated intact cognition. Review of Resident #3's care plan dated 02/29/2024 revealed in part, Resident #3 may have bilateral assist rails to promote independence in bed mobility; provide supportive care. Review of Resident #3's medical record failed to reveal a Side Rail Utilization Assessment had been conducted quarterly as per policy. Observation on 06/30/2025 at 3:15 p.m. revealed Resident #3 resting in bed with bilateral hand assist rails in use. Observation on 07/01/2025 at 8:50 a.m. revealed Resident #3 resting in bed with bilateral hand assist rails in use. During an interview on 06/30/2025 at 3:15 p.m. Resident #3 reported he used the hand assist rails to adjust and sit on the bedside. During an interview on 07/01/2025 at 3:20 p.m. S1DON (Director of Nursing) confirmed the Side Rail Utilization Assessment contained both assessment and consent. S1DON reported a Side Rail Utilization Assessment should have been completed quarterly per policy and had not been completed for Resident #3.

Based on record reviews and interviews, the facility failed to ensure an alleged violation involving abuse was reported to the State Survey and Certification Agency for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. Findings: Review of Facility's Abuse and Neglect Policy (revised October 15, 2022) revealed: Policy Statement - The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a sage resident environment and protect residents from abuse. Staff to resident abuse of any type: The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident. Staff are expected to be in control of their behavior and behave professionally .Treatment/Management: 2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies. Review of Resident #1's medical records revealed an admitted [DATE] with the following diagnoses, including in part: persistent mood (affective) disorder/unspecified, other specified mental disorders due to known physiological condition, insomnia/unspecified, neurocognitive disorder with Lewy Bodies, dementia in other diseases classified elsewhere/ unspecified severity with agitation, history of falling, cognitive communication deficit, pseudobulbar affect, anxiety disorder/unspecified, age-related physical debility and major depressive disorder/recurrent/unspecified. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 03 (severely impaired cognition). Review of Facility's State Survey and Certification Agency Reports since last survey failed to reveal an incident of alleged abuse for Resident #1. Review of Facility's investigation of Resident #1's alleged abuse reported on 12/25/2024 revealed interviews with the staff reporting the abuse and the staff accused of abuse. Further review revealed witness written statements, body audits completed on residents residing in the memory care unit and an in-service conducted on reporting abuse. During an interview on 01/07/2025 at 2:40 p.m. S1 DON (Director of Nursing) confirmed she was notified on 12/25/2024 by S1 CNA (Certified Nursing Assistant) S2 CNA kicked resident when she stepped over him and cursed at Resident #1. S1 DON acknowledged the incident involving Resident #1's alleged abuse was investigated but the facility failed to notify the State Agency and should have.

Based on record review, observation, and interview the facility failed to ensure a resident received ADL (Activities of Daily Living) care for 1 (Resident #3) out 4 (Residents #1, #2, #3, #4) residents reviewed. Findings: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part a primary diagnosis of muscle wasting and atrophy. Other diagnoses included COPD (Chronic Obstructive Pulmonary Disease), bronchitis, cough, anxiety, dysphagia, bipolar disorder, insomnia, hypertension, pain, and osteoporosis. Review of Resident #3's minimum data sheet dated 09/10/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 which would indicate the resident was cognitively intact. Review of Resident #3's comprehensive care plan revealed a care plan with a focus indicating the resident has an ADL self-care performance deficit related to decreased vision, impaired balance. Interventions included personal hygiene: resident requires assistance with personal hygiene. Observation on 10/28/2024 at 8:15 a.m. revealed Resident #3's finger nails to left and right hands were long and dirty. During an interview on 10/28/2024 at 8:15 a.m. Resident #3 was asked if he wanted to have long fingernails and Resident #3 indicated he did not and the nails needed to be cut. Resident #3 also indicated he had asked for his nails to be trimmed a week ago. On 10/28/2024 at 8:25 a.m. S2 DON (Director of Nursing) observed Resident #3's fingernails and S2 DON confirmed Resident #3's fingernails to right and left hands were dirty and needed to be trimmed.

Based on record review, facility's video footage review, and interviews the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure, Resident #4 was checked every two hours for incontinence. Findings: Review of Resident #4's medical record revealed an admitted [DATE] and reentry date of 05/28/2024 with diagnoses including, but not limited to, schizoaffective disorder bipolar type, Alzheimer's disease, history of falls, and osteoarthritis. Review of Resident #4's MDS (Minimum Data Set) dated 08/26/2024 revealed a BIMS (brief interview for mental status) score of 2 indicating severely impaired cognition. Review of Resident #4's comprehensive care plan revealed, in part, the problem of frequent bowel incontinence with intervention including, but not limited to, check resident every two hours. On 10/28/2024 at 2:00 p.m., review of facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 7:15 a.m. revealed in part, S3 CNA (Certified Nursing Assistant) entered Resident #4's room on 10/21/2024 at 11:08 p.m. and exited Resident #4's room [ROOM NUMBER] seconds later. Further review of facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 7:15 a.m. revealed no staff member entered Resident #4's room again until 10/22/2024 at 6:25 a.m. During an interview on 10/28/2024 at 2:30 p.m. S1 Administrator confirmed, after reviewing facility video surveillance, S3 CNA entered Resident #4's room on 10/21/24 at 11:08 p.m. and did not enter Resident #4's room again until 10/22/24 at 6:25 p.m. S1 Administrator also confirmed no other staff entered Resident #4's room between 10/21/24 at 11:08 p.m. and 10/22/24 at 6:25 p.m. During an interview on 10/29/2024 at 10:30 a.m., S2 DON (Director of Nursing) confirmed Resident #4's current comprehensive care plan included an intervention to check on Resident #4 every two hours related to incontinence. During an interview on 10/29/2024 at 10:30 a.m., S1 Administrator confirmed, based on facility's video footage from 10/21/2024 at 11:00 p.m. to 10/22/2024 at 6:25 a.m., staff did not check on Resident #4 every two hours.

Based on record review and interviews, the facility failed to ensure residents were treated with dignity and respect. The facility failed to address 1 resident (#1) out of 3 (#1, #2, #3) residents in a dignified and respectful manner. Findings: Review of Facility's Resident Rights Policy (revised October 4, 2022) revealed: Employees shall treat all residents with kindness, respect, and dignity .These rights include the resident's right to: a. a dignified existence; and c. be treated with respect, kindness, and dignity . Review of Resident #1's medical records revealed an admitted [DATE] and a discharge date of [DATE] with the following diagnoses, including in part: Chronic Obstructive Pulmonary Disease (COPD)/unspecified, centrilobular emphysema, chronic respiratory failure with hypoxia, unspecified diastolic (congestive) heart failure, pneumonia/unspecified organism and pulmonary hypertension/unspecified. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review revealed Resident #1 was receiving oxygen therapy and hospice. During a telephone interview on 10/08/2024 at 10:00 a.m. S5 Complainant confirmed after the incident with the administrator Resident #1 became fearful, felt threatened and didn't want to be left alone. During an interview on 10/08/2024 at 2:35 p.m. S3 Licensed Practical Nurse (LPN) reported Resident #1 told her he was leaving the facility because of the way the administrator spoke to him, how he was rude. S3 LPN further reported Resident #1 was oriented and indicated he was actively dying. During an interview on 1/08/2024 at 2:45 p.m. S4 Certified Nursing Assistant (CNA) reported she took care of the resident. S4 CNA reported the resident told her he was leaving the facility because he didn't like the way he was treated. During an interview on 10/09/2024 at 8:50 a.m. S2 Business Office Manager reported she asked S1 Administrator to join the meeting in an attempt to help Resident #1 and his son understand the payment process. S2 Business Office Manager confirmed S1 Administrator told Resident #1 if his funds were not used to pay his bill at the facility Adult Protective Services (APS) would be notified and he could be arrested. S2 Business Office Manager confirmed Resident #1 was visibly shaken by what S1 Administrator said about notifying APS. S2 Business Office Manager confirmed Resident #1 was adamant about leaving the facility and not feeling safe after the conversation with S1 Administrator regarding APS notification. During an interview on 10/09/2024 at 10:45 a.m. S1 Administrator acknowledged he told Resident #1 if he didn't pay on the day of admission he would call APS.

Based on observations, record reviews, and interviews the facility failed to ensure residents have a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (Resident #360) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. The facility failed to ensure: 1.) a side rail utilization assessment was completed, 2.) a consent for the use of side rails was obtained, and 3.) a physician's order was in place for the use of bedrails for Resident #360. Review of facility's Use of Restraints policy with a revision date of April 2017 revealed in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline of staff convenience or for the prevention of falls. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed . 6. Prior to placing a resident in restraints, there shall be a Restraint Necessity/Positioning Device Assessment Form and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions . 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical symptom); b. how the restraint will be used to benefit the resident's medical symptom; and c. the type of restraint. Review of Resident #360's medical record revealed an admitted [DATE] with diagnoses including heart failure, essential hypertension, and muscle wasting and atrophy. Review of Resident #360's Brief Interview for Mental Status (BIMS) Evaluation dated 08/14/2024 revealed Resident #360 had a BIMS score of 00, indicating severe cognitive impairment. Review of Resident #360's Nursing Admission assessment dated [DATE] revealed in part, Resident #360 was totally dependent on staff for bed mobility, transfers and locomotion. Review of Resident #360's Admission Fall Risk assessment dated [DATE] revealed Resident #360 was at high risk for falls. Review of Resident #360's physician's orders failed to reveal a physician's order for the use of side rails. Review of Resident #360's medical record failed to reveal an Admission Side Rail Utilization Assessment had been completed on 08/14/2024. Further review of the medical record also failed to reveal a consent for the use of side rails from Resident #360 or the Responsible Party (RP). Review of Resident #360's Admission Side Rail Utilization assessment dated [DATE] at 11:00 a.m. revealed in part, Resident #360 had a history of falls, an alteration in safety awareness and displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed. Further review revealed Resident #360 was not currently using the side rails for positioning or support and side rails were not indicated for mobility assistance. Review of Resident #360's interdisciplinary notes revealed nursing note entries by S8ADON (Assistant Director of Nursing) which read in part: 08/19/2024 at 9:45 a.m. Resident #360 pulling to left side and continues to put arm in side rail. Pillow placed on left side for protection. 08/19/2024 at 2:33 p.m. Resident #360 continues to pull to left side and put left arm in rail. An observation on 08/19/2024 at 8:30 a.m. revealed Resident #360 was asleep in bed with bilateral upper side rails in use. An observation on 08/19/2024 at 12:30 p.m. revealed Resident #360 was asleep on left side and positioned close to the upper left side rail with legs partially hanging out of bed. Resident #360 appeared restless and was reaching at left side rail. An observation on 08/20/2024 at 8:20 a.m. revealed Resident #360 was asleep on left side and positioned near the raised upper left side rail. During an interview on 08/21/2024 at 4:20 p.m., S3Corporate Nurse acknowledged Resident #360 had bed rails in use without a physician's order, side rail assessment or consent. S3Corporate Nurse acknowledged Resident #360 would not be able to use an assist rail for mobility and side rails were used as a restraint. During an interview on 08/22/2024 at 9:00 a.m., S9Physical Therapist acknowledged Resident #360's admission side rail assessment failed to reveal side rails were indicated for mobility assistance. S9Physical Therapist acknowledged Resident #360 had bilateral upper side rails in use without a completed admission side rail assessment.

Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of 5% or greater by committing 2 errors (#19, #93) out of 29 opportunities for an error rate of 6.9%. Findings: Resident #19 Observation during medication pass on 08/20/2024 at 8:20 a.m. revealed S6 LPN (Licensed Practical Nurse) administered Fluticasone Propionate and Salmeterol 250mcg (microgram) /50mcg by oral inhalation to Resident #19. Review of Resident #19's current physician orders revealed a 07/16/2024 order for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act (actuation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease. During an interview on 08/20/2024 at 2:30 p.m. S6 LPN reviewed Resident #19's medication container from medication cart which read Fluticasone Propionate and Salmeterol 250mcg/50mcg and reviewed Resident #19's physician order and reported the medication was not administered as per the physician order and should have been. Resident #93 Observation of the medication pass on 08/20/2024 at 7:37 a.m. revealed S6 LPN administered one-half tablet of Metoprolol Succ (Succinate) ER (Extended Release) 25mg (milligram) by mouth to Resident #93. Review of Resident #93's current physician orders revealed a 03/13/2024 order for Metoprolol Succinate ER Tablet Extended Release 24 hour 25mg - give 1 tablet by mouth one time a day related to essential hypertension. During an interview on 08/20/2024 at 2:35 p.m. S6 LPN reviewed Resident #93's medication card from the medication cart which contained half tablets equaling 12.5mg in each blister and read Metoprolol Succ ER 25mg tab (Toprol XL 25mg) - give one-half tablet by mouth once daily and reviewed Resident #93's physician order and reported the medication was not administered as per the physician order and should have been. During an interview on 08/20/2024 at 2:37 p.m. S7 NP (Nurse Practitioner) reviewed the order for Resident #93's Metoprolol Succinate ER 25mg tablet and confirmed Resident #93 should have received a full tablet. During an interview on 08/20/2024 at 3:50 p.m. S2 DON (Director of Nursing) observed Resident #19's medication container for Fluticasone Propionate and Salmeterol 250mcg/50mcg and Resident #93's medication card for Metoprolol Succinate and agreed the medications did not match the physician orders.

Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails. The facility failed to assess residents for use of bed rails (side rails), obtain an informed consent from resident or resident representative prior to installation of bed rails, and/or obtain physician order for bed rails for 11 (#3, #17, #23, #41, #66, #68, #72, #78, #80, #88, #96) out of 17 (#3, #17, #23, #39, #41, #66, #68, #72, #75, #78, #80, #87, #88, #96, #358, #360 and #361) residents investigated for physical restraints. Findings: Review of the facility's Proper Use of Side Rails policy with a revision date of January 16, 2024 revealed in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of the side rails as restraints unless necessary to treat a resident's medical symptoms. Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint. General Guidelines 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. bed mobility b. ability to change positions, transfer to side of bed and from bed to chair, and to stand and toilet; c. risk of entrapment from the use of side rails and d. that the bed's dimensions are appropriate for the resident's size and weight. 4. Consent for use of side rail will be obtained if used as a restraint, from the resident or legal representative after presenting the potential benefits and risk using the Informed Consent for Use of Bed Rails. 10. The resident will be checked at least every shift for safety and proper functioning of the side rail use Resident #3 Review of Resident #3's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, hypothyroidism, pain, other seizures, hereditary and idiopathic neuropathy unspecified, schizophrenia, and chronic obstructive pulmonary disease unspecified. Review of Resident #3's physician orders revealed an order dated 02/02/2024 that read: May have (Right/Left/Bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #3's medical record failed to reveal a side rail assessment had been conducted. Review of Resident #3's medical record failed to reveal a consent for side rails had been obtained. Observation on 08/19/2024 at 1:30 p.m. revealed Resident #3 was lying in bed with head of bed elevated and side rails were raised to each side of upper bed. Observation on 08/21/2024 at 8:25 a.m. revealed Resident #3 had a side rail raised on the left side of the upper bed. During an interview on 08/22/2024 at 1:10 p.m. S3 Corporate Nurse reviewed Resident #3's medical record and reported Resident #3 did not have an assessment or consent for side rails. Resident #17 Review of Resident #17's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: Alzheimer's disease, spinal stenosis, and history of falling. Review of Resident #17's physician orders revealed an order dated 01/31/2024 that read: May have (Right/Left/Bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #17's August 2024 MAR (Medication Administration Record) failed to reveal check for placement and functioning of side/assist rails had been conducted. Review of Resident #17's medical records failed to reveal a consent for side rails. Observation on 08/19/2024 at 9:30 a.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/19/2024 at 3:45 p.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/21/2024 at 10:30 a.m. revealed Resident #17's side rails were raised on each side of upper bed. Observation on 08/22/2024 at 8:15 a.m. revealed Resident #17's side rails were raised on each side of upper bed. During an interview on 08/21/2024 at 11:30 a.m. S3 Corporate Nurse confirmed that there was no consent for bed rails for resident #17. S3 Corporate Nurse also confirmed that medical records for resident #17 failed to reveal any checks completed for placement or function of bilateral assist rails. Resident #23 Review of Resident #23's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: schizoaffective disorder bipolar type, repeated falls, restlessness and agitation, other seizure, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #23's physician orders revealed an order dated 08/20/2024 that read: May have (bilateral) assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Directions: every shift for promote independence. Further review of Resident #23's physician orders revealed failed to reveal an order for side rails prior to 08/20/2024. Review of Resident #23's medical record failed to reveal a consent for side rails prior to 08/20/2024. Observation on 08/19/2024 at 09:10 a.m. revealed Resident #23's right upper side rail was raised while lying on back in bed. Observation on 08/20/24 at 08:45 a.m. revealed Resident #23's side rails were raised on each side of upper bed. Observation on 08/20/2024 at 3:06 p.m. revealed Resident #23 was resting quietly in bed with side rails were raised on each side of upper bed. During an interview on 08/22/2024 at 1:10 p.m. S3 Corporate Nurse reviewed Resident #23's medical record and reported Resident #23 did not have a side rail assessment, consent for side rails, or physician order for side rails prior to 08/20/2024. Resident #41 Review of Resident # 41's medical record revealed an initial admitted [DATE] and a re-entry admitted [DATE] with the following diagnoses, including but not limited to: idiopathic progressive neuropathy, overactive bladder, history of falling, unspecified dementia, and lack of coordination. Review of Resident #41's physician orders failed to reveal an order for side rails. Review of Resident #41's current medical record failed to reveal a quarterly side rail utilization assessment had been done after the initial assessment was done on 05/31/2022. Observation on 08/20/24 at 10:09 a.m. revealed Resident # 41 was in bed resting with eyes closed. Further observation revealed side rails were raised on each side of upper bed. Observation on 08/21/2024 at 12:30 p.m. revealed Resident #41 was in room sitting up in wheel chair. Further observation revealed side rails were raised on each side of upper bed. Observation on 08/21/2024 at 8:10 a.m. revealed Resident #41 in bed eating breakfast. Further observation revealed side rails were raised on each side of upper bed. During an interview on 08/22/2024 at 1:30 p.m. S3 Corporate Nurse reviewed Resident # 41's current medical record and confirmed a quarterly side rail assessment had not been done. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reviewed medical record and confirmed Resident #41 did not have a physician order for side rails. Resident #66 Review of Resident #66's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia and depression. Review of Resident #66's physician orders revealed an order dated 01/30/2024 that read: May have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #66's medical record failed to reveal a consent for side rail use had been obtained. Review of Resident #66's medical record failed to reveal a quarterly side rail utilization assessment had been done after the initial assessment was done on 07/29/2022. Observation on 08/19/2024 at 10:30 a.m. revealed Resident #66's side rails were raised on each side of upper bed. Observation on 08/20/2024 at 8:30 a.m. revealed Resident #66 was in the bed with side rails raised on each side of upper bed. Observation on 08/21/2024 at 8:20 a.m. revealed Resident #66 was asleep in bed with side rails raised on each side of upper bed. During an interview on 08/21/2024 at 4:20 p.m., S3 Corporate Nurse acknowledged a consent for side rail use had not been obtained and ongoing quarterly assessments had not been completed on Resident #66 and should have been. Resident #68 Review of Resident #68's medical record revealed an initial admitted [DATE] and an admission (re-entry) date of 08/06/2024 with the following diagnoses, including but not limited to: pressure ulcer of sacral region, stage 4 and pressure ulcer of sacral region, stage 3, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and muscle wasting and atrophy, multiple sites. Review of Resident #68's physician orders failed to reveal an order for side rails. Observation on 08/20/2024 at 10:01 a.m. revealed Resident #68 was resting with eyes closed with side rails raised on each side of upper bed. Observation on 08/20/2024 12:05 p.m. revealed Resident #68 was resting with eyes closed with side rails raised on each side of upper bed. Observation on 08/21/2024 at 8:00 a.m. revealed Resident # 68 was resting with eyes closed with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:50 p.m. S3 Corporate Nurse reviewed medical record and confirmed Resident #68 did not have physician orders for side rails. Resident #72 Review of Resident #72's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: cerebral vascular accident, hemiplegia and hemiparesis on right side and lack of coordination. Review of Resident #72's physician orders revealed an order dated 01/31/2024 that read: May have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning every shift. Review of Resident #72's August 2024 MAR (Medication Administration Record) failed to reveal any monitoring for placement and functioning had been conducted. Review of Resident #72's medical record failed to reveal a consent for side rails or quarterly assessments for side rail utilization. Observation on 08/19/2024 at 9:30 a.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/19/2024 at 3:45 p.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/21/2024 at 10:30 a.m. revealed Resident #72 had side rails raised on each side of upper bed. Observation on 08/22/2024 at 8:10 a.m. revealed Resident #72 had side rails raised on each side of upper bed. During an interview on 08/21/2024 at 11:30 a.m. S3 Corporate Nurse confirmed that there was no consent for bed rails for resident #72. S3 Corporate Nurse also confirmed that medical records for resident #72 failed to reveal any monitoring had been completed for placement or function of bilateral assist rails. During an interview on 08/22/2024 at 1:25 p.m., S3 Corporate Nurse confirmed that there are no quarterly assessment for side rail utilization assessment for resident #72. Resident #78 Review of Resident #78's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: Parkinsonism, pain unspecified, restlessness and agitation, pure hypercholesterolemia unspecified, dementia, type 2 diabetes mellitus without complications. Review of Resident #78's physician orders failed to reveal an order for the use of side rails. Review of Resident #78's August 2024 MAR failed to reveal any monitoring had been conducted in regard to Resident #78's side rails. Observation on 08/19/2024 at 9:10 a.m. revealed Resident #78's side rails were up on each side of upper bed. Observation on 08/21/2024 at 8:10 a.m. revealed Resident #78's side rails were up on each side of upper bed. During an interview on 08/22/2024 at 1:15 p.m., S3 Corporate Nurse reviewed Resident #78's medical record and reported Resident #78 did not have an order for side rails and monitoring had not been conducted for Resident #78 who used side rails. Resident #80 Review of Resident #80's medical record revealed an admitted [DATE] with following diagnoses, but not limited to: muscle wasting and atrophy, multiple sites, type 2 DM, muscle weakness (generalized), primary generalized (osteo) arthritis, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and lack of coordination. Review of Resident #80's physician orders failed to reveal an order for the use of side rails. Observation on 08/20/2024 at 9:09 a.m. revealed Resident #80 was in bed watching television with side rails raised on each side of upper bed. Observation on 08/21/2021 at 8:10 a.m. revealed Resident #80 was in bed eating breakfast with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m., S3 Corporate Nurse reviewed Resident #80's medical record and confirmed Resident #80 did not have a physician order for side rails. Resident #88 Review of Resident #88's medical record revealed an initial admitted [DATE] and a re-entry date of 03/06/2024 with the following diagnoses, including but not limited to: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, type 2 diabetes mellitus, abnormalities of gait and mobility, lack of coordination, muscle wasting and atrophy. Review of Resident #88's physician orders failed to reveal an order for the use of side rails. Observation on 08/20/24 at 9:09 a.m. revealed Resident #88 was in bed watching television with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reported Resident #88 did not have a physician order for bed rails. Resident #96 Review of Resident #96's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to: rhabdomyolysis, lack of coordination and rheumatoid arthritis. Review of Resident #96's physician orders failed to reveal an order for the use of side rails. Review of Resident #96's medical record failed to reveal a side rail utilization assessment consents. Observation on 08/20/24 at 9:40 a.m. revealed Resident # 96 was in bed with side rails raised on each side of upper bed. Observation on 08/20/2024 at 12:20 p.m. revealed Resident # 96 was in bed watching television with side rails raised on each side of upper bed. Observation on 8/21/2024 at 8:10 a.m. revealed #96 in bed eating breakfast with side rails raised on each side of upper bed. During an interview on 08/22/2024 at 1:40 p.m. S3 Corporate Nurse reported an initial side rail assessment and consent had not been completed for Resident #96. S3 Corporate Nurse further reported Resident #96 did not have a physician order for side rails. 36921 40015 44414

Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of PBJ (Payroll Based Journal) [NAME] Report 1705D for the fiscal year 2024, 2nd quarter (January 1-March 31) revealed excessively low weekend staffing was triggered. During an interview on 08/22/2024 at 10:10 a.m S1 Administrator reported S5 Human Resources submits the agency staffing information to corporate and corporate submits PBJ report quarterly to CMS (Centers for Medicare & Medicaid Services). S1 Administrator reported the facility had adequate staff. S1 Administrator reported an agency invoice may have been missed or corporate may not have had the agency invoice at the time of reporting. During an interview on 08/22/2024 at 10:25 a.m. S5 Human Resources reported the PBJ staffing report is completed by the corporate office. S5 Human Resources reported when staffing agencies send staffing hours to the facility late, the staffing hours reported to corporate office will show that the facility did not have enough staff. S5 Human Resources reported when staffing agency hours are late to the facility and corporate sends the information into the PBJ system, the staffing numbers do not show the agency staff hours and it appears the facility did not have adequate staffing.

Based on observations and interview the facility failed to accommodate the needs of 1 (#78) of 26 sampled residents. The facility failed to ensure Resident #78's call light was within reach. Findings: Review of Resident #78's medical record revealed an admitted [DATE] with diagnoses that included, in part, parkinsonism, unspecified dementia with psychotic disturbance, type 2 diabetes mellitus, pain unspecified, restlessness and agitation, and insomnia. Review of Resident #78's 06/06/2024 Quarterly MDS (Minimum Data Set) revealed Resident #78 had a Brief Interview Mental Status (BIMS) of 03 which indicated a severe cognitive impairment and required extensive assistance with bed mobility, transfer, and toilet use. Observation on 08/19/2024 at 8:20 a.m. revealed Resident #78's call light was on the bedside table where Resident #78 could not reach it. During an interview on 08/19/2024 at 8:20 a.m. this surveyor asked Resident #78 if he could reach his call light and Resident #78 was observed feeling around on his bed and answered no. Observation on 08/19/2024 at 8:56 a.m. revealed Resident #78 calling help repeatedly as this surveyor approached Resident #78's room. Call light was observed on Resident #78's bedside table and out of Resident #78's reach. During an interview on 08/19/2024 at 8:59 a.m. S4 CNA (Certified Nursing Assistant) observed Resident #78's call light on Resident #78's bedside table and reported the call light was out of Resident #78's reach and should not be.

Based on record review and interviews the facility failed to ensure provision of services in compliance with all applicable Federal, State, and local laws, regulations and codes by failing to investigate an incident involving resident to staff violence for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to follow the facility's policy by failing to investigate a resident to staff verbal exchange that progressed to a physical exchange between Resident #1 and S6 LPN (Licensed Practical Nurse). Findings: Review of Workplace Aggression/Violence Policy revised April 2023 Policy Statement It is the policy of this facility that all employees, residents, family members, visitors, contractors, vendors, etc., enjoy a positive, respectful, productive and safe environment while on our premises. Policy Interpretation and Implementation 1. Workplace violence is defined as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. Violent acts include, but are not limited to: a. Verbal or physical harassment; b. Verbal or physical threats; c. Assaults or other violence made directly or indirectly by words, gestures, or symbols; d. Any other behavior that causes others to feel unsafe (e.g., bullying, sexual harassment); and/or . 2. This facility has implemented a Workplace Corporate Compliance Program. The goal of this program is to promote an environment free of behavior, actions, or language causing or contributing to workplace violence, harassment or bullying. . 5. It is the responsibility of all employees to notify the appropriate supervisor or HR (Human Resources) Director of any threats which they have witnessed, received, or been told that another person has witnessed or received. . Review of Resident #1's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, bipolar disorder current episode depressed moderate 05/07/2024, anxiety disorder 11/16/2023, and violent behavior 05/22/2024. Review of Resident #1's 06/12/2024 Admission MDS (Minimum Data Set) revealed Resident #1 had a BIMs score of 15 which indicated Resident #1 was cognitively intact. Review of Resident #1's Progress Notes revealed a 05/21/2024 at 22:42 Nurses Note by S6 LPN which read in part: 12am: . resident was rolling down hallways yelling, screaming and using profanity . Writer entered resident room and observed resident sitting in wheelchair by door. Writer informed resident to not yell down hallways while others are sleeping. resident rolled next to writer . writer then asked resident . to move back away from writer and resident then stood up and pushed writer out of resident room and slammed door . Writer then . went to front nurses station and notified DON (Director of Nursing). Resident then came to front nurses station yelling at staff and saying to writer just wait until I finish with you, you _(profanity)__, you won't have a job. Writer informed resident to please leave nurses station and go back to room. Resident then left nurses' station. Review of undated witness statement documentation revealed the following: To whom it may concern, On May 21st on the 11-7pm shift I witnessed Resident #1 push the nurse, S6 LPN and slammed the door. Sincerely, S7 CNA (Certified Nursing Assistant) Review of the facility's Incident Log failed to reveal an incident report with investigation had been completed in regard to the 05/21/2024 incident between Resident #1 and S6 LPN. During an interview on 06/26/2024 at 3:03 p.m. S7 CNA reported she had been seated in the dining room near the hall entrance and in sight of Resident #1's door, and heard Resident #1 yelling and cussing and got up to see what was going on and saw Resident #1 push S6 LPN, who had been standing in Resident #1's doorway, toward the hallway and slam the door. During an interview on 06/25/2024 at 11:29 a.m. S5 DON reported an incident report had not been completed for the 05/21/2024 incident between staff and Resident #1 as she saw the progress note entered in Resident #1's medical record and did not think it was necessary to write an incident report for it. During an interview on 06/25/2024 at 10:22 p.m. S4 Administrator reported an incident report had not been completed for what occurred between Resident #1 and S6 LPN on 05/21/2024, he had not viewed the camera recording from the 05/21/2024 incident, and the recording of the incident was no longer available. During an interview on 06/25/2024 at 2:35 p.m. S9 NP (Nurse Practitioner) reported Resident #1 had a history of running into people with his wheelchair, would roll over their feet, would throw trays, would scream and yell, had charged a nurse, would fly off the handle when he did not get his way and always denied any accusations. S9 NP further reported she had been made aware of the incident that occurred between Resident #1 and staff member the night of 5/21/2024 and she had visited with Resident #1 on the morning of 05/22/2024 and found Resident #1 to be more aggressive than normal and was unable to calm Resident #1 down. The decision was made to PEC (Physician's Emergency Certificate) Resident #1 and after Resident #1's refusal to go, police were called and assisted with transfer to Behavioral hospital. During a phone interview on 06/27/2024 at 10:11 a.m. S8 NP reported he had been consulted by S9 NP the morning of 05/22/2024 regarding Resident #1's current behavior of agitation and pushing of a staff member the night before. S8 NP further concurred the behavior was notably above Resident #1's baseline, it was reasonable Resident #1 could be aggressive again, and was in need of an inpatient treatment. During an interview on 06/27/2024 at 9:05 a.m. S1 Regional Vice-President reported, if notified of a workplace violence issue, that issue would be reported to the facility's Corporate Compliance Officer. S1 Regional Vice-President further reported the facility had not considered the 05/21/2024 occurrence between Resident #1 and a staff member an incident, but a behavior and it was not investigated nor was it reported to the facility's Corporate Compliance Officer. S2 Corporate Nurse was present during the interview and confirmed.

Based on observations, record reviews and interview, the facility failed to ensure 1 (Resident #3) of 3 (Resident #1, #2, #3) sampled residents was free of accidents and hazards. Findings: Review of Resident #3's medical records revealed admitted [DATE] with the following diagnoses, in part: muscle wasting and atrophy/multiples sites, other abnormalities of gait and mobility, other lack of coordination, anxiety disorder/unspecified, shortness of breath, Type 2 diabetes mellitus without complications, pain/unspecified, heart failure/unspecified, and pulmonary fibrosis/unspecified. Review of Resident #3's Comprehensive Care Plan revealed: risk for falls r/t (related to) gait/balance problems, Psychoactive drug use - fall mats x 2, keep bed in low position Be sure the resident's call light is within reach . Review of Resident #3's Physician's Orders revealed an order dated 04/09/2024 - patient to have low bed and fall mats. Observation on 04/15/2024 at 10:10 a.m. revealed Resident #3 lying in bed with call bell hanging off side of bed out of reach. Bed in high position. Observation on 04/15/2024 at 4:00 p.m. revealed Resident #3 lying in bed asleep. Bed in high position. Call bell wrapped around assist rail and hanging down out of reach. Observation on 04/16/2024 at 8:10 a.m. Resident #3 lying in bed with bed in high position and call bell on floor. Observation on 04/16/2024 at 10:25 a.m. revealed Resident #3's call bell on floor and bed in high position. During an interview on 04/16/2024 at 10:25 a.m. S1 Restorative Aide acknowledged the bed should be lowered and the call bell should not be on the floor.

Based on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for a resident with a known critically high white blood count for 1 (#1) resident out of 5 (#1-#5) sampled residents by: 1. Failing to give antibiotics in a timely manner and 2. Failing to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice resulted in an actual harm on [DATE] at approximately 6:00 PM when Resident #1 was found to have altered mental status, clammy skin, decreased blood pressure, and increased heart rate. Resident #1 was transferred to the hospital where he was found to be lethargic and minimally responsive. Lab work drawn at the hospital on [DATE] at 7:31 PM revealed a wbc (white blood count) of 29.4 (4.,d+[DATE].0 reference range) and a creatinine of 5.22 (0.,d+[DATE].30 reference range). Resident #1 progressively worsened and expired on [DATE] at 5:55 PM. Resident #1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed laboratory results for Resident #1 dated [DATE] with a WBC (white blood count) of 19.1 (normal range 4.,d+[DATE].2). The lab results contained a statement that read, Made several attempts to reach nurse of patient. 1506 1530 1641. Results can be found online. Further record review revealed lab work for Resident #1 dated [DATE] with a WBC of 17.8. The lab also read Medical Alert result verified and called with read back to S3 LPN (Licensed Practical Nurse) at 01:49 PM on [DATE]. In a phone interview on [DATE] at 1:33 PM, S3 LPN confirmed she received the phone call from the lab on [DATE] and received the critical lab value of a 17.8 white blood count. S3 LPN explained she contacted S4 NP (Nurse Practitioner) and reported the lab value to her. S3 LPN confirmed she received an order at 4:19 PM from S4 NP to start Resident #1 on [MEDICATION(S)] 500 mg (milligrams) by mouth twice daily for 5 days. S3 LPN explained she faxed the order to the pharmacy and reported she thought she gave the resident the first dose of antibiotics. Review of the February 2022 MAR (Medication Administration Record) revealed Resident #1 received the first dose of [MEDICATION(S)] 500 mg by mouth on [DATE] at 8:00 PM. Further review revealed no doses were documented as given on [DATE] through [DATE] prior to the 8:00 PM dose on [DATE]. Review of S4 NP's Progress Note dated [DATE] revealed Resident #1 was being evaluated for leukocytosis as the chief complaint. S4 NP stated in the history Discussed with Dr. ______, we will restart [MEDICATION(S)] X 7 additional days, I will reassess for improvement tomorrow. Further review revealed the following orders noted under diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It further read to continue [MEDICATION(S)] 500mg every 12 hours for 7 additional days. Review of S4 NP's progress note dated [DATE] revealed Resident #1 was being reevaluated for leukocytosis and progress of debilitation. Further review revealed the following order beneath diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record failed to reveal any evidence of the urinalysis, chest x-ray, or KUB ordered on [DATE] and [DATE] being completed. Review of the nurses' notes for Resident #1 revealed the following entry: [DATE] at 6:10 PM: Aide brought to writer's attention that resident was not looking well. This staff went to evaluate resident and decided to send resident to hospital at approximately 18:00 to be evaluated due to resident's altered mental status, clammy skin, and decreased blood pressure and increased heart rate. NP was notified. Responsible party was notified. By: S3 LPN Review of hospital records revealed on [DATE] at 18:42, Resident #1's blood pressure was ,d+[DATE]. Pulse was 119, respirations were 22, oxygen saturation was 92, and temperature was 98.4. Resident #1 was seen by the provider at 18:50 and was found to be lethargic and minimally responsive. Lab drawn on [DATE] at 19:31 resulted in a WBC of 29.4 (reference 4.,d+[DATE].0) and a creatinine of 4.93 (reference 0.,d+[DATE].30). The hospital course was described as a patient with aspiration pneumonia and septic shock who was noted to have acute hypoxic respiratory failure. Patient was intubated and on mechanical ventilation who continued to progressively worsen. Discussed with family who reported patient was DNR (do not resuscitate) and did not want aggressive measures. Patient was extubated and passed away at 17:55 on [DATE]. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on [DATE] at 12:15 PM, S4 NP confirmed she ordered the urinalysis, chest x-ray, and KUB on [DATE] and [DATE] to try to determine why Resident #1's white blood count was elevated. S4 NP was aware the tests ordered were not completed and said she was working with them on that in reference to the facility not completing the ordered tests. In an interview on [DATE] at 4:15 PM, S2 RN Unit manager confirmed Resident #1's [MEDICATION(S)] was not started until the evening of [DATE] and should have been started earlier if it was ordered on [DATE]. She reported, We want the resident to get it as soon as possible. She explained when the order is received, the floor nurse should put it in the computer and fax it to the pharmacy. She further explained the floor nurse should then call the pharmacy to see if they can stat it over and if not able to do so, the nurse can pull it out of the emergency kit. S2 RN Unit Manager confirmed [MEDICATION(S)] is generally kept in the emergency medication kit. S2 RN Unit Manager confirmed nurses are taught to give the first dose of antibiotics as soon as possible and to not wait until the next day if at all possible. S2 RN Unit Manager confirmed a urinalysis, chest x-ray and KUB had not been done as ordered by S4 NP. S2 RN Unit Manager confirmed stat orders should be done right away. S2 RN Unit Manager explained when stat x-ray orders are received, the floor nurse should call the x-ray provider and give them the stat order and they usually arrive within an hour to do the x-rays. S2 RN Unit Manager reported for a stat urinalysis, the floor nurse should go ahead and do an in and out catheter to collect the urine, complete a lab requisition form, and call the lab to report the stat order and to come pick the urine up. S2 RN Unit Manager confirmed it should be done right away and placed in the refrigerator for pick up. During an interview on [DATE] at 4:25 PM, S1 DON (Director of Nurses) confirmed the urinalysis, chest x-ray and KUB were not done as ordered on [DATE] and [DATE] by S4 NP. S1 DON further confirmed Resident #1 did not receive the first dose of [MEDICATION(S)] 500 mg by mouth until 8:00 PM on [DATE], although it was ordered on [DATE] at 4:19 PM. S1 DON confirmed it should have been started by the morning of [DATE] at the latest. S1 DON explained if the medication had not yet arrived from the pharmacy by the following morning, then Resident #1's nurse should have pulled the medication from the emergency medication kit and given it to the resident.

Based on record review and interviews, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to attain or maintain the highest practicable physical well-being, as determined by resident assessments and individual plans of care, for 1 (#1) of 8 sampled residents. The facility failed to: 1. Ensure Resident #1's critically high potassium level of 7.60 mmol/L (millimole per liter) was reported upon receipt to the physician/medical director or nurse practitioner, and 2. Ensure Resident #1 received [MEDICATION NAME] 15 gm/60ml by mouth and 2000 ml of Normal Saline IV to decrease the resident's potassium level. The deficient practice resulted in actual harm for Resident #1 on 12/6/19 when the nursing staff failed to act upon a critically high potassium level of 7.60 mmol/L. On 12/6/19 the facility's S5 Nurse Practitioner discovered the critical potassium level of 7.60 mmol/L and ordered [MEDICATION NAME] 15 gm (grams)/60 ml (milliliters) by mouth to be given on 12/6/19 and 12/7/19 along with Normal Saline 2000 ml IV (intravenous) at 150 ml per hour. The resident never received the ordered medications. On 12/07/19 Resident #1 was observed to be lethargic and slightly confused. The resident was transferred to a local hospital and diagnosed with [REDACTED]. The resident received emergent [MEDICAL TREATMENT] and was placed in ICU. The facility implemented corrective actions which were completed prior to State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident #1's nursing facility [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (high potassium), CKD ([MEDICAL CONDITION]), Hypertension, [DIAGNOSES REDACTED] Fibrillation, Type 2 Diabetes, [MEDICAL CONDITION], and Acute or Chronic [MEDICAL CONDITION]. Review of Resident #1's physician's orders [REDACTED]. --Potassium Chloride Extended Release 20meq tablet. Give 1 tablet by mouth once daily Potassium Chloride Extended Relaese 20 mEq was started on 8/15/19 and discontinued on12/6/19. --12/6/19 - [MEDICATION NAME] 15G/60ml give 60ml today and tomorrow for [MEDICAL CONDITION]. --12/6/19- Normal saline 2000ml intravenous (IV) at 150ml per hour for IVVD (Intravascular Volume Depletion), AKI (Acute Kidney Injury) on CKD ([MEDICAL CONDITION]). Review of Resident #1's MAR (Medication Administration Record) for (MONTH) 2019 revealed that Sodium [MEDICATION NAME] ([MEDICATION NAME]) 15 gm/ 60 ml (12/6/19 and 12/7/19) and 2000 ml of Normal Saline IV (12/6/19) were not given per the Nurse Practitioner's order on 12/6/19 (The order for 2000 ml of Normal Saline was not administered due to no IV access.) Further review of the MAR indicated [REDACTED]. Review of Resident #1's Nurses' Notes showed the following: Note on 12/6/19 by S8LPN- NP made rounds and want to start PIV for IVF and ABX. If unable to access PIV, obtain midline/PICC. NS 2000ml IV at 150cc/hr for IVVD, AKI on CKD. [MEDICATION NAME] 60ml today and tomorrow for [MEDICAL CONDITION] and forward urine culture as soon as available. Responsible Party notified. Note on 12/6/19 at 11:28by S7LPN- two failed attempts to obtain peripheral IV, report off to oncoming nurse. Note on 12/7/19 at 7:39pm by S9LPN- Resident lying in bed lethargic and slightly confused. 113/77 Blood Pressure, 105 Heart Rate, 98.9 Temperature, 98% Pulse Oximetry on room air. Family requested that she be sent to --- ER. S5FNP notified with order noted to send to ER. Her daughter was notified and will meet her at ER. Resident to ER per ambulance. (Per Hospital emergency room Records Resident #1 arrived in the emergency room 0n 12/7/19 at 2:19 p.m.) During an interview on 01/14/2020 at 11:13am, S2DON indicated that the [MEDICATION NAME] 60ml that was ordered for Resident #1 on 12/6/19 was to be given by mouth. S2DON confirmed that [MEDICATION NAME] is kept in the emergency medicine kit available to staff for administration. S2DON explained S8LPN scheduled the med to be given at 10:00 pm. S2DON confirmed the oncoming 7p-11p LPN (S7LPN) somehow overlooked the medicine in the MAR for the 10:00pm dose and did not give the [MEDICATION NAME] to Resident #1. S2DON indicated that the [MEDICATION NAME] should have been given by one of the 2 nurses and it was not given. S2DON further indicated that the [MEDICATION NAME] should have been given as soon as possible due to it being in the emergency medicine kit and Resident #1 having a critically high potassium level. During the survey process, neither S7LPN nor S8LPN were available for interview. S7LPN had been terminated and S8LPN had resigned pending termination. During an interview on 01/13/2020 at 12:00pm, S2DON indicated Resident #1 had a critical lab value of 7.60 mEq/l on 12/3/19. S8LPN was noted by the Lab Company as the person who they reported the critical lab to. S2DON verified S8LPN did not notify the nurse practitioner or physician/medical director of the critical lab value. S2DON indicated S8LPN denied receiving the critical lab value from _________Laboratories. Review of Resident #1's ___________Laboratories Lab results report dated 12/3/19 revealed a potassium level of 7.60 mmol/L (millimole/liter). Further review revealed the potassium level was verified and called back to S8LPN. During an interview on 1/14/20 at 2:35 p.m., S23Laboratory Supervisor at ____Laboratories explained the process for reporting critical lab values are notifying the nurse taking care of the resident and having the nurse repeat back the critical lab value. __________Laboratories takes the name of the nurse and inserts it on the lab value/results report and then faxes it to the facility. During an interview on 01/13/2020 at 3:20 pm, S5 Nurse Practitioner indicated that she was reviewing Resident#1's labs on 12/6/19 and noticed resident had a critical potassium level on 12/3/19 and she had not been notified of the critically high value. Further indicated that on 12/6/19 she ordered for [MEDICATION NAME] 60ml to be given on 12/6/19 and 12/7/19 and also ordered Normal Saline to be given at a rate of 150ml/hr (hour) for a total of 2000ml via PIV (intravenous catheter) or PICC (Peripherally Inserted Central Cather) if a PIV could not be obtained. S5Nurse Practitioner confirmed she was not notified that Resident #1 had not received the ordered medications and was not aware Resident #1 was still receiving Potassium. S5Nurse Practitioner confirmed Resident #1 should not have continued to receive Potassium with a critical potassium level. S5Nurse Practitioner confirmed she had not been notified that the ordered medications were not given and only became aware when Resident #1 was transferred to a local emergency roiagnom on [DATE]. Review of the Facility's: Lab and Diagnostic Test Results - Clinical Protocol Policy revealed the following: Identifying Situations that Warrant Immediate Notification: High or toxic serum medication levels. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above the therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. Review of Resident #1's medical record did not reveal any documentation the physician or nurse practitioner were notified the ordered [MEDICATION NAME] and IV fluids were not given after being ordered on [DATE]. During an interview on 01/15/2020 at 9:58 a.m., S22CNA indicated that she took care of Resident #1 on a routine basis. S22CNA indicated on 12/7/19 she checked on Resident #1 around 10:30 am and Resident #1 seemed lethargic. At that point S22CNA notified Resident #1's nurse and she came to look at her. S22CNA recalled the resident was transferred to a local emergency room later that afternoon. Review of Resident #1 hospital records from 12/7/19- 12/13/19 revealed in part, Resident #1's potassium level was 9.3, Bun 87, Creatinine 2.92. Consultation dated 12/7/19 read as follows: Reason for consultation- 1. Acute kidney injury on [MEDICAL CONDITION] stage IV. 2. Life threatening [MEDICAL CONDITION]. 3. Metabolic acidosis. Consultation continued- .was sent to ER (emergency room ) today where potassium was found to be 9.3, [MEDICATION NAME] of 11, and anion gap of 12 was transferred to_-----------hospital we were consulted here in regards to lab abnormalities. Impression- 1. [MEDICAL CONDITION] (CKD) stage IV with baseline creatinine 3-3.5 in 9/2019, 2. Acute kidney injury previously. 3. Severe [MEDICAL CONDITION] in the context of acute kidney injury. 4. Metabolic acidosis, give [MEDICATION NAME] drip and check lactic acid. 5. [MEDICAL CONDITION], give empiric antibiotics. 6. Chronic [MEDICAL CONDITION] . 7. Type 2 diabetes. 8. [MEDICAL CONDITION]. 9. Patient had a very guarded condition given severe [MEDICAL CONDITION] which is life threatening. Reasons for hospitalization and brief clinical summary: [AGE] year old white female admitted to intensive care unit (ICU) .The patient's potassium level was 9.3 at time of admission. The patient was evaluated by Nephrology. Received IV [MEDICATION NAME] and temporary [MEDICAL TREATMENT] catheter placement. Patient underwent [MEDICAL TREATMENT] emergently. Potassium level came down to 7.7, 4.1. Patient was transferred to step down unit from ICU. Patient's symptoms improved. During an interview with the S2DON and the S6 Medical Director on 1/17/20 at 12:00 p.m. they indicated a root cause analysis was conducted and it was determined that a system failure occurred in several areas leading to the outcome for Resident#1. S2DON and S6 Medical Director implemented processes to prevent incident from occurring again. During interviews with Nurses on all shifts the nurses were able to explain the process for reporting critical lab values and holding medications until the nurse practitioner/physician could be contacted for further guidance. In addition, records of residents with critical lab values were reviewed and staff reported the critical values and followed up appropriately. The facility has implemented the following actions to correct the deficient practice from 12/3/19-12/7/19: 1. SIMS investigation was opened on Monday, (MONTH) 09, 2019 following the weekend on which the incident occurred. 2. The two nurse responsible for the failing to administer the [MEDICATION NAME], S8LPN and S7LPN were both terminated and referred to the state nursing board. 3. DON and Medical Director conducted a root-cause analysis in which they reviewed the exact circumstances and series of events that lead to Resident #1's elevated potassium level, as well as the role of the nurse practitioner and how the nurse practitioner was involved in the events that took place, and they concluded with a review of the lab process at the facility. 4. S2DON and S4 Unit Manager met with a Laboratory Representative to discuss their concerns with the facility not receiving lab results. Through the discussion with the lab rep weak areas of the lab process were identified, and through collaboration with the facility's IT (Information Technology) team and the laboratory, changes were made to the process. A new system called Care Evolve Auto-Connect was implemented to send lab results to the facility every two hours from 9am to 8pm as applicable, and lab was set-up to fax stat and critical lab results and accompany each fax with a phone call to notify nursing personnel at the facility of any critical results. Nursing personnel have been instructed to notify DON of any critical labs, as well as notifying the resident's physician. 5. After the lab discussion S4UM was commissioned to oversee the lab system. Each day (weekdays) during the Quality Assurance meeting, S4UM is seeking the lab results that were ordered, tracking them, and logging them into a binder to ensure each lab result is reviewed. S4UM is able to log in into lab portal to view the lab results from her computer, which is done daily as well (weekdays). 6. S11QA RN has started QAPI program regarding the lab process; the QAPI plan includes an in-service for nursing personnel, as well as further oversight of the process to ensure the lab results are being reviewed and action is taken when applicable. 7. The following in-service topics were covered as a result of the investigation: a recap of the incident; updated the nursing staff to notify the DON, physician, and nurse practitioner of all critical lab results, and get confirmation from the physician before administering potassium following a critical potassium lab result; a list of phone numbers of ancillary service providers was compiled, reviewed and posted, including the lab company, PICC line placement, pharmacy, x-ray, Doppler imaging and others. 8. Medical Director discussed the use of verbal orders with nurse practitioner, and the nurse practitioner also began documenting the specific time when she writes an order. 9. DON is reviewing all of the nurse practitioner's progress notes and highlighting concern areas to be addressed with each unit manager. 10. S3 Corporate Nurse was involved in the implantation of the aforementioned process changes and monitoring. 11. Correction date was 12/13/19.

Based on record reviews, interviews and observation, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#1) of 6 (#1, #2, #3,#4, #5, #6) sampled residents reviewed for quality of care. This deficient practice resulted in an actual harm for Resident #1 on 8/16/2019 when the resident was observed to have a change in condition which included the inability to ambulate, talk, feed herself, take her medications and make her needs known. Prior to this change in condition, the resident had been ambulatory, responsive, talkative, able to feed herself, take her medications and make her needs known. When the change in condition was observed on 8/16/2019, the nursing staff did not take any immediate actions to ensure the resident received care and treatment in accordance with professional standards of practice, including but not limited to, notifying the resident's NP or physician of these changes. On 8/17/2019 at approximately 9:16 a.m., when the night shift nurse observed that the resident was non-verbal and unresponsive, the NP was notified and the resident was transferred to a local hospital where she was diagnosed with [REDACTED]. Findings: Review of Facility's Change in Resident's Condition Status Policy revealed: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the residents' medical/mental condition and/or status Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d) significant change in the resident's physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Review of Resident #1's medical records revealed an admitted [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan revealed the following problems and approaches: Problem: Impaired cognitive function/dementia (Onset 7/27/18); Approaches: Monitor/document/report PRN any changes in cognitive function, specifically changes in: difficulty expressing self, mental status. Problem: ADL (Activities of Daily Living) self-care performance deficit (Onset 7/27/18); Approaches: Eating: I am able to feed self with set up assist and require 1 staff participation with transfers. Problem: Communication problem (Onset 7/27/18); Approaches: Monitor/document resident's ability to express and comprehend language and report to nurse changes in ability to communicate. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the following: Section G: Functional Status -Bed mobility, toilet use, personal hygiene extensive assistance with one person assist; Locomotion on unit independent. Locomotion off unit independent with setup, Transfer, dressing limited assistance with one person assist; Eating supervision with one person assist; Bathing total dependence with one person assist; Functional Limitation - no impairment; Mobility device - Walker Review of Resident #1's Nurse's Notes revealed the following entries: 8/16/19 12:04 PM - Pt. (Patient) has been unresponsive today only responding to chest rub. Pt. just lying in bed with eyes open, can hear you talking to her but will not say anything in response. Blood Pressure 141/80, Temperature 98.6, Pulse 107, Respirations 18, O2 (oxygen)sat 95%. She didn't take her meds today. RP (Responsible Party) ___ contacted but no answer, left message and NP (Nurse Practitioner) notified . 8/16/19 12:04 PM (Late Entry for 9:00 AM med pass) - The resident refused to take her medications which included Potassium CL ER 20 mEq, Aspirin 325 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] Succ ER 50 mg, Memantine HCL 10 mg, and [MEDICATION NAME] 250 neutral tablet five. Further review revealed, Pt. has been unresponsive only responding to chest rub. 8/17/19 9:16 AM - Resident still verbally unresponsive. Vitals are stable. Resident looks around and is alert to name being called but no verbal response. FNP (Facility Nurse Practitioner) ___ made aware. S2 DON made aware. Resident being transported to ______ ER (emergency room ). Attempted to notify RP ____ of transport. No answer. ______ left facility with resident at 9:15 am. Report called in to _____ local hospital ER 9:20 am . Review of Resident #1's local hospital ER Physician Documentation with arrival date of 8/17/19 at 9:40 AM revealed the following entries: 10:10 AM HPI (History of Present Illness): This [AGE] year unknown female presents to ED (Emergency Department) .with complaints of altered mental status x 2 days (decreased talking). The patient presents with decreased mental status, decreased responsiveness, dysphasia. Onset: The symptoms/episode began/occurred acutely, 2 day (s) ago. 11:11 AM ED Course: tPA (Tissue Plasminogen Activator) [MEDICAL CONDITION] indicated. NIH (National Institute of Health) 18 (15-20 = moderate/severe stroke), sx (symptom) onset greater than 48 hours ago - discussed with Dr. _ Review of Resident #1's local hospital Physician Consultation revealed the following: Date of Consultation: 8/17/19 Reason for Consultation: This is a [AGE] year old Caucasian female nursing home resident who presented with a 2 to 3 day history of decreased speech output .CT (Computed Topography) of the head without contrast imaging was personally reviewed with evidence of a subacute to acute-appearing left anterior cerebral artery territory infarction. No IV (intravenous) tPA was indicated as the patient presented greater than 24 hours after symptom onset. IR ([MEDICATION NAME] Radiologic) thrombectomy was also not indicated for the same .History and physical exam are greatly limited as the patient has minimal speech output. Review of Resident #1's local hospital Physician Consultation revealed the following: admitted : 8/17/19 Chief Complaint: Altered Mental Status, weakness History of Present Illness: apparently was noted to be less responsive than her usual self over the past 2 days She is very aphasic, but per nursing home statement, apparently patient 2 days ago was doing very well, was talkative and communicative. But over the past 2 days, she has been increasingly weak, not communicating much and she was noted to have right-sided weakness. Her nurse had come back from being out of town and when she noted her like this, she alerted EMS (Emergency Medical Response) who brought the patient to the emergency department. Review of Resident #1's local hospital Physician Interpretation of MRI (Magnetic Resonance Image) of Brain Final Report dated 8/18/19 revealed: Impression: Acute Ischemic Infarction corresponding to the left anterior territory. No hemorrhagic transformation. Clinical Information: Altered Mental Status Review of the Resident #1's Nurses Notes dated 08/21/19 revealed- Late entry for 8/20/19. Resident arrived to facility AAO (alert and oriented) to name only. Able to answer some simple questions. Able to follow some simple commands. Able to make some needs known. Able to feed self using left hand. Unable to bear weight to right side. Unable to use right side due to stroke diagnosis. By: ______LPN Review of Resident #1's Admit Day 5 MDS (Minimal Data Set) assessment dated [DATE] following the resident's hospitalization revealed the following: Section G: Functional Status -Bed mobility, transfer, toilet use extensive assistance with two person assist; Locomotion on/off unit, dressing, eating, personal hygiene and bathing extensive assistance with one person assist; Functional Limitation- impairment on both sides of lower extremities; Mobility device - Wheelchair An observation on 09/12/19 at 9:50 AM revealed Resident #1 sitting up in wheelchair dressed, well-groomed and clean with no odors noted. Further observation revealed Resident #1's right arm drawn up to torso and right hand contracted. Resident #1's right leg/foot was on foot rest attached to the wheelchair. Review of Resident #1's Nurse Practitioner Progress Note dated 8/22/19 revealed the following: 8/22/19 - readmitted to SNF (Skilled Nursing Facility) at the nursing home facility 8/20/19. History of Present Illness - readmitted following recent hospitalization at____8/17 - 8/20/19 for acute left ACA (Anterior Cerebral Artery) ischemic infarct, A-fib with RVR (Rapid Ventricular Response) .Late effects [MEDICAL CONDITION] right [MEDICAL CONDITIONS], delay in swallowing, decreased functional level, AMS (altered mental status). During an interview on 9/11/19 at 12:31 PM S3 LPN (Licensed Practical Nurse) stated on 8/16/19 I could tell something was different about Resident #1 because she wasn't perky. S3 LPN stated Resident #1 would not open her mouth to take meds and S3 LPN reported to S5 LPN Unit Manager to come look at Resident #1. S3 LPN reported S5 LPN Unit Manager performed a chest rub on Resident #1 and she made a noise and opened her eyes. S5 LPN Unit Manager instructed S3 LPN to keep an eye on Resident #1 and monitor her. S3 LPN stated I kept an eye on her, told CNA's (Certified Nursing Assistant) to keep an eye on her and notified the next nurse. S3 LPN further reported NP was notified in writing utilizing the facility's communication book regarding Resident #1's changes that were noted. S3 LPN acknowledged if there was an emergent situation she would call the NP but did not on 8/16/19. S3 LPN acknowledged she never spoke with the NP regarding Resident #1's change in condition. During an interview on 9/11/19 at 1:05 PM S5 LPN Unit Manager confirmed S3 LPN asked her to come look at Resident #1 on 8/16/19. S5 LPN Unit Manager confirmed she performed a chest rub on Resident #1 and she made a noise. S5 LPN Unit Manager further confirmed S3 LPN was instructed to get vitals, monitor Resident #1 and if she doesn't improve notify the NP. S5 LPN Unit Manager stated regarding Resident #1, she thought she was sleepy. S5 LPN Unit Manager confirmed the NP is supposed to be or should have been notified if there is something urgent with residents and stated staff usually handle things on their own when notifying the NP. During an interview on 9/11/9 at 1:35 PM S7 CNA reported on 8.16.19, S8 CNA told her Resident #1 was just lying there and was different. S7 CNA reported S8 CNA reported Resident #1 wouldn't eat or pick up her spoon. S7 CNA verified that was not Resident #1's norm. S7 CNA stated S8 CNA said something's wrong and told the LPN. S7 CNA reported that S8 CNA was instructed to get vitals. S7 CNA further confirmed S8 CNA said something still wasn't right so S8 CNA went to S2 DON (Director of Nursing) and told him. S7 CNA confirmed S2 DON came to the room and looked at Resident #1. During an interview on 9/11/19 at 1:43 PM S2 DON confirmed he was informed about Resident #1 and assessed her on 8/16/19 at approximately 2:00 PM. S2 DON stated Resident #1's eyes were open and she would not talk. S2 DON reported Resident #1 was usually talkative and always asked for pain medicine and ambulated around the facility. S2 DON reported the LPN was told to monitor Resident #1, notify NP if there were no improvements and if it gets worse send Resident #1 out. S2 DON confirmed that he did not follow-up on 8/16/19 after the initial assessment of Resident #1. During a telephone interview on 9/11/19 at 3:00 PM S6 NP stated she did not receive a phone call on 8/16/19 regarding Resident #1's change in condition/symptoms. S6 NP verified she was notified regarding Resident #1's condition 8/17/19 and instructed nurse to send to ER. S6 NP confirmed she did not assess Resident #1 in person on 8/17/19. S6 NP further stated she relies on the report given and this was unlike the resident (Resident #1). S6 NP reported if a nurse indicated any thoughts of stroke or if resident was unresponsiveness she would have sent Resident #1 to the hospital. During an interview on 9/12/19 at 11:50 AM S8 CNA stated on 8/16/19 in the morning she observed Resident #1 lying in her bed and appearing to be watching the television. S8 CNA reported she talked to Resident #1 but did not get a response which she stated is unlike Resident #1 who is usually talkative. S8 CNA reported she proceeded to get Resident #1 ready for the day and when touching/moving Resident #1's legs got no response. S8 CNA further stated Resident #1 usually complains about her legs being painful all the time but she did not complain that morning. S8 CNA further verified that this was not Resident #1's norm and she notified the nurse on duty. S8 CNA further verified that the nurse went and found a Unit Manager from another hall to come look at Resident #1. S8 CNA stated Resident #1 was trying to move her mouth but no words came out. S8CNA reported she had to feed Resident #1 in her room and that the resident usually ate all of her meals in the dining room unassisted. S8 CNA reported around 2:00 PM on 8/16/19 she went and told S2 DON about Resident #1 not acting her norm and that she is usually very talkative. S8 CNA further reported S2 DON came into Resident #1's room and called her name then told the staff to watch her. During a telephone interview on 9/12/19 at 2:30 PM, S4 LPN confirmed she worked the 11p-7a shift on 8/16/19. S4 LPN stated she went into Resident #1's room to give her 6am meds and when she woke her up she seemed off and was not verbally responsive. S4 LPN reported she took her vital signs and notified NP, DON and RP who did not answer. S4 LPN further stated the day shift on 8/16/19 reported to her that Resident #1 didn't talk during the day. S4 LPN sent Resident #1 to local hospital via ambulance. During multiple interviews on 09/11/19 and 09/12/19, S1 Administrator and S9 Corporate Nurse acknowledged the Nurse Practitioner or physician and responsible party were not but should have been notified of Resident #1's change in condition on 08/16/19 when she was found unresponsive and unable to communicate.

Based on record review, interview and observation, the facility failed to inform the resident's responsible party (RP) and physician of a resident's change in condition for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) residents reviewed for notification of change. This deficient practice resulted in an actual harm for Resident #1 on 08/16/2019 when the resident was observed to have a change in condition which included the inability to ambulate, talk, feed herself, take her medications and make her needs known. Prior to this change in condition, the resident had been ambulatory, responsive, talkative, able to feed herself, take her medications and make her needs known. When the change in condition was observed on 08/16/2019, the nursing staff did not immediately notify the resident's NP (Nurse Practitioner) or physician of these changes. On 08/17/2019 at approximately 9:16AM, when the night shift nurse observed that the resident was non-verbal and unresponsive, the NP was notified and the resident was transferred to a local hospital where she was diagnosed with [REDACTED]. Findings: A review of the facility's Change in Resident's Condition Status Policy revealed: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the residents' medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d) significant change in the resident's physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b) Impacts more than one area of the resident's health status, c) Requires interdisciplinary review and/or revision to the care plan; and d) Ultimately is based on judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. A review of Resident #1's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the following: Section G: Functional Status -Bed mobility, toilet use, personal hygiene extensive assistance with one person assist; Locomotion on unit independent. Locomotion off unit independent with setup, Transfer, dressing limited assistance with one person assist; Eating supervision with one person assist; Bathing total dependence with one person assist; o Functional Limitation - no impairment o Mobility device - Walker Review of Resident #1's Comprehensive Care Plan revealed the following problems and approaches: Problem: Impaired cognitive function/dementia (Onset 7.27.18); Approaches: Monitor/document/report PRN any changes in cognitive function, specifically changes in: difficulty expressing self, mental status. Problem: ADL (Activities of Daily Living) self-care performance deficit (Onset 7.27.18); Approaches: Eating: I am able to feed self with set up assist and require 1 staff participation with transfers. Problem: Communication problem (Onset 7.27.18); Approaches: Monitor/document resident's ability to express and comprehend language and report to nurse changes in ability to communicate. A review of Resident #1's nurses' notes revealed the following: 08/16/19 at 12:04PM: Patient has been unresponsive today only responding to chest rub. Patient just lying in bed with eyes open, can hear you talking to her but will not say anything in response. BP 141/80, Temp 98.6, Pulse 107, Respirations 18, Oxygen saturation 95%. She didn't take her medications today. RP contacted but no answer, left message and Nurse Practitioner notified. By: S3LPN (licensed practical nurse). 8/16/19 12:04 PM (Late Entry for 9:00 AM med pass) - The resident refused to take her medications which included Potassium CL ER 20 mEq, Aspirin 325 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] Succ ER 50 mg, Memantine HCL 10 mg, and [MEDICATION NAME] 250 neutral tablet five. Further review revealed, Pt. has been unresponsive only responding to chest rub. 08/17/19 at 9:16AM: Resident still verbally unresponsive. Vitals are stable. Resident looks around and is alert to name being called but no verbal response. S6NP (nurse practitioner) made aware. S2DON (Director of Nurses) made aware. Resident being transported to emergency room . Attempted to notify RP of transport. No answer. Ambulance left facility with resident at 9:15AM. Report called in to _____ at the emergency room at 9:20AM. By: S4LPN A review of the hospital's nurse's notes dated 08/17/19 revealed: 09:45AM Presentation: Emergency Medical Services states she is at a nursing facility, they said she has been less verbal for the last 2 days, denies complaints. Symptoms began 2-3 days ago. A review of Resident #1's MRI (Magnetic Resonance Imaging) of Brain final report dated 08/18/19 revealed: Impression: Acute Ischemic Infarction corresponding to the left anterior territory. No hemorrhagic transformation. A further review of Resident #1's hospital record revealed the following history and physical dated 08/17/19: [AGE] year old unknown female presents to emergency department with complaints of altered mental status x 2 days, (decreased talking). The patient present with decreased mental status, decreased responsiveness, and dysphagia. Onset: The symptoms/episode began/occurred acutely, 2 days ago. Emergency department course: tPA [MEDICAL CONDITION] not indicated. NIH 18 (a scale for assessing the severity of a stroke), symptom onset greater than 48 hours ago - discussed with Dr._____. A further review of Resident #1's hospital record revealed the following consultation: Consulting Physician: ______________ Date of Consultation: 08/17/19 Reason for Consultation: This is a [AGE] year old Caucasian female nursing home resident who presented with a 2 to 3 day history of decreased speech output .CT (computed tomography) of the head without contrast imaging was personally reviewed with evidence of a subacute to acute-appearing left anterior cerebral artery territory infarction. No IV (intravenous) tPA was indicated as the patient presented greater than 24 hours after symptom onset. IR thrombectomy was also not indicated for the same . Review of Resident #1's nurses' notes dated 08/21/19 revealed a late entry for 8/20/19: 08/21/19 - Late entry for 8/20/19. Resident arrived to facility AAO (alert and oriented) to name only. Able to answer some simple questions. Able to follow some simple commands. Able to make some needs known. Able to feed self using left hand. Unable to bear weight to right side. Unable to use right side due to stroke diagnosis. By: ______LPN A further review of Resident #1's medical record revealed a Minimum Data Set ((MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 2 indicating the resident had a severe cognitive impairment. The MDS further revealed Resident #1 required extensive assistance by two person assist with bed mobility, transferring, and toilet use. Resident #1 was coded as using a wheelchair for mobility. An observation on 09/12/19 at 9:50AM revealed Resident #1 sitting up in wheelchair dressed, well-groomed and clean with no odors noted. Further observation revealed Resident #1's right arm drawn up to torso and right hand contracted. Resident #1's right leg/foot was on foot rest attached to the wheelchair. Review of Resident #1's Nurse Practitioner Progress Note dated 8/22/19 revealed the following: 8/22/19 - readmitted to SNF (Skilled Nursing Facility) at the nursing home facility 8/20/19. History of Present Illness - readmitted following recent hospitalization at____8/17 - 8/20/19 for acute left ACA (Anterior Cerebral Artery) ischemic infarct, A-fib with RVR (Rapid Ventricular Response) .Late effects [MEDICAL CONDITION] right [MEDICAL CONDITIONS], delay in swallowing, decreased functional level, AMS (altered mental status). During an interview on 09/11/19 at 12:31PM, S3LPN reported on 08/16/19 I could tell something was different about Resident #1 because she wasn't perky. S3LPN stated Resident #1 would not open her mouth to take meds and S3LPN could tell she wanted to say something but couldn't get it out. S3LPN stated she asked S5LPN (Unit Manager on another hall) to come look at Resident #1. S3LPN stated S5LPN performed a chest rub on Resident #1 and the resident made a noise and opened her eyes. S5LPN instructed S3LPN to keep an eye on Resident #1 and to monitor her. S3LPN stated I kept an eye on her, told CNAs (certified nursing assistant) to keep an eye on her and notified the next nurse. S3LPN further reported she notified the NP by entering in the Nurse Practitioner communication book the changes that were noted for Resident #1 but didn't verbally speak with the NP. S3LPN acknowledged she wrote the information in the communication book on Friday 08-16-19 and the NP would not see it until Monday. S3LPN stated in an emergent situation she would call the Nurse Practitioner. S3LPN reported she called and left a message for the RP that morning but did not indicate that she ever tried to contact the RP again. During an interview on 09/11/19 at 1:05PM, S5LPN (Unit Manager) verified S3LPN asked her to come look at Resident #1 on 08/16/19. S5LPN reported she performed a chest rub on Resident #1 and the resident made a noise. S5LPN further reported she instructed S3LPN to get vitals, monitor Resident #1 and if Resident #1 doesn't improve notify the NP. S5LPN indicated she knew Resident #1 from the past but thought she was sleepy. S5LPN reported she notifies the NP if there is something urgent with residents but that staff working on the hall usually handle things on their own as far as notifying the NP. During an interview on 09/11/19 at 1:35PM, S7CNA reported on 08/16/19 S8CNA told her Resident #1 was just lying there and was different. S7CNA reported S8CNA stated Resident #1 wouldn't eat or pick up her spoon which was not normal for Resident #1. S7CNA stated S8CNA said somethings wrong and told the LPN and she was instructed to get vitals. S7CNA further reported S8CNA said something still wasn't right so S8CNA went and told S2DON. S7CNA verified S2DON came and looked at Resident #1. During an interview on 09/11/19 at 1:43PM, S2DON acknowledged he was told about Resident #1 and went to assess her on 08/16/19 at approximately 2PM. S2DON reported Resident #1's eyes were open and she would not talk. S2DON acknowledged Resident #1 was usually talkative and reported she always asked for pain medicine and ambulated around the facility. S2DON further reported he told S3LPN to monitor and notify the NP if no improvements; if it gets worse send Resident #1 out. S2DON confirmed that he did not follow-up on 08/16/19 after his initial assessment of Resident #1. During a telephone interview on 09/11/19 at 3:00PM, S6NP stated she did not receive a phone call on 08/16/19 regarding Resident #1's change in condition or symptoms. S6NP verified she did send Resident #1 to the emergency roiagnom on [DATE], but did not assess the resident in person. S6NP further indicated she relies on the report given and this was unlike Resident #1. S6NP confirmed if the nurse had indicated any thoughts of stroke or unresponsiveness she would have sent Resident #1 to the hospital. During an interview on 09/12/19 at 11:50AM, S8CNA reported on the morning of 08/16/19 she observed Resident #1 lying in her bed, facing the television and appearing to be watching the television. S8CNA talked to Resident #1 but did not get a response, which she indicated is unlike Resident #1 who is usually talkative. S8CNA reported she proceeded to get Resident #1 ready for the day and when touching or moving the resident's legs did not get a response. S8CNA stated Resident #1 usually complains about her legs being painful all the time. S8CNA confirmed she notified the nurse on duty and took Resident #1's vital signs. S8CNA reported that the nurse located a Unit Manager from another hall to come look at Resident #1. S8CNA stated Resident #1 was trying to move her mouth but no words came out. S8CNA reported she had to feed Resident #1 in her room and that the resident usually ate all of her meals in the dining room unassisted. S8CNA reported around 2:00PM she went and told S2DON about Resident #1 not acting her norm. S8CNA further reported S2DON came into Resident #1's room, called her name and then told the staff to watch her. During a telephone interview on 9/12/19 at 2:30PM, S4LPN confirmed she worked the 11PM-7AM shift on 08/16/19. S4LPN reported she went into Resident #1's room to give her 6AM medications and when she woke her up she seemed off and was not verbally responsive. S4LPN verified she took the resident's vital signs, notified S6NP and S2DON, and called the responsible party who did not answer to notify him Resident #1 was being transported to the emergency room . S4LPN further indicated the day shift (08/16/19) reported to her that Resident #1 didn't talk during the day. S4 LPN sent Resident #1 to local hospital via ambulance. During multiple interviews on 09/11/19 and 09/12/19, S1Administrator and S9Corporate Nurse acknowledged the Nurse Practitioner or physician and responsible party were not but should have been notified of Resident #1's change in condition on 08/16/19 when she was found unresponsive and unable to communicate.

Based on record reviews and interviews the facility failed to ensure the resident's physician was immediately notified of a change in condition for 1 (#2) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for pain out of a total resident sample of 8. The facility failed to ensure a resident was free from actual harm by failing to: 1. Ensure the evening shift nurse immediately notified the physician of a resident's new complaints of leg pain when she was notified by the CNA on the evening of 10/21/12 after resident sustained [REDACTED]. 2. Ensure the night shift nurse immediately notified the physician of a resident's complaints of leg pain on 10/22/12 at 5:00 a.m. 3. Ensure the day shift nurse immediately notified the physician of a resident's continued complaints of leg pain and decline in their activities of daily living, as a result of the pain on 10/22/12. Findings: Review of the facility's Incident Log from August 2012-October 2012 revealed resident #2 had a documented incident on 10/21/12 at 4:00 p.m. that occurred in resident #2's room and resulted in a hospital admission. Review of resident #2's electronic nurse's notes revealed the following: 10/21/12 at 9:06 p.m.-4:00 p.m. called to resident #2's room per CNA and upon entering room, observed 3 CNAs holding resident up about to transfer her to bed. CNA stated when transferring resident from bed to wheelchair, resident lost balance so she eased her to the floor. CNAs transferred resident to bed and assessment completed with no reddened areas, bruises, or breaks noted. Range of motion within normal limits to bilateral upper and lower extremities. Resident stated she lost her balance because she had an incontinent episode of stool. Resident denied discomfort/pain at that time. Vital signs stable. Family and physician notified of incident without injury-LPN #S9. 10/22/12 at 1:37 p.m.-Late Entry 7:15 a.m.-Resident lying in bed crying and complains of left leg pain. (name of x-ray company) x-ray of left leg-LPN #S8. During an interview on 10/31/12 at 9:40 a.m. CNA #S18 stated she worked the 11p-7a shift on 10/21/12 and cared for resident #2. CNA #S18 stated resident #2 was fine when she started her shift and had no complaints. CNA #S18 stated no one had told her resident #2 had a fall earlier on the previous shift. CNA #S18 stated the CNA assisting her on the hall that morning, CNA #S19, went to get resident #2 up around 4:00 a.m. on the morning of 10/22/12 and resident #2 told CNA #S19 her leg hurt and that "they" had broken her leg, but did not say who "they" were. CNA #S18 stated CNA #S19 told her about resident #2's comment and stated the resident had not complained all night, so CNA #S19 told the nurse (LPN #S23) and was informed to leave resident #2 in bed. During an interview on 10/31/12 at 9:50 a.m. CNA #S20 stated she worked the 3p-11p shift on 10/22/12 and when she made rounds on resident #2, resident was still in bed which was unusual for resident #2. CNA #S20 stated resident #2 was crying in pain and said her leg was broken. CNA #S20 stated it was a couple of hours later that resident #2 was sent to the hospital. During an interview on 10/31/12 at 11:15 a.m. LPN #S23 stated she cared for resident #2 on the 11p-7a shift on 10/21/12. She stated she was told by the nurse on the previous shift resident had lost her balance and was slid to the floor by 2 CNAs. LPN #S23 stated resident #2 did not complain of pain that night until about 5:00 a.m. the morning of 10/22/12 when she told the CNA her left leg was hurting. LPN #S23 stated she checked on resident #2 and she was not yelling or screaming in pain, but told her the left leg was hurting. LPN #S23 stated she had only worked at the facility for 2 weeks and this was the first time caring for resident #2 and since she did not know her, she waited for the day shift nurse to come in and reported resident #2's complaints to her to get her advice on because resident only complained of pain the one time. LPN #S23 stated she did not call the physician about resident #2's complaint of pain. During an interview on 10/31/12 at 12:40 p.m. ADON #S4, interim DON/Corporate Nurse #S2, Corporate Nurse #S3, and Administrator #S1 were notified that, through interviews, resident #2 complained of pain around 5:00 a.m. on 10/22/12 and the nurse did not call the physician or administer any pain medication that resident already had ordered. They were informed LPN #S23 waited until the morning shift arrived and notified LPN #S8 that resident #2 had complained of pain to her left leg. They were also notified of the decline in resident #2's daily functioning because she was used to being up and out of the bed, but was confined to bed due to the pain and possible fracture. Corporate Nurse #S3 agreed LPN #S23 should have called and notified the physician of resident #2's complaints of pain. Corporate Nurse #S3 agreed because the physician was not notified of resident #2's pain and did not received her pain medication, resident #2 had a decline in her activities of daily living by having to remain in bed all day. During an interview on 10/31/12 at 1:35 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 stated they reviewed the 24 hour nursing report book and LPN #S23 had documented resident #2's pain, but did not document she had called the physician. During an interview on 10/31/12 at 2:15 p.m. CNA #S24 stated she worked on 10/22/12 from 7a-3p and cared for resident #2. CNA #S24 stated resident #2 complained of pain to her left leg and her left shoulder down to her left wrist. CNA #S24 stated she informed the day nurse and asked about getting her up and was told by the nurse to keep her in bed and she was going to have an x-ray done. CNA #S24 stated resident #2 was usually up in her wheelchair and about the facility most of the day. CNA #S24 stated resident #2 needed assistance to get into the wheelchair, but once she was in it, she could move around the facility without assistance. CNA #S24 stated resident #2 had asked all day on 10/22/12 to get out of the bed, but was in so much pain every time she moved she was not able to get up. CNA #S24 stated resident #2 liked being up and out of the bed. During an interview on 10/31/12 at 3:35 p.m. CNA #S22 stated on 10/21/12 around 3:50 p.m. resident #2 asked to get out of bed so she went and got CNA #S21 to assist her. CNA #S22 stated as they were transferring resident #2 from the bed to the wheelchair, resident #2 began to slide like she was going to fall so she told CNA #S21 to help slide resident to the floor and once she was on the floor they called the nurse to the room. CNA #S21 went to get a male CNA (#S25) to assist getting her back to the bed. CNA #S22 stated LPN #S9 came and stood at the door and told them to get the resident back in the bed and get vital signs. CNA #S22 stated LPN #S9 did not come and assess resident #2. CNA #S22 stated they got resident #2 back in bed and she cleaned her up and took vital signs and reported them to the nurse. CNA #S22 stated resident #2's husband came in later that evening and requested that the resident be gotten up to go smoke, so she asked the nurse and was told it was fine. CNA #S22 stated she and CNA #S25 got resident #2 up and during the transfer she complained of pain to the left leg so CNA #S25 told her that they would not place her shoe on that foot just in case it started swelling. CNA #S22 stated resident #2 went to smoke with her husband and she notified LPN #S9 that resident #2 complained of pain to the left leg. During an interview on 10/31/12 at 4:00 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 were informed that CNA #S25 stated resident #2 had complained of pain on the evening of 10/21/12 after the incident had occurred and the nurse was notified. Corporate Nurse #S3 agreed she did not see any documentation from the nurse that resident #2 complained of pain or that the physician was notified.

Based on record reviews and interviews the facility failed to ensure an assessment of the resident's pain and decline in activities of daily living was completed by the nurses for 1 (#2) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for assessments out of a total resident sample of 8. Findings: Review of the facility's Incident Log from August 2012-October 2012 revealed resident #2 had a documented incident on 10/21/12 at 4:00 p.m. that occurred in resident #2's room and resulted in a hospital admission. Review of resident #2's electronic nurse's notes revealed the following: 1. 10/21/12 at 9:06 p.m.-4:00 p.m. called to resident #2's room per CNA and upon entering room, observed 3 CNAs holding resident up about to transfer her to bed. CNA stated when transferring resident from bed to wheelchair, resident lost balance so she eased her to the floor. CNAs transferred resident to bed and assessment completed with no reddened areas, bruises, or breaks noted. Range of motion within normal limits to bilateral upper and lower extremities. Resident stated she lost her balance because she had an incontinent episode of stool. Resident denied discomfort/pain at that time. Vital signs stable. Family and physician notified of incident without injury. The entry was electronically signed by LPN #S9. 2. 10/22/12 at 1:37 p.m.-Late Entry 7:15 a.m.-Resident lying in bed crying and complains of left leg pain. (name of x-ray company) x-ray of left leg. The entry was electronically signed by LPN #S8. 3. 10/22/12 at 3:22 p.m.-X-ray's faxed to physician and call placed to office reporting finding of x-rays. The entry was electronically signed by LPN #S8. Further review of the nurse's notes failed to reveal a documented assessment regarding resident #2's pain, what was done for the pain, or continued assessment from the time the x-ray was obtained until the time the results were obtained and faxed to the physician. Review of resident #2's medical record revealed the following x-ray results: Left tibia-fibula x-ray-Impression: 1. Comminuted fracture (a fracture in which bone is broken, splintered or crushed into a number of pieces) of the proximal third of the tibia. 2. There also appeared to be a [MEDICAL CONDITION] fibula. During an interview on 10/31/12 at 9:40 a.m. CNA #S18 stated she worked the 11p-7a shift on 10/21/12 and cared for resident #2. CNA #S18 stated resident #2 was fine when she started her shift and had no complaints. CNA #S18 stated no one had told her resident #2 had a fall earlier on the previous shift. CNA #S18 stated the CNA assisting her on the hall that morning, CNA #S19, went to get resident #2 up around 4:00 a.m. on the morning of 10/22/12 and resident #2 told CNA #S19 her leg hurt and that "they" had broken her leg, but did not say who "they" were. CNA #S18 stated CNA #S19 told her about resident #2's comment and stated the resident had not complained all night, so CNA #S19 told the nurse (LPN #S23) and was informed to leave resident #2 in bed. During an interview on 10/31/12 at 11:15 a.m. LPN #S23 stated she cared for resident #2 on the 11p-7a shift on 10/21/12. She stated she was told by the nurse on the previous shift resident #2 had lost her balance and was slid to the floor by 2 CNAs. LPN #S23 stated resident #2 did not complain of pain that night until about 5:00 a.m. the morning of 10/22/12 when she told the CNA her left leg was hurting. LPN #S23 stated she checked on resident #2 and she was not yelling or screaming in pain, but told her the left leg was hurting. LPN #S23 stated she had only worked at the facility for 2 weeks and this was the first time caring for resident #2 and since she did not know her, she waited for the day shift nurse to come in and reported resident #2's complaints of pain to her to get her advice because resident #2 only complained of pain the one time. LPN #S23 stated she did not call the physician and did not give resident #2 anything for pain. LPN #S23 stated she told the CNAs not to get resident #2 out of bed. LPN #S23 stated she did write in the 24 hour report book that resident #2 had pain, but did not document an assessment in the nurse's notes. During an interview on 10/31/12 at 12:40 p.m. ADON #S4, interim DON/Corporate Nurse #S2, Corporate Nurse #S3, and Administrator #S1, Corporate Nurse #S3 agreed because the physician was not notified of resident #2's pain and did not receive her pain medication, resident #2 had a decline in her activities of daily living by having to remain in bed all day. Corporate Nurse #S3 reviewed resident #2's closed electronic medical record and stated LPN #S23 did not document in the nurse's notes regarding the resident's complaints of pain. During an interview on 10/31/12 at 2:15 p.m. CNA #S24 stated she worked on 10/22/12 from 7a-3p and cared for resident #2. CNA #S24 stated resident #2 complained of pain to her left leg and her left shoulder down to her left wrist. CNA #S24 stated she informed the day nurse and asked about getting her up and was told by the nurse to keep her in bed and she was going to have an x-ray done. CNA #S24 stated she was not aware of the incident that had occurred the day before. CNA #S24 stated resident #2 was usually up in her wheelchair and about the facility most of the day. CNA #S24 stated resident #2 needed assistance to get into the wheelchair, but once she was in it, she could move around the facility without assistance. CNA #S24 stated resident #2 had asked all day on 10/22/12 to get out of the bed, but was in so much pain every time she moved she was not able to get up. CNA #S24 stated resident #2 liked being up and out of the bed. During an interview on 10/31/12 at 3:35 p.m. CNA #S22 stated on 10/21/12 around 3:50 p.m. resident #2 asked to get out of bed so she went and got CNA #S21 to assist her. CNA #S22 stated as they were transferring resident #2 from the bed to the wheelchair, resident #2 began to slide like she was going to fall so she told CNA #S21 to help slide resident #2 to the floor and once she was on the floor they called the nurse to the room. CNA #S21 went to get a male CNA (#S25) to assist getting her back to the bed. CNA #S22 stated LPN #S9 came and stood at the door and told them to get the resident back in the bed and get vital signs. CNA #S22 stated LPN #S9 did not come and assess resident #2. CNA #S22 stated they got resident #2 back in bed and she cleaned her up and took vital signs and reported them to the nurse. CNA #S22 stated resident #2's husband came in later that evening and requested that the resident be gotten up to go smoke, so she asked the nurse and was told it was fine. CNA #S22 stated she and CNA #S25 got resident #2 up and during the transfer she complained of pain to the left leg so CNA #S25 told her that they would not place her shoe on that foot just in case it started swelling. CNA #S22 stated resident #2 went to smoke with her husband and she notified LPN #S9 that resident #2 complained of pain to the left leg. Review of resident #2's electronic medical record failed to reveal documentation of an assessment regarding resident #2's complaints of pain on the evening of 10/21/12. During an interview on 10/31/12 at 4:00 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 were informed that CNA #S25 stated resident #2 had complained of pain on the evening of 10/21/12 after the incident had occurred and the nurse was notified. Corporate Nurse #S3 agreed she did not see any documentation from the nurse that resident #2 complained of pain.

Based on record reviews and interviews the facility failed to ensure services provided by the facility met professional standards for 2 (#2, #4) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for medication administration out of a total resident sample of 8. The facility failed to ensure a resident who complained of pain received their ordered pain medication and that the physician was notified immediately of a change in the residents condition leading to unrelieved pain and a decline in activities of daily living, which resulted in actual harm (#2). The facility further failed to ensure a medication dose was not changed without a physician's orders [REDACTED]. Findings: 1. Review of the facility's Incident Log from August 2012-October 2012 revealed resident #2 had a documented incident on 10/21/12 at 4:00 p.m. that occurred in resident #2's room and resulted in a hospital admission. Documentation on the Resident Incident Follow-up form revealed the following: 10/21/12 moves all extremities, denies c/o discomfort 10/21/12 resident denies c/o pain or discomfort, mae (move all extremities), states she is a little sore, but does not want any pain med 10/21/12 resident uncomfortable, medicated for pain to left leg, x-ray ordered awaiting results 10/21/12 x-rays back, fx tib/fib to left leg, md and family notified, sent to ER for eval, no discomfort at present Review of resident #2's electronic nurse's notes revealed the following: 10/21/12 at 9:06 p.m.-4:00 p.m. called to resident #2's room per CNA and upon entering room, observed 3 CNAs holding resident up about to transfer her to bed. CNA stated when transferring resident from bed to wheelchair, resident lost balance so she eased her to the floor. CNAs transferred resident to bed and assessment completed with no reddened areas, bruises, or breaks noted. Range of motion within normal limits to bilateral upper and lower extremities. Resident stated she lost her balance because she had an incontinent episode of stool. Resident denied discomfort/pain at that time. Vital signs stable. Family and physician notified of incident without injury-LPN #S9. 10/22/12-7:00 a.m.-staff reported resident complained of left leg pain, x-ray in process, staff implementing measures for pain control, and diagnostic measures underway. 5:00 p.m.-staff reported [MEDICAL CONDITION]/fibula with family and physician notified and resident in route to hospital. IDT (Interdisciplinary Team) notified with recommendation to continue with current implementations/recommendations. Therapy notified to continue with new screening process upon return for her mobility status-former DON. 10/22/12 at 1:37 p.m.-Late Entry 7:15 a.m.-Resident lying in bed crying and complains of left leg pain. (name of x-ray company) x-ray of left leg-LPN #S8. 10/22/12 at 3:22 p.m.-X-ray's faxed to physician and call placed to office reporting finding of x-rays-LPN #S8. 10/23/12 at 3:18 p.m.-Late Entry for 10/22/12-Notified physician of x-ray results. Instructed to send resident to emergency room . Resident sent to local hospital per ambulance via stretcher. Responsible party notified. Review of resident #2's October 2012 physician's orders [REDACTED]. Review of resident #2's medical record revealed the Physician's Standing Orders for Nursing Homes with the following prn (as needed) medications: For Aches and pains (minor or chronic): Tylenol 325 mg (milligram) 2 po (by mouth) every 6 hours as needed for mild pain. If ineffective x24 hours notify Physician. For Severe Pain: Notify Physician. Review of resident #2's electronic October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 10/30/12 at 2:00 p.m. resident #2's roommate random resident #R1 stated she was in the room when resident #2 fell . Resident #2's roommate stated the curtain was closed so she did not see anything, but she did hear resident #2 yell. Resident #2's roommate stated she believed 2 CNAs were in the room to help get resident #2 out of bed, but she was not sure. Resident #2's roommate stated resident #2 seemed to be in pain. During an interview on 10/31/12 at 9:40 a.m. CNA #S18 stated she worked the 11p-7a shift on 10/21/12 and cared for resident #2. CNA #S18 stated resident #2 was fine when she started her shift and had no complaints. CNA #S18 stated no one had told her resident #2 had a fall earlier on the previous shift. CNA #S18 stated the CNA assisting her on the hall that morning, CNA #S19, went to get resident #2 up around 4:00 a.m. on the morning of 10/22/12 and resident #2 told CNA #S19 her leg hurt and that "they" had broken her leg, but did not say who "they" were. CNA #S18 stated CNA #S19 told her about resident #2's comment and stated the resident had not complained all night, so CNA #S19 told the nurse (LPN #S23) and was informed to leave resident #2 in bed. During an interview on 10/31/12 at 9:50 a.m. CNA #S20 stated she worked the 3p-11p shift on 10/22/12 and when she made rounds on resident #2, the resident was still in bed which was unusual for resident #2. CNA #S20 stated resident #2 was crying in pain and said her leg was broken. CNA #S20 stated she asked what happened and resident #2's roommate random resident #R1 told her 2 CNAs had dropped her the day before when transferring her from the bed to the wheelchair. CNA #S20 stated no one had told her resident #2's leg was broke and to leave her in bed. CNA #S20 stated she did not find out about it until the resident and her roommate told her. CNA #S20 stated the CNAs usually completed a shift report, but when she came in she did not see the CNA so she just began to make rounds. CNA #S20 stated it was a couple of hours later that resident #2 was sent to the hospital. During an interview on 10/31/12 at 10:00 a.m. CNA #S21 stated she assisted CNA #S22 with getting resident #2 up around 4:00 p.m. on 10/21/12 when resident #2 lost her balance and they slid her to the floor, but the resident never fell . CNA #S21 stated the LPN was notified and the resident was assessed. They were told to get her back in the bed so they got assistance from a male CNA and the 3 of them put her in the bed. CNA #S21 stated resident #2's legs were in an Indian style position and the resident complained of pain until she straightened out her leg and then resident #2 said nothing else about pain. During an interview on 10/31/12 at 10:10 a.m. LPN #S8 stated she was told resident #2 was lowered to the floor. LPN #S8 stated resident #2 complained of pain about 7:20 a.m. on 10/22/12 so she called the physician and got an order for [REDACTED].#S8 stated the physician called back on the evening shift and ordered to send resident #2 to the hospital. LPN #S8 stated resident #2 did not receive any medication for pain because the physician did not order anything and she thought resident #2 would be sent to the hospital a lot faster than what she was. LPN #S8 stated resident #2 was one of the residents who was always up and out of bed. During an interview on 10/31/12 at 11:15 a.m. LPN #S23 stated she cared for resident #2 on the 11p-7a shift on 10/21/12. She stated she was told by the nurse on the previous shift resident #2 had lost her balance and was slid to the floor by 2 CNAs. LPN #S23 stated resident #2 did not complain of pain that night until about 5:00 a.m. the morning of 10/22/12 when she told the CNA her left leg was hurting. LPN #S23 stated she checked on resident #2 and she was not yelling or screaming in pain, but told her the left leg was hurting. LPN #S23 stated she had only worked at the facility for 2 weeks and this was the first time caring for resident #2 and since she did not know her, she waited for the day shift nurse to come in and reported resident #2's complaints of pain to her to get her advice because resident #2 only complained of pain the one time. LPN #S23 stated she did not call the physician and did not give resident #2 anything for pain. LPN #S23 stated she told the CNAs not to get resident #2 out of bed. LPN #S23 stated she did write in the 24 hour report book that resident #2 had pain, but did not document in the nurse's notes. During an interview on 10/31/12 at 12:40 p.m. ADON #S4, interim DON/Corporate Nurse #S2, Corporate Nurse #S3, and Administrator #S1 were notified that, through interviews, resident #2 complained of pain around 5:00 a.m. on 10/22/12 and the nurse did not call the physician or administer any pain medication that resident #2 already had ordered. They were informed LPN #S23 waited until the morning shift arrived and notified LPN #S8 that resident #2 had complained of pain to her left leg. They were further notified that LPN #S8 stated resident #2 had complained of pain to her left leg around 7:20 a.m. on 10/22/12 at which time she contacted the physician for an order to obtain an x-ray, but did not administer any pain medication that resident #2 had ordered. They were also notified of the decline in resident #2's daily functioning because she was used to being up and out of the bed, but was confined to bed due to the pain and possible fracture. Corporate Nurse #S3 agreed LPN #S23 should have called and notified the physician of resident #2's complaints of pain and agreed resident #2 had an as needed (prn) pain medication ordered and should have received it as ordered for her complaints of pain. Corporate Nurse #S3 agreed because the physician was not notified of resident #2's pain and did not receive her pain medication, resident #2 had a decline in her activities of daily living by having to remain in bed all day. Corporate Nurse #S3 reviewed resident #2's closed electronic medical record and stated resident #2's prn pain medication was not documented and that LPN #S23 did not document in the nurse's notes regarding the resident's complaints of pain. Corporate Nurse #S3 further stated she was not aware of why the former DON documented resident #2 received pain medication on the Incident Follow-up report because it was not documented anywhere. Corporate Nurse #S3 stated she thought the former DON must have assumed resident #2 received pain medication, but there was no documentation that resident #2 received her ordered pain medications. During an interview on 10/31/12 at 1:35 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 stated they reviewed the 24 hour nursing report book and LPN #S23 had documented resident #2's pain, but did not document she administered any pain medications. During an interview on 10/31/12 at 2:15 p.m. CNA #S24 stated she worked on 10/22/12 from 7a-3p and cared for resident #2. CNA #S24 stated resident #2 complained of pain to her left leg and her left shoulder down to her left wrist. CNA #S24 stated she informed the day nurse and asked about getting her up and was told by the nurse to keep her in bed and she was going to have an x-ray done. CNA #S24 stated she was not aware of the incident that had occurred the day before. CNA #S24 stated resident #2 was usually up in her wheelchair and about the facility most of the day. CNA #S24 stated resident #2 needed assistance to get into the wheelchair, but once she was in it, she could move around the facility without assistance. CNA #S24 stated resident #2 had asked all day on 10/22/12 to get out of the bed, but was in so much pain every time she moved she was not able to get up. CNA #S24 stated resident #2 liked being up and out of the bed. During an interview on 10/31/12 at 3:35 p.m. CNA #S22 stated on 10/21/12 around 3:50 p.m. resident #2 asked to get out of bed so she went and got CNA #S21 to assist her. CNA #S22 stated as they were transferring resident #2 from the bed to the wheelchair, resident #2 began to slide like she was going to fall so she told CNA #S21 to help slide resident #2 to the floor and once she was on the floor they called the nurse to the room. CNA #S21 went to get a male CNA (#S25) to assist getting her back to the bed. CNA #S22 stated LPN #S9 came and stood at the door and told them to get the resident back in the bed and get vital signs. CNA #S22 stated LPN #S9 did not come and assess resident #2. CNA #S22 stated they got resident #2 back in bed and she cleaned her up and took vital signs and reported them to the nurse. CNA #S22 stated resident #2's husband came in later that evening and requested that the resident be gotten up to go smoke, so she asked the nurse and was told it was fine. CNA #S22 stated she and CNA #S25 got resident #2 up and during the transfer she complained of pain to the left leg so CNA #S25 told her that they would not place her shoe on that foot just in case it started swelling. CNA #S22 stated resident #2 went to smoke with her husband and she notified LPN #S9 that resident #2 complained of pain to the left leg. During an interview on 10/31/12 at 4:00 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 were informed that CNA #S25 stated resident #2 had complained of pain on the evening of 10/21/12 after the incident had occurred and the nurse was notified. Corporate Nurse #S3 agreed she did not see any documentation from the nurse that resident #2 complained of pain or that the physician was notified. 2. Review of the physician's orders [REDACTED]. Review of the October, 2012 MARs revealed on 10/02/12 the Phoslo was decreased to 2 caps, but further review failed to reveal a physician's orders [REDACTED]. During an interview on 10/30/12 at 1:35 p.m. with the ADON #S4 and the Quality Assurance (QA) nurse #S5, the ADON #S4 looked in the computerized nurses notes and stated there was an entry on 10/02/12 regarding the resident inquiring about reducing the Phoslo and the nurse contacted the [MEDICAL TREATMENT] center and was told there was no change in his orders. At 2:00 p.m. after searching through the chart and the thinned record, the QA nurse #S5 stated there was no order to decrease the Phoslo. During an interview on 10/30/12 at 2:28 p.m. with the Licensed Practical Nurse (LPN) #S7, she stated she looked at the original order for the Phoslo for July, 2012 for 2 Phoslo capsules with meals and when she went to give his medication on 10/02/12 she saw it was listed as 3 capsules and thought that was an error. The LPN #S7 stated she changed the Phoslo on the MAR indicated [REDACTED]. She stated she thought she was fixing an incorrect order and did not realize the post hospital order was for 3 capsules. The LPN #S7 stated she did not get an order from the physician to decrease the medication. The Interim Director of Nurses #S2 stated the order had not been changed by the [MEDICAL TREATMENT] physician. Review of the facility's policy/procedure manual revealed a policy for physician's orders [REDACTED].

Based on record reviews and interviews the facility failed to ensure 1 (#2) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) residents reviewed for pain out of a total resident sample of 8 received the necessary care and services to treat pain that resulted in actual harm when the resident experienced unrelieved leg pain from 10/22/12 at 5:00 a.m. until transferred to a local hospital on [DATE] at 5:00 p.m. The facility failed to: 1. Assess and document a resident's pain level on 10/22/12 at 5:00 a.m. 2. Notify the physician immediately of a resident's new complaint of leg pain on 10/22/12 after sustaining a fall on 10/21/12. 3. Administer ordered pain medication when a resident complained of leg pain at 5:00 a.m. on 10/22/12 after sustaining a fall on 10/21/12. 4. Administer pain medication to a resident complaining of leg pain from 5:00 a.m. on 10/22/12 until transferred to the hospital for treatment of [REDACTED]. Findings: Review of the facility's Incident Log from August 2012-October 2012 revealed resident #2 had a documented incident on 10/21/12 at 4:00 p.m. that occurred in resident #2's room and resulted in a hospital admission. Documentation on the Resident Incident Follow-up form revealed the following: 10/21/12 moves all extremities, denies c/o discomfort 10/21/12 resident denies c/o pain or discomfort, mae (move all extremities), states she is a little sore, but does not want any pain med 10/21/12 resident uncomfortable, medicated for pain to left leg, x-ray ordered awaiting results 10/21/12 x-rays back, fx tib/fib to left leg, md and family notified, sent to ER for eval, no discomfort at present Review of resident #2's electronic nurse's notes revealed the following: 10/21/12 at 9:06 p.m.-4:00 p.m. called to resident #2's room per CNA and upon entering room, observed 3 CNAs holding resident up about to transfer her to bed. CNA stated when transferring resident from bed to wheelchair, resident lost balance so she eased her to the floor. CNAs transferred resident to bed and assessment completed with no reddened areas, bruises, or breaks noted. Range of motion within normal limits to bilateral upper and lower extremities. Resident stated she lost her balance because she had an incontinent episode of stool. Resident denied discomfort/pain at that time. Vital signs stable. Family and physician notified of incident without injury-LPN #S9. 10/22/12 at 8:05 a.m.-Addendum: 10/21/12-Instructed resident if feels need to have bowel movement during transfers notify staff so they can wait to transfer for the safety of her and the staff. Interdisciplinary team agreed with plan and discussed with therapy to provide demonstration to CNAs on transfer techniques and easing them to the floor during the next in-service. 10/22/12-7:00 a.m.-staff reported resident complained of left leg pain, x-ray in process, staff implementing measures for pain control, and diagnostic measures underway. 5:00 p.m.-staff reported [MEDICAL CONDITION]/fibula with family and physician notified and resident in route to hospital. IDT (Interdisciplinary Team) notified with recommendation to continue with current implementations/recommendations. Therapy notified to continue with new screening process upon return for her mobility status-former DON. 10/22/12 at 1:37 p.m.-Late Entry 7:15 a.m.-Resident lying in bed crying and complains of left leg pain. (name of x-ray company) x-ray of left leg-LPN #S8. 10/22/12 at 3:22 p.m.-X-ray's faxed to physician and call placed to office reporting finding of x-rays-LPN #S8. 10/23/12 at 3:18 p.m.-Late Entry for 10/22/12-Notified physician of x-ray results. Instructed to send resident to emergency room . Resident sent to local hospital per ambulance via stretcher. Responsible party notified. Review of resident #2's October 2012 physician's orders [REDACTED]. Review of resident #2's medical record revealed the Physician's Standing Orders for Nursing Homes with the following prn (as needed) medications: For Aches and pains (minor or chronic): Tylenol 325 mg (milligram) 2 po (by mouth) every 6 hours as needed for mild pain. If ineffective x24 hours notify Physician. For Severe Pain: Notify Physician. Review of resident #2's electronic October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of resident #2's medical record revealed the following x-ray results: Left tibia-fibula x-ray-Impression: 1. Comminuted fracture (a fracture in which bone is broken, splintered or crushed into a number of pieces) of the proximal third of the tibia. 2. There also appeared to be a [MEDICAL CONDITION] fibula. During an interview on 10/31/12 at 9:40 a.m. CNA #S18 stated she worked the 11p-7a shift on 10/21/12 and cared for resident #2. CNA #S18 stated resident #2 was fine when she started her shift and had no complaints. CNA #S18 stated no one had told her resident #2 had a fall earlier on the previous shift. CNA #S18 stated the CNA assisting her on the hall that morning, CNA #S19, went to get resident #2 up around 4:00 a.m. on the morning of 10/22/12 and resident #2 told CNA #S19 her leg hurt and that "they" had broken her leg, but did not say who "they" were. CNA #S18 stated CNA #S19 told her about resident #2's comment and stated the resident had not complained all night, so CNA #S19 told the nurse (LPN #S23) and was informed to leave resident #2 in bed. During an interview on 10/31/12 at 9:50 a.m. CNA #S20 stated she worked the 3p-11p shift on 10/22/12 and when she made rounds on resident #2, the resident was still in bed which was unusual for resident #2. CNA #S20 stated resident #2 was crying in pain and said her leg was broken. CNA #S20 stated she asked what happened and resident #2's roommate random resident #R1 told her 2 CNAs had dropped her the day before when transferring her from the bed to the wheelchair. CNA #S20 stated no one had told her resident #2's leg was broke and to leave her in bed. CNA #S20 stated she did not find out about it until the resident and her roommate told her. CNA #S20 stated the CNAs usually completed a shift report, but when she came in she did not see the CNA so she just began to make rounds. CNA #S20 stated it was a couple of hours later that resident #2 was sent to the hospital. During an interview on 10/31/12 at 10:00 a.m. CNA #S21 stated she assisted CNA #S22 with getting resident #2 up around 4:00 p.m. on 10/21/12 when resident #2 lost her balance and they slid her to the floor, but the resident never fell . CNA #S21 stated the LPN was notified and the resident was assessed. They were told to get her back in the bed so they got assistance from a male CNA and the 3 of them put her in the bed. CNA #S21 stated resident #2's legs were in an Indian style position and the resident complained of pain until she straightened out her leg and then resident #2 said nothing else about pain. During an interview on 10/31/12 at 10:10 a.m. LPN #S8 stated she was told resident #2 was lowered to the floor. LPN #S8 stated resident #2 complained of pain about 7:20 a.m. on 10/22/12 so she called the physician and got an order for [REDACTED].#S8 stated the physician called back on the evening shift and ordered to send resident #2 to the hospital. LPN #S8 stated resident #2 did not receive any medication for pain because the physician did not order anything and she thought resident #2 would be sent to the hospital a lot faster than what she was. LPN #S8 stated resident #2 was one of the residents who was always up and out of bed. During an interview on 10/31/12 at 11:15 a.m. LPN #S23 stated she cared for resident #2 on the 11p-7a shift on 10/21/12. She stated she was told by the nurse on the previous shift resident #2 had lost her balance and was slid to the floor by 2 CNAs. LPN #S23 stated resident #2 did not complain of pain that night until about 5:00 a.m. the morning of 10/22/12 when she told the CNA her left leg was hurting. LPN #S23 stated she checked on resident #2 and she was not yelling or screaming in pain, but told her the left leg was hurting. LPN #S23 stated she had only worked at the facility for 2 weeks and this was the first time caring for resident #2 and since she did not know her, she waited for the day shift nurse to come in and reported resident #2's complaints of pain to her to get her advice because resident #2 only complained of pain the one time. LPN #S23 stated she did not call the physician and did not give resident #2 anything for pain. LPN #S23 stated she told the CNAs not to get resident #2 out of bed. LPN #S23 stated she did write in the 24 hour report book that resident #2 had pain, but did not document in the nurse's notes. During an interview on 10/30/12 at 2:00 p.m. resident #2's roommate random resident #R1 stated she was in the room when resident #2 fell . Resident #2's roommate stated the curtain was closed so she did not see anything, but she did hear resident #2 yell. Resident #2's roommate stated she believed 2 CNAs were in the room to help get resident #2 out of bed, but she was not sure. Resident #2's roommate stated resident #2 seemed to be in pain. During an interview on 10/31/12 at 12:40 p.m. with ADON #S4, interim DON/Corporate Nurse #S2, Corporate Nurse #S3, and Administrator #S1, ADON #S4 stated to her knowledge resident #2 was being transferred from the wheelchair to the bed and had a bowel movement, slid, and was eased to the floor. ADON #S4 stated resident #2's husband was here that night and the resident did not complain of pain and the next day she complained of pain and x-rays were done at which time a fracture to the tibia/fibula was noted and the resident was sent to the hospital. ADON #S4 stated, after making her aware of resident #2's fracture, the former DON stated to get therapy to in-service staff on transfers during the monthly in-service scheduled on 11/5/12. ADON #S4, interim DON/Corporate Nurse #S2, Corporate Nurse #S3, and Administrator #S1 were notified that, through interviews, resident #2 complained of pain around 5:00 a.m. on 10/22/12 and the nurse did not call the physician or administer any pain medication that resident #2 already had ordered. They were informed LPN #S23 waited until the morning shift arrived and notified LPN #S8 that resident #2 had complained of pain to her left leg. They were further notified that LPN #S8 stated resident #2 had complained of pain to her left leg around 7:20 a.m. on 10/22/12 at which time she contacted the physician for an order to obtain an x-ray, but did not administer any pain medication that resident #2 had ordered. They were also notified of the decline in resident #2's daily functioning because she was used to being up and out of the bed, but was confined to bed due to the pain and possible fracture. Corporate Nurse #S3 agreed LPN #S23 should have called and notified the physician of resident #2's complaints of pain and agreed resident #2 had an as needed (prn) pain medication ordered and should have received it as ordered for her complaints of pain. Corporate Nurse #S3 agreed because the physician was not notified of resident #2's pain and did not receive her pain medication, resident #2 had a decline in her activities of daily living by having to remain in bed all day. Corporate Nurse #S3 reviewed resident #2's closed electronic medical record and stated resident #2's prn pain medication was not documented and that LPN #S23 did not document in the nurse's notes regarding the resident's complaints of pain. Corporate Nurse #S3 further stated she was not aware of why the former DON documented resident #2 received pain medication on the Incident Follow-up report because it was not documented anywhere. Corporate Nurse #S3 stated she thought the former DON must have assumed resident #2 received pain medication, but there was no documentation that resident #2 received her ordered pain medications. During an interview on 10/31/12 at 1:35 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 stated they reviewed the 24 hour nursing report book and LPN #S23 had documented resident #2's pain, but did not document she administered any pain medications. During an interview on 10/31/12 at 2:15 p.m. CNA #S24 stated she worked on 10/22/12 from 7a-3p and cared for resident #2. CNA #S24 stated resident #2 complained of pain to her left leg and her left shoulder down to her left wrist. CNA #S24 stated she informed the day nurse and asked about getting her up and was told by the nurse to keep her in bed and she was going to have an x-ray done. CNA #S24 stated she was not aware of the incident that had occurred the day before. CNA #S24 stated resident #2 was usually up in her wheelchair and about the facility most of the day. CNA #S24 stated resident #2 needed assistance to get into the wheelchair, but once she was in it, she could move around the facility without assistance. CNA #S24 stated resident #2 had asked all day on 10/22/12 to get out of the bed, but was in so much pain every time she moved she was not able to get up. CNA #S24 stated resident #2 liked being up and out of the bed. During an interview on 10/31/12 at 3:35 p.m. CNA #S22 stated on 10/21/12 around 3:50 p.m. resident #2 asked to get out of bed so she went and got CNA #S21 to assist her. CNA #S22 stated as they were transferring resident #2 from the bed to the wheelchair, resident #2 began to slide like she was going to fall so she told CNA #S21 to help slide resident #2 to the floor and once she was on the floor they called the nurse to the room. CNA #S21 went to get a male CNA (#S25) to assist getting her back to the bed. CNA #S22 stated LPN #S9 came and stood at the door and told them to get the resident back in the bed and get vital signs. CNA #S22 stated LPN #S9 did not come and assess resident #2. CNA #S22 stated they got resident #2 back in bed and she cleaned her up and took vital signs and reported them to the nurse. CNA #S22 stated resident #2's husband came in later that evening and requested that the resident be gotten up to go smoke, so she asked the nurse and was told it was fine. CNA #S22 stated she and CNA #S25 got resident #2 up and during the transfer she complained of pain to the left leg so CNA #S25 told her that they would not place her shoe on that foot just in case it started swelling. CNA #S22 stated resident #2 went to smoke with her husband and she notified LPN #S9 that resident #2 complained of pain to the left leg. During an interview on 10/31/12 at 4:00 p.m. Corporate Nurse #S3 and interim DON/Corporate Nurse #S2 were informed that CNA #S25 stated resident #2 had complained of pain on the evening of 10/21/12 after the incident had occurred and the nurse was notified. Corporate Nurse #S3 agreed she did not see any documentation from the nurse that resident #2 complained of pain or that the physician was notified.

Based on record review and interviews the facility failed to ensure all alleged violations involving mistreatment, or abuse were reported immediately to the Administrator and to other officials in accordance with State law. The facility failed to ensure further potential abuse was prevented for 1 of 2 residents investigated for mistreatment out of a total sample of 6. (#6) Resident #6 was placed in immediate jeopardy when an allegation of abuse was reported on 10/21/11 and the facility failed to prevent further potential abuse by allowing the CNA to continue to work during the investigation. The immediate jeopardy ended when resident #6 was sent to the hospital on [DATE]. The deficient practice continues at a pattern of more than minimal harm (scope and severity "E") for any resident in the facility with an allegation of abuse as the facility had not put a system in place to ensure alleged perpetrators will not continue to work during the alleged abuse investigation. Findings: Review of the Grievance file revealed a grievance dated 10/26/11 for resident #6 which was made by her daughter-in-law. She complained of bruises that were noted on the resident when resident #6 was admitted to the hospital on [DATE]. The grievance information included that the daughter-in-law stated " that the staff had beat her up here ". Under the follow-up section was the following " Otis report, interviews with staff, residents, requested medical records from hospital, in-serviced staff, suspended assigned CNA for " 10/20/11 " (incident). 10/28/11 DON/ADON to hosp to assess resd " . Review of the investigation for the alleged 10/20/11 incident for resident #6 revealed the following: 1. A hand written statement by LPN #S5 that started with " Late Entry for 10/20/2011 " . The LPN's written statement included that the daughter-in-law called her on 10/20/11 and told her of the resident's accusation that she had been beaten up. The LPN #S5 wrote that the resident had not stated she had been hit by anyone. The LPN #S5 did write that the resident was agitated and breathing hard while sitting in the hallway after getting a shower. The resident stated to the LPN #S5 she did not want " that girl " in her room and " keep her away from me " . The LPN #S5 did not mention in her statement who the staff was. 2. There was a departmental note by the DON #S2 dated 10/26/11 at 3:52 p.m. which documented a conversation the DON #S2 had with resident #6's daughter-in-law at 10:30 a.m. The daughter-in-law insisted to see the Administrator but he was not in the building. The daughter-in-law showed the DON and ADON pictures of the resident's bruise on her upper arm above her elbow that wrapped around the circumference of her arm, " in the shape of a blood pressure cuff, appearing very fresh in nature, and one to the left hand that showed a bruise around the base of her thumb to the inner portion between her pointer finger and thumb, and bruising to her bilateral legs which she states occurs from crossing her legs and shuffling her wheelchair around. The daughter-in-law described a black female CNA with possibly a gold tooth. The daughter-in-law also conveyed to the DON #S2 results of a rib x-ray that identified trauma to the resident's ribs. 3. There was a written statement by a CNA #S6 with the date " 10/20/11 " at the top of the page. The written statement included that the CNA showered the resident after she had a large BM and she sat the resident in the hallway by the nurses' station and put her oxygen on. CNA #S6 wrote that the 3-11 nurse LPN #S5 told her to go ahead and put the resident back to bed. The CNA #S6 wrote that another nurse tried to apply the oxygen but the resident refused. CNA #S6 put the resident back to bed " the nurse by my side and the nurse gave her her meds " . The CNA #S6 wrote the resident was stating that someone beat her up and the nurse told her no one beat her up. The CNA #S6 wrote that no sooner as they walked out of the room the resident called her daughter-in-law on the phone and said someone beat her up. The CNA #S6 wrote she was at the nurses' station when the family called the nurses' station and talked to the nurse and the nurse told her they had just put the resident to bed but no one beat her. The CNA #S6 stated she did not see any new bruises on the resident. The CNA #S6's statement included that she thought the incident happened after supper about 6:30 p.m. or 7:00 p.m., she was not sure. 4. A written statement dated 10/26/11 by CNA #S7 revealed she had worked with resident #6 on 10/21/11 on the 7-3 shift and noted resident #6 had bruises on her left hand and right elbow, and the resident said her ribs hurt. The resident told the CNA #S7 she had been beaten up and every time she breathed in and out it hurt and when she sat up. The CNA #S7 wrote she also noticed a quarter sized bruise on her right upper arm. All marks were purple and/or dark purple. The CNA #S7 wrote that the marks were not there the day before. " She told someone of 11-7 shift hurt her. " 5. A written statement dated 10/24/11 by the CNA #S11 included that the CNA #S11 bathed resident #6 on the day she went to the hospital and she had a bruise on her hand (which hand was not specified) and little spots from the knee down due to the crossing of the legs. During an interview on 11/02/11 at 10:10 a.m. with the ADON #S3,she stated resident #6's daughter-in-law came in on 10/26/11 and showed them pictures on her phone of some bruises that was supposed to be resident #6's arm and claimed resident #6 had been beaten up on 10/20/11. The ADON stated the 3-11 nurse, LPN #S5, stated she knew about the allegation on 10/20/11, but she did not report it. The ADON #S3 stated neither she nor the DON #S2 knew about the allegation until 10/26/11. The ADON #S3 stated the LPN #S5 should have reported that to the Administrator immediately. The ADON #S3 stated the facility had an Executive Nurse on call and she could have notified her. Regarding the investigation, the ADON #S3 stated she had terminated CNA #S6 that morning on 11/02/11. The ADON #S3 stated they found the allegation to be substantiated. The ADON #S3 stated the CNA #S6 denied being abusive to the resident, but there was no one with her during the time the CNA gave the resident a shower. The ADON #S3 stated they had not completed the in-services to all staff and for those staff who did not attend the 10/25/11 in-service, they were providing one-on-one in-services. The ADON #S3 stated neither she nor the DON #S2 knew about resident #6's allegation of abuse until 10/26/11. During an interview on 11/02/11 at 12:25 p.m. with the CNA #S7, while referencing her written statement, she stated she worked on 10/21/11 on the day shift and cared for resident #6. CNA #S7 stated resident #6 stated she been beaten up by someone on the night shift. The CNA #S7 stated she went right then and told the LPN #S9 and LPN #S9 said OK. The CNA #S7 stated she went back to resident #6 and took her to the shower. CNA #S7 stated when she undressed resident #6 she saw a quarter size bruise on her upper right arm, her right elbow was red, and the resident said her ribs hurt, but she did not see any discoloration on her ribs. The CNA #S7 stated the resident told her it hurt her ribs to sit and it hurt to breathe and was hard to breathe. The CNA#S7 stated she told the nurse LPN #S9 about the resident ' s complaints. During an interview on 11/02/11 at 1:00 p.m. with LPN #S9, she stated CNA #S7 reported to her that resident #6 said she had been beaten up, but LPN #S9 did not remember what day that was. She stated she went into the resident ' s room and asked her if she was ok and resident #6 said yes. LPN #S9 stated she did not get information during the shift change report that the incident had happened and she did not chart anything. The LPN #S9 stated she looked at resident #6 's arms but did not pull her clothes up. She stated she did not see any bruises. LPN #S9 stated resident #6 said she was fine. LPN #S9 stated she did not report the resident 's allegation to anyone. LPN #S9 stated she was supposed to report it, but did not. During an interview on 11/02/11 at 4:10 p.m. with the LPN #S5 regarding the evening of 10/20/11, LPN#S5 stated after resident #6's shower, resident #6 stated to keep that girl away from her, referring to CNA #S6. The LPN #S5 stated she stayed in the resident's room while CNA #S6 put the resident to bed and until CNA #S6 left resident #6 ' s room. LPN #S5 stated she watched resident #6's door and made sure the CNA #S6 did not go back in her room that evening. The LPN #S5 stated the resident never said anything about being beaten; she stated it was after the daughter-in-law called that she learned of the complaint of having been beaten. The LPN #S5 stated she did not notify anyone of the daughter's complaint. The LPN #S5 stated if anything like that happened again, she would call the Administrator and DON. The LPN #S5 stated resident #6 was alert and oriented to person, place, and time. During an interview on 11/02/11 at 4:41 p.m. with the SS #S4, while she referenced her computerized note dated 10/25/11 at 8:53 a.m. for resident #6, she stated her note included that resident #6's daughter-in-law informed her on 10/24/11 that resident #6 was calling her repeatedly, was saying she was going to die, had taken her oxygen off, was looking for her granddaughter, and staff had beaten her. Review of the computerized note revealed the SS #S4 informed the nurse on 10/25/11. When asked what the policy says about any allegation of abuse, the SS #S4 stated to report it to the Administrator and the DON so an investigation can be done. SS #S4 stated she did talk with the DON and ADON. The SS #S4 stated she did not think the daughter-in-law thought someone had really beaten her up, she was just saying there had been a change in her. Review of the time card for CNA #S6 revealed she worked on 10/20/11 from 6:00 a.m. to 11:00 p.m., on 10/21/11 from 6:00 a.m. to 11:00 p.m., on 10/24/11 6:00 a.m. to 2:00 p.m., and on 10/26/11 from 6:00 a.m. to 2:15 p.m. During an interview on 11/03/11 at 9:20 a.m., the Administrator #S1 stated the DON#S2 and he were not informed of the allegation of abuse for resident #6 until 10/26/11 when the resident's daughter-in-law came to the facility. Review of the hospital discharged record for resident #6 revealed the resident was admitted to the hospital with [REDACTED]. The Admission assessment dated [DATE] at 6:35 p.m. revealed the skin assessment included " multiple bruises noted to generalized body " .

Based on record review and staff interviews, the facility failed to implement written policies that prohibit mistreatment, neglect, and abuse of residents for 2 (#6, #3) of 2 (#6, #3) residents investigated for abuse out of a total sample of 6. The facility failed to ensure the facility's abuse policy/procedure was followed for the prevention, identifying, reporting, investigation allegations of abuse, and protection of residents alleging abuse. Resident #6 was placed in immediate jeopardy when an allegation of abuse was reported on 10/21/11 and the facility failed to prevent further potential abuse by allowing the CNA to continue to work during the investigation. The immediate jeopardy ended when resident #6 was sent to the hospital on [DATE]. The deficient practice continues at a pattern of more than minimal harm (scope and severity "E") for any resident in the facility with an allegation of abuse as the facility had not put a system in place to ensure alleged perpetrators will not continue to work during the alleged abuse investigation. Findings: 1. Review of the Grievance file revealed a grievance dated 10/26/11 for resident #6 which was made by her daughter-in-law. She complained of bruises that were noted on the resident when resident #6 was admitted to the hospital on [DATE]. The grievance information included that the daughter-in-law stated "that the staff had beat her up here". Under the follow-up section was the following " Otis report, interviews with staff, residents, requested medical records from hospital, in-serviced staff, suspended assigned CNA (Certified Nursing Assistant) for "10/20/11" (incident). 10/28/11 DON/ADON to hosp to assess resd " . Review of the investigation dated 11/26/11 for the alleged incident on 10/20/11 for resident #6 revealed the following: 1. A hand written statement by Licensed Practical Nurse (LPN) #S5 that started with "Late Entry for 10/20/2011". The LPN's written statement included that the daughter-in-law called her on 10/20/11 and told her of the resident's accusation that she had been beaten up. The LPN #S5 wrote that the resident had not stated she had been hit by anyone. The LPN #S5 did write that the resident was agitated and breathing hard while sitting in the hallway after getting a shower. The resident stated to the LPN #S5 she did not want "that girl" in her room and "keep her away from me". The LPN #S5 did not mention in her statement who the staff was. 2. The investigation included interviews with 19 other residents/family. None of the residents/family reported being hit by any CNA (Certified Nursing Assistant). 3. There was a departmental note by the Director of Nurses (DON) #S2 dated 10/26/11 at 3:52 p.m. which documented a conversation the DON #S2 had with resident #6's daughter-in-law at 10:30 a.m. The daughter-in-law insisted to see the Administrator but he was not in the building. The daughter-in-law showed the DON and ADON (Assistant Director of Nurses) pictures of the resident's bruise on her upper arm above her elbow that wrapped around the circumference of her arm,"in the shape of a blood pressure cuff, appearing very fresh in nature, and one to the left hand that showed a bruise around the base of her thumb to the inner portion between her pointer finger and thumb, and bruising to her bilateral legs which she states occurs from crossing her legs and shuffling her wheelchair around. The daughter-in-law described a black female CNA with possibly a gold tooth. The daughter-in-law also conveyed to the DON #S2 results of a rib x-ray that identified trauma to the resident's ribs. 4. There was a written statement by a CNA #S6 dated "10/20/11". The written statement included that the CNA showered the resident after she had a large BM and she sat the resident in the hallway by the nurses' station and put her oxygen on. CNA #S6 wrote that the 3-11 nurse LPN #S5 told her to go ahead and put the resident back to bed. The CNA #S6 wrote that another nurse tried to apply the oxygen but the resident refused. CNA #S6 put the resident back to bed "the nurse by my side and the nurse gave her her meds". The CNA #S6 wrote the resident was stating that someone beat her up and the nurse told her no one beat her up. The CNA #S6 wrote that no sooner as they walked out of the room the resident called her daughter-in-law on the phone and said someone beat her up. The CNA #S6 wrote she was at the nurses' station when the family called the nurses' station and talked to the nurse and the nurse told her they had just put the resident to bed but no one beat her. The CNA #S6 stated she did not see any new bruises on the resident. The CNA #S6's statement included that she thought the incident happened after supper about 6:30 p.m. or 7:00 p.m., she was not sure. 5. A written statement dated 10/26/11 by CNA #S7 revealed she had worked with resident #6 on 10/21/11 on the 7-3 shift and noted resident #6 had bruises on her left hand and right elbow, and the resident said her ribs hurt. The resident told the CNA #S7 she had been beaten up and every time she breathed in and out it hurt and when she sat up. The CNA #S7 wrote she also noticed a quarter sized bruise on her right upper arm. All marks were purple and/or dark purple. The CNA #S7 wrote that the marks were not there the day before. 6. A written statement dated 10/24/11 by the CNA #S11 included that the CNA #S11 bathed resident #6 on the day she went to the hospital and she had a bruise on her hand (which hand was not specified) and little spots from the knee down due to the crossing of the legs. During an interview on 11/02/11 at 10:10 a.m. with the ADON #S3, stated resident #6's daughter-in-law came in on 10/26/11 and showed them pictures on her phone of some bruises that were supposed to be resident #6's arm and claimed resident #6 had been beaten up on 10/20/11. The ADON stated the 3-11 nurse, LPN #S5, stated she knew about the allegation on 10/20/11, but she did not report it. The ADON #S3 stated neither she nor the DON #S2 knew about the allegation until 10/26/11. The ADON #S3 stated the LPN #S5 should have reported that to the Administrator immediately. The ADON #S3 stated the facility had an Executive Nurse on call and she could have notified her. Regarding the investigation, the ADON #S3 stated she had terminated CNA #S6 that morning on 11/02/11. The ADON #S3 stated they found the allegation to be substantiated. The ADON #S3 stated the CNA #S6 denied being abusive to the resident, but there was no one with her during the time the CNA gave the resident a shower. The ADON #S3 stated they had not completed the in-services to all staff. During an interview on 11/02/11 at 12:25 p.m. with the CNA #S7, while referencing her written statement, she stated she worked on 10/21/11 on the day shift and cared for resident #6. CNA #S7 stated resident #6 stated she been beaten up by someone on the night shift. The CNA #S7 stated she went right then and told the LPN #S9 and LPN #S9 said OK. The CNA #S7 stated she went back to resident #6 and took her to the shower. CNA #S7 stated when she undressed resident #6 she saw a quarter size bruise on her upper right arm, her right elbow was red, and the resident said her ribs hurt, but she did not see any discoloration on her ribs. The CNA #S7 stated the resident told her it hurt her ribs to sit and it hurt to breathe and was hard to breathe. The CNA#S7 stated she told the nurse LPN #S9 about the resident's complaints. During an interview on 11/02/11 at 1:00 p.m. with LPN #S9, she stated CNA #S7 reported to her that resident #6 said she had been beaten up, but LPN #S9 did not remember what day that was. She stated she went into the resident's room and asked her if she was ok and resident #6 said yes. LPN #S9 stated she did not get information during the shift change report that the incident had happened and she did not chart anything. The LPN #S9 stated she looked at resident #6 ' s arms but did not pull her clothes up. She stated she did not see any bruises. LPN #S9 stated resident #6 said she was fine. LPN #S9 stated she did not report the resident's allegation to anyone. LPN #S9 stated she was supposed to report it, but did not. During an interview on 11/02/11 at 4:10 p.m. with the LPN #S5 regarding the evening of 10/20/11, LPN #S5 stated after resident #6's shower, resident #6 stated to keep that girl away from her, referring to CNA #S6. The LPN #S5 stated she stayed in the resident's room while CNA #S6 put the resident to bed and until CNA #S6 left resident #6's room. LPN #S5 stated she watched resident #6's door and made sure the CNA #S6 did not go back in her room that evening. The LPN #S5 stated the resident never said anything about being beaten; she stated it was after the daughter-in-law called that she learned of the complaint of having been beaten. The LPN #S5 stated she did not notify anyone of the daughter's complaint. The LPN #S5 stated resident #6 was alert and oriented to person, place, and time. During an interview on 11/02/11 at 4:41 p.m. with the Social Services (SS) #S4, while she referenced her computerized note dated 10/25/11 at 8:53 a.m. for resident #6, she stated her note included that resident #6's daughter-in-law informed her on 10/24/11 that resident #6 was calling the daughter-in-law repeatedly, was saying she was going to die, had taken her oxygen off, was looking for her granddaughter, and staff had beaten her. The SS #S4 stated she went to the nurse #S9 and told her exactly what the daughter-in-law said and she did call the doctor. The computerized note revealed the SS #S4 informed the nurse on 10/25/11. When asked what the policy says about any allegation of abuse, the SS #S4 stated to report it to the Administrator and the DON so an investigation can be done. SS #S4 stated she did talk with the DON and ADON. The SS #S4 stated she did not think the daughter-in-law thought someone had really beaten her up, she was just saying there had been a change in her. Review of the time card for CNA #S6 revealed she worked on 10/20/11 from 6:00 a.m. to 11:00 p.m., on 10/21/11 from 6:00 a.m. to 11:00 p.m., on 10/24/11 6:00 a.m. to 2:00 p.m., and on 10/26/11 from 6:00 a.m. to 2:15 p.m. During an interview on 11/03/11 at 9:20 a.m., the Administrator #S1 stated the DON #S2 and he were not informed of the allegation of abuse for resident #6 until 10/26/11 when the resident's daughter-in-law came to the facility. Review of the hospital discharged record for resident #6 revealed the resident was admitted to the hospital with [REDACTED]. The emergency room documentation did not include any mention of bruising. The Admission assessment dated [DATE] at 6:35 p.m. revealed the skin assessment included "multiple bruises noted to generalized body". Further review of the hospital's closed record failed to reveal an x-ray for rib detail. The only x-ray was for a chest x-ray dated 10/25/11 which revealed left basilar retrocardiac lower lobe atelectasis/infiltrate. The findings also included: Probable small effusion and stable cardiac enlargement with mild vascular congestion. 2. Review of the grievance file revealed a grievance dated 10/11/11 made by LPN #S16 for sampled resident #3. The grievance explanation included that the resident told LPN #S16 staff was mean to her on 10/13/11. She stated staff jerked on her legs and slung her around and told her last night that she needed to stop that before she broke something. Resident had night/day confused. Tried to get the resident to tell or describe the CNAs, All she stated was the CNA was little and short and some are big. On 10/11/11 the charge nurse had a meeting with CNAs the day she obtained the complaint. Informed resident to turn her call light on whenever someone came in being mean to her. Verbalized an understanding. The complaint was signed by the ADON #S3 and dated 10/11/11 for person completing the report and the responsible department head with dated signature of 10/13/11. At the bottom of the page and on the back, the following was documented: Explained to the resident that due to her bedfast status that the CNAs probably were not trying to hurt her but she probably felt that her legs were being jerked during positioning, turning while in bed and when CNAs transfer. Informed her that if she really felt like she was being "jerked" to turn her call light on so it could be looked into at the time the incident occurred. During an interview on 11/02/11 at 10:10 a.m. with the ADON #S3 regarding what the LPN #S16 reported to her on 10/11/11 regarding resident #3, she stated she did not remember. While referencing the grievance form dated 10/11/11, the ADON #S3 stated she remembered and stated the nurse told her the staff had been mean to her and were jerking her around on the 11-7 shift. She stated she spoke to the resident to find out what she considered to be "jerked". The ADON #S3 stated she interviewed the staff and wrote up an in-service. After looking in her file, the ADON #S3 stated she did not do an in-service, but thought she did. She stated she tried to get the resident to explain who the staff was, but she could not tell her who the staff member was. When asked if the complaint from resident #3 should have been reported to the Administrator, State Office and investigated, the ADON #S3 stated after looking at it again, yes, it should have been reported and investigated. Review of the facility abuse and neglect policy revealed the following: Policy: It is the policy of the facility that residents are not subject to abuse. Each resident has the right to be free from mistreatment, neglect, and misappropriation of property. Procedure: The facility will provide immediate access to any representative of the Secretary of the Department of Health and Human Services, the State, the resident ' s individual physician, the State long term care ombudsman, or the agencies responsible for the protection of nursing facility residents. The appropriate contact information will be posted in the facility and available for all Residents/Family Members/Employees to view. Abuse Prohibition Program Includes: Screening, training, prevention, identification, investigation, protection, and reporting/response. Prevention: Supervisory staff is taught how to recognize signs of burnout, frustration, and stress that may lead to abuse. Employees are required to report any abuse or neglect suspicions immediately. Identification: Interviews with any and all persons having knowledge of the event will be held. Written statements will be taken. Any necessary outside agencies will be utilized and/or informed. Residents prone to be abused or abuse others are discussed in daily QA meetings. Investigation: The OTIS system will be used for reporting to DHH as per current regulations. An internal investigation will be conducted and the results will be filed in the Administrator ' s office. Follow up with the appropriate agencies will be done in accordance to all state and local laws. Protection: Any and all parties who provide information about any incident will be given protection from retaliation in the form of private interviews, retention of any written information (kept in the strictest confidence) and in the case of more serious allegations; protection by state and local authorities will be sought. Families, residents, and employees will be assured that they can communicate concerns without any fear of reprisal. Reporting/Response: Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property shall report the incident to the Administrator. If the Administrator is not in the facility or not reachable by phone and an allegation of abuse occurs, the DON, Nursing Supervisor, or Nurse on call will be informed immediately. Should there be an allegation of abuse levied against employee/employees, it will result in that person ' s immediate suspension pending the results of our investigation. The facility will report all allegations and substantiated occurrences of abuse, neglect, or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The facility will report to the state board of nursing, nurse aide registry, or other licensing authority any substantiated allegation. The facility administration will analyze all occurrences to determine what changes are needed, if any, to the facilities policies and procedures to prevent further occurrences.