Every finding on record at The Meridian

Based on interview and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for 1 of 4 residents (Resident #1) reviewed for PASRR. Resident # 1 did not receive a Medicaid service because of the following: The facility failed to follow instructions and submit a NFSS Request for Resident #1 by a specific deadline. The facility failed to follow up on the NFSS Request submittal to ensure the request was approved to provide specialized services for PASRR for Resident #1 when it was denied. This failure could cause a delay in receiving services for residents who require a specialized PASRR service. Findings included: - Record review of Resident #1's face sheet dated 08/26/2026 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included spastic quadriplegic cerebral palsy (a severe form of lifelong condition that affect the body's movement, muscle control, balance and posture caused by damage in the brain), acute respiratory failure with hypoxia (a sudden, life-threatening condition where the lungs fail to move enough oxygen into the blood, starving vital organs of the oxygen they need to function) and aphasia (a brain related communication disorder causing trouble speaking, understanding speech, reading or writing). Record review of Resident #1's comprehensive MDS assessment dated [DATE], reflected Section B (Hearing, Speech and Vision) indicated Resident #1 had unclear speech, was usually understood and usually understood others. Section C0500 (Cognitive Patterns) revealed Resident #1 had a BIMS score of 00 indicating severe cognitive impairment, and she was dependent for all ADL and care. Record review of Resident #1's care plan dated 08/01/2026 revealed Resident #1 required assistance with ADLs due to weakness related to cerebral palsy with interventions for care to be provided with 1 person assistance for bathing, bed mobility, turning and positioning, dressing, grooming. eating, drinking, incontinent care and personal hygiene. The care plan further revealed Resident #1 was considered PASRR positive due to cerebral palsy with interventions to provide service coordination with a representative from LIDDA and report any need to evaluate for rehabilitative services and or DME to maintain the resident's current level of function. Record review of Resident #1's medical records revealed, Resident #1 was sent to the hospital on [DATE] due to respiratory issues and had not returned to the facility as of 08/26/2026. Resident #1's had a PASRR Level 1 screening that was completed by the MDS Nurse on 03/27/2026 indicating YES for Developmental Disability and YES for Intellectual Disability. A PASRR Evaluation was completed on 03/30/2026 by a PE evaluator from The Gulf Coast Center. Record review of Resident #1's medical records revealed a PCSP form for an initial IDT/SPT with date of meeting as 04/10/2026. Attendees to this meeting were the Local Authority for Intellectual and Developmental Disability, facility MDS nurse, facility RN, social worker and Resident #1's responsible party. Nursing Facility Specialized Services were indicated for Specialized Assessment Occupational Therapy, Specialized Assessment Physical therapy, Specialized Occupational Therapy and Specialized Physical Therapy. IDD Specialized Services were indicated for Habilitation Coordination and Independent Living Skills Training. Nursing facility's comments read in part .RP informed of all services that Resident #1 was eligible for. RP chose to start PT, OT, ILS and HC services to the benefit of Resident #1. LA-IDD Specialized Services comments read in part .Resident #1, RP and SPT discussed and reviewed services. Resident #1 and RP want to have the following services HC, ILS, PT and OT. OT and PT assessment have been requested for Resident #1 to receive PT and OT through PASRR. All services were agreed upon as indicated. Further record review of Resident #1's medical records revealed a second PCSP form for Local Authority Update was held on 05/04/2026 with comments read in part .Individual and SPT discussed change in service. The following services will be discontinued, ST assessment, ST, OT assessment, OT and ILS. The services that will continue to be ongoing are HC, PT assessment and PT. Two NFSS forms that were submitted on 5/4/2026 for PT and OT were not accepted in the Simple LTC portal and was returned with instructions to correct the PT and OT assessment date and submit the necessary paperwork to establish the appropriate services authorizations before resubmitting the NFSS form. During an interview on 08/26/2026 at 11:33am, MDS B stated he was taking over the entire MDS unit since MDS A, that was responsible for PASRR, was no longer working at the facility. MDS B stated that when a new resident was admitted to the facility, a PASRR Level 1 is submitted to Simple LTC to determine if the resident's diagnosis qualifies PASRR services. If qualified, the PASRR coordinator will setup up an initial IDT meeting. MDS B stated the availability of services and specialized equipment will be determined. MDS B stated if there were any recommendations indicated during the IDT meeting, the MDS nurse must submit a NFSS form within 20 days after the IDT meeting and the MDS nurse was responsible for following through in the portal to address any further inquiries regarding the application. MDS B stated if the NFSS was rejected, the MDS nurse will find out what the rejection was about and will follow through with any corrections needed. MDS B stated he will need to review Resident #1's application, as he was not directly involved in Resident #1's PASRR application. During an interview on 08/26/2026 at 1:50 pm, MDS B stated the MDS nurse that was working on Resident #1's application did not follow through with the PASRR process. MDS B stated the previous MDS nurse did not submit the NFSS form after the initial IDT meeting on 04/10/2026. MDS B stated a second IDT meeting was conducted on 5/4/2026 and two NFSS forms were filed on 5/4/2026 after the IDT meeting but were not followed through in the Simple LTC Portal. MDS B stated Resident # 1 was on skilled services for 100 days upon admission to the facility, but the Resident was sent to the hospital several times due to a change in health condition. MDS B stated he will request for another IDT meeting once Resident #1 readmitted from the hospital. MDS B stated he will follow through with the recommendations, submit a new NFSS form, and follow up in Simple LTC portal. During a phone interview on 08/26/2026 at 2:40pm with MDS A, MDS A stated she was responsible for following through on Simple LTC portal for updates after the application was submitted. MDS A stated she did not know why an NFSS was not submitted for Resident #1 after the initial IDT meeting on 04/10/2026. MDS A stated she did not recall receiving any email regarding any corrections needed for Resident #1's application. MDS A stated she did not know why she failed to follow through after the application was filed. During an interview on 08/26/2026 at 2;50pm, the ADM was made aware that Resident #1's NFSS form was not filed after the initial IDT meeting on 4/10/2026, and the NFSS form that was filed on 5/4/2026 was not followed through in Simple LTC. The ADM stated he was not aware that Resident #1's application was not followed through. The ADM stated his expectation was for the MDS nurse to follow the PASRR process to ensure PASRR positive residents are receiving PASRR services and specialized equipment as per recommendations. The facility's policy on PASRR guidelines and regulations was requested from the Administrator upon entrance. The policy was not provided at exit. A Policy on admission Criteria was provided instead.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 2 halls (Residents #1, #2,#3) rooms reviewed for environment. -The facility temperature of the facility floors 200 and 300 were recorded to be outside and above of the range of 71-81 degrees. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. The findings include: Resident #1 Record review of Resident #1's facility admission sheet undated revealed an 89 -year-old male admitted on [DATE] with diagnoses that included anxiety disorder ( any of a group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats, leading to altered behavior and often to physical symptoms such as increased heart rate or muscle tension) and hypertension (abnormally high blood pressure). Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed that a BIM score of 2 indicating severe cognitive impairment. He required substantial/maximal to partial moderate assistance with ADL's. Record review of Resident #1's care plan with a target of 10/14/26 revealed a care plan require assistance with ADL's R/T NSTEMI (non-st segment elevation myocardial infarction. Resident #2 Record review of Resident #2's facility admission record undated revealed an 88 -year-old female admitted on [DATE] with diagnoses that included Chronic diastolic congestive heart failure (Chronic diastolic congestive heart failure, also known as heart failure with preserved ejection fraction (HFpEF), occurs when the left ventricle of the heart becomes stiff, thickened, and less elastic, impairing its ability to relax and fill with blood during the diastolic phase of the cardiac cycle) and Acute respiratory failure (Acute respiratory failure occurs when there is a rapid impairment of gas exchange between the lungs and the blood, leading to hypoxemia (low oxygen) with or without hypercapnia (high carbon dioxide). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that a BIM score of 15 indicating she was cognitively intact. She required partial to moderate assistance with ADL's.Record review of Resident #2's care plan dated: Target Date: 7/30/26 revealed a care plan require assistance with ADL's R/T weakness R/T DM, MI, CHF. Resident #3 Record review of Resident #3's facility admission record undated revealed a [AGE] year-old-female admitted on [DATE] with diagnoses that included Congestive Heart Failure (condition in which the heart cannot pump efficiently enough to meet the body's need for blood) and Dementia (Dementia is a pattern of mental decline caused by different diseases or conditions. Most commonly, dementia occurs when brain nerve cells (neurons) die, and connections between neurons are interrupted). Record review of Resident #3's Discharge MDS assessment dated [DATE] revealed in section C1000-Cognitive Skills for Daily Living a score of 1 indicating modified independence. She required substantial/maximal to partial moderate assistance with ADL's. Record review of Resident #3's care plan dated: Target Date: 9/02/26 revealed a care plan Resident #3 has impaired cognitive function/dementia or impaired thought processes. Record review of the facility temperature logs dated 8/8/26 revealed that the highest temperature in the facility was 82 degrees. Record review of the facility temperature logs dated 8/9/26 revealed that the highest temperature in the facility was 80.7 degrees. Record review of the facility temperature log dated 8/10 revealed the highest temperature was 74.2 degrees. Record review of the facility temperature logs dated 8/12/26 revealed that the highest temperature in the facility was 79 degrees. Record review of the facility map revealed that 16 rooms on the rehabilitation side of 200 were equipped with their own personal ac units and were not affected. Observation on 8/8/26 at 8:45 am of the 3rd floor, hall 300 revealed of the facility revealed multiple portable a/c units in the sitting area, and ends of both halls hooked to white plastic tubing operating. There were 2 large industrial fans at both ends of 200 hall and multiple individual fans in multiple areas of the hall. During observations of areas on this hall the thermometer meter was used, temperatures varied from 76-79 degrees. During an interview on 8/8/26 at 8:45 am with LVN A, she said the that she did not know how long the ac had not worked, the maintenance guy-name unknown had made rounds this morning to check the temperatures and was making daily rounds at different times to check the temperatures. She said that no one was sent out for distress due to heat, the staff were making rounds and encouraged residents to hydrate. During an interview on 8/8/26 at 9:05 am with RN B, he said he did not know how long the ac unit had been off but the staff were monitoring residents, providing ice water and were making rounds often. Observation on 8/8/26 at 9:10 am of the 2nd floor, hall 200 of the facility revealed multiple portable a/c units in the sitting area, and ends of both halls hooked to white plastic tubing operating. There were 2 large industrial fans at both ends of 200 hall and multiple individual fans in multiple areas of the hall. During observations of areas on this hall the thermometer meter was used, temperatures varied from 77-80.4 degrees. During a telephone interview on 8/8/26 at 9:22 am, the Administrator said that the ac unit was causing problems intermittently on 8/1/26, the maintenance and ac service company would have it resolved and then concluded that the part that was malfunctioning needed to be replaced and was ordered. He said that he did not complete a self-report to the state because the temperatures had not risen to the level to be out of compliance and that if the temperatures did rise to that level, he would self-report. He said that there were no residents discharged to the hospital due to heat related issues. During an interview on 8/8/26 at 9:10 am with RN A, she said she was not sure how long the air conditioning had not worked, but thought it was 2-3 days ago since the a/c was not working. She said the staff were monitoring residents for heat related issues and had not observed any, they were passing out ice water, they had not observed anyone in distress. During an interview on 8/8/26 at 9:15 am with CNA A, she said that the ac had not worked on the left side of the hall for a while, but she was unsure how long, she said the right side of the hall was rehab skilled nursing and those rooms have their own ac units. Observation on 8/8/26 at 10:00 am of Resident #3 in room [ROOM NUMBER] in room appeared to be asleep no odors were noticed, the call light and hydration were in place, the temperature was taken and found to be 80.7 degrees.Observation and interview on 8/8/26 at 10:03 am room [ROOM NUMBER] Resident #1 was lying in his bed with a fan blowing on him, he said it's been hot the air conditioning isn't working, and he has a fan in room. The temperature was taken and found to be 81.5 degrees with the fan in his room. Observation on 8/10/26 at 1:45 pm of the 2nd floor (hall 200) revealed multiple residents sitting around in common areas, the facility was cool with temperature readings within 72-75 degrees. Observation on 8/10/26 at 1:55 pm of the 3rd floor (hall 300) revealed the temperatures ranged between 69-75 degrees. During a telephone interview on 8/8/26 at 4:06 pm, the Maintenance Director said the ac unit had been broken since 8/5/26, they reset the compressor, it was fixed and shut down again. they determined compressor was not holding compressor goes to 2nd stage. He was going to drive to a different state to have the part here on Monday 8/10/26, installed on Tuesday, 8/11/26. He said that the overall temperatures he logged were 79- 80 degrees in afternoon and regulations said that the temperatures were supposed to be between 72 and 82 degrees.Observation and interview on 8/8/26 at 12:56 pm with Resident #2, she said it's sad it's hotter than hell, we have a couple of fans, but this is ridiculous they were working on the ac yesterday here and it has been broken for about a week. Resident #2 was observed sitting in her wheelchair, she had a fan pointed at her. The temperature at this time was 80.1 in her room. During an interview on 8/8/26 at 2:40 pm with an anonymous complainant they said that the facility did not have working ac since 8/1/26 and that the residents were at risk due to humidity and temperatures in the facility rising to over 83 degrees. The complainant added that the facility was known to take a long-time making repairs. Interview and record review on 8/8/26 at 3:26 pm with the Administrator revealed the narrative below for the measures to address the broken ac.On 8/1 the compressor high current switch was triggered and the compressor shut down. After resetting the compressor, it functioned correctly. After 24 hours of running properly the compressor shut down again with the same problem. The switch was reset and the compressor worked. Since the compressor has been repeating this pattern, a serviceman was requested and dispatched on Wednesday 8/5. The serviceman recommended to replace the compressor. The compressor was ordered on 8/6. On Sunday 8/9, the facility will drive to Atlanta to pick up the compressor on Monday from the manufacturer and have it installed by the serviceman on 8/11. Actions Taken by the FacilityThe facility has taken the following actions. Initiated a temperature log Implemented the use of portable and temporary air conditioning unitso 5 on the 2nd flooro 9 on the 3rd floor Implemented use of fans Placed the PTACs on high in unoccupied rooms with the doors open Provided additional hydration During an interview on 8/10/26 at 2:10 pm with the Administrator he said that the facility had placed multiple ac units in resident rooms that preferred an ac unit and those that did not, they made accommodations for them to remain in warmer parts of the facility. He said many residents were saying that it was too cold. He said he would continue to communicate via email the status of temperatures taken during this process. Record review of the facility policy and procedure entitled Homelike Environment, dated revised February 2021 read in part. Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment; comfortable and safe temperatures (71 F - 81 F).

39977 Based on interviews and record review, the facility failed to ensure resident assessments were electronically transmitted with MDS data to the CMS System for discharge return not anticipated for 2 of 32 residents (CR #1 & 58) reviewed for encoding and transmitting resident assessments. - The facility failed to submit/transmit/export a Return Not Anticipated MDS for CR #1- within the required timeframe. - The facility failed to submit/transmit/export a Return Not Anticipated MDS for CR #58 within the required timeframe. This failure could place discharged residents at risk of not receiving proper Medicaid benefits after discharge and of not having their assessments transmitted/exported timely. Findings included: -CR #1 Record review of CR # 1's face sheet dated 10/30/24 revealed an 81-year -old female admitted to the facility on [DATE]. Her diagnoses included anemia (low red blood count), hypothyroidism (a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormones), heart disease, and lower back pain. Record review of CR #1's clinical records nurse's note dated 11/29/2023 15:48 read in part: Resident was brought to nurse's station by PTA staff. Large edematous hematoma to RLE. Measures 8.3 cm x 4.6 cm. Staff explained res hit her leg-on-leg rest during transfer to wheelchair. RLE elevated and ice pack applied to site. Res did complain of pain 8 out of 10- and one-time order for Tylenol #4 obtained and administered. Son notified via voicemail of incident. Will continue to monitor for changes. Record review of emergency transfer note indicated CR #1 was sent to the hospital due to uncontrolled pain. Record review of CR#1's discharge MDS with ARD date 11/29/23 coded as returned not anticipated was completed and transmitted on 07/03/24. CR# 58' -Record review of CR# 58's admission record dated 10/30/2024 revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), insomnia (persistent problems falling and staying asleep), depression (a common mental disorder that involves depressed mood or loss of pleasure in activities for long periods of time), fracture (break) of unspecified part of neck of left femur (thighbone), and subsequent encounter for closed fracture with routine healing and pain in left hip. She discharged from the facility AMA (against medical advice) on 05/19/2024. Record review of CR #58's Admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15 which indicated she had no cognitive impairment. She required set-up assistance with eating and oral hygiene. She required moderate assistance with most other ADLs (Activities of Daily Living). Record review of CR#58's Release of Responsibility for Discharge Against Medical Advice, dated 5/19/24 at 2:20 pm revealed CR#58 signed the document on 5/19/24 and it was witnessed by CR#58's family member and RN C. Record review of CR 58's nursing clinical progress note dated 05/15/2024 at 5:34pm revealed, Progress Notes: Res was persistent about wanting to discharge home d/t husband being discharged from Hospital A. Res explained husband (sic) has terminal leukemia and only had a few weeks to live. Dr. A saw resident during rounds and resident reported to Dr. A that she had a cousin who would be able to stay and assist with care. Staff were preparing to discharge resident when Death Doula, arrived (sic) to facility, and asked to speak with ADON. The Death Doula explained her role was to stay with the family until CR #58's husband passed away. However, the Death Doula refused to stay with the family d/t the house being uninhabitable when the Death Doula explained the circumstances, CR #58 became irate and began cussing and throwing things around the room. Demanded that she was leaving the facility . Record review of CR 58's EMR on 10/30/2024 revealed her Discharge Return Not Anticipated was dated as completed on 5/19/24 and was highlighted in red under the submission tab with the date 10/29/2024. Interview and observation with MDS A at 12:45 PM on 10/30/24 he said that CR#58's MDS Discharge Return not anticipated MDS dated [DATE] was no completed until 10/29/24. MDS A said that the highlighted date in red meant that the assessment was submitted late. MDS A said there had been no full time MDS Coordinator at the facility since June/July of 2023 when he went down to 3 days per week. MDS A said he just missed the dates and submitted the assessment for CR#58 late. MDS A said that he just failed to get it completed within the 7-14-day timeframe and the facility only recently hired a full time MDS Coordinator, MDS B, about 2 weeks ago. MDS A said that CR#58 could have negative payment or reimbursement issues because of the late Discharge Return Not Anticipated MDS Submission. MDS A said he used the RAI manual as his policy and procedure for the completion and submission of the MDS. In an interview with the DON at 12:12 pm on 10/30/2024 she said that she did not sign any facility MDS'. She said the ADON did. She said that MDS A was responsible for the completion, accurate and timely submission of MDS assessments. The DON said she was not sure when the new full time MDS B started and that she really did not know much about any of the MDS information or assessments . In an interview with the Administrator at 1:23 pm on 10/30/24 he said that he was aware that there were issues with the MDS department. He said they had hired another part-time MDS person, but they did not work out. The Administrator said there was an audit tool in PCC (EMR) that he would and could review but did not recall how frequently he had done that. The Administrator said from that report he could see which assessments were late. The Administrator said he started working at the facility in June 2024 and identified that the MDS department needed a full-time MDS Coordinator, and the facility had just hired one about 2 weeks ago . In an interview with the ADON at 1:31 pm on 10/30/24 shesaid she had worked at the facility for 3 years. The ADON said she was the only RUG certified RN in the building. She said she signed the MDS' but only signed that they were completed not for accuracy, or submission. She said she did check to see if assessments were completed on time and caught a few that had not been completed on time but could not recall any specific resident or assessment. The ADON said there had been no full time MDS Coordinator since last year, 2023. She said there was a large corporate level shift and some staff turnover. She said that the DON and the Admin were responsible for MDS oversight but in her opinion the Corporate MDS A was ultimately responsible and should oversee the facility assessments. The ADON said that possible adverse consequences for late submission of assessments could be financial for CR #58 and that CMS could take money back from the the facility. She said Corporate Nurse A trained her on completing MDS assessments but was no longer with the company. During a follow up interview with the Administrator at 4:42 pm on 10/30/24 he said that a possible negative or adverse effect for a resident with an incomplete, inaccurate, or late submission MDS assessment could be that the resident could run into problems with state reimbursement being affected, issues with qualifying stays, and that it could be a multitude of problems. Record review of CMS's RAI Version 3.0 Manual dated October 2023, Chapter 2; 2-37 revealed the following: 09. Discharge Assessment-Return Not Anticipated Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. o Must be submitted within 14 days after the MDS completion date +14 days.

Based on interviews and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (CR #1) of one resident reviewed for transfer/discharge. The facility failed to readmit CR#1 to the facility after she was sent to the hospital on 11/29/24. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health. Findings included: Record review of CR # 1 face sheet dated 10/30/23 revealed an 81-year -old female admitted to the facility on [DATE]. Her diagnoses included anemia (low red blood count), hypothyroidism (a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormones), heart disease, and lower back pain. Record review of CR#1's close MDS record indicated she was discharged from the facility on 11/29/24 coded as return not anticipated. Record review of CR #1's nurse's note dated 11/29/2023 15:48 read in part: Resident was brought to nurse's station by PTA staff. Large edematous hematoma to RLE. Measures 8.3 cm x 4.6 cm. Staff explained res hit her leg-on-leg rest during transfer to wheelchair. RLE elevated and ice pack applied to site. Res did complain of pain 8 out of 10- and one-time order for Tylenol #4 obtained and administered. Responsible party notified via voicemail of incident. Will continue to monitor for changes. Record review of emergency transfer note indicated CR #1 was sent to the hospital due to uncontrolled pain. During an interview with the Resident's responsible party on 10/30/24 at 3:30pm, she said CR #1 was admitted to the facility around November of 2023. She said CR #1 was injured at the facility and was sent to the hospital due to severe pain. RP said the facility refused to accept CR #1 back after completing her treatment at the hospital. She said CR #1 had to be transferred out of town because the facility refused to take CR # 1 back because CR #1 had an infection. During an interview with the facility's DON on 10/30/24 at 4:00pm, she said CR #1 was not accepted back to the facility due to Resident #1's communicable disease of Candida-Auris (a fungus infection acquired by patient with low immune system). The DON said the facility could not care for CR #1 due to the infection and for the protection of other residents at the facility. No answer was provided on placing CR #1 on isolation precautions. The DON said the decision was from the corporate office. In an interview with the Corporate Clinical Staff on 10/30/24 at 4:10PM, she said she does not recall CR #1. She said Candida Auris would be a condition that the facility would not accept due to the facility's population. She said candida auris can easily spread. No answer was provided on how the action of the facility might have affected the resident. During an interview with the facility's Administrator on 10/31/24 at 4:00pm, he said he was not at the facility at that time, but the facility had to protect other residents at the facility. He said normally the facility would evaluate the resident and assist the resident in locating a facility that could take care of the resident. Record review of facility's policy's policy dated 2001 revised 2022 titled Transfer or Discharge, Facility-Initiated read in part Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .

Based on observations, interviews and record reviews the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 resident reviewed for care plan accuracy (Resident # 27). --Resident # 27's care plan was not revised to reflect a healed deep tissue injury. This failure placed residents at risk of not receiving care according to their individual needs. Findings include: Record review of Resident # 27's face sheet revealed a [AGE] year-old male with admitted [DATE] and diagnoses including Diabetes (too much sugar in the blood), hypertension (high blood pressure), heart disease (conditions affecting the heart), hemiplegia and hemiparesis following a stroke (partial or complete paralysis affecting one side of the body), muscle weakness, reduced mobility, chronic kidney disease (longstanding kidney disease leading to kidney failure). . Record review of the annual MDS dated [DATE] revealed Resident #27 had a BIMS score of 07 indicating moderately impaired cognitive skills, always incontinent of bowel and bladder, and required maximum staff assistance for hygiene, dressing, bathing, and toileting, and dependent on staff assistance for transfers. Record review of wound evaluation from wound care Doctor dated 9/18/24 revealed unstageable DTI of right first toe (resolved 9/18/24), epithelialized and resolved. Record review of Resident # 27's care plan, undated, revealed I have an unstageable DTI of my right big toe, wound treatment as ordered. Interventions included: discontinue this care plan when problem was resolved. Observation and interview with Resident # 27 on 10/28/24 at 10:30am revealed he was resting in bed and said he did not have any wound on his toe. He said they used to treat it but the last time the wound care doctor looked at it, it was healed. Interview on 10/30/24 at 10:45am, LVN L said there were no skin issues with Resident # 27. Interview on 10/30/24 at 10:48 am, MDS A and B said there should not be a care plan for a wound if it was healed. MDS B assessed Resident #27 and said there was no wound on his right front toe, and the care plan would be revised. In further interview, they said the risk of having inaccurate care plans would be the resident not getting the right care according to their individual assessment. Interview on 10/30/24 at 11:40 am, the DON said the care plan should be accurate and match the resident. She said the former MDS nurse left, and a full-time MDS nurse started here 2 -3 months ago, which would help them get caught up with correct assessments. She said the risk to residents of inaccurate assessments would be they would not be getting proper care. Record review of the facility policy Comprehensive Resident-Centered Care Plans, revised March 2022, read, in part: assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .the interdisciplinary team reviews and updates the care plan .

Based on observations, interviews, and record review, the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, for ---2 of 16 (Resident #19 and #47) residents reviewed for MDS accuracy. -Resident #19 was not assessed for her lack of natural teeth on her oral cavity. -Resident #47's Admission assessment did not reflect his cognition and his lack of natural teeth on his oral cavity. These failures could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: - Resident #19: Record review of Resident #19's face sheet dated 10/29/24 revealed a 73-year -old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypokalemia (low blood potassium levels), anxiety, heart disease, osteoarthritis (condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness), weakness, anemia ( low red blood count), and essential hypertension ( high blood pressure). Record review of Resident #19's annual MDS dated [DATE] revealed Resident #19 had a BIMS score of 15 out of 15 which indicated she was cognitively intact. Record review of section L of the MDS oral dental section was coded 0 which indicated she has all her natural teeth with no difficulty. Observation and interview on 10/28/24 at 9:15 am, revealed Resident # 19 was in her room alert and oriented. During an interview she said she had her dentures, but she did not use them because they don't fit and were very painful. She pointed to her dentures and said they were in that white cup. She said she had told someone but does not remember who she spoke to. During an interview with the MDS coordinator on 10/29/24 at 12:20pm, he said he was not responsible for section L of the MDS. He said that was done by the Dietary Manager. Resident #47 -Record review of Resident #47's Face Sheet, dated 10/30/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Resident #47's diagnoses included essential hypertension (high blood pressure, hypothyroidism (condition when the thyroid gland doesn't make enough thyroid hormone),. Cerebral infarction (a condition where there is a decrease flow of blood to the brain), chronic obstructive, and pulmonary disease (a type of progressive lung disease, convulsions). Review of Resident #47's Comprehensive MDS Assessment, dated 12/07/23 reflected Resident #47 had severe impairment in cognition with a BIMS score of 99. Record review of section L-oral dental section was coded as 0 which indicated he had all his natural teeth with no problem on his oral cavity. Observation and interview, on 10/28/24 at 10:40AM, revealed Resident #47 was in his room with a bag of chips in his hand, he was alert and oriented during an interview, and he said that was his snack. Observation indicated he had no teeth in his oral cavity. He said he lost his dentures and doid with what he could. He said he was not sure where he lost them between seizures, hospital, and the facility. He asked if someone could help him to get them back. He said he ate mostly soft food, but he surely missed his dentures. During an interview with CNA E on 10/29/24 at 12:30PM, CNA E said she regularly worked with Resident # 47. She said Resident #47 was always awake, alert, and oriented X3, enough to answer questions, and did not seem to be cognitively impaired. CNA E said for most ADL care including oral care, she was able to provide set-up assistance for the resident and had no knowledge of his denture status. During an interview with the DON on 10/29/24 at 1:15 PM she said she had been communicating with Resident #47 without a problem since his admission. She said the Dietary Manager was responsible for doing section L of the MDS (oral cavity). She said the social worker was responsible for doing section B (Hearing, Speech, and Vision) and section C (Cognitive patterns) of the MDS. She said the facility had an audit on the MDS assessment and was aware of the corrections the process of making sure that all MDS accurately reflected resident's condition. She said the facility had just hired a new social worker that started this week (10/21/21 ). During an interview with the Dietary Manager on 10/30/24 at 3:00PM, she said she was responsible for section L of the MDS. She said she was told to ask residents if they had any problems eating and swallowing. She said she would code the MDS according to their answer. She said she did not understand how to code the MDS but was only doing what she was asked to do by a staff that no longer worked at the facility. Record review of facility's policy on Resident assessment dated 2001, revised 2022, titled Policy Statement: did not address accuracy of MDS assessment.

Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, comfortable environment for 1 resident of 37 (Resident #11), staff and visitors in 1 resident room (room [ROOM NUMBER] W). Resident #11's room [ROOM NUMBER] had 2 unsecured oxygen tanks standing next to each other on the floor. This failure could place residents, staff, and visitors at risk of living and working in an unsafe, dangerous environment. Findings included: Record review of Resident # 11's Admission Record dated 10/30/24 revealed she was a [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: diffuse traumatic brain injury with loss of consciousness of unspecified duration, post traumatic seizures ( seizures that occur after a traumatic brain injury), epilepsy and recurrent seizures (a brain disorder causing recurrent, uncontrolled jerking, movements caused by abnormal activity in the brain), tracheostomy status (surgical procedure that creates an opening in the neck and into the windpipe that helps a person breath), and aphasia (language disorder that affects a person's ability to communicate including inability to speak). Record review of Resident #11's Annual MDS dated [DATE] revealed she was coded as having no ability to talk and her SAMS revealed she was severely cognitively impaired and was dependent on staff assistance for ADL's. Resident #1 was also coded as having tracheostomy care and oxygen therapy in section O of the MDS - Special Treatments, Procedures, and Programs . Observation of Resident #11 on 10/29/24 at 08:34 a.m. revealed 3 oxygen cylinders canisters. The 3 oxygen tanks were standing next to the bedside oxygen concentrator machine. 1 oxygen tank was in a secured metal stand. The other 2 oxygen tanks were standing on the floor with no stand, or cart and they were not secured or anchored to anything to keep them from falling and potentially releasing pressurized oxygen rapidly and turning into a heavy metal projectile. Observation and interview at 8:42 am on 10/29/24 with RN B who when shown the 2 unsecured oxygen tanks standing in Resident #11's room next to a bedside oxygen concentrator (a device that produces a higher concentration of oxygen from the surrounding air). RN B said that Resident #11 had significant family involvement and input into the resident's care, and often requested additional oxygen tanks for use at the bedside. RN B said that the 2 unsecured oxygen tanks should not be free standing on the floor next to the resident's bedside. RN B said other staff sometimes keep the empty tanks at the bedside to have on hand per family request and that someone must have forgotten to remove the oxygen tanks. When asked how the oxygen tanks should be stored, RN A said they should be kept in a stand to secure them and not just left standing on the floor. RN A quickly removed the tanks from Resident #11's bedside and room. RN B said that if the tanks had fallen, they could have blown up and was unsure if they were empty. Interview with DON at 8:55am on 10/29/24 who was advised of the 2 unsecured, free standing oxygen tanks on the floor in Resident #11's room . The DON said they should not have been there and that they posed a potential hazard if they fell . The DON said the 2 oxygen tanks should have been secured and stored properly per policy and procedure. Record review of facility policy and procedure titled: Fire, Safety and Prevention, dated Revised May 2011, revealed the following: f. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. Do not store oxygen cylinders in any resident room or living area; q. Ensure oxygen cylinders in use are on approved carts or stands and are attached to the residents' beds.

Based on observations, record review, and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for 1 of 9 residents (Resident #38) reviewed for unnecessary medications. in that: -The facility failed to ensure Resident that Resident #38 did not have an appropriate diagnosis associated with the use of Abilifya and his clinical record did not contain a diagnosis beyond the diagnosis on the consent which was identified as psychotic behavior. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medicines) and receiving unnecessary medications. Findings included: Record review of Resident #38's face sheet dared 10/30/24 revealed a 72- year-old female admitted on to the facility on [DATE]. Her diagnoses included essential hypertension (high blood pressure, hypothyroidism (condition when the thyroid gland doesn't make enough thyroid hormone), alcohol dependence, Alzheimer's disease, and depression. Record review of Resident #38's Admission MDS assessment dated [DATE] indicated Resident #38 had a BIMS score of 11 out of 15 which indicated moderate impairment on cognition. Record review of Resident #38's physician orders and medication administration revealed Resident # 38 was on the following medications: -Amlodipine Besylate Tablet 10 MG- Give 1 tablet by mouth one time a day for HTN start date 09/13/2024. -Aricept Tablet 5 MG (Donepezil HCl) Give 1 tablet by mouth at bedtime for dementia -Start Date-09/12/2024 1900 -Aripiprazole Tablet 5 MG Give 1 tablet by mouth one time a day for depression resistant to treatment Start Date- 09/13/2024 -Bupropion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Give 1 tablet by mouth one time a day for depression -Start Date-09/13/2024 - -Escitalopram Oxalate Tablet 20 MG Give 1 tablet by mouth one time a day for Depression -Start Date-09/13/2024 - -Levothyroxine Sodium Tablet 75 MCG Give 1 tablet by mouth one time a day for low thyroid hormone Give 1 hour before or after meals -Start Date-09/13/2024 - Meloxicam Tablet 15 MG Give 1 tablet by mouth one time a day for anti-inflammatory (left hip pain) Start Date 09/13/2024 Record review of Resident #38's consent for psychotropics revealed Resident #38 and her physician signed the consent to receive Abilify (Aripiprazole) for psychotic behavior. During an interview on 10/30/24 at 2:30PM, the DON said Resident # 38 was admitted to the facility with the medication and she would call Resident #38's physician to clarify the use of Abilify for psychotic behavior. During a phone interview with Resident #38's Physician on 10/30/24 at 4:50PM, she said Resident #38 was already on Abilify at the hospital because Resident # 38 had tried other medication and the result was not favorable and resident #38 responded well to Abilify. She said she would refer Resident #38 to psychiatric for evaluation and proper diagnoses. Facility's policy on the use of psychotropic medication was requested but was not provided prior to exit on 10/30/24.

Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, final status at discharge and a reconciliation of medications for 1 resident of 1 resident (CR #64) reviewed for discharge summary. The closed record for Resident #64 that was reviewed did not contain a discharge summary that included a recapitulation of the resident's stay. This failure could place residents at risk of not receiving needed care and services after discharge. Findings included: The closed record face sheet for Resident #64 revealed an admitted [DATE] with diagnoses that included unspecified fracture of left femur, presence of left artificial hip joint, hypertension (a condition in which the force of the blood against the artery wall is too high), and hyperlipidemia (excess lipids or fat in the blood). Interview with admission's director on 10/29/2024 at 2:35 PM stated that they could not get in contact with the resident, but the resident's brother stated the resident was not coming back to the facility and if he needed to signto sign anything, it needed to be mailed. Interview with DON on 10/29/2024 at 3:40 PM stated they did not receive any notes from the doctor, and they did not mail out an AMA form for the patient to sign. The DON stated that everyone should have a discharge summary, and nothing was mailed out to the resident. The DON stated that the social worker was responsible for the discharge paperwork and mailing out discharge and AMA forms. Interview with the social worker on 10/30/2024 at 12:17 PM stated that the social worker was responsible for discharge planning, mailing discharge, and AMA forms but was not working during the time the resident was at the facility. The social worker stated that a discharge summary and AMA form should have been mailed to the resident. Record review of the facility's policy titled, Discharge Summary and Plan, dated revised October 2022, read in part that .when a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan.

Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments for two (Nurse Medication Cart Second Floor and Medication Aide Medication Cart Third Floor) of six medication carts observed for storage of medications. The facility failed to ensure the Nurse medication cart second floor and Medication Aide medication cart third cart were secured when unattended. These failures could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Observation and interview on the second floor on 09/12/2023 at 2:28 PM revealed the Nurse medication cart was parked unlocked in the hall near room [ROOM NUMBER]. No staff, residents or visitors were in the hall. As the observation continued at 2:31 PM, LVN A arrived at the medication cart from room [ROOM NUMBER]. LVN A stated this was the medication cart she was working on. LVN A stated she forgot to lock the medication cart. LVN A stated she went into the room to help transfer a resident. LVN A stated the medication carts were to be locked when unattended. LVN A stated the risk of the medication carts not being locked was a resident could take a medication out they should not have. LVN A stated to prevent this again she will make sure the medication carts were locked before leaving it. Inventory of the Nurse medication cart second floor at this time accompanied by LVN A revealed: First drawer- Insulin Insulin syringes Second drawer- Acidophilis (dietary supplement to add good bacteria naturally found the digestive tract) Tylenol Resident individual medication packs Lactulose (liquid medication to treat constipation and liver disease) Empty locked narcotic box Third drawer Respirator breathing treatment medications Creams and lotion skin medications Observation of the third floor on 09/13/2023 at 7:23 AM revealed MA B gathered a resident's medications and walked into room [ROOM NUMBER]. The MA medication cart third floor was left unlocked and unattended in the hall out of her sight. Staff was observed going in and out of rooms on the hall providing care. No visitors or residents were observed in the hall. Observation and interview on 09/13/2023 at 7:28 AM, MA B returned to the medication cart. MA B stated she realized she forgot to lock the medication cart when she was in the middle of giving medications to the resident. MA B stated she was unable to leave the resident at that time. MA B stated it was important to lock the medication cart when leaving it because it can be a risk to the resident. MA B stated a resident may take something out of the medication cart. MA B continued and stated it was important to keep medications safe. MA B stated the next time she will make sure the medication cart was locked prior to leaving it. Inventory of MA medication cart third floor on 09/13/2023 at 7:28 AM accompanied by MA B revealed: Left side of cart: Drawer One: Mulitvitamins, Melatonin, Stool softer, Tylenol, Magnesium, Tums, laxatives. Drawer 2: Medication supplies Drawer 3: Nasal sprays Drawer 4: Empty Right side of cart: Drawer 1: medication supplies Drawer 2: Locked empty narcotic box Drawer 3: Liquid oral medications, Protein supplements Drawer 4: Empty Interview on 09/13/2023 at 9:24AM, the DON stated she expected all medication carts were locked when left. The DON stated no medication carts were to be unattended and unlocked. The DON stated staff were to wear the key on their wrist as a reminder to lock before leaving the cart. The DON stated the risk was a resident could get into the medication cart and take medications or scissors out. The DON stated there were residents with dementia which could result in harm. The DON stated she and the ADON would plan to train the staff on locking the medication carts when unattended. Interview on 09/13/2023 at 11:59 AM, the Administrator stated she expected the company policy was to be followed. The medication carts were to be locked when left unattended. The Administrator stated the risk was anyone could get into the medication carts and take medications. The Administrator stated locking the medication cart was for resident safety. The Administrator stated they will plan to do daily monitoring of the medication carts. Record review of the facility's policy, Storage of Medications. Revised Dated April 2019 read in part Policy Statement The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation ad Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 9. Unlocked medication cares are not left unattended . Record review of the facility policy, Security of Medication Cart. Revised Dated April 2007 read in part Policy Statement The medication cart shall be secured during medication passes. Policy Interpretation and Implementation 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 4. Medication carts must be securely locked at all times when out of the nurse's view .

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plans were reviewed and revised by the Interdisciplinary team after each assessment for 2 of 13 residents reviewed for care plan accuracy (Residents # 15, #27). --Resident # 15's clinical chart did not contain a care plan for ADL assistance and had care plans for a healed stage 3 sacral ulcer and a healed sore on her great toe. --Resident #27's was care planned for wander guard for risk of elopement, which had been removed by facility Findings include: Record review of Resident #15's face sheet revealed a [AGE] year-old female with admitted [DATE] and diagnoses including Alzheimer's disease (progressive disease that destroys memory and mental functions), malignant neoplasm (cancer) of female breast, cerebral infarction (disruption of blood flow to the brain), functional Quadriplegia (paralysis that affects all 4 limbs), hypertension (high blood pressure). Record review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS summary score of 05, indicating severely impaired cognitive skills, required extensive assistance from 2 staff members for bed mobility, transfer, dressing, hygiene, toileting and eating, always incontinent of bowel and bladder, and one stage 3 (full thickness tissue loss) pressure sore. Observation 9/14/23 at 10:30 AM revealed Resident #15 was in bed, and said she needed to get up in her wheelchair and put on her shoes, but she had to have someone help her get up and get dressed. Record review of Resident #15's clinical chart revealed no care plan with focus, goals, or interventions for assistance with ADL's. Record review of Resident #15's care plan, reveiwed 7/11/23, revealed a stage 3 pressure ulcer to sacrum, with interventions including perform treatments as ordered, perform weekly wound evaluation, and monitor for signs and symptoms of infection . Record review of Resident # 15's care plan, reveiwed 7/11/23, revealed infection to left great toe, with interventions including infection will be resolved, monitor for signs of infection, administer medications as ordered, perform treatments as ordered . Record review of pressure sore list revealed Resident # 15's sacral pressure sore was resolved on 7/13/23 and left great toe infection was resolved on 9/4/23. In an interview on 9/13/23 at 1:30 PM, the ADON said Resident #15's stage 3 pressure sore to sacrum was healed on 7/13/23 and left great toe infection was healed on 9/4/23, and the care plan needed to be revised for the healed pressure sores and assistance with ADL's. In interview on 9/14/23 at 11:30 AM, DON said the care plans for Resident #15 needed to be revised for the healed pressure sores. She said the risk of having inaccurate care plans would be the care plan system needed to be reviewed. Record review of Resident #27's face sheet revealed an [AGE] year-old female with admitted [DATE] and diagnoses including heart failure, Dementia (loss of intellectual functioning caused by a brain disease), osteoporosis (brittle and fragile bones from tissue loss), Diabetes (impaired insulin production with elevated glucose levels in blood), and neuropathy (nerve damage in hands or feet). Record review of Resident #27's Quarterly MDS dated [DATE] revealed a BIMS summary score of 09 indicating moderately impaired cognitive skills, limited assistance required for bed mobility, dressing, toileting, and extensive assistance required for hygiene and bathing, always incontinent of bladder and bowel, and wander/elopement alarm used daily. Observation and interview with Resident #27 on 9/13/23 at 10:00 AM revealed she was quietly sitting in a chair in the dining room for the Resident Council meeting as part of the annual survey. Observation at that time revealed a wander guard was not present on her ankle or wrist. Interview with Resident #15 at that time revealed she did not have the wander guard any-more, and she did not want to try to leave the facility. Record review of Resident #15's care plan, reveiwed 9/6/23, revealed focus, goals and interventions for wander guard related to risk for elopement/wandering. Focus included I want to go outside at times and like to go outside for fresh air. I now have a wander guard. Interventions included check daily to ensure my wanderer's bracelet is on and accurately working. Interview on 9/14/23 at 11:30 pm, DON said Resident #27's wander guard had been removed by the facility apprx. 2 weeks ago because she was no longer a risk for elopement, her care plan needed to be revised, and the care plan system would have to be reviewed to reflect the resident's current condition. Interview on 9/13/23 at 1:00 pm with MDS nurse revealed he has been doing care plans and MDS since April of this year, and some needed to be updated. The care plans for these residents needed to be updated to reflect their current conditions. He said the risk of not having care plans updated for the residents' current condition is that staff would not know how to care for residents properly. Record review of the facility Care Plan policy, revised Dec. 2016, revealed care plans would be reviewed and revised by the Interdisciplinary team after each assessment and as needed.

Based on observation, interview and record review, the facility failed to coordinate an assessment with Pre-Admission Screening and Resident Review program (PASRR) under Medicaid and initiate services within 30 days after the date that the services are agreed upon in the IDT meeting, to ensure that individuals with mental illness or intellectual developmental disabilities receive the care and services they need in the most appropriate setting for 1 of 3 residents (Resident #44) reviewed for pre-admission screenings. -The facility failed to submit a Form 1018, Request for a Customized Manual Wheelchair (CMCW) within 30 days of the date that the services were agreed upon in an IDT meeting addressing Resident #44's needs. This failure could place 2 other residents requiring PASRR services at risk of them not having their special needs assessed and met by the facility. Findings include: An observation of Resident #44 on 9/12/2023 at 9:39 a.m., the resident was sitting in his specialized wheelchair, groomed, and sitting in front of the nursing desk. The resident is not interview able. Record review of documentation provided by the facility revealed a PASRR/IDT meeting was held on 2/23/2023 with recommendations to order a custom wheelchair for Resident #44. Interview on 9/12/2023 at 2:09 a.m. with the Administrator, she said that there were changes with Resident #44 during this time(after the IDT meeting in February 2023 was held), there were plans in place dealing with guardianship and discharge to another location that led to the issue with PASRR/IDT and the receipt of his wheelchair. The facility was told that by the wheelchair manufacturor that the wheelchair would not be ready prior to his discharge and that the wheelchair would be ordered after his discharge so that the delivery would go to his new home, so the order was held and the staff that was previously dealing with the wheelchair was no longer an employee but the email correspondence regarding the ordered wheelchair was being emailed to her old email and they were not aware. Interview on 9/14/2023 at 9:00 a.m. with the MDS Coordinator, he said that he did not assume the position of MDS Coordinator until 4/18/2023 and that the MDS Coordinator is responsible for PASRR/IDT and making sure that the resident receives services as requested. He said that he did not know that Resident #44 had orders to receive a new wheelchair because the staff that was previously dealing with the wheelchair was no longer an employee but the email correspondence regarding the ordered wheelchair was being emailed to her old email address. He said that he began to work on this then and the wheelchair is supposed to be delivered today 9/14/2023. He said that the negative outcome of a resident not receiving services or equipment would be that the facility would not be following PASRR recommendations. Interview on 9/14/2023 at 2:45 p.m. the Administrator said that the wheelchair was delivered today (9/14/2023). Record review of the admission record dated 9/14/2023 for Resident #44 revealed he was [AGE] years old and admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently. Signs of this lifelong condition appear during childhood), cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth) and obstructive hydrocephalus (it occurs when the flow of CSF is blocked along one of more of the passages connecting the ventricles, causing enlargement of the pathways upstream of the block and leading to an increase in pressure within the skull). Record review of Resident #44's Re-entry MDS assessment dated [DATE] revealed a cognitive skill for daily decision-making score of 3, indicating he was severely impaired cognitively. He required extensive assistance of one person for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Record review of Resident # 44's care plan dated 9/6/2023 revealed a care plan to address PASRR/IDT, intellectual disabilities/communication and cognitive function. Record review of the order form and specifications for the wheelchair dated February 2023 for Resident #44's specialized wheelchair, revealed that the resident received an assessment and the wheelchair was ordered. Record review of the Authorization Request for Nursing Facility Specialized Services (NFSS) NFSS for Customized Manual Wheelchair (CMCW) dated 3/20/2023 revealed an order for Resident #44's specialized wheelchair. Record review of the Customized Manual Wheelchair/Durable Medical Equipment (CMWC/DME) assessment dated [DATE] for Resident # 44's customized wheelchair revealed that Resident #44 received an assessment for his customized wheelchair and that the new request for the wheelchair was submitted. Record review of the facility policy entitled Preadmission and Screening Resident Review (PASRR) Rules Guidelines Policy, revision date 1/1/2021 read in part .the Service Planning Team (SPT) develops, revises and monitors a transition plan as necessary.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 14 residents (CR#1) reviewed for quality of care. Three licensed Nurses, RN A, LVN A, and LVN B failed to reassess interventions for CR #1 after an unwitnessed fall with suspected head injury and significant change in condition. This deficient practice could place residents requiring reassessment after unwitnessed falls at risk for adverse effects including traumatic injury and or death. Findings included: CR #1 Record review of CR #1's Admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with some of the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's Admission MDS on [DATE] at 10:33 am dated [DATE] revealed she had a BIMS that was left blank and a SAMS that indicated she had both, short and long- term memory problems and was coded as being severely impaired in her cognitive skills for daily decision making. She was also coded as having fluctuations in inattentive and disorganized thinking. Further record review revealed CR #1 had behaviors not directed toward others that occurred 4 to 6 days and required two- person physical assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, used a wheelchair for mobility and was always incontinent of bowel and bladder. Continued record review of the admission MDS revealed CR#1 was coded as having a fall within the last month, and within the last ,d+[DATE] months. Record review of CR #1's Fall risk Evaluation on [DATE] at 10:38 am that was undated revealed she had a score of 13 which revealed Score 10 or higher indicated the resident is at high risk of fall. Further record review of CR #1's Fall Risk Assessment Form dated [DATE] but was not signed as completed until [DATE], which was after the fall on [DATE], by LVN A, revealed she had a fall risk score of 13 with total score of 10 or above representing high risk. Record review of SBAR communication form dated [DATE] on[DATE] at 4:26 pm revealed the following: . SITUATION .The change in condition, symptoms, or signs observed and evaluated is/are: Altered mental status, Behavioral symptoms (e.g., agitation, [CONDITION(S)]), Falls, Functional decline (worsening function and/or mobility), Other change in condition: Lethargy upon checking on resident after shift change. Husband at bedside before shift/states fall. This started on: [DATE] .Since this started it has gotten .Unable to determine . . Medication Alerts. Resident is on other anticoagulant (blood thinner) (direct [MEDICATION(S)] inhibitor or platelet inhibitor). . Pulse Oximetry (measure of oxygen in the blood with 100% being the most oxygenated) .91% on O2 (Room Air). .+1. Mental Status Evaluation (compared to baseline; check all changes that you observe) .with Decreased level of consciousness (sleepy, lethargic). check marked as observed. .2. Functional Status Evaluation (compared to baseline; check all that you observe) . with Decreased mobility, and Falls (one or more), check marked as observed. .3. Behavioral Evaluation .Other behavioral changes (describe) .Describe symptoms or signs: lethargy, non-responsive to physical responsiveness. .4. Respiratory Evaluation. Abnormal lung sounds (rales, rhonchi, wheezing) .Labored or rapid breathing. Check marked as observed. .6. Abdominal/GI Evaluation . Nausea and/or vomiting. Check marked as observed. .8. Skin Evaluation .Other (describe) .Describe symptoms or signs: pale. Check marked as observed. .10. Neurological Evaluation .Decreased level of consciousness and Other neurological symptoms (describe). Describe symptoms or signs: lethargy, unresponsiveness to external stim, 2 mm (sic) pupi (pupils are supposed to dilate and enlarge in bright light. This note reflects that when a bright light was shone into CR #1's eyes, her pupil size did not respond and remained small and pinpoint which was an abnormal reaction to light). . Code Status CODE STATUS: DNR. . APPEARANCE. Summarize your observations and evaluation: lethargic, pale, 2mm nonrestrictive pupils, unresponsive to ext. stim, s/p fall post pt. . REVIEW AND NOTIFY .Date: [DATE] .Time: 8:00PM. Recommendations of Primary Clinicians .Md states since resident POA doesn't want her to go to the hospital, hold aspirin for 5 days and continue neuro's. Further record review revealed there was no SBAR completed when CR #1 discharged to the hospital on [DATE] at 1:40pm. Record review of CR #1's undated comprehensive care plan on [DATE] at 2:43pm revealed the following: I am at risk for falls, I have a history of falling. CAA #11 .Goal. I will not have a fall till the next quarterly review. Target Date: [DATE] . Interventions. Ensure call light is within reach and remind resident to use call light to call staff for assistance before getting up. Anticipating resident needs since she is non- verbal. . I have executed NO CPR directive. Record review of CR #1's Baseline Care Plan on [DATE] at 3:13 pm revealed the following: H. Safety Risks 1. Does resident have a history of falls? B. Yes. 21 a. Specify fall during the last month prior to admission. fell at the previous facility. Record review of CR #1's Progress Notes on [DATE] at 3:34pm created by RN A and dated as signed on [DATE] revealed the following entry: 7:30pm: Resident was assessed by this RN A and found to have change in physical and neurological baseline. Resident unresponsive to sternal rub .Resident is normally confused but (sic) but alert. Appears pale. Resident is of DNR status and RP .at bedside until approximately 10:00pm. I spoke to family member and explained to him the situation, that his wife vitals were trending low and that she was pale, and I wanted him to understand exactly what that means. At approx., 8:00pm I notified the RN Supervisor, who could also get no neuro logical response out of CR #1. I once again explained the situation at hand to family member, with supervisor at bedside, and told him I knew it was rough to talk about, but we needed to know that he understood and he explained that he was medically inclined for the past [AGE] years, as a nuclear medicine technologist and, so he understood completely and his children and he had already made a decision on what they wanted. Family member said they wanted to keep CR #1 comfortable and to remain at the facility and he emphasized that absolutely No Resuscitative measure were to be carried out on CR #1. Family member stated he did not want CR #1 going to the ER because she was not going to get any better. Family member explained he had seen the brutality of a resuscitation/code and CR #1 was not to experience that. Attempted to telephone interview RN A repeatedly throughout the investigation on [DATE] at 11:10am, on [DATE] at 10:33 am and at 2:15 pm with no response. Advised by Administrator that RN A no longer worked for the facility. Record review of CR #1's Progress Notes: on [DATE] at 3:55pm created by LVN A and dated as signed on [DATE] revealed: Post Fall Physician A was notified CR #1 alert and oriented X 1, CR #1 was found on the floor near wheelchair head to toe assessment completed, neuro assessment started, contact family for hospitalization directive, fall measures are in place. Continue to monitor, no new orders at this time. Assess meds and hold all blood thinners. Attempted to telephone interview LVN A repeatedly throughout the investigation on [DATE] at 1:16 pm and at 2:52 pm and again on [DATE] at 1:08 pm with no response. Record review of CR #1's Nursing Note on [DATE] at 4:08pm created by RN Supervisor and dated [DATE] at 8:12pm read in part: Resident is s/p fall today at 5:00pm. CR #1 had an unwitnessed fall and is taking ASA 81 mg daily. Since the fall this resident has a significant change in condition from her baseline. Writer spoke with Family member, and he wishes to not sent this resident to the ER for evaluation and treatment. He wants to let her rest in bed because he (sic) feel like she will not get any better and do not want her to go through all of those tests. RN Supervisor notified Physician A about the change in status. He gave a telephone order to hold scheduled aspirin for 5 days and to continue neuro checks. Neuro checks in progress. Record review of CR #1's hospital records on [DATE] at 11:40 am revealed she was treated on [DATE] for a large traumatic intraparenchymal hemorrhage (bleeding in the brain), involving the right temporoparietal lobe (junction or hub of the brain that affects the thalamus, limbic, visual and auditory systems of the body), that required a craniotomy. In an interview with Supervisor on [DATE] at 3:50pm he said that he no longer worked at the facility but remembered the incident. RN Supervisor said that CR #1 supposed had an unwitnessed fall with head injury after a physical therapist left her unattended at the bedside after therapy. He said that normally he would send a resident with that history of events out to the hospital for a head CT to rule out a brain bleed but did not because he was told by RN A that CR #1's family member did not want her sent to the hospital because she was a DNR. When asked if any staff member including himself, ever explained the difference between DNR and significant change in condition to family member, RN Supervisor said he was not the nurse assigned to care for CR #1 and was simply assisting RN A. RN Supervisor said that he assessed CR #1 at the bedside and she was not talking anymore of moving or responding normally as reported by RN A. When asked why he did not send CR #1 out to the hospital after his assessment he said that he could not work alone and would need a physician order. He said that in his clinical judgement he would have ordinarily sent CR #1 out to the hospital because anytime a resident had an unwitnessed fall with suspected head injury and significant change in condition, and was on blood thinners, that was what they were supposed to do. He said he had not been trained on what to do at this particular facility but had worked other places and knew that was what was supposed to happen. He said he did not because the family did not want CR #1 sent. He said that he did notify the DON and Physician A around 8:00pm but was not sure if he had written a note. He said that he heard the family changed their mind the next day and that CR #1 was sent to hospital with a major brain bleed. He repeated that he was not her nurse and no longer worked at the facility and had only worked at the facility for about 45 days. Interview with DON on [DATE] at 4:14pm she said that yes, ordinarily they would send a resident to the hospital if they had an unwitnessed fall and was on blood thinners. She said that they would normally just send them out for a head CT but they were abiding by the family members wishes. When asked if she or LVN A, RN A or Physician A spoke directly to the family member about the difference between a DNR and a significant change in condition, she said no. When asked if she or LVN A, RN A or Physician A had spoken with the family member about placing CR #1 on palliative care or Hospice care, she said no. Interview with DON on [DATE] at 10:28am she said that she came into the facility on [DATE] the day after CR #1's fall between 8:30 and 9:00pm and assessed the resident with LVN A. She said that CR #1 had not improved and was lethargic and not talking or responding like her normal self. She said she called Physician A after calling the family member and there was no answer. She said she went to LVN A and told her to call Physician A and get CR #1 out to the hospital. When asked why she did not notify Physician A herself, she did not answer. When asked why it took LVN A until 1:40 pm to send CR #1 out to the hospital via 911 if she had given instructions between 8:30 aam-9:00am, the DON said she did not know. Interview with Physician A on [DATE] at 3:36pm he said that staff had contacted him about CR #1 and that he briefly touched on the topic of palliative care with another one of CR #1's family members but had not spoken with them about hospice or palliative care to set in motion an actual order. He said he had not been asked by staff to speak with family member regarding the difference between DNR and significant change in condition or asked to speak with family about Hospice or Palliative care after CR 31's condition did not improve. Physician A said that the family did not want any aggressive measure and had made her a DNR. Physician A said that there were small things that the facility could have done differently or handled differently and that there was always room for improvement, such as timeliness related to response times. He said he was unsure if he spoke with DON during the course of CR #1's care but that he spoke with a lot of people and gave the order to send CR #1 to the hospital after the family member agreed. He said he did not know exactly what time he gave the order or what time CR #1 was actually sent to the hospital. Record review of facility policy/procedure titled Discharging the Resident and dated as Revised [DATE] read in part: Documentation. 5. If the resident refused the discharge, the reason(s) why and the intervention taken. Record review of facility policy/procedure titled Falls-Clinical Protocol dated as Revised [DATE] revealed in part: Monitoring and Follow-Up. 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Record review of facility policy/procedure titled Steps in the Procedure dated as Revised [DATE] revealed the following: b. Respirations are increased and shallow with ICP (Intracranial Pressure). Record review of facility policy/procedure titled Acute Condition Changes-Clinical Protocol dated as Revised [DATE] and read in part, as follows: 2. As needed, the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation in the facility or the need for hospitalization .

Based on interview and record review, the facility failed to ensure that a resident who was incontinent of bowel received appropriate treatment and services to prevent fecal impaction for 1of 33 residents (CR # 62) reviewed for incontinent bowel care in that: The facility failed to ensure CR #62 did not develop bowel complications while at the facility that resulted in hospitalization and a fecal impaction. This failure could place residents at risk for developing bowel complications including impaction and hospitalization . Findings included: Record review of CR #62's admission record dated 7/6/22 revealed she was a [AGE] year old female who admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #62 discharged from the facility to hospital emergency roiagnom on [DATE]. Record review of CR #62's Admission MDS dated [DATE] revealed that her BIMS was 12 out of 15 indicating her cognition was intact with moderate impairment. CR #62 required extensive assistance of one staff for toilet use and had impaired range of motion to one side of her upper and lower extremities and was frequently incontinent of bowel and bladder. Record review of CR #62's Admission Care plan dated 05/23/2022, revealed the following: Focus area CR #62 was at risk for alteration on bowel elimination: Constipation related to use of iron supplement, use of pain medication. Goal: CR #62 will establish normal elimination pattern with the ordered intervention in the next 90 days. Interventions: check for fecal impaction in rectal vault as needed. Monitor (sic)med list for any (sic) meds that may cause constipation, medicate as ordered by physician and monitor and report to (sic)md efficacy of (sic) meds. . Focus area CR #62 had pain from her hemorrhoids, bleeding from her rectum. . Goal: CR #62's pain will be managed effectively with the medication ordered by her MD through the next review date. .Interventions: Staff will monitor for pain and bleeding from her rectal area every shift and document. Further record review of CR #62's EMR revealed there was no documentation every shift, of CR #62's pain and whether she had any bleeding. There was no documentation of any checks for fecal impaction in rectal vault conducted by staff or physician on CR #62. Record review of CR #62's undated consolidated physician's order summary report revealed the following orders which CR #62 was receiving: .[MEDICATION(S)] Powder 17 GM/scoop ([MEDICATION(S)]) Give 1 scoop by mouth one time a day for constipation with a start dated 5/24/2022. .[MEDICATION(S)] tablet 5 325 MG ([MEDICATION(S)] Acetaminophen) Give 1 tablet by mouth every 12 hours as needed for pain with a start dated 06/09/2022. .Preparation H Cream 1% (Hydrocortisone) Apply to rectum topically every 8 hours as needed for hemorrhoids with a start dated 5/23/2022. .Preparation H Suppository 0.25 88.44% ([MEDICATION(S)] Cocoa Butter) Insert 1 suppository rectally every 12 hours as needed for hemorrhoids .with a start dated 6/07/2022. .Tylenol with [MEDICATION(S)] #3 Tablet 300 30MG (Acetaminophen [MEDICATION(S)]) Give 1 tablet by mouth every 4 hours as needed for pain. .[MEDICATION(S)] Sulfate tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for supplement. Record review of CR #62's TAR dated 6/1/2022 6/30/2022 revealed she received 1 Preparation H Suppository 0.25 88.44% ([MEDICATION(S)] Cocoa Butter) Insert 1 suppository rectally every 12 hours as needed for hemorrhoids on 6/9/22 which was documented as being effective. Interview with the DOR on 7/6/22 at 1:04 p.m., said she remembered and had worked with CR #62. The DOR said CR #62 frequently complained of pain to her rectum and CR # 62 did not participate in therapy the way she was supposed to because of painful hemorrhoids. She said she and other therapy staff always reported her complaints and concerns to nursing and it was usually the charge nurse assigned to care for CR #62 on that day. The DOR said she could not recall how many times she notified nursing about CR #62's pain. Record review of nursing progress notes on 7/6/22 at 12:55 p.m., by Former MDS Coordinator revealed the following entry dated 6/10/22: Call placed to CR #62's family member regarding concerns with constipation and pain, call placed with nurse on duty (sic)was explained that during shower this am she had a large bowel elimination and she had just had another bowel elimination and hemorrhoidal suppository had been applied. Family member said that CR #62 had a high tolerance for pain and that if she was unable to get up for therapy, she wanted her transferred to the ER. Attempted to contact nurse who wrote the progress note on 7/6/22 at 1:00pm, but nurse no longer worked for the facility and contact number voicemail box was full. Record review of nursing progress notes on 7/6/22 at 1:03 p.m. by Former MDS Coordinator dated 6/10/2022 . Per family request resident is being sent to hospital ER. 911 in facility to transport resident to ER call placed to hospital ER Triage and report was given to RN. Record review of social services note on 7/6/22 at 1:12 p.m. dated 6/11/2022 Late Entry: Since residents admission writer has talked with family member on many occasions, family member has contacted insurance company and insurance case manager contacted writer about concerns and writer wrote a grievance on family members complaints. CR #62 was (sic)(Draft)refusing therapy and writer and DOR went to her room to talk to her bout needing to participate CR #62 states she had concerns with her hemorrhoids .it was reported to writer that CR #62's family member was bringing medication from home to give to CR #62 Family member continued to complain about no one assisting with CR #62's hemorrhoids and the pain she is going through. Physician A had been notified several times and saw the resident several times. Interview on 7/6/22 at 1:11 p.m., the SW said she remembered CR #62 and the resident frequently had pain and was not participating in therapy. She said she wanted to transfer or go to a facility with a higher level of care for therapy, but it was difficult to forward records for acceptance because she was not participating and was refusing. She said CR #62 told her about painful hemorrhoids and she would tell the charge nurse and had also notified the DON and the Corporate Nurse about CR #62's concerns. SW said she spoke with CR #62's family members frequently and was trying to help because the family said they could not take the resident home and the resident was not well enough to go back to living on her own. Record review of CR #62's hospital records dated 6/10/2022 6/20/2022 revealed the following: CT ABDOMEN PELVIS W CONTRAST Result Date: 6/10/2022 Impression: 1. Severe rectal fecal impaction . HOSPITAL COURSE: General Surgery consulted and performed bedside disimpaction . (Use of finger to remove stool from rectum). Telephone interview on 7/7/22 at 2:01 p.m., Physician A said he was the physician for CR #62 and completed physical examinations on the resident during her stay at the facility. He said that CR #62 was having loose stools and got a [MEDICATION(S)] and oral stimulant and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He said he was aware that the resident did have a fecal impaction after the June 10, 2022 admission to the hospital but did not think there was anything additional, he should have prescribed or done for the resident. He said that he felt like the staff cared for CR #62 appropriately and per his orders. Record review of the facility policy titled Bowel (Lower Gastrointestinal Tract) Clinical Protocol dated 2001 MED PASS, Inc (Revised September 2017) read in part: Assessment and Recognition .1. As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. 2. Examples of lower gastrointestinal tract conditions and symptoms include: b. Fecal incontinence; d. pain with defecation; f. Alteration in bowel movements; h. Residents taking antidiarrheal medications or medications related to bowel motility. 3. In addition, the nurse shall assess and document/report the following: b. Quantitative and qualitative description of diarrhea (how many episodes in what period, amount, consistency, etc.); d. Presence of fecal impaction; f. Abdominal assessment; g. Digital rectal examination .5. The staff and physician will characterize symptoms related to bowel function; for example, location and [CONDITION(S)] of abdominal pain, time relationship to meals, presence or cramps or bloating, etc6. Check for diffuse or localized tenderness and listen for bowel sounds in area of suspected ileus or obstruction

Based on observation, interview, and record review the facility failed to ensure that the facility provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 14 residents (Resident #110) reviewed for pharmacy services. The facility failed to ensure that Resident #110's [MEDICATION(S)] ([MEDICATION(S)]) pain medication was ordered from the pharmacy and received timely. This failure could place residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen. Findings Included: Record review of Resident #110's face sheet revealed she was a [AGE] year old female who was admitted to the facility on [DATE]. She was diagnosed with pain, scoliosis (a sideway curvature of the spine), fusion of spine (surgery to permanently connect two or more vertebrae in the spine, eliminating motion between them) and [CONDITION(S)] (a condition in which bones become weak and brittle). Record review of Resident #110's MDS dated [DATE], revealed she had a BIMS of 15 (cognitively intact); she did not exhibit any symptoms of [CONDITION(S)] or behaviors; she required limited assistance from one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; Resident #110 was occasionally incontinent of bowel and bladder. The resident reported her worst pain over the last five days was eight. Record review of Resident #110's baseline care plan dated 06/28/2022 revealed she was on opioids (documented), she had a presence of back pain, and the resident had post surgical wounds. Record review of Resident #110's Physician's Order Summary Report for July 2022 revealed: [MEDICATION(S)] tablet: 4 Mg. every four hours for pain management for seven days. Start Date: 07/01/2022, End Date 07/08/2022. Record review of Resident #110s MAR for July 2022 revealed: [MEDICATION(S)] tablet 4 Mg Give one tablet by mouth every four hours for pain management for seven days. Start Date 07/01/2022. Hold 07/03/2022 at 1949 (7:49 PM). Further review of the record revealed the medication was not administered on 07/03/2022 at: 3:00 AM, 7:00 AM, 11:00 AM, 3:00 PM and 7:00PM. Record review of Resident #110's Nurses Progress Notes revealed: 07/03/2022 at 5:57 AM, LVN J wrote Completely out of [MEDICATION(S)], 07/03/2022 at 10:29 AM and 5:15 PM, LVN F wrote [MEDICATION(S)] 4 Mg pending pharmacy, 07/03/2022 at 6:22PM, LVN L wrote physician notified resident did not have [MEDICATION(S)] available. Observation and interview on 07/05/2022 at 11:56 AM, revealed Resident #110 was sitting up in bed awake, alert, and oriented. The resident had healing abdominal and back surgical wounds. The resident stated she had surgery on June 7 and June 10, 2022. Her level of pain was five out of ten. Resident #110 reported she was getting her scheduled [MEDICATION(S)] the first few days she was here then it ran out and it was not available. The resident reported she had been receiving Tylenol with [MEDICATION(S)] and [MEDICATION(S)]. In an interview on 07/06/22 at 07:15 AM, LVN S stated she worked on an as needed basis. She stated the first time she worked with Resident #110 her [MEDICATION(S)] was here then when she came back to work the next time, she heard the medication was not available. LVN S stated to prevent a medication from running out the nurse was to notify the physician and pharmacy to refill the medication order. It did take longer to refill [MEDICATION(S)] due to having to get the triplicate prescription. The medication was to be refilled prior to it running out, but she was not sure how close to the end it should be refilled. LVN S stated the resident received Tylenol with [MEDICATION(S)] along with [MEDICATION(S)] to cover her pain until the [MEDICATION(S)] was received. All nurses who work on the cart and care for the resident were responsible for making sure there was enough medications available. The risk was the resident's pain may not be covered, she said it happened because it was not filled timely before it ran out. In a phone interview on 07/06/2022 at 01:01 PM, a facility pharmacist stated the [MEDICATION(S)] required a triplicate prescription or e script and it cannot be ordered for more than 30 days at a time. To prevent the resident from running out the required prescription needed to be reordered prior to the medication running out. The pharmacist stated she was on call over the weekend and the nurses made multiple requests to get the medication and the physician was notified for the need to refill the order. She stated the process was to stock the Omnicell (a medication dispensing machine) and replenish as needed until the total that was ordered had been provided then a new order must be received as required. An unsuccessful attempt was made to contact LVN J by phone on 07/06/2022 at 12:42 PM and 4:24 PM. In a phone interview on 07/06/2022 at 04:35 PM, LVN F stated when she worked on 7/3/2022 Resident #110's [MEDICATION(S)] was out each time it was due to be given. She stated she documented on the number nine on the MAR and a blank space for comments came up. LVN F stated she documented pending pharmacy meaning pending pharmacy delivery of the [MEDICATION(S)]. She stated as soon as she saw the medication was out she called the physician and pharmacy but the pharmacy did not fill it. LVN F stated she believed this occurred because the medication was not refilled before it ran out and it could have been prevented if it was reordered before it got low especially over a holiday weekend. She continued and stated everyone working on the cart and with the resident's medication was responsible for making sure there was enough medication available. Running out had a big risk of not managing a resident's pain. In a phone interview on 07/07/2022 at 09:52 AM, the Physician stated the interruption with Resident #110's [MEDICATION(S)] was because he was attempting to wean her off the [MEDICATION(S)] back to the medication she was on prior to her surgery. He stated he was in communication with her pain specialist, and they managed her pain with Tylenol #3 and with [MEDICATION(S)] orally. He stated Resident #110 was not at risk of not having her pain uncontrolled. The physician stated his physical exam of the resident did not reveal that her pain was not in control. In an interview on 07/07/2022 at 10:31 AM, the DON stated she knew there was an interruption in the [MEDICATION(S)] on 07/03/22. She stated on 07/01/22 the physician gave a verbal order to the nurse to discontinue the [MEDICATION(S)] but the nurse did not follow through and write the order. Since the discontinuation order for the [MEDICATION(S)] was never followed through and entered into the system there was still a current active [MEDICATION(S)] order for the resident and the medication was not available to give. She said we did Performance Improvement and took it to our Quality Assurance Performance Improvement so this will not occur again. She said we are having all verbal orders go through me so I can follow up and make sure the orders were followed. The resident did not have any risk because she was having her pain controlled with other medications for pain. The DON stated she will make sure all medications are available on Friday going forward to help ensure this does not occur again. In an interview on 07/07/2022 at 11:00 AM, the Administrator stated the medication issue was going to Quality Assurance Performance Improvement. She stated she agreed the DON will make sure the residents have their medications every Friday. The administrator also said every day in the morning they will run an order listing report to monitor medication availability to prevent this from occurring again. Record review of, Administering Medication, Revised April 2019 revealed, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame . Record review of, Medication Orders, Revised November 2014 revealed, Purpose The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs (in the presence of adverse consequences which indicate the dose should be reduced or discontinued/for excessive duration/without adequate indications for use/duplicate therapy), for 1 of 3 residents (Resident #8) reviewed for unnecessary [CONDITION(S)] medications. Resident #8 was receiving antidepressant, [MEDICATION(S)] ([MEDICATION(S)]), for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could place the resident at risk for complications resulting from receiving unnecessary medication. Findings included: Resident #8 Record review of the admission sheet for Resident #8 revealed an [AGE] year old[AGE] year old female that who admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #8's comprehensive MDS assessment dated [DATE] revealed the resident has a moderate cognitive impairment with a BIMS score 8 out of 15. Record Review of Resident #8's most recent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8 Treatment Administration Record (TAR) from 06/01/2022 07/06/2022 revealed that Resident #8 received anti depressants behavior monitoring, and antidepressant medication side effects monitoring daily. Record review of Resident #8's care plan dated on 06/05/2022 revealed the following: Focus: Potential for complications RT depression. Required the use of antidepressant medication. Goal: Will show decreased episodes of depression through the next review date. Intervention: Give antidepressant medication ordered by physician. Monitor/document side effects and effectiveness of antidepressant. Monitor/document/report to MD PRN ongoing s/sx of depression unaltered by antidepressant meds. Record Rreview of the Medication Regimen Review (MRR) completed by consultant pharmacist on 06/21/2022 revealed Resident #8 was reviewed for psycho active drug, [MEDICATION(S)] HCL([MEDICATION(S)]), antidepressant. A summary of the pharmacist's recommendation was for a gradual does reduction attempt for [MEDICATION(S)] 25mg. The consultant pharmacist communication to physician document was not available upon record review. In an interview on 07/06/2022 at 12:10 p.m., with the DON revealed that the MRR was completed by the consultant pharmacist on 06/21/2022. She stated that the Consultant Pharmacist communication to physician document was left for Physician B to review on 06/22/2022, but the Physician B had not been to the facility to complete the document. She stated that, she had not contacted Physician B because she had over 100 to follow up on, she had not got to them yet, and the review was just completed on the 22nd. She stated that with the fourth of July holiday, she planned to follow up with Physician B on 07/05/2022, but she was delayed due to the survey. She agreed to provide a copy of the consultant pharmacist communication to physician document that was left for the Physician B. She stated that the SW was responsible for ensuring that Gradual Dose Reduction (GDR) were completed. In an interview on 07/06/2022 at 12:47 p.m., with the SW revealed that she was not the oversite for GDR, and she only assist with scheduling the meeting once she is notified the meeting is needed. She stated that the last GDR she scheduled was in October of 2021 to address Resident #8's [MEDICATION(S)]. In an interview and observation on 07/07/2022 at 09:10 a.m., with Resident #8, revealed that Resident was alert and oriented, . Sshe stated that she is given her medications daily. She stated that she takes medication for a few reasons, but she could not name her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the consultant pharmacist communication to physician document revealed that it was printed and dated on 06/22/2022 for Resident #8's antidepressant gradual dose reduction attempt for [MEDICATION(S)] 25mg daily. The document was viewed to be incomplete and had not been signed by a Physician B. Record review of a policy for Psychoactive Medications with no date provided revealed a policy statement: All physicians' orders will be screened to determine if they have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . E. The designee will review, at least quarterly on all residents on psychoactive medications. 1. Gradual dosage reduction or discontinuation will be recommended by the physician/psychologist/psychiatrist/nurse practitioner and the pharmacy consultant. Record review of the policy dated April 2007 for Medication Therapy revealed a policy statement: 1. Each residents' medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, whishes, and responses. 3. All medication orders will be supported by appropriate care processes and practices. The policy interpretation and implementation revealed: 4. Periodically, and when circumstances are present that represent a greater risk for medication related complications, the staff and practitioner will review the medication regimen for continued indications, proper dosage and duration, and possible adverse consequences. 5. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication. 8. On monthly basis the Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff.

Based on interview and record review, the facility failed to complete and transmit a resident assessment within the required time frame for 1 of 33 residents (CR#1) reviewed for data completion and transmission in that: - CR #1's did not have a Discharge MDS completed within the required timeframe. - CR#1 did not have a Discharge MDS transmitted within the required timeframe. This failure affected 1 prior resident and could place an additional 52 current residents at risk of not having their assessments transmitted timely. Findings Include: Record review of CR #1's admission sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's EMR assessments on 7/6/22 at 08:48 am revealed there was no discharge MDS. The last MDS assessment listed for CR #1 was a Medicare 5 day/MDS 3.0 dated 2/4/2022. Further record review revealed a progress note dated 2/9/22 that read in part, as follows: Resident discharged home with her sister with Hospice A. Record review of CR #1's EMR census and billing listing lines on 7/6/22 at 9:00am revealed the following entry: 2/8/2022 .Stop billing. Interview with DON on 7/6/22 at 9:03 am who said that she did not know anything about MDS' and assessments. The DON said that the Corporate Nurse was now the MDS RN A. In an interview on 7/6/22 at 9:58 am with the Corporate Nurse she said she was now also the MDS RN A for the facility. She said that she began working as the facilities MDS RN A about 2 weeks ago. She said she was the RN who signed the facility MDS' because the DON at the facility did not have the appropriate certification to sign MDS'. When she was shown CR #1's Medicare 5 day MDS dated [DATE] that had her initials, she confirmed those were her initials and that she had been signing the facility MDS' in February of 2022 and had signed that MDS for CR #1. When shown the MDS assessment list for CR #1 she said she also, did not see a discharge MDS and said that CR #1 should have one. She stated Yep, can't argue that it is not there. She said that the previous MDS nurse should have caught that there was no discharge MDS for CR #1, because that was ultimately his job because back in February, she was the Corporate Nurse. She said the Corporate MDS Consultant would have been responsible for oversight of all MDS' at that time. She said that the RAI manual was the policy and procedure they use for the completion of MDS'. Telephone interview with Corporate MDS Consultant on 7/6/22 at 11:49 am who said that with regard to CR #1's discharge MDS assessment, unfortunately we missed it. He said that when he looked at it today and there was no discharge assessment for CR #1 who told MDS RN A to just do one dated for today (7/6/22) because CR #1 was supposed to have one. He said that he was oversight for 7 buildings and that ultimately it was the responsibility of the previous MDS Coordinator at the facility to ensure all MDS' were completed and on time. He said the previous MDS Coordinator left on 6/27/22 and that he had not conducted any audits yet since his departure. He said the facility uses the RAI manual as the policy and procedure for completing MDS'. Record review on 7/6/22 at 2:18pm of CMS Submission Report MDS 3.0 NH Final Validation Report .Submission Date/Time: 07/06/2022 12:58 and had the following warning .Assessment Completed Late:(assessment completion date) is more than 14 days after . (assessment reference date). Record review of CMS's RAI manual version 3.0 dated October 2019 revealed the following: Discharge assessment .MDS Completion Date .No Later Than .discharge date +14 Calendar Days. Transmission Date No Later Than .MDS Completion Date +14 Calendar Days.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one (Resident #1) of four residents reviewed for wounds. The facility failed to provide wound care treatment as ordered for Residents #1 on 03/02/2022. This failure could place residents at risk for developing infections and deterioration of their wounds. Findings included: Record review of the admission sheet for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the BIMS score was 05 out of 15, which indicated severely impaired cognitively. The MDS revealed she required limited assistance from one staff with transfers, dressing and toilet use. Record review of Resident #1's care plan initiated on 08/11/2021 and revised on 03/15/22 revealed the following care plan: Focus: I have a stage 2 pressure wound to my sacrum. I am at risk for complication r/t DM, obesity, weakness. Goal: My wounds will be managed effectively in the next 90 days. Interventions: Treat wound per MD orders Record review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and attempted interview on 3/2/22 at 10:31 a.m., revealed Resident #1 was resting in her bed. She was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make her self-understood and did not respond appropriately to asked questions about her pressure sore/injuries. Observation on 3/2/22 at 10:45 a.m., revealed the Wound Care Nurse providing wound care for Resident #1. The WCN was assisted by Certified Nurse Aide (CNA) O. The WCN gathered the supplies at the treatment cart in the hallway before bringing them into Resident #1's room. Prior to initiation of the treatment, Resident #1 was assisted on to her right side. WCN removed the resident's soiled sacral area wound dressing and placed it in the biohazard bag taped to the bedside table. The dressing contained a moderate amount of serosanguinous drainage. There was no date visible on the dressing. Continued observation revealed an open area of approximately 3.0 centimeters in diameter. The WCN then cleansed the pressure wound with the wound cleanser, pat dried, applied xeroform to the wound bed, covered with dry dressing. The WCN did not use skin prep as ordered by the physician. In an interview on 3/2/22 at 11:37a.m., with the WCN, she confirmed she forgot to put the skin prep prior to placing the xeroform. She said the skin prep, protected the skin and helped reduce friction during removal of soiled dressing. This Surveyor reviewed resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she knew what treatment to apply for residents when providing care by following physician orders. She said the DON would spot check her once a month. In an interview on 3/2/22 at 2:07p.m., with the Regional Nurse, this surveyor shared observation from earlier. The Regional Nurse said the wound care nurse should have applied skin prep as it was in the facility's policy. She said it was facility's policy to apply skin prep as residents skin were fragile. Skin prep protected the skin and made a seal which helped while removing the tape. She said the DON spot checked the WCN. She said the DON worked last night at the facility and was not there today. At that time the WCN skill competency check off was requested. In an interview on 3/29/22 at 12:14p.m., with the DON, this surveyor shared the observations from 3/2/22. The DON said her exception was for wound dressings to be changed daily and as needed if soiled or dislodged according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it was important to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time the WCN skill competency check off was requested. Record review of WCN's procedures checklist dated 3/8/22 did not include wound care skills competency checkoffs. Record review of facility's Wound Care policy (Revised October 2010) read in part: .Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in procedure: 12. Apply treatments as indicated .

Based on interview and record reviews the facility failed to maintain an effective infection prevention and control program designed to provide safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 44 of 152 staff and visitors in that: The facility failed to ensure visitors and staff temperatures were checked, and they were screened for signs and symptoms of COVID-19 prior to entering the facility. This deficient practice could place residents at risk of contracting COVID-19 infection or other infectious diseases. Findings include : Record review of screening logs for staff and visitors, dated 1/3/2022 through 1/15/2022, revealed temperatures missing for 4 of 152 visitors and staff and 40 of 152 visitors and staff did not answer the signs and symptoms questions for COVID-19. In an interview with Receptionist A on 2/3/22 at 1:23 PM, she stated she was trained by the ICP on how to complete COVID-19 screenings. She explained when a person entered the building, she wrote their name, took their temperatures, and asked all the questions on the form ( and filled out the form before the individual was allowed entrance. She stated the screenings were done as a means of preventing COVID-19 from coming into the facility. She further stated she was unsure why there were blanks on the forms and believed it was done by the previous receptionist who no longer worked at the facility . In an interview with the ICP on 2/3/22 at 1:39 PM, she stated she was responsible for training the staff who completed the COVID-19 screenings and they were trained to take temperatures and ask all the questions on the forms and document each answer. She explained the expectation was the form to be answered completely and it appeared the individual who left the blanks was not doing their job and no longer worked in the facility. The IPC stated she was responsible for reviewing the forms once they were completed and turned in to her, but she must have missed some when she was out on leave . Surveyor requested a copy of the facility's policy and procedure for Covid-19 staff and visitor screening, but one was not provided upon exit.

Based on observation, interview and record review the facility failed to provide immediate access to any resident by any representative of the Office of the State long term care ombudsman for 2 of 2 ombudsman (Ombudsman A and B) reviewed for resident rights. The facility failed to allow two ombudsmen upstairs where residents resided in the facility due to the COVID - 19 outbreak. This failure could place residents at risk for their needs and concerns not being addressed by not allowing the Ombudsman access to the residents. Findings include: Interview on 10/15/21 at 12:15 PM, Ombudsman C said her supervisor (Ombudsman A) and another Ombudsman (Ombudsman B) attempted to make a visit to the facility on [DATE] and were told they could not visit the residents because of the COVID-19 outbreak they were experiencing. Ombudsman C said Ombudsman A and Ombudsman B were not allowed past the first-floor lobby, so they were unable to make infection control observations concerning the COVID - 19 outbreak. Interview on 10/15/21 at 12:44 PM, RN A said there were no visitors allowed on the 3rd floor because the facility was in complete lockdown due to COVID - 19 outbreak. RN A said the only people who were allowed on the 3rd floor were the staff assigned to work. RN A said the facility currently had one COVID - 19 positive resident who was isolated in their room. Observation on 10/15/21 at 12:45PM, the third floor of the facility had 38 residents living on the floor. There was one resident on isolation precautions for COVID - 19 out of the 38 residents on the 3rd floor. Further observation of the 3rd floor revealed there was only staff members on the floor who were all dressed in full personal protective equipment (PPE) (gown, gloves, N-95 mask, face shield, shoe protectors, and hair covering). Observations on 10/15/21 at 1:00PM, the second floor of the facility had 6 residents residing on the floor. Staff were wearing N-95 masks, there were no residents on isolation precautions, a home health nurse was present on the floor assisting a resident. Interview on 10/15/21 at 2:16 PM, the Receptionist said the facility was on lockdown last week (10/3/21 - 10/9/21) and did not allow visitors in to see residents because of the COVID-19 outbreak. The receptionist said the facility was allowing visitation again which started on 10/11/21 . Record review of facility COVID-19 tracking revealed on 10/6/21 there were 4 COVID-19 positive residents in the building. Further review of the tracking revealed on 10/7/21 one additional resident tested positive for COVID-19, 10/8/21 2 additional resident tested positive for COVID - 19, and on 10/9/21 one additional resident tested positive for COVID-19. Interview on 10/15/21 at 3:30 PM, the Administrator said the facility COVID - 19 outbreak started with family not following COVID - 19 precautions and not wearing mask appropriately during visits with residents. The Administrator said as more residents began to test positive in the facility, they strongly encouraged no one to visit. The Administrator said the facility had not denied anyone visitation if they insisted on seeing residents despite the COVID - 19 outbreak . Interview on 10/19/21 at 2:00 PM, Ombudsman A said her, and Ombudsman B went to the facility on [DATE] to attend a resident council meeting. Ombudsman A said they entered the facility and were screened by the receptionist. She said they told the receptionist they were Ombudsman there to attend the resident council meeting and the receptionist said they were not able to go upstairs because they had a COVID - 19 outbreak. The receptionist said she would get the Social Worker for them to talk to and asked them to remain in the lobby. Ombudsman A said the Activity Director came down to talk to them and asked them to step outside to talk. The Activity Director informed them the facility was on lockdown due to a COVID - 19 outbreak and they were unable to go upstairs to see residents because they did not know which residents were positive for COVID - 19. Ombudsman A said her, and Ombudsman B left the facility without visualizing or speaking to any residents. Interview on 10/19/21 at 5:30 PM, the Administrator said the two Ombudsman were not denied access to the residents on 10/6/21 and stated the facility would never deny ombudsman access to the residents. Record review of the facility's, undated, policy and procedure for visitation revealed in part, .The facility can now permit: close/personal contact during any visitation for full vaccinated residents. Outdoor visitation at all facilities, even when the facility has an outbreak, all visitation without time limits, while adhering to infection prevention and control measures . During an outbreak, the facility will strongly encourage visitors to refrain from personal visits and will instead encourage face time, skype, or face time

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident # 1) reviewed for accidents in that: -The facility failed to provide 2 person assistance to Resident #1, who required 2 person assistance for bed mobility, was turned by one staff during care. Resident #1 sustained a fall out of the bed during care and resulted in 2 staples to the head. This failure could affect residents who required assistance with bathing and placed them at risk of accidents or injury. Finding include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old female initially admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnosis included unspecified dementia with behavioral disturbance, restless leg syndrome, vascular dementia, other seizures, generalized muscle weakness, unspecified abnormalities of gait and mobility, unspecified intracranial injury with loss of consciousness unspecified duration, major depressive disorder, deficiency of other vitamins, [CONDITION(S)], anxiety disorder, [CONDITION(S)], essential hypertension, [CONDITION(S)] following unspecified [CONDITION(S)] disease, dysphagia unspecified [CONDITION(S)] disease, gastrostomy status, and constipation. Record review of Resident #1's annual MDS assessment dated [DATE] revealed Resident #1 was rarely/never understood. Further review revealed Resident's cognitive skills for daily decision making was severely impaired. She required extensive assistance of two persons for bed mobility, dressing, and personal hygiene. She was totally dependent on two persons for transfers, toilet use and bathing. Record review of Resident #1's care-plan revealed: * Focus: I have an ADL self care performance deficit related to [CONDITION(S)] accident, dementia, muscle weakness and abnormal gait/mobility. (Target date: 9/11/20) Interventions: I have ¼ rails on my bed, used as an enabler to assist me with bed mobility . Resident requires extensive assist of 1-2 for bed mobility transfers (Times 2 with hoyer), ambulation (wheelchair), dressing, peg tube feed, incontinent care of bowel and bladder, personal hygiene, shower on scheduled days and as needed. * Focus: I resist care at times related to vascular dementia and decreased mobility. I have [CONDITION(S)] so I cannot express myself. I become combative when my staff is rendering care, I swing my arms and legs. (Target date: 9/11/20). * Focus: I am at risk for injury related to weakness, history of falls, use of medications whose adverse effects may increase the risk for falls. (Target date: 9/11/20). * Focus: I have a laceration to my scalp with 2 staples. I am at risk for complications as evidenced by decreased mobility related to [CONDITION(S)] accident. (Target date: 10/22/20) Focus: I had a fall. Slid from bed to fall mat (Target date: 10/23/20) Record review of Resident #1's incident report dated 10/20/20 revealed: * Incident location: Resident's room * Incident description: Resident being bathed in bed by CNA and assistance. CNA shifted resident to side and resident slid from bed to fall mat. Bed in low position. Head hit partial siderail. MD informed and gave order for [hospital] evaluation and treatment. * Immediate action taken: Assessment of head noted. Bleeding, no swelling. 2,5 cm laceration. MD gave order to send to [hospital] for CT of head. Range of motion within normal limits. No signs or symptoms of distress noted. Resident taken to hospital. * Injuries observed at time of incident: Laceration, back of head. Record review of Resident #1's nurse progress notes dated 10/20/20 (Created by LVN #2) revealed in part . Resident being bathed in bed by CNA and assistance - cna shifted res to side and res slid from bed to fall mat - bed in low position - head hit partial side rail - MD informed - gave order for [hospital] evaluation and treatment . Record review of Resident #1's hospital clinical records dated 10/20/20 revealed: * Reason for visit: Fall * Diagnosis: Traumatic injury of head, Scalp laceration, bleeding in brain. * Done today: Laceration repair. * Imaging tests: CT cervical spine without contrast. CT head without contrast. Performed 2 times. In an interview with LVN #1 on 10/22/20 at 2:50 PM, the LVN stated she did not work on the day of Resident #1's incident, she learned of it upon returning to work the following day. LVN further stated she was informed that Resident #1 sustained a fall which resulted in a laceration to the head, the resident was sent to the hospital where she got 2 staples to the head. LVN 1 stated she observed Resident #2's staples, and it was intact and dry, no redness or secretions. Observation of Resident #1 on 10/22/20 at 2:55 PM revealed Resident #1 laying in bed, eyes open, but non-verbal. Observation of Resident's head revealed 2 staples to the upper right side of the resident's head. Area dry, staples intact, no redness or secretions. In an interview with CNA #1 on 10/22/20 at 3:41 PM, she stated on the day of Resident #1's incident, she was in the room with CNA #2 giving Resident #1 a bed bath when a resident across the hall began to scream, she left the room to go see what was going on, and shortly after CNA #2 called her back to the room. Upon returning she saw Resident #1 on the floor and CNA #2 told her that after she left the room, CNA #2 continued the bed bath, turned the resident to wipe her and the resident fell out of the bed. CNA #1 further stated when she left the room, the siderails were up on both sides of the bed and the resident slid off the bed on the side that she had been standing on when she was in the room. CNA #1 further stated resident's body was on the floor mat while her head was on the floor. In an interview with CNA #2 on 10/22/20 at 3:45 PM, she stated on the day of the incident, she and CNA #1 were giving Resident #1 a bed bath, CNA #1 left the room, and she continued to give the bed bath. She turned the resident to the side to wipe her down and Resident #1 became combative and fell to the floor. CNA #1 explained that the side rails were up on both sides of the bed, and the resident slid out on the right where CNA #1 had been standing. CNA #2 further stated the resident slid out of the bed on the side of the side rail, she did not roll over the side rail. Resident's body was on the floor mat and her head was on the floor. CNA #2 then proceeded to call everyone in the room to assist. In an interview with LVN #2 on 10/22/20 at 3:48 PM, she stated on the day of the incident, the CNA's were getting Resident #1 ready for a family visit when the more experienced CNA (CNA #1) was called out of the room, and CNA #2 proceeded to clean the resident, and the resident became combative and shifted and fell out of the bed. LVN #2 stated when she entered the room, the resident was on the floor mat and it looked as though the resident might have hit her head on the side rail. There was bleeding to the head, but no swelling. A cool compress was placed on the laceration. LVN #2 further stated she believed the less experienced CNA (CNA #2) should have waited for the more experienced CNA (CNA #1) to return to the room before continuing with the bed bath. In an interview with DON on 10/22/20 at 3:58 PM, she stated on the day of the incident, Resident #1 was getting a bed bath because her family was coming in to visit, the resident became combative during the bed bath, slid out of the bed and sustained a laceration to the head. The resident was sent to the hospital where a CT scan of the head was completed, along with 2 staples. DON further explained that she was in the facility when the incident occurred, and she was called to the room, and the CNA told her what happened.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 13 residents (CR #1) reviewed for quality of care in that: The facility failed to assess, monitor, and supervise CR #1 who had been recently diagnosed with [REDACTED].#1 was found dead with his oxygen nasal cannula underneath him and with signs of rigor mortis. Autopsy revealed cyanosis (bluish discoloration due to inadequate oxygenation) to upper extremities. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 1 former resident and placed all residents at risk of a change in condition being unnoticed and a delay in medical intervention that could result in death. Findings include: Record review of CR #1's admission record revealed he was an [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]., and [MEDICAL CONDITION]. His advance directive status was DNR. CR #1 was pronounced dead at the facility on [DATE]. Record review of CR#1's Quarterly MDS assessment dated [DATE] revealed CR #1 had a BIMS of 6 out of 15 indicating he had severely impaired cognitive skills for daily decision making. He had the behavior of rejection of care 1 to 3 days. He required extensive assistance of one staff for bed mobility, locomotion off the unit, dressing, toilet use, and personal hygiene. He required limited assistance of one staff for transfers and walking in the room. He used a walker and wheelchair for mobility. He was frequently incontinent of bladder and always continent of bowel. He was receiving oxygen therapy. Record review of CR #1's TAR for (MONTH) 2019 revealed CR #1 was documented as receiving continuous oxygen at 3 liters per minute via nasal cannula continuously every shift. Further review of CR #1's MAR for (MONTH) 2019 revealed: -Oxygen at 3 liters via nasal cannula continuously every shift with a start date of [DATE]; documented O2 sats from [DATE]-[DATE] ranged from 90 to 97 percent. -[MEDICATION NAME] Solution 0XXX,[DATE].5 (3) mg/3ml 3ml inhale orally every 6 hours for PNA (pneumonia) for 10 days with a start date of [DATE] at 12:00 p.m. LVN [NAME] documented administering CR #1 nebulizer treatments on [DATE] at 12:00 pm and 6:00 p.m. LVN A documented administering CR #1's nebulizer treatments on [DATE] at midnight and 6:00 a.m. Observation of CR #1's automated electronic monitoring (AEM) video footage of his room dated [DATE] from 10:32 p.m. through until [DATE] at 1:33 am. revealed LVN A was not on footage administering a midnight nebulizer treatment at any time during that time period. Record review of CR #1's MAR for (MONTH) 2019 revealed the following: -[MEDICATION NAME] Capsule give 100 mg by mouth two times a day for Pneumonia for 10 days with a start date of [DATE] at 9:00 a.m. The initial dose of the new antibiotic was documented as being administered by MA A on [DATE] at 9:00 am. Record review of CR #1's undated Care Plan revealed, in part: Focus: I have [MEDICAL CONDITION], HTN, Cardiac HTN, Hx MI and [MEDICAL CONDITION], and CKD Stage 3 with episodes of [MEDICAL CONDITION]. My weight needs be monitored for significant changes r/t [MEDICAL CONDITION]. I have a pacemaker. Goal: I will have clear lung sounds, heart rate and rhythm within normal limits through the review date. Interventions: . I will need my breath sounds and monitored/documented for labored breathing. Monitor/document for my the use of accessory muscles while breathing. Focus: I have [MEDICAL CONDITION] and require interventions including follow ups with vascular as indicated. Goal: I will remain free of complications related to [MEDICAL CONDITION] through 90DAY review date. Interventions: . I will need to be monitored/documented/reported to MD PRN any s/sx of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain. Focus: I have pneumonia and am at risk for complications Goal: pneumonia will be resolved without complications by review date. Interventions: . Monitor/document/report to MD PRN for the following s/sx of pneumonia: Fever, Chills, Cough, purulent sputum, pleuritic chest pain, tachypnea, anxious flushed appearance, [MEDICAL CONDITION], confusion disorientation. Observe for changes in mental status, stupor and s/sx of [MEDICAL CONDITION]. Observe for mental changes. In the elderly, pneumonia may initially present as mental changes and cough only. Observe for/assess/report to MD recurrent fever which may indicate bacterial resistance to antibiotic therapy. Observe for/report to MD PRN for the following s/sx of Aspiration pneumonia: fever but no chills, pink, frothy foul-smelling sputum, cyanosis. Focus: I am taking an antibiotic ([MEDICATION NAME] x 10 days) for pneumonia. I am at risk for complications. Goal: will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions: Administer medication as ordered Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Observe for possible side effects every shift Report pertinent lab results to MD Focus: resident has an ADL Self Care Performance Deficit r/t dx: dementia Goal: resident will improve current level of function in transfers, Dressing, Toilet Use and Personal Hygiene, through the 90-day review date. Interventions: . Focus: At times I resist care such as ADL/peri care, non-compliant with oxygen, I refuse or remove my oxygen. Goal: RESIDENT WILL HAVE DECREASED EPISODES OF RESISTING CARE DAILY BY NEXT REVIEW IN 90 DAYS Interventions: ALLOW RESIDENT TO PRACTICE HIS OR HER RESIDENTS RIGHTS ALWAYS APPROACH CALMLY AND UNHURRIEDLY AND ALWAYS SPEAK IN A CALM VOICE EXPLAIN ALL PR[NAME]EDURE AND REASON PRIOR TO PERFORMING THEM EXPLAIN WHY CARE IS NEEDED NOTIFY MD IF BEHAVIOR INTERFERES WITH CARE STOP RENDERING CARE WHEN THE RESIDENT IS UPSET AND REATTEMPT WHEN RESIDENT IS CALM Focus: I have executed No DNR directive and I have chose to live here Long Term. Goal: Respect CR #1's wishes for no resuscitation and artificial prolongations of life Interventions: Adhere to no CPR request Involve CR #1, family, and MD in decisions that may arise Provide resident/family opportunities to discuss concerns regarding end of life decisions Focus: OXYGEN USE Goal: WILL NOT EXPERIENCE RESPIRATORY DISTRESS FOR NEXT 90DAYS Interventions: ADMINISTER O2 AS ORDERED ASSESS SKIN COLOR & TEMP AND REPORT TO MD AS APPROPRIATE CHANGE CANNULA AND TUBING PER POLICY OBSERVE FOR SOB, DSYPNEA (sic), DECREASED PERFUSION. REPORT SIGNIFICANT CHANGES TO MD. Oxygen at 3L via nasal cannula continuously. Record review of CR #1's Nurse's Notes revealed the following: --[DATE] 5:47 p.m. written by LVN E: Resident non-compliant with continuous oxygen use. This nurse has notified resident's Family Member and MD. Resident's Family Member wants him to be on portable oxygen tank at all the (sic) times. This nurse has explained to the Family Member that his Family Member's o2 (sic) sat level is not always maintained when on the oxygen tank alone. I encouraged him to allow his Family Member to use the oxygen concentrator while in his room. The note was marked as to be shown on the Shift Report and the 24 Hour Report. --[DATE] 9:53 p.m. written by LVN F: .Spoke with family member about o2 (sic) advised (sic) o2 (sic) was not on -tank was on chair but not tunred (sic) on-family member said he turned on- I assessed resident o2 (sic) was at 92% at 3L o2 (sic) via NC (Nasal Cannula) (sic) advised (sic) staff to make sure o2 (sic) was in place and on at all times (sic) will (sic) cont (continue) to moniter (sic) . The note was marked as to be shown on the Shift Report and the 24 Hour Report. -[DATE] 3:30 p.m. written by LVN G: Checked resident (sic) v/s (vital signs), noted temp (temperature) 101.4 tympanic (ear), BP ,[DATE] P 75, R 16 & O2 96% n/c (nasal cannula). Physician A called & ordered [MEDICATION NAME] 1 gram IM (Intramuscularly), Tyleno 650mg, one time only for high temp, Stat CBC, BMP, & Stat Chest -ray (sic) (X-ray). The note was marked as to be shown on the Shift Report and the 24 Hour Report. Record review of CR #1's laboratory results dated as collected on [DATE] revealed, in part, a WBC count of 12.6, high, out of a normal range of 3.8 to 10.1; RBC count of 3.68, low, out of a normal range of 4XXX,[DATE].80; HGB 9.6, low, out of a normal range of 13XXX,[DATE].2, HCT 35.2, low, out of a normal range of 41XXX,[DATE].0. Record review of CR #1's X-ray results dated [DATE] read in part, .Reason for Study: .FEVER .Conclusion: 1. Enlarged cardiac silhouette and bilateral diffuse interstitial and alveolar opacities. In the appropriate clinical setting, diffuse [MEDICAL CONDITIONS], and atypical pneumonia would be considered. 2. Following an initial course of empirical therapy, followup imaging is suggested, and if there is no improvement, CT (Computed [NAME]ography) chest would be advised. Alternatively, CT chest be performed now as clinically directed. Record review of CR #1's Progress Note created by Nurse Practitioner B, dated [DATE] read in part, XXX[AGE] year old male seen today for evaluation of ongoing issues. Staff reports fever over the weekend, workup revealed possibly atypical pneumonia. On-call NP considered clinical picture and started him on [MEDICATION NAME] 100mg po q 12 hr x 10 days as well as prn nebs. No fevers reported the last 24 hr. He reports feeling well, denies any issues during ROS but is minimally reliable due to dementia. Blood work revealed continued CKD and [MEDICAL CONDITION], but stable overall. Nursing reports no issues at this time. Vitals remain stable. .PHYSICAL EXAM General: Elderly male who appears stated age. Sitting up in a wheelchair, pleasantly confused and appears comfortable. Respiratory: Normal respiratory effort. Normal to auscultation, but diminished at bases. No wheeze, crackles, rhonchi or rales. Psychiatric: Alert and oriented x2, mood/affect appropriate, poor judgment. .LABS/RADIOLOGY/TESTS Labs: [DATE] .WBC ([NAME] Blood Cell Count) 12.8 hemoglobin 9.9 hematocrit 31.9 . SUMMARY OF PLANS .Time Spent: I spent 39 minutes discussing treatment plan and concerns with RP, Family Member and nursing. RP was more concerned as to why his Family Member was ill compared to one month ago (hospitalized for [REDACTED]. He also went on to report issues with not trusting the nursing staff. States he has come to the facility multiple times and his Family Member's O2 tank is on red' and worries they cannot judge if his Family Member needs a breathing treatment or not. Nursing states RP insists his Family Member is on a tank and thinks they are isolating him if he is on a concentrator - nursing reports sats lower with tank vs concentrator and that is why they prefer to keep him on concentrator if possible. They deny ever letting him run out of oxygen and specifically report a story in which RP went and got a tank while the pt was on concentrator because he was so worried about the patients O2 tank being empty. Nurse and RP state administration is aware of all concerns. RP not open to looking into other facilities at this time as he wants to 'give the new faces a chance'. Observation on [DATE] at 12:33 pm of CR #1 revealed his body was in his bed covered with a blanket. CR #1's skin was pale and his body had been prepared for the funeral home. There was an oxygen concentrator by the bed. The oxygen [NAME] tank cylinder was not in the room. Observation of CR #1's AEM video footage of him in his room revealed on the night of [DATE] beginning at 7:05 p.m. through to the morning of [DATE] at 7:43 a.m. CR #1's oxygen was not checked for either oxygen tank level or to ensure he was receiving oxygen via his oxygen concentrator instead of the [NAME] tank. CR #1 put himself into bed and no staff came to check the level of oxygen in the [NAME] tank or change him from his [NAME] tank to his oxygen concentrator. He was last seen moving on [DATE] at approximately 11:45 p.m. per the date and time stamps on the video footage. Staff did not physically check to see if his [NAME] tank had oxygen sufficient to meet his ordered rate to last throughout the night, nor did they switch the oxygen tubing from the [NAME] tank to the oxygen concentrator so that the resident could receive a continuous supply of oxygen throughout the night. CNA A was observed to come to the bedside on [DATE] at 1:33 a.m., 4:41 a.m. and 5:48 a.m. LVN A was not observed coming to the bedside until [DATE] at 5:48 a.m. Observation of the video footage revealed: -[DATE] 7:44 p.m.: CR #1 was observed to be in his room in his wheelchair. He stood up and transfered himself to bed. He placed his ball cap on top of the bedside table. No one came in to change his oxygen supply from the [NAME] tank to the concentrator. -[DATE] 11:06 p.m.: CR #1 was observed making attempts to reach for a picture balanced on the window sill on the left side of his bed. His bed was positioned against the wall, with the left side of his bed directly under the window. He made two attempts but was unable to get the picture. He appeared to be attempting to grab the left side of the bed with his right arm, in an attempt to leverage himself up to be able to reach the picture, but was unable. He was moving his legs and appeared to be attempting to find something to push again to help him reach the picture. There were no staff at the bedside for assistance or assessment. -[DATE] 11:08 p.m.: CR #1 was observed making attempts to reach for a picture balanced on the window sill on the left side of his bed. He made two attempts but was unable to get the picture. There were no staff at the bedside for assistance or assessment. -[DATE] 11:10 p.m.: CR #1 was observed again reaching for the picture on the wall. He was able to reach it with his fingertips but, again, was unable to get the picture. He made another attempt and this time was able to knock the picture off of it's perch on the window sill. There were no staff at the bedside for assistance or assessment. -[DATE] 11:12 pm.: CR #1 appeared to try to reposition himself in bed, attempting to bring his legs up, as they were hanging off the end of the bed. He rolled more onto his left side. His right arm was bent at the elbow at a 90 degree angle with his right wrist resting on top of a picture of his family member below his left elbow. There were no staff at the bedside for assistance or assessment. -[DATE] 11:16 p.m.: CR #1 was lying in his bed slightly tilted onto his left side. He was low in the bed. His right leg, from the knee down, was hanging off of the end of the bed. His left leg was bent, with his calf on the footboard of the bed. His left arm was bent at the elbow with his fingers over his nose. His right arm was bent at the elbow at a 90 degree angle with his right wrist resting on top of a picture of his family member below his left elbow. His left leg twitched. He appeared to attempt to move both of his legs, resulting in a slight twitch of his right leg. His left leg slid further off the end of the bed, ending in the foot of the bed and the end of the mattress catching and stopping his leg in the crook of his knee. A picture of his family member was on the bed beside him. There were no staff at the bedside for assistance or assessment. - [DATE] 11:45 p.m.: CR #1 was observed to be in the identical position as he had been in on [DATE] at 11:16 p.m. His entire body jerked one time. All movement then ceased. There were no staff at the bedside for assistance or assessment. -[DATE] 01:33 a.m.: CR #1 was observed to be in the identical position as he had been in on [DATE] at 11:16 p.m. CNA A entered the room, touched his right knee and spoke to him. He did not move. She did not attempt to reposition him although his legs were hanging off the end of the bed. She stared at him for approximately 7 seconds, turned, and left the room. - [DATE] 04:41 a.m.: CR #1 was observed to be in the identical position as he had been in on [DATE] at 11:16 p.m. CNA A was observed to come into CR #1's room. She appeared to touch his leg and spoke to him. He did not move. She did not assess him further. She picked up his urinal and left the room. She quickly returned and replaced the urinal. She then left the room. - [DATE] 5:37 a.m.: CR #1 was observed to be in the identical position as he had been in on [DATE] at 11:16 p.m. There were no staff at the bedside for assistance or assessment. - [DATE] 5:43 a.m.: CR #1 was observed to be in the identical position as he had been in on [DATE] at 11:16 p.m. There were no staff at the bedside for assistance or assessment. -[DATE] 05:48 a.m.: LVN A is observed entering CR #1's room and speaking to him. CR #1 is in the identical position as he had been in on [DATE] at 11:16 p.m. LVN A repeatedly said CR #1's name and touched his right knee. She continued to say his name but did not check for a pulse or listen for heart or breath sounds. She left the room, leaving CR #1 alone. She returned after 38 seconds and turned on the light in the room. LVN B was with her. CR #1's oxygen tubing was observed to be running underneath his body. The tubing was attached to an [NAME] tank on his wheelchair. While the oxygen concentrator was in the room and was on, , as evidenced by bubbles in the humidifier bottle, the tubing from the oxygen concentrator was coiled on top of the bedside table. LVN A and LVN B again left the bedside and returned afte 8 seconds at which time they were observed donning gloves. Neither assessed CR #1 to determine if he was alive. LVN A and LVN B returned and put on exam gloves and continued to speak CR #1's name. LVN B traced his oxygen tubing from his [NAME] tank on his wheelchair, under his body, and to his face. LVN B continued to say his name, but did not check for a pulse, listen for breath sounds, or listen for a heartbeat. Neither checked his pupils for a reaction. Neither checked his eyes at all. LVN B removed the oxygen tubing from CR #1's face. LVN B removed CR #1's [NAME] tank from the holder on the wheelchair and placed it beside the bed. CNA A and CNA C entered the room briefly. CNA C left the room and CNA A remained, watching from the foot of the bed. LVN B moved CR #1's oxygen [NAME] tank to the foot of his bed. CR #1's call light was now visible and was observed to be out of his reach, in the seat of a recliner in the room. LVN B lowered the head of the bed. Almost five miutes into this video clip, none of the three staff in the room had checked for a pulse, heartbeat, or breath sounds. LVN A and CNA A pulled CR #1 up in the bed. His arms were observed to be stiff and did not move when the staff moved him. -[DATE] 05:55 a.m. through 05:58 a.m.: CNA A was observed in the room. The room light was now on. She used the bed controler to raise the height of the bed. CR #1's right and left arms were in the same positions as the night before although CR #1 had now been pulled up in the bed. CNA A removed his belt and struggled to remove his pants. Once his pants were removed, she threw them in the trash can that was in the room. She pulled his underwear off and threw them in the trash can. She did not clean his body. She put a brief on him. CNA A unbuttoned CR #1's shirt and struggled to remove it. She could not get his right arm through the sleeve opening to remove the shirt. After about 3 attempts, she was able to get CR #1's right arm free. She removed her gloves and left the room. CNA C and CNA D came into the room, looked at CR #1, but did not check for a pulse or respirations. CNA C touched CR#1's right leg. Neither had a stethoscope or a blood pressure cuff. CNA D did not touch CR #1. CNA D left the room after 12 seconds and CNA C left the room after 27 seconds. -[DATE] 05:59 a.m.: The staff members returned to the room. They did not appear concerned. The male staff member stood at the foot of the bed. The female had sheet that she handed to CNA [NAME] CNA A rolled CR #1 onto his left side. His arms remained bent at the elbows with his left hand still on his face. The male staff member left the room. CNA A and the female staff member appeared to be discussing that the wrong type of sheet had been brough in. No one assessed CR #1. No one felt for a pulse, listened for a heartbeat, or watched or listened for breath sounds. No one shined a light in his eyes to see if his pupils reacted. No one checked his eyes. -[DATE] 06:00 a.m.: CNA A, the female staff member, and the male staff member, continued to roll CR #1 to position a draw sheet under him. Then, a different male staff member entered. He had a stethoscope and listed to CR #1. He used his cell phone and appeared to shine the light into CR #1's eyes, then left the room. Interview on [DATE] at 12:04 pm. with the DON she said one resident, CR #1, passed away that morning at approximately 6:00 a.m. She said the family had been notified. She said CR # 1's body was still in the resident room. She said CR #1's body had been prepared for the funeral home to pick up. When asked which staff had worked during the shift when CR #1 passed away, she said LVN A, LVN B, RN A, CNA A, CNA B, CNA C and CNA D. She said all the staff that worked had left but RN A and CNA's A, B, C, and D would be back tonight. Further record review of CR #1's Nurse's Notes revealed the following: -[DATE] 6:02 a.m. written by RN A: .resident (sic) noted non responsive, pupils dilated, no respiration and no pulse. Physician A oncall was notified. family (sic) was notifed. time (sic) of death 0602am (6:02 a.m.). The note was marked as to be shown on the Shift Report and the 24 Hour Report. -10//,[DATE] at 6:59 a.m. written by LVN A: .At around 0430 (4:30 a.m.) aide CNA A made rounds and checked on resident. At 0545 (5:45 a.m.) nurse went to go give resident his scheduled breathing tx (treatment) and noted resident laying in bed with O2 on @ 3L per nasal cannula with Family Member's picture laying beside him on the bed. @ (sic) (At) 0602 (6:02 a.m.) RN A pronounced resident deceased . Interview on [DATE] at 1:00 pm with an anonymous person revealed the person began to cry. The interviewee said he was concerned about whether CR #1 had been receiving oxygen per physician orders [REDACTED]. The anonymous interviewee added that the concerns were shared with the Administrator and the DON, but staff did not follow the physician orders. During an interview with CNA A on [DATE] at 6:30 a.m., she stated she checked CR #1 throughout the night (on [DATE] through [DATE]), 6p, 8p, 10p, and so on. Q 2 hours, and .that's what y'all require. She said CR #1 always got up to the bathroom by himself, he was very do-it-yourself-ish. She said, I just went in and glanced at four when I was doing my last round, and it looked normal to me. It looked like he was just sleeping from where I was standing at the curtain in the middle of the room. Last time I saw him ok I looked at him at four and he looked fine. He had a picture of his Family Member next to him and we left it there after we straightened him up. He had a concentrator beside him, the kind that plug into the wall. It was on. I think the nasal cannula was on his face. I don't know. If it wasn't I would go fix it. I was standing at the curtain and I couldn't see if it was on him or not. I can't remember. I don't know if anyone uses a portable (oxygen) tank in this building. If anyone is on oxygen, they take the concentrator with them when they go to the dining room. They take it everywhere. I'm not here during the day. My shift is 6p to 6a. I knew his oxygen was on because I heard it bubbling at the wall but I guess it wasn't on his face. If a person who needed oxygen didn't have it on I guess they would lose vital organs and decease (sic). Someone told me he was up in the dining room earlier in the day. My job is to chart poop and pee, turn residents q 2 hours, if they ate and how much, how much they drank, if they walked, locomotion on and off unit, to what degree they need help, if they got a shower, things like that. I don't think he was stiff and he didn't feel cold to me when I was changing his clothes. I've been a CNA on and off since 2005. I've worked here since late (MONTH) 2019. When asked why she did not assist CR #1 back up onto the bed when she noted his legs hanging off, CNA A stated, I just left him alone because he did stuff himself and when he needed something he would call. When asked specifically what she would do if she found a resident hanging off the side of the bed, CNA A said, If a resident is hanging off the side of the bed .he was hanging off the side of the bed. I didn't touch him. During an interview with LVN A on [DATE] at 7:10 a.m., she stated CR #1 was fine throughout the night. She said he had been up in his wheelchair and went to bed around 9 or a little after. She said, I remember around 8 he was still up and he had his oxygen tank on and he had his nasal cannula in at that time. I looked in at him a few times, and his roommate, about every three hours or so; I'd have to go back and look at my documentation. His oxygen was on. He gets up and goes to the bathroom by himself. He has the concentrator, and it was on and the [NAME] tank was on too. He was on the concentrator. He must have got up to go to the bathroom because the [NAME] tank was on and had ,[DATE] tank left. But he was on the concentrator. I can't recall the last time I saw him alive. He was getting a nebulizer at 5:00 a.m. and I noticed he was cool to touch and not breathing so I got my blood pressure and I took his blood pressure but didn't get a reading. He was on his back and his feet were hanging off a little bit and he had his Family Member's picture but he usually had that sometimes. He did that. He was wearing khaki pants and a button up T-shirt. He wasn't wet or soiled. I went and got the RN from the 2nd floor. First I got LVN B. I did his vital signs at the beginning of the shift. I went to the bedside to check on him every time I checked him, about every three hours. I didn't try to arouse him or anything. I was the first person to notice he was dead. He was a DNR. I knew he was DNR before I went in there. If someone else had come and told me he was deceased I would have gone and assessed him. During an interview on [DATE] at 7:40 a.m. with LVN B, she stated she was not assigned to CR#1 that night ([DATE]-[DATE]), she had only helped when LVN A called her for assistance. She said, LVN A had wanted a second opinion if CR #1 was deceased and I asked her if he was a full code or DNR and she said he was a DNR and we needed an RN. We called the RN A to come and I told CNA A she needed to clean him up and make him presentable and RN A came down and pronounced him. After that LVN A took care of it, called family and everything. I helped CNA A with everything; make the patient look presentable, straighten the bed and everything. He had O2 on when LVN A asked me to go in. He had it on behind his ears and in front of his nostril. He was on the concentrator. He has a tank but when he goes to bed he's on the concentrator. I don't know how much O2 was in the tank or if it was on or off. RN A checked his heart and everything but I knew he was dead before. He was't really stiff except in his jaw area. Record review of the Journal of Forensics Sciences and Criminal Investigation article titled, Time since Death from Rigor Mortis: Forensic Prospective published on (MONTH) 5, (YEAR) revealed in part, .Swenson Arne, Wend Otto and Fisher, Barry [NAME][NAME] (1914) Stated that the biochemical changes in the body produce stiffening known as rigor mortis, which usually appears within ,[DATE] hrs. After death. Rigor mortis begins in the muscles of the jaws and neck and proceeds then downwards in the body and trunk and extremities and it is completed within ,[DATE]hrs (hours). The rigidity remains for ,[DATE] days and disappear in the same order in which it appeared. The very young and very old will likely developed less rigidity than adults with well-developed musculature . The quoted article was found on Juniper Publishers website, https://juniperpublishers.com/jfsci/pdf/JFSCI.MS.IDXXX 1.pdf. During an interview on [DATE] at 11:40 a.m. the DON said she expected her staff to round on residents at least every two hours. She stated, You don't have to be a nurse or CNA if a call light goes on, you go in to see what the patient needs. They should be checking on the residents. Go in and make sure that all of their needs are met and their call light is within reach. They shouldn't just go to the door and look at them, they need to go into the room and check everything. The DON stated vital signs were taken at the beginning of the shift but should also be done as needed and if there were specific orders from a doctor to check them more frequently. The DON said oxygen tanks could last differing time frames, depending on if they had a regulator on them, and what type of regulator they were using. She said they were trying to replace all of their old regulators with a newer oxygen conserving regulator that helped oxygen tanks last longer. She said she did not know when CR#1's tank was checked or the last time it was changed. She said, If a resident was on an oxygen tank and it ran out, they would 'de-sat' (desaturate; a drop in oxygen levels in the blood), and go into respiratory distress. She said the facility nurses should check residents on oxygen for signs and symptoms of [MEDICAL CONDITION] (a state of low blood oxygen level) every shift and as needed. Record review of CR #1's Autopsy dated [DATE] read in part, .PROVISIONAL ANATOMIC [DIAGNOSES REDACTED].#1).Comment #1: Cyanosis involving the bilateral upper extremeties is suggestive of [MEDICAL CONDITION]. Record review of CR #1's Department of State Health Services Vital Statistics State of Texas Certificate of Death documented a date of death as [DATE], manner of death, natural, and immediate cause of death as, PROBABLY ACUTE [MEDICAL CONDITIONS]. Approximate interval onset to death was documented as unknown. Record review of facility Policy and Procedure titled Medication Orders, revised (MONTH) 2007, read in part: .The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. .3. Oxygen Orders a. When recording orders for oxygen, specify: b. The rate of flow, route and rationale (i.e., O2 ,[DATE] L/min. per nasal cannula prn SOB). .6. Treatment Orders a. When recording treatment orders, specify: b. The specific treatment, frequency and duration of the treatment (). Record review of facility Policy and Procedure titled Oxygen Administration, revised (MONTH) 2007 read in part: .The purpose of this procedure is to p

Based on observation, interview, and record review, the facility failed to provide two residents (Resident #1 and Resident #2) of 12 residents reviewed for accidents, adequate supervision and assistance devices in order to prevent accidents. Resident #1 was propelled by staff in a wheelchair without footrests, and caught her foot on the floor, causing her to fall forward from the wheelchair to the floor. Because of this fall, Resident #1's hand was dislocated. Her progress in her physical therapy program was delayed due to her injury. Resident #2, when pushed by staff out of the dining room in a wheelchair without footrests, put his feet on the ground and fell on to the floor. This failure affected two residents and placed 49 residents who used wheelchairs for ambulation at risk for injury due to staff not following their individualized safety precautions. Findings include: Record review of Resident #1's Admission Record reflected she was [AGE] years old and was originally admitted to the facility on [DATE]. The Admission Record reflected she was re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected she had both short-and long-term memory deficits, and had difficulty focusing attention. Record review of Resident #1's Fall Risk assessment dated [DATE] reflected she was at "High Risk" for falls. Record review of Resident #1's Care Plan (CP) initiated 2/11/15 revealed only two approaches: (1) the resident was to be in a geri-chair when out of bed and (2) "Assure call light within reach and answer promptly when on." Record review of Resident #1's Incident Report dated 02/08/15 revealed "Nurse found resident (Resident #1) on floor with another nurse applying ice to resident's forehead. CNAS (Certified Nurse Aides) on the floor assisting the nurse. LVN (Licensed Vocational Nurse) stated resident was being transported to her room with 2 cnas and residents leg got caught in w/c (wheelchair and he (sic) fell forward." The Report did not reflect the names of the CNAs. A Nurses' Note dated 02/08/15 at 7:25 p.m. reflected the two CNAs were CNA D and CNA E. Observation on 04/02/15 at 10:42 a.m. revealed Resident #1 was not in her room. A neck orthotic device was observed on the counter. Interview with a family member on 04/02/15 at 12:45 p.m. revealed the family member visited Resident #1 daily. The family member stated that the resident had experienced a fall while she was in a wheelchair without footrests. The family member stated that the resident exhibited memory deficits, and was incapable of holding her feet up when propelled in the wheelchair. Interview with Therapy Staff (TS) A on 04/02/15 at 1:43 p.m. revealed that prior to a fall in February 2015, the resident was able to ambulate with maximum assist with the parallel bars. TS A stated that following the fall, the resident was not able to ambulate at all. TS A stated that Resident #1 had been approved by the therapy department to use a wheelchair. TS A stated that bilateral footrests were included in the approval. TS A stated, "Resident #1 had the strength to hold her feet up but I would never make a decision to not use the footrests. I don't think it would be safe." Record review of Resident #1's file did not find a document that addressed Resident #1's move from a geri chair to a wheel chair with footrests. Interview with TS B on 04/02/15 at 1:50 p.m. revealed the therapy department used footrests on Resident #1's wheelchair. TS B stated, "TS A went on a search for footrests. Resident #1 definitely needed them. She had multiple knee surgeries. She didn't have the strength to hold them (her feet) up. TS B stated that the fall "Set us back a few weeks." Observation on 04/02/15 at 2:00 p.m. revealed Resident #1 was in the therapy department gym. The resident was sitting in a wheelchair, and the wheelchair had footrests with a full-width leg support. TS A assisted the resident with a transfer, using maximum assist. The resident required several cues prior and during the process. TS A stated that the resident was back to the level of ability demonstrated prior to the fall in February. Interview on 04/02/15 at 2:40 p.m., LVN C said "I witnessed the whole thing." LVN C stated she was sitting at the nurses' desk, and witnessed CNA D pushing the Resident #1's wheelchair. LVN C stated "They got to the ridge (an elevated junction in the floor). When they got to the laminate (flooring) Resident #1's foot got caught. I ran (to catch her). The CNA D tried to grab her. She fell this way (to the right). As I got to her, her head hit the floor. We kept her there, got pillows. She had her collar on." LVN C stated that 911 was called. LVN C continued, "EMTs (Emergency Medical Technicians) came, asked about her right arm. She did not lose consciousness at all. They came and took her." LVN C was asked to describe the wheelchair. LVN C stated, "Not a high-back, regular wheelchair. I don't know why. She didn't have foot pedals (footrests)." In an interview on 04/02/15 at 3:07 p.m., CNA E denied she was with the resident when the incident occurred. She said she heard a "boom" and ran to see what happened. CNA E stated she observed footrests on the wheelchair, but stated that she arrived after the resident was on the floor. An attempt to contact CNA D via telephone was unsuccessful. Record review of the Nurses' Notes (NN) dated 02/08/15 at 7:25 p.m. revealed the writer stepped off of the elevator and saw LVN C, CNA D, and CNA E next to Resident #1, who was lying on the floor. The NN reflected "Resident lying on floor on back with LVN C holding ice to R (right) side of forehead. Deforming noted to R (right) hand." The NN reflected," Questioned LVN C about what happened: states CNA D was transporting resident to room in w/c (wheelchair) when resident's foot got caught in wheelchair and resident began to fall forward. CNA D tried to catch resident but she fell face forward." Record review of the subsequent NN, dated 02/09/15 at 12:23 a.m. revealed Resident #1 returned from the hospital with a [DIAGNOSES REDACTED]." The NN reflected, "Has reopened laceration to OD (right eye). Steristrips to hematoma to R forehead ..." In an interview on 05/01/15 at 1:32 p.m., the Therapy Department Program Director (TDD) was asked how the resident's functional status and equipment needs were communicated to the nurses and CNAs. TDD stated, "We tell the MDS (Minimum Data Set) Coordinators and the Social Worker. The Social Worker has a family conference, and a Care Plan meeting." TDD stated the meeting included the Social Worker, a nurse, and the MDS Coordinator. The MDS coordinator does a seven day notice that they're going to finish their therapy." When asked how specific needs of each resident was communicated, TDD answered, "That's communicated in our notes. They usually go to Restorative, then Restorative takes it from there. We write the Restorative Plan." (Medicare defines "restorative" or "maintenance" programs as repetitive services required to maintain function that do not involve complex and sophisticated physical therapy procedures and do not require the judgment and skill of a qualified therapist for safety and effectiveness). In an interview on 05/01/15 at 3:40 p.m., the MDS Coordinator stated the CNAs had an ADL (Activities of Daily Living) sheet in a Kardex located in the Nurses' Station. The MDS Coordinator stated that TDD would attend the morning meetings and "At time of discharge will tell us why (the person was being discharged ) and what physical needs (the person had)." The MDS Coordinator was asked how the information was conveyed to the other direct care staff. The MDS Coordinator answered, "It would depend. Usually the ADON (Assistant Director of Nurses). The ADON would tell the nurses and CNAs. In an interview on 05/01/15 at 4:00 p.m., the ADON was asked how the needs of the residents were communicated from the Therapy Department. ADON stated, "With TDD we utilize communication forms. Interdepartment, just like Dietary, Social Worker, etcetera. They're supposed to use that form. That was explained by me to TDD a month ago." The ADON referred to a communication form with dietary recommendations as an example. The ADON stated the residents who transitioned to Restorative would have a plan kept in the MDS office. In an interview with the MDS Coordinator on 05/01/15 at 4:35 p.m., with the ADON present, the MDS Coordinator stated the Restorative plans were kept on a different floor in the Restorative Nurse Aide (RNA) book. In an interview with the ADON on 05/01/15 at 4:35 p.m., the ADON stated, "We had a meeting with Therapy that there was a communication gap between Therapy and our staff in regards to residents' progression and functional level. Regarding change of equipment. Our nurses weren't being made aware of that. That was a result of Resident #1's fall. We weren't being made aware of changes." The ADON added, "Therapy said they were informing the nursing staff on the floor by notes in the charts. We haven't been able to locate notes every day. If there's a change from one plane to another device I asked TDD to put it in writing so we can go from one nurse to another." Resident #2 Record review of Resident #2's Admission Record revealed he was [AGE] years old, and was originally admitted to the facility on [DATE]. He was most recently re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's most recent Minimum Data Set (MDS) assessment, dated 03/12/15, reflected Resident #2 exhibited "Moderately Impaired" cognitive skills for daily decision making, and had both short- and long-term memory deficits. He did not ambulate, and required "Extensive Assistance" of one person for locomotion. He required a wheelchair. Record review of Resident #2's Care Plan dated 11/14/14 reflected "Resident #2 is at risk for falls r/t (related to) history of falls, fractured hip, cognitive impairment, lack of coordination, tremors, involuntary muscle movement, and Parkinson's disease." His interventions included: "Fall risk assessments to be completed upon admission/quarterly and anytime Resident #2 falls." Record review of Record review of Resident #2's Incident Report dated 04/16/15 revealed Resident #2 "...was being pushed down the hall to his room to administer medicine and while he was being pushed he planted his feet on the ground causing him to go forward and fall on the floor." The section labeled "Other Info" reflected "Place footrests on the wheelchair to avoid falls." The person listed as preparing the report was the Director of Nurses (DON). Record review of Resident #2's Nurses' Note (NN) dated 04/16/15 at 11:30 a.m. revealed "I was pushing resident to his room to administer his medication. While I was pushing him he planted his feet on the floor and fell forward. No injuries noted other than small abrasion to left side of forehead." The person reflected as signing the NN was Licensed Vocational Nurse (LVN) F. In an interview on 05/05/15 at 11:00 a.m., LVN F stated that on the date of the fall, she was behind Resident #2's wheelchair, propelling him towards his room. LVN F stated the resident did not have footrests because he could 'move his chair.' Record review of Resident #2's most recent Fall Risk Assessment located in the clinical record was dated 11/26/14. The Assessment reflected a total score of 10, indicating he was at high risk for falls. Record review of Resident #2's PT (Physical Therapy) Therapist Progress & Discharge Summary dated 03/30/15 reflected that as of 03/23/15 "The patient demonstrates muscle strength of 3/5 fair (full ROM (Range of Motion) against gravity with no added resistance) of B LE (Bilateral Lower Extremeties)." Observation on 05/05/15 at 9:17 a.m. revealed Resident #2 being propelled from the dining room in his wheelchair. Certified Nurse Aide (CNA) G was pushing the resident's wheelchair. Observation revealed no footrests on the wheelchair, and Resident #2 was holding his feet up off of the ground. Observation on 05/05/15 at 10:58 a.m. revealed Resident #2 was not in his room. Two wheelchair footrests were observed to be under his bed. In an interview on 05/05/15 at 11:00 a.m., CNA G stated Resident #2 did not use footrests on his wheelchair because he could propel himself. Observation and interview on 05/05/15 at 11:05 a.m. revealed Resident #2 was in the common area in his wheelchair. There were no footrests on the wheelchair. Resident #2 was observed to propel himself backwards for approximately a half of a foot. He appeared to be confused. At that time, LVN F stated that, at times, Resident #2 could propel himself, and at other times he was unable to do so. In an interview on 05/05/15 at 11:55 a.m., the DON was asked what procedures were in place to address resident falls from wheelchairs. The DON stated ADON H had addressed the issue after Resident #1 fell out of her wheelchair in February of 2015. When asked how the CNAs would know if a resident required footrests, the DON stated "We're working on a matrix but right now the nurses tell them." When asked what should be done if a resident was being propelled in a wheelchair and started dragging their feet, the DON replied, "Then I would do a footrest." At that time, the DON was asked for all in-service training sign-in sheets since February 2015. In an interview on 05/05/15 at 12:40 p.m., the DON stated that she could not find the packet of documentation regarding Resident #1's fall in February 2015, and that the in-service documentation was in the packet. On 05/05/15 at 1:30 p.m., ADON H presented a "Record of In-Service" dated 02/10/15 at 2:30 p.m. The In-Service title was reflected as "Assessment." ADON H was listed on the form as the facilitator. The In-service reflected the charge nurse was to check for footrests every two hours, and that staff was to place a hand on the resident's torso when propelling in the wheelchair. On 05/05/15 at 1:40 p.m. the Record of In-Service dated 02/10/15 at 2:30 p.m. was reviewed. The signature sheet reflected nineteen signatures, with ADON H as the first. Comparison of the signature sheet versus the staff sign-in sheets for 05/05/15 revealed eighteen of the remaining nineteen signatures were of staff scheduled to work on 05/05/15. Record review of the Timecard Report dated 02/10/15 revealed 25 direct care staff worked on that date that did not have signatures on the signature sheet. In an interview on 05/05/15 at 3:37 p.m., ADON H stated that she obtained 17 of the 19 signatures for the In-Service dated 02/10/15 on 05/05/15, not on 02/10/15. In an interview on 05/05/15 at 1:46 p.m., Medication Aide (MA) Q was shown the Record of In-Service dated 02/10/15 at 2:30 p.m. MA Q stated she was not hired at the facility until after 02/10/15, and that she had not attended the in-service. MA Q did not state when she signed the signature sheet. - Record review of the personnel file for MA Q revealed her hire date was 02/20/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of CNA J. - Record review of CNA J's personnel file revealed a hire date of 04/04/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of Registered Nurse (RN) K. - Record review of RN K's Personnel file revealed a hire date of 03/02/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of CNA L. - Review of CNA L's personnel file revealed a hire date of 03/31/15. In an interview on 05/05/15 at 1:50 p.m., when asked about the in-service training provided on 2/10/15, LVN F stated she remembered an in-service, but did not state when she signed the signature sheet. The CMS Form 672 dated 04/02/15 reflected there were ten residents at the facility who ambulated with assistance or with an assistive device, and 51 residents who were "In a chair most of the time."

Based on observation, interview, and record review, the facility failed to implement their written policy and procedure that prohibited neglect for two residents (Resident #1 and Resident #2) of 12 residents reviewed for accidents. Resident #1 was propelled by staff in a wheelchair without footrests, and caught her foot on the floor, causing her to fall forward from the wheelchair to the floor. The fall resulted in a dislocated hand and a delay in improvement during physical therapy. Resident #2, when pushed by staff out of the dining room in a wheelchair without footrests, put his feet on the ground and fell on to the floor. This failure affected two residents and placed 49 residents who used wheelchairs for ambulation at risk for injury due to staff not following their individualized safety precautions. Findings include: Record review of Resident #1's Admission Record reflected she was [AGE] years old and was originally admitted to the facility on [DATE]. The Admission Record reflected she was re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] reflected she had both short-and long-term memory deficits, and had difficulty focusing attention. Record review of Resident #1's Fall Risk assessment dated [DATE] reflected she was at "High Risk" for falls. Record review of Resident #1's Care Plan (CP) revealed no interventions for fall prevention dated prior to 02/11/15. The fall prevention care plan included only two approaches: (1) the resident was to be in a geri-chair when out of bed and (2) "Assure call light within reach and answer promptly when on." Record review of Resident #1's Incident Report dated 02/08/15 revealed "Nurse found resident (Resident #1) on floor with another nurse applying ice to resident's forehead. CNAs (Certified Nurse Aides) on the floor assisting the nurse. LVN (Licensed Vocational Nurse) stated resident was being transported to her room with 2 cnas and residents leg got caught in w/c (wheelchair and he (sic) fell forward." The Report did not reflect the names of the CNAs. A Nurses' Note dated 02/08/15 at 7:25 p.m. reflected the two CNAs were CNA D and CNA E. In an interview on 04/02/15 at 3:07 p.m., CNA E denied she was with the resident when the incident occurred. Observation on 04/02/15 at 10:42 a.m. revealed Resident #1 was not in her room. A neck orthotic device was observed on the counter. Interview with a family member on 04/02/15 at 12:45 p.m. revealed the family member visited Resident #1 daily. The family member stated that the resident had experienced a fall while she was in a wheelchair without footrests. The family member stated that the resident exhibited memory deficits, and was incapable of holding her feet up when propelled in the wheelchair. Interview with Therapy Staff (TS) A on 04/02/15 at 1:43 p.m. revealed that prior to a fall in February 2015, the resident was able to ambulate with maximum assist with the parallel bars. TS A stated that following the fall, the resident was not able to ambulate at all. TS A stated that Resident #1 had been approved by the therapy department to use a wheelchair. TS A stated that bilateral footrests were included in the approval. TS A stated, "Resident #1 had the strength to hold her feet up but I would never make a decision to not use the footrests. I don't think it would be safe." Record review of Resident #1's file did not find a document that addressed Resident #1's move from a geri chair to a wheel chair with footrests. Interview with TS B on 04/02/15 at 1:50 p.m. revealed the therapy department used footrests on Resident #1's wheelchair. TS B stated, "TS A went on a search for footrests. Resident #1 definitely needed them. She had multiple knee surgeries. She didn't have the strength to hold them (her feet) up. TS B stated that the fall "Set us back a few weeks." Observation on 04/02/15 at 2:00 p.m. revealed Resident #1 was in the therapy department gym. The resident was sitting in a wheelchair, and the wheelchair had footrests with a full-width leg support. TS A assisted the resident with a transfer, using maximum assist. The resident required several cues prior and during the process. TS A stated that the resident was back to the level of ability demonstrated prior to the fall in February. Interview on 04/02/15 at 2:40 p.m., LVN C said "I witnessed the whole thing." LVN C stated she was sitting at the nurses' desk, and witnessed CNA D pushing the Resident #1's wheelchair. LVN C stated "They got to the ridge (an elevated junction in the floor). When they got to the laminate (flooring) Resident #1's foot got caught. I ran (to catch her). The CNA D tried to grab her. She fell this way (to the right). As I got to her, her head hit the floor. We kept her there, got pillows. She had her collar on." LVN C stated that 911 was called. LVN C continued, "EMTs (Emergency Medical Technicians) came, asked about her right arm. She did not lose consciousness at all. They came and took her." LVN C was asked to describe the wheelchair. LVN C stated, "Not a high-back, regular wheelchair. I don't know why. She didn't have foot pedals (footrests)." Interview on 04/02/15 at 3:07 p.m. with CNA E revealed she did not witness the fall, but heard a "boom" and ran to see what happened. CNA E stated she observed footrests on the wheelchair, but stated that she arrived after the resident was on the floor. An attempt to contact CNA D via telephone was unsuccessful. Record review of the Nurses' Notes (NN) dated 02/08/15 at 7:25 p.m. revealed the writer stepped off of the elevator and saw LVN C, CNA D, and CNA E next to Resident #1, who was lying on the floor. The NN reflected "Resident lying on floor on back with LVN C holding ice to R (right) side of forehead. Deforming noted to R (right) hand." The NN reflected, "Questioned LVN C about what happened: states CNA D was transporting resident to room in w/c (wheelchair) when resident's foot got caught in wheelchair and resident began to fall forward. CNA D tried to catch resident but she fell face forward." Record review of the subsequent NN, dated 02/09/15 at 12:23 a.m. revealed Resident #1 returned from the hospital with a [DIAGNOSES REDACTED]." The NN reflected, "Has reopened laceration to OD (right eye). Steristrips to hematoma to R forehead ..." In an interview on 05/01/15 at 1:32 p.m., the Therapy Department Program Director (TDD) was asked how the resident's functional status and equipment needs were communicated to the nurses and CNAs. TDD stated "We tell the MDS (Minimum Data Set) Coordinators and the Social Worker. The Social Worker has a family conference, and a Care Plan meeting." TDD stated the meeting included the Social Worker, a nurse, and the MDS Coordinator. The MDS Coordinator does a seven day notice that they're going to finish their therapy." When asked how specific needs of each resident was communicated, TDD answered, "That's communicated in our notes. They usually go to Restorative, then Restorative takes it from there. We write the Restorative Plan." (Medicare defines "restorative" or "maintenance" programs as repetitive services required to maintain function that do not involve complex and sophisticated physical therapy procedures and do not require the judgment and skill of a qualified therapist for safety and effectiveness). In an interview on 05/01/15 at 3:40 p.m., the MDS Coordinator stated the CNAs had an ADL (Activities of Daily Living) sheet in a Kardex located in the Nurses' Station. The MDS Coordinator stated that TDD would attend the morning meetings and "At time of discharge will tell us why (the person was being discharged from therapy) and what physical needs (the person had)." The MDS Coordinator was asked how the information was conveyed to the other direct care staff. The MDS Coordinator answered, "It would depend. Usually the ADON (Assistant Director of Nurses). The ADON would tell the nurses and CNAs." In an interview on 05/01/15 at 4:00 p.m., the ADON was asked how the needs of the residents were communicated from the Therapy Department. ADON stated, "With TDD we utilize communication forms. Interdepartment, just like Dietary, Social Worker, etcetera. They're supposed to use that form. That was explained by me to TDD a month ago." The ADON referred to a communication form with dietary recommendations as an example. The ADON stated the residents who transitioned to Restorative would have a plan kept in the MDS office. In an interview with the MDS Coordinator on 05/01/15 at 4:35 p.m., with the ADON present, the MDS Coordinator stated the Restorative plans were kept on a different floor in the Restorative Nurse Aide (RNA) book. In an interview with the ADON on 05/01/15 at 4:35, the ADON stated, "We had a meeting with Therapy that there was a communication gap between Therapy and our staff in regards to residents' progression and functional level. Regarding change of equipment. Our nurses weren't being made aware of that. That was a result of Resident #1's fall. We weren't being made aware of changes." The ADON added, "Therapy said they were informing the nursing staff on the floor by notes in the charts. We haven't been able to locate notes every day. If there's a change from one plane to another device I asked TDD to put it in writing so we can go from one nurse to another." Resident #2 Record review of Resident #2's Admission Record revealed he was [AGE] years old, and was originally admitted to the facility on [DATE]. He was most recently re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's most recent Minimum Data Set (MDS) assessment, dated 03/12/15, reflected Resident #2 exhibited "Moderately Impaired" cognitive skills for daily decision making, and had both short- and long-term memory deficits. He did not ambulate, and required "Extensive Assistance" of one person for locomotion. He required a wheelchair. Record review of Resident #2's Care Plan dated 11/14/14 reflected "Resident #2 is at risk for falls r/t (related to) history of falls, [MEDICAL CONDITION], cognitive impairment, lack of coordination, tremors, involuntary muscle movement, and [MEDICAL CONDITION]." His interventions included: "Fall risk assessments to be completed upon admission/quarterly and anytime Resident #2 falls." Record review of Record review of Resident #2's Incident Report dated 04/16/15 revealed Resident #2 "...was being pushed down the hall to his room to administer medicine and while he was being pushed he planted his feet on the ground causing him to go forward and fall on the floor." The section labeled "Other Info" reflected "Place footrests on the wheelchair to avoid falls." The person listed as preparing the report was the Director of Nurses (DON). Record review of Resident #2's Nurses' Note (NN) dated 04/16/15 at 11:30 a.m. revealed "I was pushing resident to his room to administer his medication. While I was pushing him he planted his feet on the floor and fell forward. No injuries noted other than small abrasion to left side of forehead." The person reflected as signing the NN was Licensed Vocational Nurse (LVN) F. In an interview on 05/05/15 at 11:00 a.m., LVN F stated that on the date of the fall, she was behind Resident #2's wheelchair, propelling him towards his room. LVN F stated the resident did not have footrests because he could 'move his chair.' Record review of Resident #2's most recent Fall Risk Assessment located in the clinical record was dated 11/26/14. The Assessment reflected a total score of 10, indicating he was at high risk for falls. Record review of Resident #2's PT (Physical Therapy) Therapist Progress & Discharge Summary dated 03/30/15 reflected that as of 03/23/15 "The patient demonstrates muscle strength of 3/5 fair (full ROM (Range of Motion) against gravity with no added resistance) of B LE (Bilateral Lower Extremeties)." Observation on 05/05/15 at 9:17 a.m. revealed Resident #2 being propelled from the dining room in his wheelchair. Certified Nurse Aide (CNA) G was pushing the resident's wheelchair. Observation revealed no footrests on the wheelchair, and Resident #2 was holding his feet up off of the ground. Observation on 05/05/15 at 10:58 a.m. revealed Resident #2 was not in his room. Two wheelchair footrests were observed to be under his bed. In an interview on 05/05/15 at 11:00 a.m., CNA G stated Resident #2 did not use footrests on his wheelchair because he could propel himself. Observation and interview on 05/05/15 at 11:05 a.m. revealed Resident #2 was in the common area in his wheelchair. There were no footrests on the wheelchair. Resident #2 was observed to propel himself backwards for approximately a half of a foot. He appeared to be confused. At that time, LVN F stated that, at times, Resident #2 could propel himself, and at other times he was unable to do so. In an interview on 05/05/15 at 11:55 a.m., the DON was asked what procedures were in place to address resident falls from wheelchairs. The DON stated ADON H had addressed the issue after Resident #1 fell out of her wheelchair in February of 2015. When asked how the CNAs would know if a resident required footrests, the DON stated "We're working on a matrix but right now the nurses tell them." When asked what should be done if a resident was being propelled in a wheelchair and started dragging their feet, the DON replied, "Then I would do a footrest." At that time, the DON was asked for all in-service training sign-in sheets since February 2015. In an interview on 05/05/15 at 12:40 p.m., the DON stated that she could not find the packet of documentation regarding Resident #1's fall in February 2015, and that the in-service documentation was in the packet. On 05/05/15 at 1:30 p.m., ADON H presented a "Record of In-Service" dated 02/10/15 at 2:30 p.m. The In-Service title was reflected as "Assessment." ADON H was listed on the form as the facilitator. The In-service reflected the charge nurse was to check for footrests every two hours, and that staff was to place a hand on the resident's torso when propelling in the wheelchair. On 05/05/15 at 1:40 p.m. the Record of In-Service dated 02/10/15 at 2:30 p.m. was reviewed. The signature sheet reflected nineteen signatures, with ADON H as the first. Comparison of the signature sheet versus the staff sign-in sheets for 05/05/15 revealed eighteen of the remaining nineteen signatures were of staff scheduled to work on 05/05/15. Record review of the Timecard Report dated 02/10/15 revealed 25 direct care staff worked on that date that did not have signatures on the signature sheet. In an interview on 05/05/15 at 1:46 p.m., Medication Aide (MA) Q was shown the Record of In-Service dated 02/10/15 at 2:30 p.m. MA Q stated she was not hired at the facility until after 02/10/15, and that she had not attended the in-service. MA Q did not state when she signed the signature sheet. - Record review of the personnel file for MA Q revealed her hire date was 02/20/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of CNA J. - Record review of CNA J's personnel file revealed a hire date of 04/04/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of Registered Nurse (RN) K. - Record review of RN K's Personnel file revealed a hire date of 03/02/15. Record review of the Record of In-Service dated 02/10/15 revealed a signature of CNA L. - Review of CNA L's personnel file revealed a hire date of 03/31/15. In an interview on 05/05/15 at 1:50 p.m., when asked about the in-service training provided to staff on 2/10/15, LVN F stated she remembered an in-service, but did not state when she signed the signature sheet. On 05/05/15 at 2:05 p.m. a meeting was held with the Administrator, the DON, and the ADON. The facility was informed that Substandard Quality of Care had been identified in the area of Accidents and Hazards, and that an Immediate Jeopardy had been identified in that area. The Administrator verbalized understanding. In an interview on 05/05/15 at 3:37 p.m., ADON H stated that she obtained 17 of the 19 signatures for the In-Service dated 02/10/15 on 05/05/15, not on 02/10/15. Record review of the Department of Aging and Disability Services' Provider Letter 14-13 dated 8/19/14, Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported, revealed the definition of neglect is: "The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness." The CMS Form 672 dated 04/02/15 reflected there were ten residents at the facility who ambulated with assistance or with an assistive device, and 51 residents who were "In a chair most of the time."