Every finding on record at The Springs Nursing & Rehab Center

Based on clinical record review, staff interview, and facility document review, the facility staff failed to accurately assess and document pnemococcal vaccine status for one of five resident records reviewed: Resident # 17. Findings include: On 9/19/23 beginning at 11:00 a.m., five resident records were reviewed for immunization status. Resident # 17 was identified as having no documentation of either having been administered or having declined the pneumonia vaccine. On 9/19/23 at 1:30 p.m., the DON (director of nursing) was asked for assistance in locating the information. On 9/20/23 at 8:30 a.m., the DON stated, I have a declination form in my notebook that was signed by the son on 5/29/23. I became DON in March 2023 and started looking at all of this, which is when I got the signed declination form . The DON was then questioned about the MDS (minimum data set) assessment for Resident # 17; noting the resident was admitted to the facility on [DATE], the Admission MDS assessment for Section O0300 documented that Resident #17 had not been offered the vaccine. The DON stated that the MDS coordinator would know about that. On 9/20/23 at 9:00 a.m., the MDS coordinator, identified as RN (registered nurse) # 3, was interviewed and asked how she obtained information for vaccine status. RN # 3 stated, I look for the paperwork; either a consent form or declination form, and also look at the MAR (medication administration record) to see if the vaccine was given. I could not find any information that the resident [Resident #17] received the pneumonia vaccine, or refused it, so I marked 'not offered' at Section O. On 9/20/23, during further review of Resident # 17's clinical record, a progress note dated 2/1/22 written by the social worker documented Received verbal consent from [name of resident's daughter] for Prevnar 23. On 9/20/23 at 9:30 a.m., the DON and ADON (assistant director of nursing) were informed of the progress note. The DON stated that she was not aware of the note, and that a social worker is not able to accept verbal consent; that is done by 2 nurses. The DON further stated, The nurse doing the admission gathers information, and then for immunizations, we [the DON and ADON], as the facility ICP's, take over from there and make sure consents and/or declinations are done. Honestly, I hadn't had time to scan the declination into the record The facility immunization policy for Pnemococcal vaccine directed, Upon admission to the facility, each resident will be evaluated for history of pnemococcal vaccinations and offered the appropriate pnemococcal vaccine in accordance with CDC recommendations for adult vaccinations . e. Declination of the vaccine will be documented in the resident's clinical record. The administrator, DON, ADON, and regional nurse consultant were informed of the above findings during a meeting with facility staff 9/20/23 beginning at 9:55 a.m. No further information was provided prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to store food properly in the main kitchen; dried food and meat were not labeled. The Findings Include: On 9/18/23 at 11:45 AM, the initial kitchen tour was conducted with the dietary manager (other staff, OS #2). The dry storage room yielded opened bulk bags of sugar, powdered gravy, and flour without dates indicating when the item was opened or when the item was to be used by. When asked about the opened containers, OS #2 said that the items should have been dated with an open date and an use by date. The reach-in refrigerator was then observed, a storage bag of approximately 15 leftover cooked pork links was also found without a label indicating when it was placed in the refrigerator (opened) or the use by date. OS #2 verbalized that the bag should have been labeled with the item contents and a use by date. OS #2 then took the bag from the refrigerator and disposed of it. On 9/19/23 at 4:00 PM, the administrator and director of nursing were notified of the above finding. A facility policy titled Date Marking for Food Safety was obtained and read in part, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. No other information was provided prior to exit conference on 9/20/23.

Based on employee file review and staff interview, the facility staff failed to follow the abuse policy for two of 25 employee files reviewed. Two employee files did not have a background investigation check obtained. Findings include: On 9/19/23 beginning at 2:00 p.m., 25 employee files were reviewed. Two files did not include background investigation checks. On 9/19/23 at 3:20 p.m., the payroll/benefit administrator, identified as Other Staff (OS) # 1, was interviewed. OS # 1 stated, We looked at that, and the previous human resource person did not print it off. I have the print out that the money and forms were sent, but if I print off the reference check, it will have today's date since it wasn't printed off and filed in the employee's record at the time it came back. The DON (director of nursing) was asked for a copy of the abuse policy 9/19/23 at 3:45 p. m. The policy Abuse,Neglect, and Exploitation included I. Screening. A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants 3. The facility will maintain documentation of proof that the screening occurred. The administrator, DON, ADON (assistant director of nursing), and regional nurse consultant were informed of the above findings during an end of day meeting on 9/19/23 beginning at 4:05 p.m. No further information was provided prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty residents (Resident #7). The findings include: Resident #7 (R7) had no care plan developed regarding moisture associated skin damage (MASD). R7 was admitted to the facility with diagnoses that included dementia with agitation, gastroesophageal reflux disease, hypertension, diabetes, major depressive disorder, dysphagia, chronic kidney disease, restless leg syndrome and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R7 with severely impaired cognitive skills, always incontinent of bladder, occasionally incontinent of bowel, and as requiring extensive assistance of one person for toileting. R7's clinical record documented a 8/26/23 nursing note which read in part, CNA [certified nurses' aide] alerted this nurse of resident with scant amount of bleeding present on resident's brief when being taken to the shower. Resident was assessed to find a [NAME] [nickel] sized opened area at the top of resident's buttocks. Area cleansed, dressing applied . R7's clinical record documented an 8/26/23 physician's order to cleanse the open buttocks area with wound cleanser, pat dry, and apply dry dressing each day. R7's treatment administration records documented that daily cleansing and dressing changes were completed as ordered. R7's plan of care (revised 6/7/23) included no problems, goals and/or interventions regarding the open area on the buttocks. The plan of care identified that R7 was at risk for pressure ulcer development due to cognitive impairment and incontinence. The plan of care made no mention of any actual skin impairments. On 9/19/23 at 3:36 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #2, R7's buttocks area was observed. R7 had red, excoriated skin at the top of both buttock cheeks over the sacral area. The red area had a prickly appearance with no opened areas observed. On 9/20/23 at 9:20 a.m., the director of nursing (DON) was interviewed about skin changes to R7's buttocks. The DON stated that she looked at the resident today and assessed the area as moisture associated skin damage. The DON stated that the MDS coordinator was responsible for care plan development/updates. On 9/20/23 at 8:53 a.m., registered nurse (RN) #3, the MDS coordinator who was responsible for care plans, was interviewed about R7. RN #3 reviewed R7's care plan and stated that she did not see anything listed about the MASD. RN #3 stated she reviewed all new physician orders and resident updates from the morning meetings and used that information to update/revise care plans as needed. RN #3 stated she was out of work when R7 acquired the MASD and another staff person from another building was assisting with MDS/care plans during that time. RN #3 stated that adding the MASD to R7's care plan was missed. This finding was discussed with the administrator, assistant administrator, and DON on 9/20/23 at 10:15 a.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to assess and/or initiate treatment for skin impairments for two of twenty residents (Resident #7 and #9) and failed to follow standards of care for medication administration during a medication pass observation on one of two units (100 hall). The findings include: 1. Resident #7 (R7) had no initial or ongoing assessments of an open skin area/rash on the buttocks that was treated daily by nursing staff. R7 was admitted to the facility with diagnoses that included dementia with agitation, gastroesophageal reflux disease, hypertension, diabetes, major depressive disorder, dysphagia, chronic kidney disease, restless leg syndrome and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed R7 with severely impaired cognitive skills, always incontinent of bladder, occasionally incontinent of bowel, and as requiring extensive assistance of one person for toileting. R7's clinical record documented a 8/26/23 nursing note which read in part, CNA [certified nurses' aide] alerted this nurse of resident with scant amount of bleeding present on resident's brief when being taken to the shower. Resident was assessed to find a [NAME] [nickel] sized opened area at the top of resident's buttocks. Area cleansed, dressing applied . R7's clinical record documented an 8/26/23 physician's order to cleanse the open buttocks area with wound cleanser, pat dry, and apply dry dressing each day shift. R7's treatment administration records documented that the daily cleansing and dressing changes were completed as ordered. Skin/body audits completed on 8/26/23 and 9/12/23 documented that R7 had a new wound but included no wound type or any description/assessment of the wound. R7's clinical record documented no initial or ongoing assessments of the skin impairment to the resident's buttocks. Nursing notes from 8/27/23 through 9/18/23 made no further mention of the open area and documented no ongoing description, size, appearance or status of the wound. R7's plan of care (revised 6/7/23) made no mention of the open area which had been identified on 8/26/23. A physician progress note dated 9/14/23 included no assessment of the area and documented, Skin: See nursing assessment for detailed skin exam . On 9/19/23 at 1:45 p.m., the assistant director of nursing (ADON) was interviewed about the skin changes to R7's buttocks and the provision of any assessment or ongoing monitoring of the impairment. The ADON stated that she had seen the open area on R7's buttocks but that no assessment was documented. Checking R7's medical record, the ADON stated, I don't see an assessment in the record. On 9/19/23 at 3:36 p.m., with the resident's permission and accompanied by licensed practical nurse (LPN) #2, R7's buttocks area was observed. The resident had areas of red, excoriated (raw) skin at the top of both buttock cheeks, over the sacral area. This red area had a prickly appearance with no drainage observed. LPN #2 stated daily treatments were completed as ordered. LPN #2 stated the assistant director of nursing (ADON) was responsible for tracking wounds. On 9/20/23 at 9:20 a.m., the director of nursing (DON) was interviewed about the skin condition of R7's buttocks. The DON stated that she had assessed the area today (9/20/23) as being moisture associated skin damage. The DON stated that the floor nurses providing treatments should have been assessing the area and documenting the status in the clinical record. The DON stated that a RN was available to assist with assessments if needed. The facility's policy titled Wound Care/Treatments Guidelines (undated) documented, .A weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description. Preferably, this will be done on an assessment sheet and placed .on the chart so nurses will be aware of the progress . This finding was reviewed with the administrator, assistant administrator and DON during a meeting on 9/19/23 at 4:15 p.m. with no other information provided prior to the end of the survey. 2. Resident #9 had no treatment orders obtained and/or entered for an assessed open skin area on the resident's coccyx. Resident #9 (R9) was admitted to the facility with diagnoses that included persistent vegetative state, cerebral infarction, epilepsy, obesity, major depressive disorder, atherosclerotic heart disease, anxiety, hypertension, contractures, COPD (chronic obstructive pulmonary disease) and chronic respiratory failure. The minimum data set (MDS) data 8/16/23 assessed no cognitive function due to persistent vegetative status, that the resident was always incontinent of bowel/bladder, and required the total assistance of two people for bed mobility and toileting/hygiene. R9's clinical record included a 9/17/23 nursing note which documented, This nurse and CNA [certified nurses' aide] were providing incontinent care, an open area was noted to top of coccyx. Sure prep and dry dressing applied at this time. MD [physician] made aware. (Sic) On 9/19/23, a review of R9's clinical record revealed no further assessment of the coccyx wound, no treatment orders for the open area, and no physician notification of the skin impairment. On 9/19/23 at 12:52 p.m., the licensed practical nurse (LPN #1) caring for R9 was interviewed about the coccyx skin impairment. LPN #1 reviewed R9's clinical record and stated that there was no order for any treatment to a coccyx wound. LPN #1 stated that she was not aware that R9 had a skin impairment on the coccyx. Reviewing the record, LPN #1 stated that the last body audit was completed on 9/12/23 and listed no new wounds. When questioned further, LPN #1 stated if a new skin impairment was found, the physician should have been notified and any new orders entered for treatment. On 9/19/23 at 12:56 p.m., registered nurse (RN) #4 that documented the note on 9/17/23 about the open area, was interviewed. RN #4 stated that R9 had .just a little open area on his coccyx that was seen during incontinence care. RN #4 stated that she applied Sure prep around the wound and a dry dressing. RN #4 stated she did not immediately notify the physician but added R9's name to the book for the physician to see on Monday (9/18/23). LPN #1 stated at this time that the physician did not come to the facility yesterday (9/18/23) and was scheduled to come today (9/19/23). RN #4 stated the assistant director of nursing (ADON) usually assessed and monitored wounds, but she had not yet assessed R9's coccyx. On 9/19/23 at 1:05 p.m., the director of nursing (DON) was interviewed about the skin impairment to R9's coccyx. The DON stated that it had been reported in the morning meeting yesterday (9/18/23) that R9 had a wound and she had thought someone had already assessed the area. On 9/19/23 at 1:14 p.m., the assistant director of nursing (ADON) responsible for wound assessments was interviewed about R9's open area. The ADON stated she had not been made aware of R9's skin impairment until today (9/19/23) and had not yet assessed the area. The ADON stated RN #4 found the area over the weekend and listed the issue in the physician book to be seen on Monday (9/18/23). The ADON stated the physician did not come in until today (9/19/23). The ADON stated that the nurse should have contacted the provider or on-call supervisor regarding the open wound and obtained/initiated standing orders for treatment of the area. On 9/19/23 at 1:30 p.m., accompanied by LPN #1, R9's coccyx area was observed. The resident had an irregular shaped discolored area over the coccyx that had a moist appearance. There was no drainage observed. On 9/19/23 at 1:30 p.m., the DON was interviewed again about the absence of treatment orders for R9's coccyx wound with no treatment orders. The DON stated that she assessed the area today and identified this area as discolored skin from an old wound. The DON stated the resident had an open area on the coccyx a long time ago that had healed. The DON stated she did not know what the resident's coccyx looked like on 9/17/23 but today (9/19/23) assessed the area as .discolored and moist but not open. On 9/20/23 at 9:20 a.m., the DON stated that there should have been an order entered for care/treatment of the open area when found on 9/17/23. The DON stated that standing orders included the use of the Sure prep with a dressing, but that the provider should have been notified and an order entered for care/treatment of the impairment. R9's plan of care (revised 3/20/23) documented that R9 was at risk for pressure ulcers and skin impairments due to incontinence and limited mobility. Interventions to prevent impaired skin included, prompt incontinence care, pressure reducing mattress, assessments as needed, nutritional supplements, and frequent turning/repositioning. The facility's policy titled Prevention of Pressure Ulcers (undated) documented on page 340, .Notify physician of impaired skin integrity and obtain 'wound care per protocol' order .Select an appropriate treatment from the Treatment Protocol for Skin Tears & Pressure Ulcers .Once an appropriate treatment has been select, write a telephone order, fax the order to the pharmacy, and order the necessary supplies .Document the initial and weekly measurement and characteristics . (Sic) This finding was reviewed with the administrator, assistant administrator, and DON during a meeting on 9/19/23 at 4:15 p.m. 3. Manufacturer's instructions/standard of care for the prevention of yeast infection were not followed during a medication pass on the 100 hall for the medication Wixela (fluticasone-salmeterol). On 9/19/23 at 7:45 a.m., a medication pass observation was conducted with registered nurse (RN) #4 administering medications to Resident #30 (R30). Included in the medications administered was Wixela (fluticasone-salmeterol) inhalation aerosol powder 500-50 mcg/act (micrograms per actuation). After activation of the dose, R30 inhaled the Wixela once from the inhaler device. R30 did not rinse his mouth after inhaling the medication and there was no prompt or instruction from RN #4 for the resident to rinse/spit after taking the medication. Manufacturer's instructions printed on the Wixela box documented that the patient should rinse and spit after inhaling the medication. R30's clinical record documented a 7/15/23 physician's order for fluticasone-salmeterol inhalation aerosol powder breath activated 500-50 mcg/act, with instructions for one inhalation orally two times per day for treatment of COPD (chronic obstructive pulmonary disease). On 9/19/23 at 8:01 a.m., RN #4 was interviewed about the lack of mouth rinse following R30's inhalation of Wixela. RN #4 stated, He [R30] usually will do it [rinse]. RN #4 stated that R30 was alert and oriented and usually rinsed his mouth .on his own. R30's clinical record documented no assessment or order for the resident to self-administer medications. The facility's pharmacy provided administration instructions for all forms of fluticasone-salmeterol powder. This document listed specific guidance regarding the administration of fluticasone-salmeterol via inhaler device, Following administration, instruct patient to rinse the mouth with water to minimize dry mouth. Do not swallow the water . The Nursing 2022 Drug Handbook on page 657 describes Wixela (fluticasone-salmeterol) as a corticosteroid used for treatment of asthma and COPD. Instructions for administration on page 660 document, Instruct patient to rinse mouth after inhalation to prevent oral candidiasis [fungal/yeast infection] . (1) This finding was reviewed with the administrator, assistant administrator, and director of nursing during a meeting on 9/19/23 at 4:15 p.m. with no further information provided prior to the end of the survey. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on observation, staff interview, and review of facility documents, the facility failed to ensure food was stored in a manner to ensure food safety, and kitchen staff failed follow proper handwashing procedures. The findings were: 1. At approximately 9:30 a.m. on 8/9/2022, during a tour of the Kitchen, the following was observed in the reach-in cooler: An open package of lunch meat in a zip-lock bag was undated. Asked about the lunch meat, the Dietary Manager said, That's sliced ham. An open package of grated cheese, identified by the Dietary Manager as Mozzarella, wrapped in saran wrap was undated. An open package of grated cheese, identified by the Dietary Manager as Parmesan, wrapped in saran wrap was undated. An open package of lunch meat, identified by the Dietary Manger as sliced turkey, wrapped in saran wrap was undated. A pitcher, approximately one-quarter full of what appeared to be orange drink, was not labeled or dated. A pitcher full of what appeared to be fruit drink was not labeled or dated. The Dietary Manager acknowledged the food items were not dated or labeled. Review of the facility's Dietary and Food Handling revealed the following in the section titled Proper Food Handling: Leftovers must be dated, labeled, covered, cooled and stored (within 1/2 hour) in a refrigerator, not at room temperature. Foods must be labeled with the date when opened and discarded, if not used, within 72 hours. 2. At 11:30 a.m. on 8/9/2022, during observation of preparation for the lunch meal, a staff member engaged in placing food on the steam table went to the handwashing sink. The staff member wet her hands, lathered with soap, and then rinsed her hands. After rinsing her hands, the staff member turned off the water and then obtained paper towels to dry her hands. Review of the facility's Dietary and Food Handling revealed the following in the section titled Personal Hygiene: Handwashing procedure: a) Wet hand thoroughly. b) Lather with soap to wrists and use friction. c) Rinse, clean nails. d) Lather second time. e) Rinse with water running from wrist down f) Dry on paper towel g) Turn faucet off with paper towel The findings were discussed during a meeting at 4:00 p.m. on 8/9/2022 that included the Administrator, Director of Nursing, and the survey team.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure specific physician's orders and interventions were in place for the the care, treatment and management of a gastrostomy tube for one of 18 residents in the survey sample, Resident #27. Findings include: Resident #27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident's cognitive status as '00', indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as requiring total assistance from two or three staff for all ADL's (activities of daily living). This MDS also assessed the resident in Section B0600. Speech Clarity as having no speech. In Section B0700. Makes Self Understood and Section B0800. Ability To Understand Others it documented the resident as, Rarely/never understands. This MDS also assessed the resident as having a abdominal (PEG) tube and receiving 51% or more of total calories through tube feeding and as receiving 501 cc/day or more per day of fluid intake. On 08/09/22 at 9:21 AM, Resident #27 was observed in bed without a shirt on, covered with a sheet from the navel down to the feet. The resident's peg tube was exposed. There was no dressing in place to the peg tube site. The tube feeding machine was sounding/beeping and observed, along with the TF (tube feeding) bottle and water flush bag. The bottle was dated 08/08/22 and timed 9:00 PM, documented 95ml/hr (milliliters per hour). The flush bag was dated the same and documented, 240 ml every 4 hours. LPN (Licensed Practical Nurse) #2 came into the room to address the machine beeping, the LPN turned the machine off and stated that she would tell LPN #4 (the resident's nurse for the day) that the resident was done. LPN #2 exited the room. At approximately 9:28 AM on 08/09/22, LPN #1 (also known as the UM/unit manager) entered the room and stated, Is it beeping. The UM was made aware that LPN #2 had just come in an shut the machine off due to it beeping and stated that the resident was done. The UM stated that the resident was not done and restarted the machine. The UM was asked about the feeding machine readings, the UM stated that the resident gets 95ml/hr of feeding and 280 every 4 hours of flush. The bottle of TF hanging had approximately 1100 cc left in bottle (approx 1500cc bottle) and the water bag flush had approximately 700 cc remaining in bag (approx 1000cc bag). On 08/09/22 at 11:26 AM, the resident was again observed. There was no dressing in place to the peg tube site. The resident's tube feeding was again observed and again was sounding/beeping. The rate on the machine was set for 95ml/hr and the flush on the machine was reading, 'flush 240 ml every 0 hours, amount infused (for flush) is 0' this is what was showing on the machine. The flush bags again has approximately 700cc remaining in the bag, as observed earlier. On 08/09/22 at 1:43 PM, the UM was again asked about the resident's tube feeding. The UM stated that it should be getting ready to come down. The UM was asked if I&O (intake and output) records (specifically intake records) are kept on this resident and the UM stated, No. The UM was asked about the resident's physician's orders and were asked to pull them up. The UM pulled the resident's orders up and stated that the TF is to start at 9PM and come down at 2PM the next day. The UM was asked if when the pump was shut down earlier by LPN #2 does the machine clear it's settings. The UM stated that the setting are not cleared, they have to cleared manually. The UM stated that an error had read on the machine earlier and that she had cleared the TF setting, but not the flush setting. The UM was asked to go to the resident's room and check the settings/volume infused. The resident was again observed without a dressing to the peg tube site. The UM observed the machine settings of 0 (amount infused) for flush and that it was set to infuse every 0 hour. The UM was made aware that this didn't make sense and was very confusing as the orders and the machine readings did not match. The UM stated that she would notify the NP (nurse practitioner) to see what she wants to do. The UM was asked how do you know what the resident is actually getting and what is actually infused, if there is no intake records. The UM stated that it's the volume is included on the physician's orders to be infused. The UM was asked or a policy and procedure on TF/peg tube care/maintenance/feeding and flush. On 08/09/22 at 1:58 PM, The UM stated that the NP ordered to do a one time manual flush and stated that she did not know how much the resident had actually received due to the machine readings and tube feeding equipment. The resident's physician's orders were reviewed and documented, .[Name of TF formula] 1.2 @ 95ml/h for total of 1615 ml total kcal [kilocalories] 1398 in 24 hours Stop at 1400, Free water flush via pump of 280ml q4 hours Minimum volume to infuse is 1445, please notify MD/FNP if minimum volume not met . The resident's CCP (comprehensive care plan) was reviewed and documented, .requires feeding by gastrostomy tube secondary to dysphagia secondary to [CONDITION(S)] [CONDITION(S)] .check placement .crush meds .flushes per order, G tube feeding per MD order, HOB elevated during feeding per order .NPO (nothing by mouth) .observe or aspiration .treatment to g tube insertion site as ordered . The policy was presented and reviewed. The policy titled, Enteral Feeding Guidelines documented, .providing residents with the highest level of care .provide safe administration of enteral feedings .administration bottles and/or bags and tubing are to be marked with the resident's name and date .feeding bottles and tubing are to be changed per manufacturer's guidelines .verify the resident's physician's orders .position resident .keep the head of bed at a minimum of 30 degrees .utilize feeding tubes in accordance with current clinical standards of practice .the resident's plan of care will address the use of feeding tube, including strategies to prevent complications .examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection .frequency of and volume used for flushing .and what to do when a prescriber's order does not specify .direction for staff regarding the conditions and circumstances under which a tube is to be changed will be provided .when to replace and/or change a feeding tube .as ordered/scheduled by the physician .when a long term feeding tube comes out unexpectedly, or when the tube is worn or clogged .documentation of all nutritional formulas and flush amounts in the electronic health record .direction for staff regarding how to manage and monitor the rate of flow .use of pump .The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the individual needs .notify and involve physician .of any complications . On 08/10/22 at 9:18 AM, the resident was again observed. The resident's bed was set at a 25 degrees, tube feeing infusing. The resident's feeding pump was set to 95 ml/hr and the flush set at 280 ml/every 4 hours. According to the TF pump, the feed volume infused read 766 ml at this time. The water flush, amount infused on the pump read 1400 ml. The bottle documented the time of 9PM [start] to 2 PM [finish] and was dated 08/10/22. The water flush bag had the date written 8/9 with a start time of 2100. The TF bottle had approximately 3/4 of feeding remaining in the bottle. The water bag flush was approximately 1/2 full. On 08/10/22 at 9:30 AM, the UM entered the room and asked if the machine was beeping again. The UM looked at the machine and then looked at the resident's bed and adjusted the head of bed higher for the resident. The UM was made aware that the bed height had been set at 25 degrees prior to that change. The UM was made aware that the volume infused shown on the pump and the amount remaining hanging and the amount ordered by the physician did not add up or make sense and was again asked if intake records are kept for this resident regarding the amount of TF and water flushes the resident is taking in each shift. The UM again stated that they do not keep intake records on this resident. The UM was made aware that Resident #27 did not have a dressing to the gastrostomy site during multiple observations on 08/09/22. The UM asked if the resident had a dressing in place now and pulled the resident's sheet down exposing the resident's peg tube and there was now a dressing in place. The UM was made aware that the resident's orders were reviewed and there was no evidence of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM stated that she would call the night shift nurse and try to get information and/or explanation regarding the TF machine reading and the amounts observed and see if something had happened. The UM stated that she didn't know unless a new bottle was hung. The UM stated that it doesn't make sense or add up. The UM stated that there is not a specific time documented on the bottle that was hung and that time should be documented when it is actually started. The UM was made aware that nothing was documented in the nursing notes regarding anything unusual pertaining to Resident #27 or the resident's peg tube, feeding and/or flushes. On 08/10/22 at 10:36 AM, the UM stated that she had spoke the NP, and she stated that the resident's weight has been stable and that they are going to adjust and extend the order to get the total volume ordered and then just resume the regular order at 8 pm tonight. On 08/10/22 at 2:14 PM, the administrator, DON (director of nursing), ADON, corporate consultant were made aware of concerns regarding the lack of specific physician's orders for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information and/or documentation was presented prior to the exit conference.

Based on complaint investigation, clinical record review, staff interview, and family interview, the facility staff failed for one of 18 residents in the survey sample, Resident # 58, to offer compassionate care visits. The family of Resident # 58 was not offered compassionate care visits while visitation in the facility was restricted. The findings were: Resident # 58 was admitted with diagnosed that included chronic systolic [CONDITION(S)], hypertension, chronic [CONDITION(S)], dysphagia, moderate protein-calorie malnutrition, [CONDITION(S)], chronic respiratory failure with [CONDITION(S)], pneumonia, and generalized muscle weakness. The resident was in the facility for five days and left before completion of the Admission Minimum Data Set. According to a complaint narrative written by the resident's daughter-in-law, the resident was married for [AGE] years and was upset that, due to COVID, was only able to visit his wife through a window. The daughter-in-law also wrote that during telephone conversation, the resident said, I just want to go ahead and die, and was begging to see his wife and hold her hand. Review of the Progress Notes in the resident's Electronic Health Record revealed the following Social Services note: 9/2/2022 - 10:34 a.m. Social Services - .(Name of Resident) stated, 'I am ready to die, I am suffering.' Social Services reported the information to the DON (Director of Nursing) and ADON (Assistant Director of Nursing) At 2:20 p.m. on 8/9/2022, LPN # 2 (Licensed Practical Nurse), who serves as a Unit Manager, and who was familiar with the resident, was interviewed regarding Resident # 58 and visitation. According to LPN # 1, the resident was placed on isolation upon admission, consistent with COVID practices at that time, even though the resident had a rapid COVID test on the day of admission that was negative. Asked about visitation, LPN # 1 confirmed that the family had window visits with the resident. When asked about compassionate care visits, LPN # 1 said, We did not offer compassionate care visits because he was not on comfort care. LPN # 1 provided the date the resident was placed on comfort care, which was the fourth day of the resident's stay. At 9:10 a.m. on 8/10/2022, the resident's daughter-in-law was interviewed by telephone. Asked if the facility offered the family compassionate care visitation, the daughter-in-law said, No. We could only do a window visit. They (the staff) would wheel him to a window and we would talk through a screen. We couldn't even touch him. On 8/10/2022 at 2:45 p.m., the facility's Operations Manager was interviewed regarding family visitation. According to the Operations Manager, the resident's daughter and daughter-in-law were allowed in the facility to do a room visit. However, the Operations Manager said he did a search of visitation logs and could find no documentation of visits made by the family. On 8/11/2022, four opportunities were made to contact the former facility Administrator for further information regarding the family's visitation and compassionate care visits. All four calls were not returned. QSO-20-39-NH Revised 3/30/21 includes the following about Compassionate Care Visits: While end of life situations have been used as examples of compassionate care situations, the term 'compassionate care situations' does not exclusively refer to end of life situations. Examples of other types of compassionate care situations include, but are not limited to: A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of family support. The findings were discussed during a meeting at 4:00 p.m. on 8/9/2022 that included the Administrator, Director of Nursing, and the survey team. COMPLAINT DEFICIENCY

Based on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for one of 18 resident's in the survey sample. Resident #59's discharge MDS assessment was coded as being discharged to the hospital instead of home. The Findings Include: diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 3/17/22. Resident #59's cognitive score was a 11 indicating moderately cognitively intact. During a closed record review, Resident #59 was added to the sample as a hospital discharge review. On 8/10/22 Resident #59's clinical record was reviewed. Section A2100 of Resident #59's discharge MDS (dated 5/26/22) documented Resident #59 had been discharged to Acute Hospital. Review of Resident #59's progress notes dated 5/26/22 read in part Resident being discharged to home today. On 08/10/22 at 2:15 PM, during a meeting with the director of nursing, administrator, and unit manager (license practical nurse, LPN #1) the above finding was presented. LPN #1 reviewed the documentation and verbalized that Resident #59 was discharged home and an error had been made on the discharge MDS assessment. No other information was presented prior to exit conference on 8/10/22.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 18 residents (Resident #32) had a targeted resident review coordinated with the appropriate state designated authority according to the Level II PASARR (pre-admission screening and resident review). Findings include: Resident #32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. This MDS also assessed the resident with major depressive disorder, recurrent, severe with psych symptoms in Section I. (I0020B. Primary Medical Condition ICD). Resident #32 triggered in the LTCSP system for 'No PASARR with diagnoses'. The resident's clinical records were reviewed and no level II could be located. On 08/10/22 at approximately 12:45 PM, the SW (social worker) was asked for the information. The SW presented the information. The resident's level II dated 06/11/2021 documented that the resident would receive services of lesser intensity at the nursing facility, but also documented the following: .A targeted resident review is scheduled in 120 days to further assess [name of resident] status in the nursing facility and his potential to transition to a community setting with appropriate support services . The SW was asked if that review had been completed. The SW stated that she was not in that role at that time and would check, but did not have anything regarding the targeted review. A policy was requested on pre-admission screening and resident review (PASARR) At approximately 1:00 PM, the administrator stated that they can't find where that review had been completed or had taken place for this resident. The policy was presented and documented, .incorporating the recommendations from the PASARR level II determination and evaluation report into the resident's assessment, care planning and transitions of care . No further information and/or documentation was presented prior to the exit conference on 08/10/22.

Based on staff interview and clinical record review, the facility failed to develop care plans for two of 18 resident's in the survey sample. Resident #7 did not have a care plan for antidepressant medication and mood. Resident #27 did not have a complete care plan for tube feeding care and management. The Findings Include: 1. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/5/22. Resident #7's cognitive score was a 15 indicating cognitively intact. Section D0200 (B) documented Resident #7 had felt down, depressed, or hopeless 7 to 11 days of the 14 day look back period. On 8/10/22 Resident #7's physician orders were reviewed and documented [MEDICATION(S)] 200 MG (milligrams) and Trazadone 100 MG (antidepressants) were ordered daily for depression and anxiety. Resident #7's care plan was then reviewed and did not evidence a care plan for mood, psychosocial or antidepressant medication. On 8/10/22 at 1:24 PM the MDS coordinator (license practical nurse, LPN #2) was interviewed. LPN #2 reviewed Resident #7's care plan and verbalized the care plans for mood and antidepressants were over-looked and would be corrected. On 08/10/22 at 2:15 PM the above information was presented to the director of nursing and administrator, during an end of day meeting. No other information was presented prior to exit conference on 8/10/22. 2. The facility failed to develop a comprehensive care plan for Resident #27 for gastrostomy tube/tube feeding care and management. Resident #27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident's cognitive status as '00', indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as requiring total assistance from two or three staff for all ADSL's (activities of daily living). This MDS also assessed the resident in Section B0600. Speech Clarity as having no speech. In Section B0700. Makes Self Understood and Section B0800. Ability To Understand Others it documented the resident as, Rarely/never understands. This MDS also assessed the resident as having a abdominal (PEG) tube and receiving 51% or more of total calories through tube feeding and as receiving 501 cc/day or more per day of fluid intake. On 08/09/22 Resident #27 was observed multiple times throughout the day without a peg tube dressing to the resident's peg tube site. On 08/09/22 Resident #27 was observed with the resident's HOB (head of bed) at a 25 degree angle during tube feeding administration. The resident's physician's orders were observed. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no specific orders for care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's CCP (comprehensive care plan) was reviewed and documented, .requires feeding by gastrostomy tube secondary to dysphasia secondary to [CONDITION(S)] [CONDITION(S)] .check placement .crush meds .flushes per order, G tube feeding per MD order, HOB elevated during feeding per order .NPO (nothing by mouth) .observe or aspiration .treatment to g tube insertion site as ordered . The resident had no physician's order regarding keeping HOB elevation and/or treatment to the resident's peg tube site. On 08/10/22 at 10:13 AM, LPN #2 (MDS/Careplan) was interviewed regarding Resident #27's care plan. The LPN was asked if the resident should have something specific on the care plan regarding a dressing changes, having the HOB (head of bed) elevated, and monitoring fluid intake since the resident is on tube feeding. The LPN stated, Yes Ma'am as far as the dressing change and HOB. The LPN stated that as far as monitoring fluid intake she would check with the regional nurse. The LPN was made aware that she had included on the resident's careplan for treatment to the peg site per the physician's orders and the HOB elevated per order, but the interventions were not specific and there were no physician's orders for those items. The LPN stated that for HOB the bed should be at 30 degrees or higher for a resident with tube feeding. At approximately 10:30 AM, the LPN returned and stated that the regional nurse stated that fluid intake information did not need to be on the care plan. On 08/10/22 at 2:30 PM, the administrator, DON (director of nursing), ADON, and corporate consultant were made aware that the resident's comprehensive care plan (CCP) was not developed with specific, specialized care and treatment interventions for this particular resident. No further information and/or documentation was presented prior to the exit summary on 08/10/22.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards during a medication pass and pour observation, for one of 14 residents, Resident #22 License practical nurse (LPN #1) was going to give Resident #22 the wrong dose of Tylenol. The findings include: On 03/22/21 at 8:31 AM, during an observation of a medication pass and pour, LPN #1 began pulling medications out for Resident #22. One of the medications scheduled to be given was Tylenol. LPN #1 pulled a bulk bottle of Tylenol was observed and documented the dosage at 500 MG (milligrams) per tablet. Review of the electronic Medication Administration Record [REDACTED] LPN #1 continued to dispense 4 Tylenol pills (equaling 2000 MG) into a medication cup along with other medications. LPN #1 then locked the cart and stepped away from the medication cart. LPN #1 was asked Are you ready to give the medications. LPN #1 said Yes. LPN #1 was then asked to stop and review the dosage on the bottle of Tylenol. After LPN #1 reviewed the dosage of Tylenol LPN #1 stated I read that so wrong. On 03/22/21 at 09:10 AM, the ADON (assistant director of nursing) was aware of the above finding. Review of the physician order [REDACTED].) in 24 hours. The start date of the Tylenol was dated 1/22/21. Review of the facilities policy for medication administration read in part ( .) Verify each time a medication is administered that it is the correct medication, at the correct dose ( .). On 03/22/21 at 04:02 PM, during an end of day facility staff meeting, the above information was presented to the director of nursing, administrator and chief nursing officer. No other information was presented prior to exit conference on 3/23/21.

Based on resident interview, clinical record review, facility document review and staff interview, the facility staff failed for one of 14 residents to conduct a complete and thorough investigation for an injury sustained during an altercation between a resident and a staff member. Resident #7 sustained a large bruise covering the left eye. The Findings Include: Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/12/21. Resident #7 was assessed with [REDACTED]. On 03/21/21 at 11:24 AM, Resident #7 was interviewed. During the interview Resident #7 was observed with a fading bruise surrounding the left eye. When asked about the bruise Resident #7 said a woman hit him about 2 weeks ago. Resident #7 was asked if the bruise was caused by a staff member. Resident #7 nodded yes but did not give anymore information. On 3/22/21 Resident #7's clinical record was reviewed. A progress note documented 3/17/2021 21:53 (11:53 PM) Nurse's Note Note Text: Was alerted by other nurse that Resident tried hitting her and struck her elbow, which deflected resident hand and he struck himself in the L (left) eye. Resident assessed, redness and some swelling noted to L eyelid along with a 1 cm scratch. Resident denies pain discomfort to area. Resident PERRLA. Speech clear. Resident alert and oriented to self usual level of orientationhe (SIC) On 3/22/21 at 1:44 PM, the administrator was interviewed and was asked if a FRI (Facility Reported Incident) had been sent to the State Agency regarding Resident #7's bruised eye. The administrator said a FRI had not been sent because the facility knew how the bruise was acquired. The administrator was told that during an interview with Resident #7, Resident #7 stated that a staff member hit him. The administrator stated That's the first time I have heard that. On 03/22/21 at 2:30 PM an interview with the ADON (assistant director of nursing) took place. The ADON said Resident #7 has behavior issues and a nurse was working as a CNA (certified nurse assistant) and was giving Resident #7 a bath, Resident #7 became combative and started trying to punch the nurse and while throwing punches Resident #7's fist deflected off the nurses elbow and he hit himself in the left eye. The ADON was asked to present all investigation documentation. A witness statement documented (name of staff member involved, identified as LPN #3) incident date and time 3/17/21 at 9:00 PM (documented by LPN #3) Resident went to hit me in the face while I was showering him. When he hit my left elbow his fist came back hitting him on the left brow. Immediate intervention: Told (name of LPN, identified as LPN #2) about incident came in and assessed. Denied pain. Fingernail caused a little cut on brow. (signature of LPN #3 and interviewer ADON). On 03/23/21 at 9:46 AM, the ADON was interviewed regarding witness statements. The ADON stated, LPN #3 was the only witness, LPN #2 did an investigation with LPN #3 at the time of the incident and said Resident #7 was on a shower bed and LPN #3 was standing above Resident #7 shaving him when Resident #7 hit LPN #3's arm deflecting off the arm hitting himself in the face. The ADON said that the physician and guardian were notified. On 3/22/21 review of Resident #7's most recent Nursing Monthly Summary dated 3/6/21 documented Resident #7's mental status as being Alert (and) Able to fully express self and understand others ( .) Resident #7's care plan was also reviewed and did evidence that Resident #7 had behaviors that included throwing meal trays, yelling and cursing at staff, and trying to strike out at staff. According to Resident #7's most recent MDS with an ARD of 3/12/21 under section G0120 Bathing Resident #7 is coded as total dependant on staff with 2 plus physical assistance from staff. On 03/23/21 at 10:27 AM, the ADON was asked about not getting a statement from Resident #7. The ADON said there was no rational for not getting a resident statement, she thought LPN #2 asked him what happened but Resident #7 said he didn't know what happened. On 03/23/21 at 10:36 AM, the ADON said herself along with the DON assessed Resident #7 on 3/18/21 and during the assessment Resident #7 was asked what happened and Resident #7 said he did not know. It was explained to the ADON that nothing about this was documented in the clinical record. The ADON said, she would put the information as a late entry. The late entry was reviewed and was dated for 3/18/21 and entered on 3/23/21 and read '( .) asked resident what happened to his eye. resident (sic) states he didn't know and for us to get out of his room. Review of the facilities abuse policy in regards to investigation read in part Designated staff will immediately review and investigate all allegations or observations of abuse. ( .) The organization will conduct analysis for trends and patterns related to incidents (i.e. falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidence.). On 03/23/21 at 02:43 PM, during a facility staff meeting, the above information was presented to the administrator, DON, ADON, and chief nursing officer (CNO). The CNO stated the facility knew what had happened and felt their investigation was completed. The ADON stated that she would try to get the nurses that were involved on the phone for an interview. On 03/23/21 at 03:06 PM, LPN #2 was interviewed via telephone. LPN #2 said she was at the nurses station and was called into shower room and nurse (LPN #3) working as a CNA (certified nursing assistant) said during Resident #7 being shaved he became combative and began swinging his arms, his fist deflected off LPN #3's elbow and hit himself in the eye. LPN #2 asked Resident #7 what happened, and he said my eye hurts. Attempt's were made to contact LPN #3, but was unavailable. No other information was presented prior to exit conference on 3/23/21.

Based on staff interview, family interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure one of 14 residents (Resident #2) was free from neglect. Facility staff failed to get an order for [REDACTED].#2, who had a history of [REDACTED]. Findings include: Resident #2 was admitted to the facility on [DATE], with the most current readmission on 03/07/21. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly review dated 12/31/20. This MDS assessed the resident as having long and short term memory impairment and modified impairment in daily decision making skills. This MDS assessed the resident as requiring extensive assistance from staff for all ADLs (activities of daily living). The resident also had a five day medicare MDS dated [DATE]. This MDS assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as having a UTI in the last 30 days. The complaint alleged that on 02/22/21 a window visitation was conducted between the son and Resident #2, and the son noticed the resident had a change in demeanor and was concerned. The son reported this information, communicated with facility staff, and asked for the resident to be seen by the physician regarding his concerns. According to the complaint the son was concerned that the resident may have a UTI. The facility submitted a Facility Reported Incident (FRI) to the State Agency regarding this concern. Resident #2 was a current resident of the facility. The resident was observed on multiple occasions and multiple attempts were made to interview the resident during the survey process. Resident #2 only spoke a few words at a time and stated that she did not remember going to the hospital. On 03/22/21, the administrator was asked for any documentation, investigation and/or follow up related to the FRI dated 03/01/21. The investigation included the following statement dated 03/01/21 from the AD (Activity Director), .02/22/21 .6:00 - 6:30 PM .I spoke with (name of Resident #2's son) while I was outside setting up chairs for a window visit with him and his mother. Two other family members were there. He told me that this mother seemed confused when he spoke to her on the phone earlier that week. He said that her confusion could indicate a UTI and he would like to have her checked for a UTI. I reported what he said to the nurse (Name of nurse/identified as Registered Nurse #1). A statement dated 03/04/21 from RN #1 documented, Was stopped by (name of Resident #2's son) after my shift had ended and was told that he wanted a U/A (urinalysis) for his mother. I told him I would put her on the doctor's book. I intended to do this in the AM when I came into work but was sick and called out. Resident #2's nursing notes were reviewed from 02/19/21 (prior to the window visit) through 03/01/21 (the date the resident went to the hospital). The nursing notes revealed the following: 2/19/2021 (5:11 AM) .Resident awake, vomited undigested food. Staff in to change gown and bed. Am meds provided. Will monitor and assess (signature RN #3). 2/19/2021 (12:17 PM) .[MEDICATION NAME] HCl Tablet 25 MG Give 1 tablet by mouth every 6 hours as needed for an/v (nausea/vomiting) 60cc dark yellow syrupy emesis (signature of RN #1). 2/19/2021 (3:21 PM) .eMAR .[MEDICATION NAME] HCl Tablet 25 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for n/v PRN (as needed) Administration was Effective Resident up in a chair and emesis has stopped for now (signature of RN #1). 2/19/2021 (5:00 PM) .eMAR .Notified RP (responsible party) and MD (medical doctor) of emesis. Resident vomited approx. 60 cc x 3 this am of the same type fluid but is feeling better after the [MEDICATION NAME]. Resident is drinking tea and is looking forward to dinner. Resident is afebrile. No other symptoms noted. Will continue to observe (signature of RN #1). 2/26/2021 (1:07 PM) .Resident received COVID vaccine yesterday. No adverse reactions noted. Tolerating well (signature of LPN #4). 2/27/2021 (2:15 AM) .Resident continues to be under skilled services .A&O (alert and oriented) x 2 .mucous membranes are pink, moist, and intact .Speech is clear .can voice needs. Lungs clear .No cough, or SOB (shortness of breath) noted or voiced .Abdomen is soft and non distended .Bowel sounds present .has no complaint of pain or discomfort .Took meds whole w/o (without) difficulty .Rsd (resident) experienced fever and vomiting during shift, Rsd given 25mg/ml [MEDICATION NAME] and started on clear liquid diet per standing orders. (name of NP/nurse practitioner) informed of rsd symptoms (signature of RN #2). A late entry nursing note dated effective for 2/27/2021 10:30 PM (creation date: 03/05/21 11:09 PM) documented, .Nurse observed rsd with emesis on chest/face/hair. Assessed rsd and low grade temp of 99.5 was noted. Rsd was given a shower due to emesis. Approx 30 min after initial temp was assessed, a normal temp of 98.6 was noted. Temp was assessed throughout the night and remained with normal limits. NP was notified of rsd condition and that rsd was started on standing orders (signature of RN #2) 2/28/2021 9:27 AM .Resident continues to be under skilled services at this time. A&O to self .mucous membranes are pink, moist, and intact .Speech is clear. Rsd can voice needs. Lungs clear .No cough, or SOB noted .no complaint of pain or discomfort .Took meds w/o difficulty or adverse effects (signature of LPN #1). 3/1/2021 9:08 AM .Resident continues .A&O x 2 mucous membranes are pink, moist, and intact .Speech is clear .can voice needs. Lungs clear .No cough, or SOB noted or voiced .abdomen is soft and non distended. Bowel sounds present no complaint of pain or discomfort .Took meds w/o difficulty .(signature of LPN #1). 3/1/2021 12:50 PM Discharge/Transfer Summary Note .altered mental status, clammy, sweaty, diaphoretic .decreased level of consciousness, clammy. BS (blood sugar) checked 202 .resident was lethargic sternal rub performed with minimal response from resident .MD aware .blood Pressure: BP 90/70 .Temperature: 98.6 . Pulse: 101 .Regular .Respiration: 16 .O2 Sats: 94 % .(signature of LPN #1). Resident #2's comprehensive care plan dated 11/02/20 (prior to resident's discharge) documented, .Resident is incontinent of urine .resident will remain as clean and dry as possible .Check and change frequently as needed .Observe for changes in urine characteristics for s/s (signs or symptoms) of an urinary infection .administer medications as ordered . On 03/22/21 at 3:45 PM, the AD was interviewed. The AD stated that she remembered that day and stated that she had got him (the son) set up with the window visit and he voiced that he was concerned that his mother was confused and he wanted her to be seen by the doctor and that the confusion may indicate the resident is getting a UTI. The AD stated, After I got him (son) set up, I went in to the nurse and told her what the family had said and that he wanted her to be checked. The AD stated that RN #1 told her, I can't just do a check like that, I have to get an order. The AD then stated that the doorbell to the facility rang and she left the nurse and went to answer the door. The AD was asked if RN #1 was working today. The AD stated that she had not seen RN #1 in about a week. On 03/22/21 at approximately 3:50 PM, the ADON (assistant director of nursing) stated that RN #1 no longer worked at the facility and her last day was on March 9th, 2021. On 03/22/21 at 4:00 PM, the administrator, DON (director of nursing), ADON and the CNO (chief nursing officer) were made aware of the concerns regarding Resident #2 and the above information. The CNO stated that RN #1 denied that the AD reported anything to her regarding Resident #2. The administrative staff were made aware that RN #1 was made aware by the resident's son, according to RN #1's statement taken on 03/04/21. On 03/23/21 at 8:45 AM, Resident #2's son was interviewed. The resident's son stated that he spoke with RN #1 on the evening of 02/22/21 around 6:30 PM and informed her of his concerns regarding Resident #2. The resident's son stated that RN #1 assured him it would be taken care of the next day, when the RN returned to work. The resident's son stated that according to the facility, RN #1 was sick the following day and did not return to work until several days later. On 03/23/21 at 10:50 AM, the NP (nurse practitioner) was interviewed. The NP stated that she did not remember being called about Resident #2 on 02/27/21 by RN #2. The NP stated that, nausea and vomiting were not uncommon for Resident #2 and stated that the resident was on multiple stomach medications. The NP stated if a resident is put on the book by nursing, the resident would been seen on the next physician's visit. On 03/23/21 at 1:00 PM, RN #2 was interviewed regarding the note written on 02/27/21 at 2:15 AM. The RN stated that she called the NP and reported concerns and did what was ordered. RN #2 stated that she did not put her on the book to be seen by the physician, as this wasn't uncommon for this resident and that the NP was called. Hospital records for Resident #2 were reviewed. The ER (emergency room ) note documented, .presents to the ED (emergency department) from NH (nursing home) .a report form NH staff of altered mental status. Per the report from NH .pt was difficult to arouse and confused .On arrival to the ED, pt is alert and in no apparent distress. She is able to answer questions and follow commands .denies any complaints . The resident was admitted to the hospital for UTI, treated with IV medications and fluids and discharged back to the facility on [DATE]. No further information and/or documetnation was presented prior to the exit conference on 03/23/21 at 3:30 PM. This is a complaint deficiency.

Based on staff interview and clinical record review, the facility staff failed to ensure documentation regarding transfer was in the clinical record for one of 14 residents, Resident #45. Resident #45 was transferred to another skilled nursing facility; there was no documentation in the clinical record regarding coordination of care and service needs of the resident prior to her discharge. Findings were: Resident #45 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 01/15/2021, assessed Resident #45 as having problems with both long and short term memory, as well as moderately impaired with daily decision making skills. The clinical record was reviewed on 03/22/2021 beginning at approximately 2:15 p.m. The progress note section on 02/12/2021, the following note was written: 15:33 (3:33 p.m.) Resident transferred to (Name of facility and Location). There was no documentation of any coordination with the receiving facility regarding the resident's needs, nor was there any documentation showing the basis for the transfer. The ADON (assistant director of nursing) was interviewed at approximately 3:30 p.m. She stated, She was the only COVID resident we had left in the facility. (Name of Facility) still had a COVID unit so we transferred her there .we asked the resident and her son and they agreed. The ADON was asked if any of that information was documented anywhere. She stated, I'm not sure .one of our social workers was working remotely. Let me see what I can find. The ADON reported back at approximately 3:45 p.m. She stated, It looks like (name of the administrator) talked to the son . I have a Notice of Transfer or Discharge form that he filled out .it is checked that the transfer or discharge is necessary to meet the resident's welfare and the resident's needs could not be met in the facility .we transferred her down there but we expected her to come back .our policy is that if a resident is COVID positive they have to stay in isolation until they have two COVID tests that are negative .she had one that was negative, we transferred her down there until she could get the second negative and then we expected her to come back, but the family decided to keep her down there. An end of the day meeting was held with the DON (director of nursing), the ADON, the administrator and the Nurse Consultant on 03/22/2021 at approximately 4:00 p.m. The above information was discussed. They were asked how the receiving facility knew what to do with the resident regarding her care .The nurse consultant stated, That is our sister facility .they have access to her records here .the whole record can be accessed from there .we've never done any kind of documentation for a transfer to them .we sent her there because she was still testing COVID positive .I know the CDC says isolation for 14 days and you don't need to retest, but our policy is more stringent .we isolate for 14 days and then require two negative COVID tests before a resident comes out of isolation .The social worker was out with COVID so (name of the administrator) discussed the transfer by phone with the resident's son. The DON stated, We were planning on getting her back, she was just transferred there because of COVID .we had to discharge her, and then when she came back we would do a new admission. At 4:55 p.m. the ADON called and stated, We don't have a discharge summary, or a transfer summary, and I don't see any discharge planning .what we have is the notice of transfer/discharge .I'll get you a copy. The Notice of Transfer or Discharge was received and reviewed. The form was completed by the administrator on 02/12/2021 and contained the following: Resident's name, date of notice (02/12/2021), transfer/discharge date (02/12/2021), the name/location of the facility receiving the resident, the reason for transfer. The transfer or discharge is necessary to meet the resident's welfare and the resident's needs could not be met in the facility, and the following statement was written at the bottom of the form: Spoke with residents RP (responsible party) (Name) for transfer to (name of facility/location) for COVID recovery. Son is in agreement with the transfer with return to the (name of facility) when recovery is complete. No further information was obtained prior to the exit conference on 03/23/2021.

Based on observation, staff interview and facility document review, the facility staff failed to ensure drugs and biologicals were stored properly in the facility's medication room. The facility failed to ensure an expired multi dose vial of influenza and a multi dose via of [MEDICATION NAME] were not available for administration; and failed to ensure a 30 ml bottle of [MEDICATION NAME] concentrate belonging to a deceased resident, was not available for administration. Findings include: On [DATE] at 8:00 AM, the facility's medication room was observed with RN (Registered Nurse) #4. In the refrigerator was an opened multi dose vial of influenza, with an open date on the bottle and the box of [DATE]. A multi dose vial of opened TB ([MEDICATION NAME]) was labeled with an open date of [DATE]. The vial box was also labeled with the same date. A 30 ml bottle of [MEDICATION NAME] concentrate was in the locked compartment of the refrigerator, the bottle had not been opened. The [MEDICATION NAME] had a fill date of [DATE]. RN #4 was asked if this resident was a current resident. RN #4 stated that she thought this resident had expired. RN #4 was asked why this medication was not returned to the pharmacy. RN #4 stated that she was not sure. Further review revealed that the [MEDICATION NAME] concentrate belonged to a resident that expired on [DATE], the same date that the medication was filled. A policy was presented on drug storage by the ADON (assistant director of nursing) on [DATE] at 8:30 AM. The policy documented, facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer .are stored separate .until destroyed or returned to the pharmacy .staff record the calculated expiration date based on date opened .if a multi dose vial of an injectable has been opened or accessed .the vial should be dated and discarded within 28 days .facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider . The administrator, ADON and DON (director of nursing) were made aware of the above on [DATE] at 11:30 AM, in a meeting with the survey team. No further information and/or documentation was provided prior to the exit conference on [DATE] at 3:30 PM.

Based on clinical record review, staff interview, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure care and treatment services for the prevention of multiple pressure ulcers for one of two residents in the survey sample, (Resident #1)y, resulting in harm. Resident #1 was admitted to the facility on [DATE] without any pressure related skin issues. On [DATE], the resident had a significant change of condition and was taken to a local hospital emergently for life saving measures. Upon arrival to the hospital emergency department, the resident was found with multiple pressure related areas, which included: one, stage 1 pressure ulcer on the right heel; one, stage III pressure ulcer to the sacrum; a large stage II-III on the right buttock; and two, stage II pressure ulcers on the resident's back. Findings include: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed Resident #1 with a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as requiring extensive to total assistance from at least two staff members for all ADL's (activities of daily living), including transfers, toileting, and hygiene. The resident was assessed as requiring extensive assistance from one staff person for eating. The resident was totally dependent upon staff for bathing. The resident was coded as not ambulating at all during the look back period. This MDS assessed Resident #1 with no pressure related areas or any other skin related issues or concerns. The resident's clinical records were reviewed. A nursing admission assessment dated [DATE] and timed 2:19 PM, assessed Resident #1 in the skin section as having a scratch on the upper-mid back (vertebrae). There were no other skin concerns identified for Resident #1. There was no other information found regarding the identified scratch. The NP (nurse practitioner) documented on [DATE], .[MEDICAL CONDITION] .weakness .has difficulty weight bearing due to painful knees .Diabetes type 2 .patient is awake .no acute distress .SKIN: Inspection: No rashes or ulcers .general weakness .patient needs skilled nursing facility care at this time secondary to .DM (diabetes mellitus) .weakness. As a consequence, the patient has incurred a significant decline in the ability to perform activities of daily living and functional mobility .requires 24 hour per day rehabilitation nursing to address .bowel and bladder .labs, skin integrity, nutrition . All of the resident's Skilled Care Daily Documentation assessments were reviewed from from admission through [DATE], specifically [DATE] through [DATE]. The skilled care daily assessment documentation forms include a check off section (Section G. Skin) that specifically asked, .General Condition of Skin: 1. intact, dry, warm, clammy, cyanotic, pale, jaundiced .2. Alterations in skin integrity: surgical wound, pressure ulcer, stasis/vascular ulcer, skin tear, laceration/abrasion .3. Other skin condition: (free text area) .4. Pressure reducing device bed, chair .skilled note (Section K.- the skilled note section was a place to enter a narrative note). A Skilled Care Daily Documentation assessment dated [DATE] and timed 10:21 AM documented in section G. that Resident #1s skin was warm and in the other skin condition section, it was documented, open area to sacral crease and bed was checked for the pressure reducing device. The narrative section documented, .continues to be skilled, alert to self .extensive assist with ADLs, incontinent of BB (bowel/bladder). Treatments to sacral crease as ordered . No other Skilled Care Daily Documentation assessments identified any type of skin issues or concerns for Resident #1. Resident #1's physician's orders [REDACTED]. Resident #1's TARs (treatment administration records) were reviewed for the month of [DATE]. The TAR documented that the above treatment was checked off as completed for [DATE]th, 15th, 17th, and 19th. (The resident was sent to the hospital on [DATE]th, 2020 where according to Resident #1's hospital records, the resident was found with multiple, pressure wounds; the resident expired a short time later.) A skin assessment dated [DATE] (created on [DATE]) documented that Resident #1 had no new skin issues and the resident's general skin condition was moist and dry. A skin assessment dated [DATE] (created on [DATE]) documented that Resident #1 had no new skin issues and the resident's general skin condition was warm and dry. A skin assessment dated [DATE] (one day before the resident was transferred to ER) (created on [DATE] - 13 days after the resident expired) documented that the resident had a stage II pressure ulcer on the gluteal fold (the crease separating the buttocks from the thigh) and measured 3 cm (centimeters) long by 3 cm wide by 0.4 cm deep. There was no additional detailed assessment information regarding this wound to determine the location or wound characteristics. There were no physician's treatment orders found for a gluteal fold wound as documented above. On [DATE] at approximately 1:25 PM, the ADON and the Area Operation Manager were informed of allegations of the complaint regarding Resident #1's skin condition upon arrival to the hospital on [DATE]. The ADON stated that the resident only had some shearing when she went out to hospital on [DATE]. The ADON stated that they do not use any type of wound documentation forms and that resident skin assessments are usually for skin issues, but not wounds. The ADON stated that they will write a nursing note in the resident's clinical record for wounds and further stated that they just started putting in wound measurements. The ADON stated that she will use a notebook/tablet that she will keep wound measurements and that is for her use, and not part of the clinical records. The ADON was asked to present any and all information and documentation regarding Resident #1's skin and wound problems/issues/concerns. The notebook/tablet that the ADON referenced above was not presented. No additional information or documentation regarding Resident #1's skin or wounds was presented. All of Resident #1's progress notes within the clinical record were reviewed from admission ([DATE]) through discharge ([DATE]). A late entry nursing note created on [DATE] 11:30 AM (13 days after the resident expired) with an effective date of [DATE] 11:29 AM documented, .called to room to look at open area to intergluteal cleft (the groove between the buttocks/sacrum area) on resident. Wound bed was pink, no odor, minimal drainage .MD (medical doctor) notified of open area. A late entry nursing note created on [DATE] 1:59 PM (13 days after the resident expired) with an effective date of [DATE] 1:58 PM documented, new orders for [MEDICATION NAME] dressing to gluteal cleft. RP (responsible party) aware. A late entry nursing note created on [DATE] 5:23 PM (4 days after the resident expired) with an effective date of [DATE] 5:19 PM (one day after resident expired) documented, .Intergluteal fold .Stage II present with wound bed beefy red, granulation tissue present, maceration noted to wound edges, no odor or drainage noted .[MEDICATION NAME] continues, RP/MD .aware .slight change noted from last week .signature ADON. There was no specific documentation to evidence the progression of this wound based on the documentation presented. The wound documentation for Resident #1 was found with discrepancies, as well multiple late entries. The skin assessment dated [DATE] (created on [DATE], 13 days after the resident expired) documented a wound on the gluteal fold, the area where the lower buttock meets the upper thigh (no indication of location, right or left) the only wound evidenced with measurements. The resident's complete POS (physician's orders [REDACTED]. Resident #1 had an order for [REDACTED]. No order was found for a wound to the gluteal fold, as described above dated [DATE]. There were no physician progress notes [REDACTED].#1's skin condition, or degree of severity. A physician's progress note dated [DATE] documented, .Skin/Breast: No rashes or skin breakdown .Skin: See nursing assessment for detailed skin exam. No physician or NP documentation was found regarding any pressure ulcers for Resident #1. Hospital records for Resident #1 were obtained for the date of [DATE]. The ER Patient Progress Notes from the hospital documented, .unresponsive in [MEDICAL CONDITION] .Assessment: pt (patient) arrived from (name of LTC facility) unresponsive and in [MEDICAL CONDITION] .pt was then cleaned and found to have very large, foul smelling stage III on sacrum with two, stage II decub on back as well .signed by hospital RN. The emergency room note documented, Time of initial provider contact: upon arrival .CHIEF COMPLAINT: Active code XXX[AGE] year old who presents tonight in active CODE STATUS. Nursing home staff toned (sic) for EMS (emergency medical services) due to high blood glucose and right sided pneumonia. EMS arrived at 2016 (8:16 PM) and witnessed patient becoming unresponsive. CPR (cardiopulmonary resuscitation) was started and the patient was brought to ER (emergency room ) .EXTREMITIES: Stage I decubitus ulcer right heel; large stage II-III decubitus ulcer on right buttock; there are 2 stage II decubitus ulcers on the mid back .[MEDICAL CONDITION] (greater than 900 mg/dl) .situation was very dire . Time of death was called at 2251 (10:52 PM) .signed by physician. The resident's CCP (comprehensive care plan) was reviewed from admission ([DATE] through [DATE]) through discharge. The CCP documented, .requires assistance with ADL's .functional limitations in ROM (range of motion) to the bilateral upper and lower extremities .hoyer lift only for transfers X 2 staff .provide assistance with feeding as needed .Provide extensive to total assistance with bed mobility and/or repositioning in the bed and chair as needed .requires two person assistance for bed mobility .resident is incontinent .related to impaired mobility .check and change frequently .provide extensive assistance with toileting .provide pericare as needed .apply barrier cream as needed .Risk for pressure ulcers related to incontinence, limitations in mobility or movement .will maintain skin integrity .incontinence care as promptly as possible to keep the resident clean .pressure reducing mattress .turn and reposition frequently . The resident's CCP did not evidence that the resident had any current skin issues or treatment interventions for pressure ulcers. On [DATE] at 3:00 PM via phone, the ADON was made aware of concerns regarding Resident #1's multiple pressure ulcers, found upon arrival to the hospital on [DATE] and the lack of skin/wound assessment information, as well as extended delay in documenting late entries regarding wound information, along with discrepancies in documentation. The ADON stated that she had looked at Resident #1 two days prior to the resident leaving for the hospital ([DATE]) and stated that she couldn't imagine the pressure ulcer getting that bad that quick. On [DATE] the administrator was asked for a policy on pressure ulcers. The policy documented, .A weekly assessment should be done on all wounds requiring treatment. This should include measurement and a description. Preferably, this will be done on an assessment sheet and placed near the nurses notes on the chart so nurses will be aware of the progress .There must be a specific order for treatment .Documentation of the treatment should be done immediately after the treatment .the care plan should reflect the current status of the wound and appropriate goals . On [DATE] at 1:00 PM, the NP was interviewed via phone. The NP was made aware of the complaint allegations regarding Resident #1's skin. The NP stated that she did not recall Resident #1 having any type of wounds. On [DATE] at 3:00 PM, RN #1 (also the MDS coordinator) was interviewed regarding Resident #1. RN #1 was made aware that Resident #1 did have a CCP (comprehensive care plan) for pressure ulcers, but there was no information in the CCP to evidence the resident actually had a pressure ulcer or any skin related concerns. RN #1 stated that the CCP would be updated on a quarterly basis or when an MDS assessment was completed. RN #1 stated that she did not recall Resident #1 having any pressure or skin problems. RN #1 stated that the way she would find out would be in morning meetings they would discuss any issues, and either she or the ADON would update the care plan accordingly. RN #1 further stated that a book/binder was kept in the ADON's office that had a sheet (Pressure Injury Management Record) for resident's with pressure ulcers. RN #1 stated these sheets were very detailed and had an area for acquired/not acquired, measurements, stage, treatment in place, color, etc. RN #1 stated that would only be filled out if the resident had a pressure ulcer. RN #1 stated that information should be kept in the resident's clinical record and would be uploaded into the computer. RN #1 stated that these were completed on a weekly basis. RN #1 was made aware that were none of these documents found in Resident #1's closed clinical records or in the EMR (electronic medical records). RN #1 again stated that she did not recall Resident #1 having any skin problems or concerns. No further information or documetnation was presented prior to the exit conference to evidence that facility staff provided Resident #1 with appropriate care and treatment services for the prevention and development of pressure ulcers, that resulted in actual harm for Resident #1. This is a complaint deficiency.

Based on clinical record review, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to provide care and treatment services for diabetes management, and failed to follow a physician's order upon admission for daily weights for [MEDICAL CONDITIONS] management for one of two residents, Resident #1. (1) Resident #1 was identified as a diabetic upon admission, standing orders for diabetes was ordered, but were not initiated. (2) Resident #1 had an order for [REDACTED].>Findings include: (1) Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. Resident #1's hospital discharge summary (prior to admission to the facility) dated [DATE] was reviewed. The discharge summary identified Resident #1 as diabetic and documented the resident had been receiving sliding scale insulin, as well as, receiving glucose checks four times daily during the resident's hospital stay from [DATE] through discharge [DATE]. Resident #1's facility admission orders [REDACTED]. The resident's initial (Baseline) admission care plan was reviewed and documented, (Name of Resident #1) .admitted : [DATE] .regular diet RCS (reduced concentrated sweets) .Medications .Insulin .Blood glucose checks: QID (four times daily) . Resident #1's medication list was reviewed and revealed that the resident was on two different oral diabetic medications, [MEDICATION NAME] 5 mg/milligrams daily and [MEDICATION NAME] 100 mg daily, when admitted to the facility. Resident #1's MARs (medication administration records) were reviewed for July and [DATE]. There was no physician's order or any information for insulin and/or blood glucose checks found on the resident's MARs. The resident's comprehensive care plan was then reviewed. There was no information regarding Resident #1 having diabetes, no information regarding the resident's oral diabetic agents, no information regarding hypo/[MEDICAL CONDITION], and no information regarding any type of interventions for the care and maintenance of Resident #1's diabetes. At 12:30 PM on [DATE], the ADON (assistant director of nursing) and AOM (area operation manager) were made aware that Resident #1's initial care plan had documented for this resident to have glucose checks four times a day. The ADON stated that they did not have orders from the hospital for glucose checks. The ADON was asked to see all of the resident's admission orders [REDACTED]. The ADON stated that they do have standing orders and they are initiated upon admission for each resident. The ADON was asked for a copy of Resident #1's physician and standing orders. The ADON was then made aware that the resident's baseline care plan information regarding blood glucose checks had not been carried over to the comprehensive care plan, and that there was no information on the comprehensive care plan for diabetes at all. The ADON stated, There's nothing on there about diabetes? The ADON stated that she would look for that information. The ADON was made aware of concerns that the initial care plan documented for Resident #1 to have glucose checks four times a day that they were not done, and the information was not carried over to the comprehensive care plan. On [DATE] at approximately 1:40 PM, the ADON presented the standing orders for Resident #1. The standing orders documented, .ROUTINE STANDING ORDERS .Resident: (Name of Resident #1) .Room: (room number of Resident #1) .admitted : [DATE] (Resident #1's admitted ) .Initiate orders as appropriate for the resident: .Diabetic .LAB TESTS .fasting blood sugar (ACHS) .as ordered .Sliding Scale For Novo log SQ (subcutaneous) based on finger stick blood sugar .Give 0 units if BS (blood sugar) less than 200, Give 4 units if BS ,[DATE], Give 6 units if BS ,[DATE], Give 8 units if BS ,[DATE], Give 10 units if BS ,[DATE], Give 12 units if BS ,[DATE], Give 15 units if BS ,[DATE], Call physician if BS greater than 500 .[DIAGNOSES REDACTED] .less than 50 .notify MD .[MEDICAL CONDITION] .greater than 500 unless parameters have been set, notify MD . Further review of the resident's clinical record revealed an order for [REDACTED]. On [DATE] at approximately 9:30 AM, the administrator and interim DON (director of nursing) were asked for policies and procedures related to care and maintenance for diabetic residents. On [DATE] at 10:00 AM, LPN (Licensed Practical Nurse) #2 was interviewed. LPN #2 was asked about Resident #1's initial care plan that documented blood glucose checks four times a day. LPN #2 stated that initial care plans are done upon admission and will have care orders for the resident. LPN #2 stated that when a resident is admitted and they are a diabetic, and admitted on any oral agent, the resident will have blood sugars checked QID (four times daily). LPN #2 stated that they will do QID blood sugar checks for 7 days and if stable the physician will discontinue. LPN #2 then stated, then we do a hemoglobin A1C. LPN #2 looked at Resident #1's initial care plan and stated, Was she on insulin? LPN #2 was made aware that Resident #1 was on two oral diabetic agents. Resident #1 did receive insulin at the hospital prior to admission and was on blood glucose checks QID at the hospital, as well. LPN #2 stated, We don't put anything into play that was in effect at the hospital. LPN #2 was then asked where do blood glucose orders/treatments come from. LPN #2 stated, It's on the standing orders. LPN #2 looked at the copy of Resident #1's Standing Orders and pointed to the diabetic section. LPN #2 stated, We automatically do QID, that's the frequency that it's ordered. LPN #2 was asked where the orders were that indicate QID, on the physician's order set or on the standing orders. LPN #2 stated, That's what we do for new admissions, it may or may not be on the orders .we use the standing orders and the frequency is QID for 7 days, if a resident is stable for 7 days (after the QID blood glucose checks) the order falls off, if the resident isn't stable for 7 days then the physician will look at them and put them back at a specified ordered frequency. LPN #2 stated that it may be once a day or twice a day. LPN #2 was asked to look for the order. LPN #2 looked at Resident #1's clinical record while being interviewed, and stated that she did not see the specific order, but that there were standing orders. LPN #2 stated, Here I'll show you. LPN #2 picked a resident that she admitted a few weeks prior with diabetes, showed the standing orders and showed the glucose checks QID and showed the how the order should have been put in and how the order dropped off. LPN #2 stated that she was the admitting nurse for Resident #1 and that they will share admissions and help each other out with putting in orders or whatever needs to be done to help out. LPN #2 stated that she started the initial care plan and she did write in the QID glucose checks, as that was what Resident #1 should have received. LPN #2 was made aware that the resident did not have any blood glucose checks at all during her stay at the facility ([DATE] admission through [DATE] discharge), until labs were drawn on the very day she was transferred to the local hospital on ([DATE]). LPN #2 stated, I see that (no blood sugars were done). LPN #2 then stated, I can't tell you why there are no blood sugars on her, she didn't come with an order from the hospital to continue them. LPN #2 was asked about her statements earlier in the interview regarding the standing orders that were entered for this resident to initiate orders (including blood glucose checks) as appropriate for the resident and that she (LPN #2) had stated that was automatic for blood glucose checks to be done QID for 7 days for any resident admitted on oral diabetic medications. LPN #2 stated, When the orders get put in, someone is supposed to go back and check to make sure .we have 24 hours to complete the admission, put in meds .and then someone will go back to check . LPN #2 was asked if blood glucose checks should have been completed/entered for Resident #1. LPN #2 stated, In my opinion, yes ma'am they should have been put in. LPN #2 then stated, I don't think anyone did anything negligent, I think it just got overlooked. LPN #2 stated that on that day ([DATE]), the resident was real sleepy and was a little crackle (lung sounds), LPN #2 stated that Resident #1 did not eat any lunch that day and that is when the orders were obtained have the chest X-ray done. LPN #2 stated the labs were ordered later that day and were drawn at the facility before she left work that day and she hand delivered the labs to the local hospital for result processing at the end of her shift. According to clinical records the labs were collected at 5:50 PM on [DATE] and the results were called back to the facility at 7:50 PM on [DATE]. The lab results revealed a blood glucose level of 917 HC (High Critical) (blood glucose range: ,[DATE] mg/dl milligrams/deciliter) .BUN (blood urea nitrogen) 131 HC (range: ,[DATE] mg/dl) .Creatinine 5.46 HC (range: 0XXX,[DATE].02 mg/dl). The chest X-ray had been completed earlier documented as complete at 12:33 PM [DATE] and reported results back to facility at 6:45 PM on [DATE]. The results of the chest X-ray showed a moderate right lower infiltrate. The resident was transferred emergently to the hospital at approximately 8:15 PM according the nursing notes on [DATE]. A policy was presented for Hyper/[DIAGNOSES REDACTED] that documented, [MEDICAL CONDITION] Definition: Diabetic Coma (also known as [MEDICAL CONDITION]) is a condition that occurs in diabetic residents when they do not receive enough insulin to metabolize carbohydrates, when there is increased stress, or infection. The onset is gradual. Signs and Symptoms: Should you observe a diabetic resident, or should a diabetic resident complain of any of the following symptoms, report it to your staff/charge nurse IMMEDIATELY: .Breathing difficulties .sweet or fruity breath .flushed skin .loss of appetite .nausea and/or vomiting .thirst and dry tongue .dry skin .increased urination .senses are dulled .complains of aches .loss of consciousness .should any of these conditions exist .blood sample should be obtained to determine the blood glucose level .elevations in blood glucose should be reported to the charge nurse and physician, if indicated. Administer insulin sliding scale coverage as ordered .for readings that exceed the maximum coverage, administer the maximum insulin .immediately notify physician .blood glucose levels should be repeated frequently, until they normalize .[DIAGNOSES REDACTED] Definition: Insulin Shock (also known as [DIAGNOSES REDACTED]) is a condition that occurs in diabetic residents when they receive too much insulin, miss a meal, or when they have too much physical activity. The onset is sudden. Signs and Symptoms: Should you observe a diabetic resident, or should a diabetic resident complain of any of the following symptoms, report it to your staff/charge nurse IMMEDIATELY: .sweating .weakness, dizziness or faintness .hunger .not able to wake up .appears in a coma, unconscious, or partially unconscious . On [DATE] at 12:25 PM, Resident #1's physician was interviewed. The physician stated that he was aware Resident #1 was a diabetic and that the NP (nurse practitioner) usually will see the resident first and take care of initial orders. The physician stated that the facility follows accucheck (blood glucose checks) orders and that those are typically from the standing orders. The physician was made aware of Resident #1's blood sugar level of 917 on the day of transfer and concerns regarding the facility not obtaining any blood glucose checks at all during her stay at the facility. The physician stated that it is very unusual for someone to have a blood sugar of over 900 and that he had actually seen Resident #1 on the 18th (2 days prior to transfer) and stated that the resident looked fine, appeared to answer questions appropriately, and didn't see anything that would indicate concerns at that time. The physician then stated, that .had we done accuchecks initially .there is no question that if we had .obviously ,[DATE] definitely would have (been alerted to a change) .it was probably just missed . The physician stated that he was shocked that Resident #1 died and that he did not see any indication that would happen two days after he saw the resident. On [DATE] at 1:00 PM, the NP was interviewed. The NP stated that if a resident is not on insulin, an A1C will be done, and usually accuchecks are done. The NP stated that if a resident is diabetic the nurses will put accuchecks in so we will have something to work with. The NP stated, They automatically put that (accuchecks) in, that's just a standard of practice. The NP stated, I don't go in and manually put in blood sugars, they (nurses) do that .it's automatic. The NP stated, It's a given that they automatically check them (blood sugars). The NP stated in response to the resident's 917 blood sugar, I bet she was septic .but I don't know that for sure . On [DATE] at 3:00 PM, RN (Registered Nurse) #1, who was also the MDS coordinator at that time, was interviewed. RN #1 stated that when a resident is admitted , an initial care plan is done on paper by the admitting nurse. RN #1 stated that after the initial care plan is created, it is then put in her box or the Social Worker's box on the day of admission, and that information is referenced for the development of the comprehensive care plan. RN #1 was asked about Resident #1's initial care plan regarding diabetes and QID glucose checks. RN #1 stated, If she (Resident #1) took insulin or took any kind of PO (by mouth) medication for diabetes, then it should have been on her CCP. RN #1 further stated that she isn't perfect and does miss things. RN #1 stated at that time (Resident #1's admission), back in the summer with COVID going on that staff were calling off, we were all over the place and that she and the ADON were doing their jobs and also working the floor. RN #1 stated that diabetes has its own care plan heading and it all fits under that. RN #1 stated that if someone is a diabetic, they should have a diabetic care plan that includes treatments, and interventions. On [DATE] at 9:00 AM, the physician was again interviewed. The physician was made aware that Resident #1's standing orders were found in the orders section and listed diabetic orders, but were not initiated by nursing staff for Resident #1, although they were ordered. The physician stated that his NP is very thorough and on top of things and he did not feel that the NP would have missed those orders. The physician again stated, that when he saw Resident #1 he had no reason to suspect any impending [MEDICAL CONDITION] or major changes. The physician stated that when Resident #1 was seen by him for admission on [DATE], he had looked at the A1C (from admission) and blood sugars from the last few days at the hospital (prior to [DATE]), Resident #1 was on two oral diabetic medications and he didn't see any problems when he saw her on the 18th. No further information and/or documentation was presented prior to the exit conference on [DATE]. This is a complaint deficiency. (2) Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #1 was receiving the following medications upon admission, [MEDICATION NAME] (diuretic) 40 mg (milligrams) daily, [MEDICATION NAME] (potassium sparing diuretic) 25 mg daily and Mybetriq (prevents urgent, frequent, or uncontrolled urination) 25 mg daily. A hospital discharge instruction form, dated [DATE] documented, .skilled nursing home .Instructions/Notify physician: If symptoms continue or become worse; Weight gain of 3 pounds, in a day or 5 pounds in a week .Notify Physician Resident #1's admission physician's orders were then reviewed. an order for [REDACTED]. The resident's comprehensive care plan was reviewed and documented, .risk for cardiac complications related to .[MEDICAL CONDITION] .administer medications as ordered .labs as ordered .observe for s/s (signs/symptoms) of cardiac complications and notify MD as indicated .vital signs as needed . Resident #1's care conference documentation dated [DATE] documented, .Unspecified Systolic heart failure . On [DATE] at approximately 1:00 PM, the ADON (assistant director of nursing) was interviewed regarding weights. The ADON was asked how often resident's were weighed upon admission. The ADON stated that resident's will be weighed on admission and then monthly if there are no specific orders for weights from the physician. On [DATE] at 10:00 AM, LPN #2 was interviewed regarding weights. LPN #2 stated, Weights are usually done on admission and the next day and then may do a third day, then after that it's monthly. LPN #2 was asked about weighing residents in the bed or lift scales. LPN #2 stated that they don't have beds that weigh or have lifts with scales. LPN #2 was asked about the above order, and LPN #2 stated that was discharge instructions, and was not an order. The resident's weight records were then reviewed. The following weights were documented as entered manually. [DATE] 16:04 156.0 mechanical lift entered by RN #3 [DATE] 16:04 156.0 mechanical lift entered by RN #3 [DATE] 15:16 156.0 mechanical lift entered by RN #3 [DATE] 11:02 154.0 mechanical lift entered by RN #3 [DATE] 11:03 156.0 mechanical lift entered by RN #3 On [DATE] at 1:00 PM, the NP (nurse practitioner) was interviewed regarding Resident #1. The NP was made aware of the discharge instructions from the hospital regarding the above order. The NP stated, They didn't put that in as an order? The NP stated, That's an order. The NP was made aware that it was not put in as an order on admission and there was no information in the resident's comprehensive care plan regarding this. The NP was asked how would anyone know if a resident had a 3 pound weight gain in a day or a 5 pound weight gain in a week, if the resident wasn't being weight daily. The NP stated, You wouldn't. The NP stated that was an order and should have been entered upon admission. The NP stated that nursing enters order for [MEDICAL CONDITION] patients for daily weights, just like a diabetic would get accuchecks. No further information and/or documentation was presented prior to the exit conference to evidence that facility staff followed an admission order for Resident #1 regarding [MEDICAL CONDITION] care and maintenance.

Based on clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to review and revise a CCP (comprehensive care plan) in the area of pressure ulcers for one of two residents in the survey sample, Resident #1. Findings include: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as requiring extensive to total assistance from at least two staff members for all ADL's (activities of daily living), including transfers, toileting, and hygiene. The resident was totally dependent upon staff for bathing. The resident was coded as not ambulating at all during the look back period. Resident #1's clinical records were reviewed. A nursing admission assessment dated [DATE] and timed 2:19 PM, assessed the resident's skin, under the skin section as having a scratch on the upper-mid back (vertebrae). There was no other assessment information related to this scratch. No other skin issues or concerns were identified on this assessment for the resident's back, buttocks, or heels. A Skilled Care Daily Documentation assessment dated [DATE] and timed 10:21 AM, documented for Resident #1 in section G. that the resident's skin was warm and in the other skin condition section, it was documented, open area to sacral crease and 'bed' was marked for the pressure reducing device. The narrative section of this assessment documented, .continues to be skilled, alert to self .extensive assist with ADLs, incontinent of BB (bowel/bladder). Treatments to sacral crease as ordered . The resident's physician's orders [REDACTED]. A skin assessment dated [DATE] (one day before the resident was transferred to ER) (created on [DATE] - 13 days after the resident expired) documented that the resident had a stage II pressure ulcer on the gluteal fold (the crease separating the buttocks from the thigh) and measured 3 cm (centimeters) long by 3 cm wide by 0.4 cm deep. There was no additional assessment information regarding this wound to determine the location or other wound characteristics. All of Resident #1's progress notes within the clinical record were reviewed from admission ([DATE]) through discharge ([DATE]). A late entry nursing note created on [DATE] 11:30 AM (13 days after the resident expired) with an effective date of [DATE] 11:29 AM documented, .called to room to look at open area to intergluteal cleft (the groove between the buttocks/sacrum area) on resident. Wound bed was pink, no odor, minimal drainage .MD (medical doctor) notified of open area. A late entry nursing note created on [DATE] 1:59 PM (13 days after the resident expired) with an effective date of [DATE] 1:58 PM documented, new orders for [MEDICATION NAME] dressing to gluteal cleft. RP (responsible party) aware. A late entry nursing note created on [DATE] 5:23 PM (4 days after the resident expired) with an effective date of [DATE] 5:19 PM (one day after resident expired at hospital) documented, .Intergluteal fold .Stage II present with wound bed beefy red, granulation tissue present, maceration noted to wound edges, no odor or drainage noted .[MEDICATION NAME] continues, RP/MD .aware .slight change noted from last week .signature ADON. The resident's CCP (comprehensive care plan) was reviewed from admission ([DATE] through [DATE]) through discharge. The CCP documented, .Risk for Pressure Ulcers related to incontinence, limitations in mobility or movement .incontinence care as promptly as possible to keep resident clean .pressure reducing mattress .RD (Registered Dietitian) consult as needed .risk assessment as needed .turn and reposition frequently as needed .skilled therapy referral as needed for positioning . On [DATE] at 3:00 PM, RN (Registered Nurse) #1, who was also the MDS coordinator at that time was interviewed. RN #1 was made aware that according to facility documentation, Resident #1 developed a pressure ulcer while a resident at the facility, but there was no CCP (comprehensive care plan) updates for any pressure ulcer areas for this resident. RN #1 stated that the CCP is usually updated on a quarterly basis with the MDS assessment. RN #1 stated that she did not recall Resident #1 having any pressure ulcers or skin problems and therefore, would not have made any updates to her care plan. RN #1 stated the way she would find out information regarding pressure ulcers for residents, would be in morning meetings they would have and discuss any skin issues or other issues happening with residents and either she, the ADON (assistant director of nursing), or the corporate nurse would update the care plan accordingly at that time for the concerns discussed and identified. RN #1 stated if Resident #1 had a pressure ulcer or skin condition it should have been on the CCP. RN #1 stated that the treatment information related to skin or pressure ulcers would also be listed on the resident's CCP as an update. RN #1 was made aware that Resident #1 had no updates on the CCP related to pressure ulcers or skin conditions. RN #1 again stated that she did not recall Resident #1 having any skin problems or concerns. No further information and/or documetnation was presented prior to the exit conference to evidence that facility staff reviewed and revised Resident #1's CCP in the area of pressure ulcers. This is a complaint deficiency.

Based on clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to develop a CCP (comprehensive care plan) in the area of diabetes for one of two residents in the survey sample, Resident #1. Findings include: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 8, indicating the resident had moderate impairment in daily decision making skills. Resident #1's hospital discharge summary (prior to admission to the facility) dated 07/29/20 was reviewed. The discharge summary identified Resident #1 as diabetic and documented the resident had been receiving sliding scale insulin, as well as, receiving glucose checks four times daily during the resident's hospital stay from 07/23/20 through discharge 07/29/20. On 11/23/20 at approximately 1:40 PM, standing orders for Resident #1 were reviewed. The standing orders documented, .ROUTINE STANDING ORDERS .Resident: (Name of Resident #1) .Room: (room number of Resident #1) .admitted : 07/29/20 (Resident #1's admitted ) .Initiate orders as appropriate for the resident: .Diabetic .LAB TESTS .fasting blood sugar (ACHS) .as ordered .Sliding Scale For Novo log SQ (subcutaneous) based on finger stick blood sugar .Give 0 units if BS (blood sugar) less than 200, Give 4 units if BS 200-250, Give 6 units if BS 251-300, Give 8 units if BS 301-350, Give 10 units if BS 351-400, Give 12 units if BS 401-450, Give 15 units if BS 451-500, Call physician if BS greater than 500 .[DIAGNOSES REDACTED] .less than 50 .notify MD .[MEDICAL CONDITION] .greater than 500 unless parameters have been set, notify MD . Resident #1's initial care plan was reviewed and documented, .regular diet RCS (reduced concentrated sweets) .Medications .Insulin .Blood glucose checks: QID (four times daily) . Resident #1's medication list was reviewed and revealed that the resident was on two different oral diabetic medications, [MEDICATION NAME] 5 mg/milligrams daily and [MEDICATION NAME] 100 mg daily, when admitted to the facility. Resident #1's comprehensive care plan was then reviewed. There was no information regarding Resident #1 having diabetes, no information regarding the resident's oral diabetic agents, no information regarding hypo/[MEDICAL CONDITION], and no information regarding any type of interventions for the care and maintenance of Resident #1's diabetes. At 12:30 PM, the ADON (assistant director of nursing) and AOM (area operation manager) were made aware of the above information. The ADON stated, there's nothing on there about diabetes? The ADON was made aware that no information was found for Resident #1. On 12/03/20 at 3:00 PM, RN (Registered Nurse) #1, who was also the MDS coordinator at that time was interviewed. RN #1 stated that when a resident is admitted , an initial care plan is done on paper by the admitting nurse. RN #1 stated that after the initial care plan is created, it is then put in her box or the Social Worker's box on the day of admission, and that information is referenced for the development of the comprehensive care plan. RN #1 was asked about Resident #1's initial care plan regarding diabetes and QID glucose checks. RN #1 stated, If she (Resident #1) took insulin or took any kind of PO (by mouth) medication for diabetes, then it should have been on her CCP. RN #1 further stated that she isn't perfect and does miss things. No further information and/or documentation was presented prior to the exit conference to evidence that the facility staff developed and implemented a CCP for Resident #1 in the area of diabetes care and management.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide supervision and ensure safety devices were in working order resulting in injury for one of 16 residents in the survey sample, Resident #12. Resident #12 with a history of falls was left unattended in the dining room. Resident #12 attempted to get up unassisted, his chair alarm did not sound, and he sustained a fall resulting in a fracture. Staff was alerted to the fall by another resident present in the dining room. Findings included: Resident #12 was originally admitted to the facility on [DATE], with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set) was a 5-day assessment with an ARD (assessment reference date) of [DATE]. This resident was assessed as having severe impairment in both his short and long term memory skills, as well as, severe cognitive impairment in daily decision making skills. On [DATE] at approximately 8:30 a.m., the clinical and electronic medical record for Resident #12 was reviewed. During this review a nurse's note dated "[DATE] 10:59," signed by LPN #1 (licensed practical nurse) stated, "At 0700 (7:00 a.m.), off going nurse, (name), reported that res (resident) had a fall in the dining room and his alarm did not sound d/t (due to) not being on. Nurse into assess and noted res lying on his back in the floor..." Further review of progress notes revealed documentation of numerous incidences of this resident falling. These included the following: [DATE] - 7:07 a.m. - Nurse's Note - "Staff responded to chair alarm in dining room, and found resident face down on dining room floor..." This fall resulted in "bruising under both eyes, abrasion to forehead, skin tear to left elbow and abrasion to left lower leg and a bruise to left hip area." [DATE] - 3:28 p.m. - High Risk Meeting - "Resident discussed in High Risk meeting due to a fall on [DATE]..." [DATE] - 7:28 p.m. - Nurse's Note - "...Fall on [DATE] 1630 (4:30 p.m.)..." This fall resulted in "small abrasion to right side mid-back area." [DATE] - 1:20 p.m. - High Risk Meeting - "Resident discussed in high risk meeting due to a fall on [DATE]. Staff responded to bed alarm and noted resident to be sitting on fall eze mats by the bed..." [DATE] - 7:24 p.m. - Nurse's Note - "Alerted by another resident to come into dining room. Resident was found laying on L (left) side in front of wheelchair..." No injuries or pain noted from this fall. [DATE] - 6:11 p.m. - Post Fall Note - "...attempted to get up multiple times following lunch..." [DATE] - 6:39 a.m. - Post Fall Note - "...continues to attempt to get out of bed unassisted not easily re-directed..." [DATE] - 10:59 a.m. - Nurse's Note - "...res had a fall in the dining room and his alarm did not sound d/t not being on. Nurse into assess and noted res lying on his back in the floor..." This fall resulted in "Laceration noted to L side of head measuring 4cm x 3.5cm, ST (skin tear) noted to L pinky near knuckles measuring 1cm x 1.5cm, and ST to L pinky near finger nail measuring 1cm x 0.5cm." Steri strips applied to all three injuries. [DATE] - 3:47 p.m. - High Risk Meeting - "Resident discussed in high risk meeting due to a fall on [DATE]..." [DATE] - 1:08 a.m. - Nurse's Note - "Resident has bruise on right buttocks and right hip. When rolled and hip palpated resident yells out in pain..." [DATE] - 10:49 a.m. - Nurse's Note - "Clarification: Rsd has bruise on L hip/coccyx. Moderate pain noted on movement." [DATE] - 12:14 a.m. - Nurse's Note - "...Received call from (mobile x-ray name) on x-ray to left hip and left buttocks area Results of x-ray were negative no fractures on displacements..." (sic) [DATE] - 2:47 a.m. - Nurse's Note - "...bruising to left buttocks and hip with c/o (complaints of) pain and discomfort when turned or assisted to bed..." [DATE] - 7:08 p.m. - Nurse's Note - "MD (physician) in this shift and made aware that resident was still having pain in L leg. New order for Xray to L femur, L knee, L ankle... (Mobile x-ray name) in this shift to obtain xrays, awaiting results." [DATE] - 3:46 p.m. - High Risk Meeting - "Resident discussed at High Risk meeting due to a fall on [DATE]..." (sic) (Should read [DATE]). [DATE] - 4:34 p.m. - Nurse's Note - "Rsd (resident) care plan meeting today. Discussed Rsd's falls... Rsd has had multiple falls this quarter..." [DATE] - 2:41 p.m. - Nurse's Note - "Resident complained of left hip pain while in shower. Resident has had previous hip xray done few weeks prior with no evidence of fx (fracture) or dislocation. Notified physician new order to repeat left hip xray..." [DATE] - 7:25 p.m. - Nurse's Note - "Xray report obtained from previous shift with results: L femoral neck subcapital fx. (Physician name) notified with new orders obtained to send res to (hospital initials ER (emergency room )... Res left facility around 1500 (3:00 p.m.) via stretcher via ambulance..." Resident #12's care plan was reviewed to include but not limited to the following: Focus: "Falls: ...requires assistance from staff with transfers..." Interventions included "Alarm to bed to alert staff of unassisted transfers/ambulation (initiated [DATE], resolved [DATE])...Bed pad alarm while in bed (initiated [DATE]), ...Chair pad and bed alarm at all times to alert staff of unassisted transfers/ambulation; check functioning status qshfit (sic) and prn; change battery per facility protocol (initiated [DATE], reolved [DATE]), ...Ensure seating in dining room in close to entrance/exit (initiated [DATE]), ...Fall prevention program per facility protocol (initiated [DATE]), ...Non slip footwear (initiated [DATE]), ...Shoes on during transfers. Gait belt use @ all times. 2 person assist for transfers from bed in AM (initiated [DATE]), and Tab monitor while up in chair (initiated [DATE])." Physician orders [REDACTED]. Additional orders dated [DATE] documented "tab monitor while in chair..." and on [DATE], "chair pad alarm to geri chair..." A copy of the fall investigation was received from the DON (director of nursing) and reviewed by this surveyor on [DATE]. Under the section "Problem/areas of concern (detail problem)" was a notation stating, "[DATE] At 0700, off going nurse, (name), reported that res had a fall in the dining room and his alarm did not sound d/t not being on. Nurse into assess and noted res lying on his back in the floor. Moderate amount of blood noted to floor from L (left) side of head and L pinky. No c/o (complaints of) pain. ROM (range of motion) accomplished... Res assisted to w/c (wheelchair) x3 (times three) staff assist... CNA (certified nursing assistant) educated on the importance of bed and chair alarms. Cause: Resident has impaired cognitive function and impaired safety awareness and is unable to ambulate even with assistance. Frequently attempts to get out of wheelchair and ambulate. Resident had a chair pad alarm in place, but did not sound at time of incident. It was determined that the pad was malfunctioning..." A second notation dated "[DATE] 15:47 (3:47 p.m.) High Risk Meeting" stated, "Resident discussed in high risk meeting due to a fall on [DATE]. Nurse was alerted by another resident to come into dining room. Upon entering, resident was found lying on left side in front of wheelchair... Frequently attempts to get out of wheelchair and ambulate. Resident has a chair alarm in place, but did not sound at time of incident..." The DON and Administrator were interviewed on [DATE] at approximately 1:00 p.m. regarding reports of falls on [DATE] and [DATE]. They were asked what the normal procedure for investigation of a fall in the facility included and if the employees involved write a statement about the incident and were interviews of staff completed. The DON stated, "Normally a written statement is obtained from each employee involved." When asked if the ,[DATE] nurse had written a statement regarding the fall on [DATE], the DON stated, "She did not write anything before she left." When surveyor asked to speak to this nurse, the Administrator stated, "(Name) no longer works here." When asked why, the Administrator stated, "She called one day and said she just wasn't coming back." No witness interviews were included in the fall investigations and no written statements had been obtained from any of the other employees involved. The DON was asked to identify the CNA that had been educated regarding alarms on [DATE] for a possible interview by the surveyor. No name was ever given to this surveyor or any member of the survey team. During this interview the DON was asked about the chair pad alarm not being turned on. She stated, "That is not true. I was here. It was on. It was a malfunctioning chair pad alarm and we changed it immediately." When asked how often pads are changed the DON stated, "pads are changed as needed. They have an expiration date, but this pad was not expired. Actually, (name), Central Supply Supervisor figured out the chair pad was not working." The DON was asked how you know if a chair pad alarm needs to be changed and how do they come. She stated, "New pads come with cord attached and you plug it into the box. The box has on/off switch and uses batteries. The box makes a 'funny squeal when low.' There is no light on the box to signal low battery." The DON was asked how she interpreted the statement, "Nurse was alerted by another resident to come into the dining room. Upon entering, resident was found lying on left side in front of wheelchair." Were no staff were present in the dining room when Resident #12 fell ? DON stated, "I would say so." The DON was asked if staff are always in the dining room when residents are in there preparing to eat a meal. DON stated, "Staff are in and out of dining room. Residents go in there to watch tv." At approximately 1:20 p.m. on [DATE], LPN #1 was interviewed regarding Resident #12's fall on [DATE]. LPN #1 stated, "CNA came right after report, maybe during narc (narcotic) count. It was definitely at beginning of shift." The CNA stated, "There is a fall in the dining room. I went to the dining room. Resident #12 (name) was either on side or back in the floor. There was skin tear on his hand somewhere, area on his head, steri strips on that. Assessed ROM and it was WNL (within normal limits). I remember it took several of us to get him back in the chair." LPN #1 was asked when she wrote the computer progress note. She stated, "I wrote it shortly after it happened." LPN #1 was asked to read the following statements and to give her interpretation of each, "[DATE] At 0700, off going nurse, (name), reported that res had a fall in the dining room and his alarm did not sound d/t not being on. Nurse was alerted by another resident to come into dining room. Upon entering, resident was found lying on left side in front of wheelchair." LPN #1 stated, "Makes it sound like his alarm didn't work because it wasn't on, but I actually think it was malfunctioning. I did not find him, it was after report. I was alerted by a staff member, not another resident." When asked if the ,[DATE] nurse found the resident, LPN #1 stated, "I don't remember." LPN #1 was asked what is the usual time residents are brought to the dining room for breakfast and what time breakfast is served. She stated, "Residents are brought to the dining room around 7:00 a.m. Breakfast is served around 7:30 - eightish." When asked if this was normal routine for Resident #12 to be in the dining room that early LPN #1 stated, "yes, several residents go in there and watch tv." At approximately 2:00 p.m., the Central Supply Supervisor (CSS) was interviewed. She stated, "chair pad alarms are good for about 180 days. When opened, you write the date opened on the bottom of the pad and the expiration date of 180 days with a sharpie. The CSS was asked how you know if a pad is going bad, she stated, "They don't alarm as loud or strong as they should. It makes different noises." CSS was asked if she remembered the morning of [DATE] when Resident #12 fell and what time she came to work on that day. She stated, "I came in about 8:30." This surveyor asked if she was asked to look at Resident #12's chair pad alarm, by whom she was asked, and where the alarm was located. CSS stated, "I think (name) DON asked me to look at it. I went to resident's room. He was in bed. The chair pad alarm was in the w/c. I turned the box on, applied pressure with my hand and released it." CSS demonstrated pressing on the chair alarm pad with the heal of her hand. "The pad made a softer sound than normal and maybe had about a two second delay. That told me it was dying and needed a new one. I went and got a new pad and changed it." She stated there was no date written on the pad. At 4:15 p.m. the Administrator was asked to read the x-ray report from [DATE] at 5:26 p.m. and give her interpretation of the report. The report stated, "Left Hip 2V (2 view) History: complains of left hip pain Portable Left Hip: There is a left femoral neck subcapital fracture. The fracture is displaced laterally and superiorly. There is osteoporosis. There is mild degenerative joint disease. Only in retrospect is a fracture also present and minimally impacted on study of [DATE] and now, with interval displacement, more apparent. The joint shows no dislocation. Impression: Left Femoral Neck Subcapital Fracture, As Described Above." The Administrator stated, "I don't have an opinion. It is what it says." This surveyor then asked her if she thought residents with a known fall history with interventions in place should be left in common areas without supervision. The Administrator stated, "I am not going to put them in jail. This is their home. They have the right to sit in the dining room without someone standing guard over them. They can sit where they want, have the right to fall, stay up all night, watch tv, eat popcorn or whatever. This is there home." The Administrator and DON were informed of the above during a meeting with the survey team just prior to the exit conference. No further information was provided to the survey team prior to the exit conference on [DATE].

Based on observation, staff interview, and clinical record review the facility staff failed to maintain acceptable parameters of nutritional status for one of 16 residents, Resident #3. The facility staff failed to identify a resident with high nutritional risk and implement interventions to prevent weight loss. Resident #3 experienced a significant, unplanned weight loss of 11.1 pounds (8%) in 30 days with no interventions or assessment by the facility staff. The facility further failed to implement a liberalized diet or other interventions to prevent weight loss as recommended by the Registered Dietitian (RD) in March and April 2013. Resident #3's food intake declined from 75% in January 2013 to 25-50% in March 2013. Resident #3 continued to lose weight and at the time of survey experienced an overall loss of 11 % in 3.5 months and a decrease in both [MEDICATION NAME] and protein levels (indicating from mild to moderate protein [MEDICAL CONDITION]). Findings include: Resident #3 was originally admitted to the facility on [DATE] with the following diagnoses, but not limited to: acute [DIAGNOSES REDACTED] ulcer, hypertension, dementia with behavioral disturbance, [MEDICAL CONDITION] and urinary tract infection. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 03/07/2013. Resident #3 was assessed as having a difficulty with both long and short term memory, as well as being severely impaired with daily decision making skills. Under Section K0300 of the MDS: "Weight Loss: Loss of 5 % or more in the last month or loss of 10% or more in last six months," Resident #3 was coded as "Yes, not on physician prescribed weight-loss regimen." The clinical record was reviewed on 04/16/2013 beginning at approximately 11:00 a.m. The following clinical information was reviewed: The following weights were recorded: 01/03/2013: 145.5 Pounds 02/03/2013: 133.4 Pounds 03/01/2013: 132.2 Pounds 04/03/2013: 131.8 Pounds 04/17/2013: 129.2 Pounds (weight taken at the time of survey) The following entries (progress notes) addressing nutrition/weight loss were observed in the clinical record: 01/04/2013 (Dietary Manager) quarterly note: Resident is on a puree NAS (no added salt) diet with ground meat and extra sauce and gravy... Supplement: 2 cal 90 cc TID (three times a day) and ice cream TID Height: 5'6" IBW (ideal body weight): 142 # (pounds) Weight: 145.5 # 1/13/2013 (Nurse's Note): ...occasional nonproductive cough, usually associated with taking in fluids. ST (speech therapy) referral sent this shift. More alert and talking with staff this shift. Appetite good at breakfast. 1/13/2013 (Nurse's Note): noted to excessively cough and get choked up on thin liquids with breakfast and lunch. New order written to change liquids to nectar thick liquids until further evaluation by ST... 01/21/2013 (Registered Dietitian) ...Rsd (resident) ht 66, wt 145.5, BMI 23.5, 112% IBW. Rsd is on a NAS, puree, nectar thick diet with 75% PO intake. Will monitor weight for changes and PO intake. Will follow up quarterly... There were no nutrition notes for the month of February. 03/04/2013 (Registered Dietitian) ...wt 132.2, BMI 21.3, Rsd is on a NAS pureed nectar liquid diet with 25-50% PO intake. Rsd has lost 13.5%/20.7 # (pounds) X 90 D (days). Recommend liberalize diet to regular-pureed with fortified foods and adding super pudding TID to stabilize wt... 3/7/2013 (Dietary Manager) Annual note: Resident is on a puree NAS diet with ground meat. Nectar thickened liquids with all meals, Supplements: Med pass 90 cc TID and Ice Cream BID...Res. has had a 13.5% weight loss over the last 90 days. 04/14/2013 (High Risk Meeting) Why is resident being reviewed/discussed at High Risk Meeting? Resident has a significant weight loss of 13.5% over the last 90 days. What interventions were in place at the time of the incident/occurrence? med pass 90 cc tid, ice cream tid. What are the risk factors or special circumstances that contribute to the area of concern? (this question was not answered) What new interventions were implemented in response to the incident/occurrence? RD consult Is the family and resident aware of these interventions? yes Additional Comments: (none were made) Attendance: Staff members listed included the DON (director of nursing), the administrator and the DM (dietary manager). 04/15/2013 (RD wt note) ...wt 131.8, BMI 21.3. Rsd is on a NAS/pureed, NTL (nectar thick liquid), ice cream TID, Med pass 90 cc TID. Dx: Unintended wt loss r/t (related to) recent UTI (urinary tract infection) AEB 10.7%, 13.6# wt loss X 180 D. Recommend adding fortified foods. Will monitor wt for changes, diet adequacy and PO intake PRN. 04/15/2013 (nurse's note) Resident is having trouble swallowing chopped meats. Continuously chewing. Changed diet/meat back to pureed. Son notified of changes. 04/16/2013 (Dietary Manager note) Resident is on a puree diet with ground meat, extra sauce and gravy with meals, nectar thick liquids. Fortified foods added tid to aide against weight loss... Other information observed in the clinical record included a dietary screening completed by the dietary manager on 3/7/2013 containing the following information: Current Issues: Difficulty Chewing/Swallowing Functional Level: Unable to Eat Independently Appetite: Fair Average Intake: Breakfast: 75% Lunch: 75% Dinner: 50% Labs: No information entered National Vital Signs: Height: 66.0 Date:10/3/2011; Most Recent Weight: 132.2 Date: 3/1/2013; UBW: no information entered; Additional Comments: none Food and Ethnic Preferences: No entries Food Dislikes: No entries Food Alleges : No known food allergies [REDACTED]. Therapeutic diet, mechanically altered diet Tube Feeding: No entries Flushes: No entries Mobility: Wheelchair Eating Environment: Dining Room Mental Status: Alert Communications: Verbal Bladder: Incontinent Bowel: Incontinent Skin Integrity: Skin Intact A Nutrition Assessment completed by the RD on 4/5/2013 was also reviewed and contained the following information: Current Issues: Difficulty Chewing/Swallowing, Constipation/Impaction History, Therapeutic Diet Restriction Pertinent Medical Diagnosis: [REDACTED]. Pertinent Medications/Vitamins/Minerals: Cranberry Supplement Labs: No entries Nutritional Vital Signs: Height: 66.0 Date: 10/3/2011 Most Recent Weight: 132.2 Date: 3/1/2013 Weight range/goal (lbs): 128-154 Nutritional Requirements/Estimated Need: Total Kcals (per day): 1800; Protein (gm/day): 60; Fluid (cc/day): 1800; Justification of Calculations: 30kcal X 60 kg 1g X 60 kg 1 kcal = 1ml Dietary Screen: Dietary Screen reviewed Diet: NAS-pureed; Hydration needs: NTL; Therapeutic diet; mechanically altered diet; Oral Supplemental/additional Foods: 2 cal Medpass 90 cc TID; extra sauce and gravy with meals Tube Feeding: No entries Flushes: No entries Skin Integrity: Skin intact Goals/Outcomes: Weight stable; No nausea/vomiting/diarrhea; Increased meal intake; adequate hydration; dietary compliance Recommendations: Recommend liberalize diet to regular pureed. Will monitor wt for changes, diet adequacy and PO intake upon follow up X 90D. Two dietary recommendation forms from the RD were observed in the clinical record. The first signed and dated 4/5/2012 contained a recommendation to liberalize diet to regular pureed. The second recommendation dated 4/15/2013 contained the following information: Significant weight loss 13.7 # in 180 days Nutritional Diagnosis: [REDACTED].# X 90 D. Interventions: Initiate fortified foods. This form was not signed but during an interview with the RD on 04/17/2013 at approximately 1:45 p.m., she confirmed the recommendations were hers. The physician order [REDACTED]. Other orders for nutrition on the POS were: 2 cal Med Pass 90 cc TID Everyday; and Ice Cream twice daily and at bedtime. The POS for April was also reviewed and contained identical orders to the March POS. Also observed on the April POS were orders for a CMP (comprehensive metabolic panel) to be done annually. The laboratory section was then reviewed. A CMP for September 2012 was observed with the following results: Total Protein: 6.2 G/DL and [MEDICATION NAME]: 3.3 G/DL. An additional CMP was ordered for 03/10/2013 due to resident's increased temperature. Results on the clinical record were: Total Protein: 6.0 G/DL and [MEDICATION NAME]: 2.4 G/DL. An [MEDICATION NAME] level of 3 - 3.4 GM/DL indicates mild protein [MEDICAL CONDITION], 2.1 - 3.0 GM/DL, indicates moderate protein [MEDICAL CONDITION]. (1) During an end of the day meeting on 04/16/2013 at approximately 5:20 p.m. the weight loss for Resident #3 was discussed with the administrator and the DON (director of nursing). They explained that the current Registered Dietitian (RD) had started in January (2013) and that she is in the facility every two weeks. Weights are taken by staff and forwarded to (name of Dietary Manager - DM) by the DON. The DM then notifies the RD. The administrative team were asked why Resident #3 was not seen by the RD in February when the weight loss began. Neither the DON nor the administrator knew why the resident had not been seen. The administrative team were asked how dietary recommendations were handled. Per the DON the recommendations come to her and she writes the orders. The DON verified that the dietary recommendation forms were how the information was relayed to her. The administrative team were asked what had occurred with the recommendations made by the RD on 03/4/2013 to "liberalize diet to regular-pureed with fortified foods and adding super pudding TID to stabilize wt..." The DON stated, "I never got that, maybe (name of the DM) did." The DON and the administrator were asked how the weight loss of 11.1 pounds in February and the continued weight loss in March were handled/addressed and what interventions were put in place. The DON stated that she did not know and would get back to this surveyor. The DON and the administrator were told that this surveyor needed to speak with the RD during survey on the following day. On 04/17/2013 at approximately 12:45 p.m., Resident #3 was observed being fed his lunch by CNA (certified nursing assistant) #2. The tray ticket indicated that Resident #3 was receiving a pureed diet with ground meat, extra sauce and gravy, nectar thick liquids and fortified food. Resident #3 was observed coughing, and coughing the ground meat out of his mouth onto the table. CNA #2 stated that Resident #3 was having a hard time with the meat and he was not going to feed him anymore. LPN (licensed practical nurse) # 4 was in the dining room, she looked at the meat and stated, "It looks chopped instead of ground." She stated would take the meat back to the kitchen to see if it was ground or chopped. She returned from the kitchen and stated, "It is ground but (name of DM) is going to grind it some more and bring it to us." CNA #2 was asked how Resident #3 was doing with his eating. He stated, "he's doing pretty good except for the meat." CNA #2 was asked what all was on the tray. He stated, "Mashed potatoes, the meat, tapioca pudding, pureed tuna casserole and pureed vegetables" CNA #2 was asked if there was any special order in which he fed the patients in when they have fortified foods. He stated, "I think the potatoes are what is fortified on his tray today...I try to give a bite of everything...sometimes if they don't eat I try something sweet first to get them to open up for me a little bit and then I can give them the other food." The DM was interviewed at approximately 1:00 p.m. on 04/17/2013 regarding fortified foods. He stated, "We add food to food...extra butter, cream, sugar...to help boost the calories. We add to the hot cereal in the mornings and they other meals it is usually the mashed potatoes or rice. At approximately 1:20 p.m., CNA # 5 was interviewed regarding resident weights. She stated that she does the weights on all the residents. She pulled a piece of paper out of her pocket and stated, "Here is who I weigh." There were residents listed on the paper and weights written down. She stated, "These are today's weights." CNA #5 was asked if she had the previous weights available to compare for accuracy of a weight. She stated, "No I get the weights and I give them to (name of the DON)..." On 04/17/2013 at approximately 1:45 p.m. the RD came to the facility to speak with this surveyor. The RD was asked if she was aware of the weight loss Resident #3 had experienced. The RD stated, "I am feeling very discouraged here...I am not included in the high risk meetings, (name of DM) goes to the meetings and tells me what happens when I come back in....I don't know who has pressure ulcers...I don't even have a mailbox here." She stated she had started working at the facility in January and during a meeting with the administrator in February she had reported to her (the administrator) that "1/3 of the facility had significant weight changes in the last 180, 90 and 30 days." She stated she had recommended to the administrator that weekly weights be done so they could "get in front of this." She stated the administrator told her "weekly weights are not going to happen." She also stated that they administrator told her that they were going to have the same person doing the weights to ensure accuracy. She stated she gives all her recommendations to the DON and the DON will have the physician look at them. She stated she was told that "she didn't need to talk to the doctor." The RD was asked how she knew whether or not her recommendations had been implemented. She stated, "I have to go through the records when I come back in and see what has been done." The RD was asked if there was any communication to her from the physician that he did or did not agree with her. She stated, "No, if the recommendations aren't done I think the doctor didn't agree." She also stated that she got a report from the DM on Monday (04/15/2013) that contained weights that were discussed in a meeting but all the weights "are a month behind" when they meet. The RD was asked if she thought more could have been done to decrease/prevent the weight loss of Resident #3. She stated, "I feel a whole lot of things could be done for a lot of the residents here..." At 2:30 p.m. the dietary manager, the administrator, and the DON were brought into the room with the RD to discuss the weight loss of Resident #3. The weight loss of 11.1 pounds in February was discussed. The DON stated that she did not get the recommendations from the RD to add fortified foods in March. The DON stated they have high risk meeting to discuss weight loss and weights are also discussed at the QM (quality management) meetings. The DM stated that the weights discussed at the meetings "are all a month behind." The DM and the DON were told that the high risk meeting documented in the clinical record was on 04/14/2013 over two months after the initial weight loss of 11.1 pounds and that it was not until after the second recommendation from the RD to liberalize the diet and add fortified foods that the recommendation was carried out. It was also pointed out that super puddings recommended three times a day had still not been implemented. As of 4/17/2013 Resident #3 had lost an additional 2.6 pounds resulting in an overall weight loss of 16.3 pounds since February. The DM, the DON and the administrator were asked if Resident #3 had been discussed in the high risk meeting and the meeting not documented in the clinical record. The DON stated she would check. At approximately 3:30 p.m. the DON returned to the conference room to speak with this surveyor. She stated, "Look we did discuss him in the February meeting." The form was observed and at the top it read "February Weights." Dates of care plan updates on the form were 03/14/2013. The DON was asked if the form was from the March meeting since the DM and the RD had both stated the weights used in the meeting were "a month behind." The DON did not answer. No further information was obtained prior to the exit conference on 04/17/2013. 1. Pronsky, Zaneta. Food Medication Interactions, 12th edition. Birchrunville, Pennsylvania: Food-Medication Interactions, 2002.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide adequate supervision and/or assistive devices for the prevention of accidents for one of 13 residents in the survey sample (Resident # 3). Resident # 3 was not provided adequate supervision and/or safety devices to prevent a fall that resulted in a right femur fracture. Findings include: Resident # 3 was admitted to the facility on [DATE] originally, with the most current readmission on 11/21/11. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment was a significant change assessment dated [DATE]. Resident # 3 was assessed as having short and long term memory impairment with severe impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance from staff for most ADL's (activities of daily living), including bed transfer and toileting. During clinical record review on 05/09/12, a nursing note dated 09/30/11 documented: "resident found on floor @ (at) 0645 (6:45 a.m.) by this nurse and anothe (sic) aide Assessed by this snurse (sic) and another staff nurse Resident trying to get himself up out of floor 2 abrasions noted on R (right) forehead neuro checks initiated On call called, left message with RP (responsible party) Resident sent to ER for eval." The POS's (physician's order sheets) for September 2011 were reviewed and documented: "...02/03/11: Assist to bathroom every 2 hours..." This order had a line drawn through it and had "D/C (discontinue) 08/29/11" hand written in. No physician's orders could be located in the clinical record regarding the discontinuation of the order to assist the resident to the bathroom every 2 hours. No information could located regarding this order. Resident # 3's CCP (comprehensive care plan) was reviewed and documented: "06/01/10 High Risk for falls...Will remain free of fall and/or injury related to falls through review date...Review (dates) 09/14/10, 12/07/10, 05/25/11, 08/23/11, 10/11/11. 10/10/10-found in room on buttocks no injuries...04/05/11-found on floor with laceration to center of forehead...09/30/11-fall-found sitting in floor d/t (due to) OA (osteoarthritis)...Gather information on past falls and attempt to determine cause. Anticipate and intervene to prevent...call light in reach...Respond promptly...evaluate for, supply adaptive equipment or devices needed...Ensure that resident is wearing appropriate footwear...Will receive the necessary assistance for toileting...Remove wet or soiled clothing, briefs; provide incontinence care;...maintain resident's dignity during incontinent care...turn and reposition as needed...02/03/11-Assist to BR (bathroom) q (every) 2 hours...Offer/assist to toilet/bedpan or urinal at scheduled intervals during the day: Q (every) 2 hours (checked)...Specify: (checked) PRN (as needed)...Provide supportive care, assistance with mobility as needed...Explain plan of care. Promote dignity by ensuring privacy...Resident wanders at times...will wander safely within environment...no falls, elopement events, injury through review date..." On 05/09/12 at approximately 11:15 a.m., a brief meeting was conducted with the DON (director of nursing). Assistance was requested in locating the original order for the discontinuation of toileting assistance that was observed on the September 2011 POS. The investigation of the resident's unwitnessed fall was also requested at this time. The investigation was later presented and reviewed and documented the following: "09/30/11...we, looked over and seen a sheet moving by the time we got in the room (first name of resident) was on the ground. He fell beside his bed on the right side. His pants were around his ankles. There was four other residents found the same way with pants around their knees to their ankles (sic). They were found at about 6:30 a.m....while...getting residents up for breakfast...signed CNA (certified nursing assistant) # 5." "09/30/11 I was called back to the unit at 0645 (6:45 a.m.). Resident was found laying in the floor with his pants around his ankles...helped get resident back to bed...resident was grabbing at his hip...On call was notified and resident was immediately sent to (initials of local hospital)...signed LPN # 3." "I (first/last name of CNA # 6) started my round at exactly 4:10 a.m., I start from the first room, which is (name of Resident # 3 and his roommate)...I change (sic) them, I dressed them, and I repeat this from room to room all the way down the hall on one side down to the other. by the time I am finished it is normally 5:50 or 6:00 a.m....signed CNA # 6." A "Record of disciplinary action", dated 09/30/11 was reviewed and revealed: "...09/30/11 CNA # 6...improperly leaving residents in bed not dressed according to proper standards of care...Negligence in the performance of job duties...suspension-per investigation...signature of former administrator." A "Record of disciplinary action", dated 10/04/11 was reviewed and revealed: "...10/04/11 CNA # 6...upon last round at approx. 4:10 a.m. employee stated she began her last round. Upon dressing resident (name of Resident # 3) she stated that she placed pants on resident to thigh for convience (sic)...negligence in the performance of job duties causing resident injury...Termination...signed CNA # 6 and former administrator." The administrator and DON were made aware of serious concerns regarding Resident # 3's fall on 05/09/12 at 4:45 p.m., in a meeting with the survey team. The administrator stated that, "we" (staff) realize the seriousness of this. On 05/10/12 at approximately 2:15 p.m., the DON stated that an original order could not be found, for the discontinuation of "assistance with toileting on 08/29/11" for Resident # 3 and that no information could be located within the clinical record to justify the discontinuation of the order. No further information or documentation was provided prior to the exit conference on 05/10/12 at 6:30 p.m.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility staff failed to ensure one of 13 residents (Resident # 13) was free from a significant medication error. Resident # 13 was administered 40 units of [MEDICATION NAME] R (regular) sliding scale insulin, which resulted in severe [DIAGNOSES REDACTED] (low blood glucose level); the resident was hospitalized on [DATE] at 5:40 a.m. and subsequently expired at the hospital the same day at 5:53 a.m. Findings include: Resident # 13, an [AGE] year old female resident was admitted to the facility [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was the annual assessment dated [DATE]. Resident # 13 was assessed as having a cognitive score of "3", which indicated the resident was severely impaired in daily decision making skills. The resident was also assessed as requiring extensive assistance from staff for all ADL's (activities of daily living). During the complaint investigation on [DATE], Resident # 13's closed clinical record was reviewed. The complainant alleged that the facility staff administered 40 units of regular, sliding scale insulin to Resident # 13; the resident was hospitalized and expired shortly thereafter. The most current POS's (physician's orders [REDACTED].< (less than) 300=6 U (units), ,[DATE]=8 U, ,[DATE]=10 U, ,[DATE]=12 U, ,[DATE]=15 U, > (greater than) 500 CALL MD (Medical Doctor) 800 (8:00 a.m.) 2100 (9:00 p.m.)[MEDICATION NAME] 850 mg (milligrams) PO (by mouth) QD (every day) 2100 (9:00 p.m.)..." The [DATE] MARs (medication administration records) were reviewed. The sliding scale insulin order that was documented on the [DATE] POS, was also documented on the [DATE] MAR. This order had lines drawn through it (as if it were discontinued, but did not have discontinued written), just below this order a hand written entry documented: "See new S/S (sliding scale) orders. Accu check before meals & (and) @ (at) HS (bedtime). ,[DATE]:4 units ,[DATE]:6 units ,[DATE]:8 units ,[DATE]:10 units ,[DATE]:12 units ,[DATE]:14 units > 500 call MD This order did not have a date as to when it was ordered or written, no initials were documented to determine who actually wrote this "new order" on the MAR. No orders could be located in the closed clinical record to verify this was the actual order in effect for Resident # 13. The administration times were hand written as well and documented: "0600 (6:00 a.m.) BS (blood sugar) AMT (amount of insulin given) site (site of administration). 1130 (11:30 a.m.) BS (blood sugar) AMT (amount of insulin given) site (site of administration). 1630 (4:30 p.m.) BS (blood sugar) AMT (amount of insulin given) site (site of administration). 2100 (9:00 p.m.) BS (blood sugar) AMT (amount of insulin given) site (site of administration). On [DATE], the date of the alleged medication error, it was documented in the 9:00 p.m. slot with initials as administered; the blood sugar reading was documented as 209 and the amount of regular sliding scale insulin administered was documented as 4 units. The remaining MARs were reviewed and revealed that Resident # 13 was also administered [MEDICATION NAME] 850 mg (an oral anti-diabetic agent) at 9:00 p.m. on [DATE]. The MARs additionally revealed that Resident # 13 also received [MEDICATION NAME] 1 mg IM (intramuscular) four times. It was documented that the resident received [MEDICATION NAME] 1 mg IM at 9:00 p.m., 11:30 p.m. on [DATE], and at 1:30 a.m. and again at 3:30 a.m. on [DATE]. The nursing notes were then reviewed and documented the following: "...04//,[DATE] 23:30 (11:30 p.m.) Late Entry: Resident given 40 units of [MEDICATION NAME] R at 1940 (7:40 p.m.). Notified (name of physician) at 2000 (8:00p.m.), message left. (name of physician) returned call back at 2030 (8:30 p.m.). Gave instructions to give [MEDICATION NAME] 1 mg IM, check BSs hourly, and may give second dose if necessary. He (physician) informed this nurse that the insulin should peak around midnight. If unable to stabilize BS, may send to ER (emergency room ). BS 96 at 2045 (8:45 p.m.). Gave [MEDICATION NAME] 1 mg IM...at 2200 (10:00 p.m.). BS 73 at 2312 (11:12 p.m.). Gave second dose of [MEDICATION NAME] 1 mg IM...at 2330 (11:30 p.m.)...BS 48 at 0130 (1:30 a.m.-[DATE]). Gave [MEDICATION NAME] 1 mg IM third dose...BS 68 at 0200 (2:00 a.m.-[DATE]). BS 40 at 0310 (3:10 a.m.-[DATE]). Gave [MEDICATION NAME] 1 mg IM fourth dose...resident not responding. 911 called...R.P. (responsible party) notified...Ambulance arrived...BS 55 at 0350 (3:50 a.m.). Before ambulance left with resident, they checked BS. Result was 71 at 0409 (4:09 a.m.). Resident admitted to (initials of local hospital) with UTI (urinary tract infection). [DATE] 12:54 p.m. a nursing note documented: "This is a discharge return anticipated MDS (minimum data set) validation note. Resident with a low blood sugar this am...Resident sent to (initials of local hospital)...for evaluation..." On [DATE] at approximately 2:15 p.m., the DON (director of nursing) was made aware that Resident # 13 was named in a complaint and was being investigated. The facility's investigation regarding the medication error and the facility's policy on medication administration was requested at this time. The investigation was later presented and reviewed, as well as the policy on medication administration. According to the investigation, LPN (Licensed Practical Nurse) # 4 submitted a hand written statement dated [DATE], two days after the incident, stating the events that transpired on [DATE]. The statement documented: "On [DATE], after getting report and counting the narcs (narcotics) I started working on finishing the new admission...Mr. (name of male resident) was yelling out every few minutes. Resident yelling at this nurse if not answered immediately. started evening meds late. Started with (name of Resident # 13). Gave her meds. Next I gave (name of Resident # 4), (name of Resident # 7) her (sic) meds. While getting (name of Resident # 7) insulin ready, I realized I had made a mistake. We had different insulin syringes then we normally use. I thought it was in 1, 2, 3, 4 units instead of 10, 20, 30, 40 units. I realized that I had give (sic) (name of Resident # 13) 40 units of [MEDICATION NAME] R (regular) (insulin) instead of 4 units. Called (name of physician) immediately. Was given instructions. See nursing note...signed LPN # 4." According to Mosby's Pocket Guide to Basic Skills and Procedures, Potter & Perry, Sixth Edition 2007 pp. ,[DATE]; "...Review provider's medication order for client's name, drug name, dose, time, and route of administration against the MAR (medication administration record)...Prepare correct medication dose. Check dose carefully. Compare dose in syringe against desired dose on MAR...page 334 NURSE ALERT SOME INSTITUTIONS REQUIRE INSULIN DOSES TO BE VERIFIED BY ANOTHER NURSE FOR ACCURACY..." (1) The facility's policy on "Medication Errors and Drug Reactions" was reviewed and documented the following: "...3. High Alert Double Check System- A medication double check or second provider verification will be required prior to administration of selected high -risk mediations. High Alert medication requiring a double check will be designated as such on the Medication Administration Risk (MAR). Documentation of the double check will be recorded on the MAR or on the same document where the medication administration is recorded. The first check must be conducted by a primary nurse and the second check will be conducted by another licensed nurse. a. Insulin has been identified as a High Alert Medication requiring a double check system... The resident's comprehensive care plan (CCP) was reviewed and documented: "Admit [DATE] READMIT [DATE]...Problem (s): Potential for hyper/[DIAGNOSES REDACTED], other complications related to Diabetes Mellitus...Goal (s): Will be free of s/sx (signs/symptoms) or complications...will maintain blood sugars..within acceptable range per MD (medical doctor)..XXX[DATE] sliding scale insulin per MD orders..XXX[DATE] [MEDICATION NAME] R per MD orders...Administer medications as ordered and monitor for side effects, effectiveness..." The DON (director of nursing) and the administrator were made aware of the serious concerns regarding this significant medication error in a meeting with the survey team on [DATE] at approximately 4:15 p.m. The administrator and DON acknowledged the the survey team's concerns. The administrator and DON were asked how could this happen. The administrator stated that she didn't know what happened and verbalized that the nurse (LPN # 4) documented in her statement that it was busy and a lot going on when the error occurred. The DON and administrator were asked about the syringes being different than normally used, as documented by LPN # 4 in her statement. The administrator stated that the same insulin syringes were ordered as had always been ordered, but the company had sent the wrong ones. The administrator and DON were asked for an order invoice at this time and a shipment invoice. The policy was reviewed with the administrator and the DON regarding the verification with another nurse for insulin administration. The administrator was asked when was this policy put into effect. The administrator stated, "...it's always been in effect..." The administrator was asked if this policy was in effect when the medication error occurred with Resident # 13. The administrator stated, "...yes, I don't know why she didn't get a second witness..." No further information or documentation was presented prior to the exit conference on [DATE] at 6:30 p.m.,. This is a complaint deficiency. (1) Potter & Perry, Sixth Edition Mosby's Pocket Guide to Basic Skills and Procedures 2007. Philadelphia, PA: Elsevier's Health Sciences.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure two of 14 residents in the survey sample (Residents #'s 3 and 13) were provided adequate supervision and safety assistive devices to prevent accidents. 1. Resident # 13 was not transferred appropriately via a Hoyer lift, which resulted in Resident # 13 incurring rib fractures. 2. Resident # 3 was not provided adequate supervision and/or an appropriate physician's orders [REDACTED]. Findings include: 1. Resident #13 was originally admitted to the facility on [DATE] with the following diagnoses, but not limited to: hypertension,[DIAGNOSES REDACTED] (clostridium difficile,) chronic obstructive pulmonary disease, obstructive emphysema, chronic bronchitis, atrial fibrillation, congestive heart failure, chronic kidney disease, diabetes mellitus and osteoarthritis. The admission MDS (minimum data set) with an ARD (assessment reference date) of 07/06/2010, assessed Resident #13 as having no problems with long or short term memory, as well as being independent in daily decision making skills. On 07/08/2011, at approximately 8:45 a.m., the clinical record was reviewed. A significant change MDS was observed with an ARD date of 08/30/2010. Resident #13 was assessed as having problems with long and short term memory, as well as some difficulty with daily decision making skills in new situations. In the nurse's note section of the clinical record, the following entry was observed: "08/22/2010 00:36 (12:36 a.m.) NOTE TEXT: 2017 (8:17 p.m.) Nurse called into room (room number) by CNA (certified nursing assistant) upon entering room nurse noted resident to be lying on top of Hoyer Lift cross ways the stand on Left side. Nurse noted blood to be on floor nurse ask (sic) CNA to assist remove lift from under resident as nurse braced resident body in position, lift was removed resident was then logged (sic) rolled to back with neck braced by nurse. This nurse ask (sic) CNA to obtain full set of v/s (vital signs) as noted 194/99 139 98.9 22 84% nurse assessed resident head to toe nurse noted skin tear to left elbow and left side of had(sic) bleeding was controlled by applied pressure with washcloth. This nurse noted resident MAEW (moved all extremities well) with in (sic) normal limits, resident stated to nurse that her L-side (left side) was hurting nurse assessed and felt for pertrusion (sic) of ribs and resident stated again L left side hurt this nurse left CNA with resident as I came to nurse (sic) station to call MD (medical doctor) (Name of MD) to inform of incident. MD (Name of MD) was on call for (MD Name) and I explained incident to her she in return ordered for resident to go to ER (emergency room ) for assessment this nurse went back and informed resident that order from MD was to go to ER for eval (evaluation,) she stated ok and to call her son (name of son) to inform him incident (sic) this (nurse) came to nurse (sic) station and called responsible party dtgr (daughter) (name of daughter) this nirse (sic) (left) voice mail for her to call, nurse called second contact and received no answer this nurse went back to resident and ask (sic) if there was anyone else she would want notified and she gave nurse to son (name of son) phone number to contact and stated he would reach other sibling this nurse resident was transported to (name of local hospital) via 911, this nurse received the f/u (follow up) call at 2245 (10:45 p.m.) nurse (name of nurse at hospital) she gave the report of a left rib fracture." A radiology report was also observed. The x-ray was of the chest and ribs with a total of seven views, conducted on 08/21/2010 at 10:57 p.m. The impression of the x-ray was: "Left lateral eight through tenth rib fractures..." Under Section G of the admission MDS, Resident #13 was coded as being totally dependant on staff and requiring the assistance of two + (plus) persons for transfers, including toilet use. The following additional nurse's notes were observed: ? 08/22/2010 14:08 (2:18 p.m.) "...Resident states she (sic) in pain but unable to give Lortab. Resident stated that she didn't want the Hoyer lift anymore when she's getting out of bed. Hoyer lift dc'd (discontinued.) ? 08/23/2010 06:28 (6:08 a.m.) "...complained of moderate amount of left sided rib pain and left sided shoulder pain...show signs of anxiety when log rolling resident to perform ADL (activities of daily living) care..." ? 08/23/2011 15:48 (3:48 p.m.) "...pain noted with rib fxs (fractures) left...Continues on Fentanyl patch...Using incentive spirometer but needs much encouragement to use. Log rolling refuses to get up and use of Hoyer." ? 08/25/2011 14:19 (2:19 p.m.) "...Increase Fentanyl patch to 25 mcg/hr...Duonebs BID (two times per day) for decrease breath sounds..." ? 08/27/2010 16:34 (4:34 p.m.) Wound Rounds "New Stage I pressure sore rt (right) buttocks-pink/purple. States 'sore.' New order to place duoderm Q3D (every three days) and prn (as needed.) Measures 8L (length) X (by 6W (wide.)...Educating on turning/repositioning-does not want to turn due to ribs Lt but this RN (registered nurse) states needs to at least turn from back to right..." This entry was later corrected to indicate Left buttocks. ? 08/30/2011 20:22 (10:22 p.m.) "...Lt buttocks now Stage II measuring 2.0L X 1.0 W wound bed pink..." ? 09/05/2010 17:05 (5:05 p.m.) "Patient noted to be SOB (short of breath) O2 (oxygen) sat (saturation) 53% on room air nurse applied 4L of O2 up to 98%. Nurse reassessed O2 sat and note that O2 have dimished (sic) to 68% nurse applied non rebreather mask and applied 10L O2 and was unable to substained (sic) above 85%. Noted expectory (sic) wheezing, also mental status change...911 was called...transported to (name of local hospital) via 911...137/62 76 97.9 85% 22." The physician's discharge summary was also observed in the clinical record. The discharge disposition was, "Resident was discharged to (name of local hospital,) then transferred to (name of larger hospital.) Upon release from there, resident was admitted to (Name of another area nursing home)." The administrator was asked for any investigation the facility had conducted regarding the incident with Resident #13. According to the facility's investigation only one CNA had been in the room with Resident #13 at the time of the fall. A written statement from that CNA was presented. According to the statement the CNA had "hooked" Resident #13 "up" to the Hoyer lift and as she was backing the Hoyer lift away from the chair the strap on the Hoyer pad broke and Resident #13 fell to the floor. An interview with the CNA had been conducted by the administrator and the DON (director of nursing) was presented. The interview took place on 08/23/2010 at 10:00 a.m. According to that interview, Resident #13 had been in the dining room playing cards and asked to get onto the bedpan. The CNA pivoted Resident #13 around to place her in the bed and the resident rolled onto her left side and fell on to the legs of the lift. "CNA heard no ripping sound of lift pad...CNA stated she knew two people are needed when using lift." The facility's conclusion of the investigation stated, "...CNA was transferring resident from chair to bed by herself while using Hoyer lift. Upon investigation, CNA did not have another CNA with her which is facility policy. Upon employee interview with Director of Nursing and Administrator CNA did not check lift pad or extend the legs on the lift when transferring resident which resulted in resident receiving three rib fractures. CNA stated she was aware that another co-worker was to be with her when using Hoyer lift, CNA was suspended pending investigation and was terminated on 08/24/2010..." The administrator and the DON were interviewed on 07/08/2011 at approximately 12:10 p.m., regarding the incident with Resident #13. The DON and the administrator stated that the CNA had attended three separate inservices regarding the use of a Hoyer Lift. They stated she was not a new CNA and had experience at the facility. The DON stated, "She was in a hurry...The Resident had to go to the bathroom...it was all technique." The DON and the administrator were asked if the Hoyer pad was damaged/torn as the CNA had stated in her original statement. The administrator stated, "The lift pad was not broken or torn." No further information was obtained prior to the exit conference on 07/08/2011. 2. Resident # 3 was admitted to the facility originally on 12/31/2010, with the most current readmission on 02/27/2011. [DIAGNOSES REDACTED]. The most current MDS with CAAS (Care Area Assessment Summary) was an admission assessment dated [DATE], which assessed Resident # 3 as having short and long term memory impairment and severe impairment in daily decision making skills. Resident # 3 was also assessed as requiring extensive assistance from staff for most ADL's (activities of daily living), including transfers, which required the physical assistance from at least one staff member. Resident # 3 was also assessed as an "8/8" (self-performance/support provided) for ambulation, which indicated the activity did not occur, and was assessed as "3/2" in transferring (extensive assist staff provided weight bearing support/one person physical assistance). Resident # 3 was assessed under section G0300 (A. moving from a seated to standing position), as being " Not steady, only able to stabilize with human assistance, (E. surface to surface transfer) Not steady, only able to stabilize with human assistance." During Resident # 3's clinical record review, it was observed that Resident # 3 had a fall on 02/25/11. A nursing note dated 02/25/11 and timed 17:22 (5:22 p.m.) documented: "CNA found resident sitting in floor of dining hall, wheelchair on the other side of table. Assessed resident for injuries, asked resident what happened unable to answer. Placed back in w/c with wheels locked @ (at) table..." A discharge note from UVA (Resident #3 was sent to Bath County Hospital first then transferred to UVA) dated 02/26/11, documented: "University of Virginia Medical Center Emergency Department...FOLLOWUPS: Private Physician When: 1 week; Recheck today's complaints Special Notes: Please follow up with in (sic) Orthopedic Clinic in 2 wks regarding the fracture in your femor (sic)..." X-rays from Bath Co. (read by UVA) documented: "...right femoral head prosthesis in place...A mildly displaced fracture through the base of the right greater trochanter is present...Right femoral head prosthesis, with right acetabular protrusio...Lucency surrounding the right femoral neck component possibly representing loosening..." On 07/07/11 at approximately 9:20 a.m., Resident # 3's thinned (closed) record was requested from the administrator, in addition to the fall investigation regarding the fall that occurred on 02/25/11. At approximately 11:30 a.m., the administrator and DON (director of nursing) requested a meeting with this surveyor to present the fall investigation on Resident # 3 and offer an explanation/review of the events that took place on 02/25/11, the day of the fall. During this meeting, the DON voiced that the resident was sent to the local acute care hospital after the fall, then was sent a short time later to a larger (sister) acute care medical center. The DON further voiced that the resident did not get admitted and was sent back to the facility (with follow up/discharge instructions) on 02/27/11. The DON and administrator verbalized that earlier that day the facility had the fire place turned on in the dining room area and the resident had voiced multiple times throughout the day that the fire needed to be "fixed" and that this may have contributed to the fall. The administrator presented the investigation and stated that no one had seen the resident fall and only one CNA (certified nursing assistant) found the resident, which was CNA # 2. The investigation consisted of a single hand written statement (from CNA # 2). The statement was observed to have no date or time as to when the statement was taken and did not contain any type of details to attempt to establish a cause or conclusion. The statement documented: On February 25th, 2011 at 5:00 p.m. in the afternoon; I walked in the main dining room and found (first and last name of Resident # 3) sitting on the floor next to the fireplace. She was holding another resident's hand at the time. We then check her vitals; which were normal and helped her back in the chair. Signature of CNA # 2 6A-6P." The administrator voiced that all staff had been educated on falls, presented an in-service log at this time, in addition to a QA (quality assurance) tool. The administrator informed the surveyor at this time that staff are educated after every fall on fall prevention. No further information was presented. On 07/07/11 at approximately 2:40 p.m., CNA # 2 was interviewed in the presence of the survey team. CNA # 2 stated that on 02/25/11 at approximately 5 to 10 minutes prior to 5:00 p.m., herself (CNA # 2) and another CNA were gathering residents and bringing them to the dining room in preparation for the evening meal. CNA # 2 voiced that Resident # 3 had already been taken to the dining room in her w/c (wheelchair) and placed at a table (in close proximity of the fire place). CNA # 2 then stated, that she left the dining room again to go get another resident and when she (CNA # 2) re-entered the dining room area, that is when Resident # 3 was found. CNA # 2 stated that, "...in just that short amount of time, she was in the floor..." CNA # 2 stated, "...the alarm was not attached to her..." CNA # 2 also stated that, the "tab" was unhooked from her shirt, no alarm was sounding, she (Resident # 3) was in the floor and another resident was holding Resident # 3's hand. CNA # 2 then stated that the the "tab" alarm was still connected (via magnet) to the box on the w/c (when disconnected from the box the device will alarm/sound). CNA # 2 was asked if Resident # 3 could have taken off the tab alarm herself. CNA # 2 stated, "...I haven't known her to..." CNA # 2 was then asked what the difference was between a "tab" alarm and a chair pad alarm, as far as function and use. CNA # 2 stated that "tab" alarm is one that attaches to the resident's clothing (shirt) and if the resident stands up, it pulls from the box causing it to alarm/sound. A chair pad alarm has an on/off button, the resident sits on it and when the resident stands up, it goes off. CNA # 2 was asked again, what type of alarm did Resident # 3 have. CNA # 2 stated, "Tab..." At approximately 3:00 p.m. further review of the clinical record revealed the following nursing notes: 01/01/11- 3:12 p.m. "Resident attempting to ambulate on own. Tab alarm in place. Resident exist (sic) seeking ...Resident is confused @ (at) all times ..." 01/02/11- 3:23 a.m. "...Continually trying to get out of chair and bed ..." 01/2/11- 6:20 p.m. "...increased level of anxiety and agitation continuously trying to stand, resident call (sic) alarm was sounding and resident was observed to be standing beside bed and resident room mate (sic) was trying to assist resident from falling to floor ...haldol 2 mg (milligrams) bid (twice a day) was order (sic) d/c (discontinue) order for haldol 1 mg ..." 01/03/11-3:06 a.m. "...At beginning of shift continually trying to get out of wheelchair ..." A social worker note documented on 01/03/11: "...resident since admission has adjusted well responds to care needs assistance with all anticipated needs, resident is a fall risk and turns off alarms and tries to get out of bed." A social worker note dated 01/21/11, documented: "...resident has adjusted well, resident still has iisues (sic) of being confused ...resonds (sic) to staff at times but does not respond to the questions in the assessment." An MDS note dated 01/22/11, documented: "...Extensive assistance noted with transfers. No ambulation noted ..." The resident's (POS's) from admission up to March 2011 were observed to include the following: ? The admission (POS) (hand written) orders, dated 12/30/10 and 12/31/10 documented: "...Admit to facility (date): 12/31/10...*****ALARM TYPE/APPLIANCES***** CHAIR PAD ALARM d/t (due to) hx (history of falls)..." ? The POS dated 01/01/11 (hand written for January 2011) was then observed and documented: "...Admit to facility (date): 12/31/10*****ALARM TYPE/APPLIANCES***** CHAIR PAD ALARM HX FALLS ..." Resident # 3 had a hospital stay in January (January 22-26) and was readmitted to the facility on [DATE]. ? The POS dated 01/26/11 (hand written) documented: "...Admit to facility (date): 01/26/11...*****ALARM TYPE/APPLIANCES***** CHAIR PAD ALARM (blank) ..." The line provided for specifics related to the chair pad alarm was blank. ? The POS dated 02/01/11 through 02/28/11 (computer generated) documented: "...*****TREATMENTS*****...12/31/10 (order date): CHAIR PAD ALARM EVERY SHIFT-DUE TO HX FALLS..." Resident # 3's comprehensive care plan (CCP) was then observed and documented: "12/31/10-Hx (history of) falls ...Gather information on past falls and attempt to determine cause ...Anticipate and meet needs ...Provide education and safety reminders ...Fall eze mats @ (at) bedside ..." Resident # 3 was readmitted on [DATE], which was documented on the CCP; the review date was documented under the readmitted and was observed as 03/16/11. No other fall interventions (safety devices) were listed on the resident's CCP for this time period. The CCP further documented: "HX (history of) of Falls...(2/25/10-FALL)...2/26/11-Transfer to (initials of local acute care hospital) ER (emergency room ) for eval. (evaluation)...3/10/11 Fall risk will be free of falls and injury related to falls through review date TAB ALARM/BED ALARM...3/10/11-CHAIR ALARM AS ORDERED... (Note: Added after the fall on 02/25/11) A nursing summary with an effective date of 02/16/11 documented that Resident # 3 was confused, anxious, resistive to care, had occasional pain-treated with oxycodone, and always incontinent of bowel and bladder. In the progress note at the end of the summary documented: "...stable...UTI (urinary tract infection) prophylaxis...Pleasantly confused." Resident # 3's fall risk assessments were then observed from admission up to the 02/25/11 (the date of the fall), the following was documented: 12/31/11- A score of 12 was given to Resident #3. The fall risk assessment was observed to be incomplete and inaccurate according to the resident's clinical record. Section C. (ambulation/elimination status) was blank. Resident # 3 should have received a "2" (Chairbound ...assist with elimination) in this section; this would have increased the resident's score to a 14. Section G. (medications-anesthetics, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemic, narcotics, psychotropics, sedatives/hypnotics) received a score of 2 (Takes 1-2 of these medications ...), which should have been "3" (Takes 3-4 ...) that would have given the resident a score of 15. Section H. (predisposing diseases) the resident was scored a "2" here (1-2 present), but according to the resident's medical history should have been scored a "4" (3 or more present), which would have gave Resident # 3 a total fall risk assessment score of 18, not 12. 01/26/11-The readmission fall risk assessment gave Resident # 3 a total score of "9." This fall assessment was not accurate according to the resident's clinical record and history. Section B. (history of falls) a score of "0." The resident should have been scored a 2 (1-2 fall in the past 3 months). Section E. (Gait/balance) was scored as a 1 (decreased muscular coordination), but should have also had an additional score of 1 (balance problem while standing). Section G. (medications) was scored "0." According to the clinical record the resident should have received a score of 4 (takes 3-4 of these medications currently and/or within the last 7 days). Lastly, section H. (predisposing diseases) was scored as a 2, and should have been scored as 4. This would have given Resident # 3 a total fall risk assessment score of 18, not 9. The MARS/TARS (medication administration records/treatment administration records) for the month of February 2011 were then observed. The TAR documented: "...12/31/10 (order date) CHAIR PAD ALARM EVERY SHIFT-DUE TO HX FALLS..." The TAR was documented with initials on 02/25/11, but did not have a specific time that the chair pad alarm was checked. On 07/07/11 at approximately 3:15 p.m., the DON, administrator, and administrative staff # 3 were informed in a meeting with the survey team of the fall Resident # 3 had, which resulted in a fracture and informed them of the discrepancies found between the facility's investigation (written statement from CNA # 2), the actual statement CNA # 2 gave to the survey team when interviewed, and the inconsistent documentation in the medical record. The facility staff were also made aware of the survey team's concerns regarding the lack of thoroughly investigating Resident # 3's fall. On 07/07/11 at approximately 3:15, the DON confirmed the operating functions/use of the chair pad alarm and the tab alarm (as described earlier by CNA # 2 in the interview with the survey team). The DON further voiced that the chair pad alarm "is not accessible, nothing to unclip..." At approximately 4:30 p.m., the administrator, DON, and administrative staff # 3 again met with the survey team. The survey team expressed serious concerns to the administrative staff regarding actual harm incurred by Resident # 3, as a result of the fall on 02/25/11. The administrative team were again informed of the discrepancies with the information/documentation (as described above) gathered during this investigation. The facility's policy was reviewed at this time. The policy documented: "...Residents care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents...The administrator or designee shall thoroughly investigate all allegations...Results of the investigation related to the resident's incident shall be reported to officials (state and federal)...Reports will be made...including an injury of unknown source...All allegations will be reported immediately to the Health Department...Injuries of unknown origin must be regarded in the same regulatory light as mistreatment, neglect, and abuse...The DON will ensure that the appropriate supervisor investigates...department head will investigate all...record the details of the incident...INVESTIGATIONS...will follow a systemic approach to include: establish the who, what, where, why, and how regarding the incident...Investigation guidelines and an investigation checklist are attached as enclosure 2... The computerized "fall investigation" was presented on 07/07/11 at approximately 3:45 p.m. The fall investigation was incomplete and did not provide any additional information regarding the fall. Resident # 3 was observed multiple times during the survey process with a "tab alarm" attached to her clothing. On 07/08/11 Resident # 3 was observed at approximately 10:50 a.m. in the hallway with a "tab" alarm attached to the resident's clothing and a sensor pad box was also observed on the back of the recliner with a cord attached. At approximately 4:30 p.m. the survey team met again with the DON, administrator and administrative staff # 3. The facility staff were informed of the interview with CNA # 2 and the discrepancies found during the survey process. The administrator stated that she (the administrator) did know how CNA # 2 could remember that far back. The administrator also stated that the nurse (identified as the ADON-assistant director of nursing) on duty when the fall occurred investigated the fall and stated that she (the ADON) was "new" and didn't know how to conduct the investigation and that the fall had occurred on the weekend. The facility staff were informed of the alterations observed on the TARs and that no identifiable information to determine who documented the alterations or when they were made. Administrative staff # 3 stated that whatever was documented is what we (the facility) had. Administrative staff # 3 further stated that staff are educated after every fall and she (Admin. # 3) didn't know how to respond that. No further information or documentation was provided prior to the exit conference on 07/08/11 at 2:15 p.m., to evidence that Resident # 3 had appropriate supervision and the appropriate (correct) physician's orders [REDACTED].