Every finding on record at The Vosswood Nursing Center

Based on interview and record review the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 (Sunday 01/01/2023, Sunday 01/08/2023 and Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023 of 90 days reviewed for RN coverage. The facility failed to maintain registered nurse coverage for 8 hours a day/7days a week on Sunday 01/01/2023, Sunday 01/08/2023,Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023. This failure could place residents at risk of adverse events and not having staff to attend to events. The findings were: Record review of the staffing schedule from Sunday 01/01/2023, Sunday 01/08/2023, Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023 revealed 5 of 90 days there was not eight-hour continuous registered nurse coverage on the weekends (Saturday/Sunday) for the dates reviewed. Interview with the DON on 6/19/2023 12:30 pm, she stated the reason an RN's are needed at least 8 hours a day to oversee and manage residents in the event of emergency, triage and/or skilled intervention. She stated she was notified when an RN is scheduled and doesn't show up, and she will attempt to staff it or come to the facility herself to assure proper RN coverage. She stated she is aware there was no RN coverage on 01/01/2023, 01/08/2023, 02/25/2023, 03/25/2023 and 03/26/2023. DON stated she was not employed during this time. Interview with the Staffing Coordinator on 6/19/2023 12:40 pm revealed she performed scheduling and has full time coverage for RNs during the week and on weekends; the schedule was reviewed and verified. She states she is notified when the registered nurse doesn't come in and will try to staff the vacancy and will call the DON when needed. Review of the facility's Policy and Procedure for staffing did not address the need for RN coverage 7 days a week.

Based on observation, interview and record review, the facility failed to inform and enable participation in treatment in a way she could understand for 1 of 13 residents (Resident #16) reviewed for care plans, in that: Resident #16 did not have a comprehensive care plan completed to address her communication-barrier within 7 days after the completed of her comprehensive assessment. This failure placed residents at risk of not receiving services that could maintain the resident's highest practicable mental, and psychosocial well-being. Findings Included: Record review of Resident #16's face sheet, dated 06/20/2023, revealed a [AGE] year-old female resident who was admitted into the facility on [DATE] and was diagnosed with metabolic encephalopathy, overactive bladder and cognitive communication deficit. Record review of Resident #16's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating the resident's cognition was severely impaired and was assessed to not need or want an interpreter to communicate with staff. In an interview with Resident #16 on 06/18/23 at 9:39AM, surveyor attempted to complete the interview in English but Resident #16 could not respond. With the use of a Vietnamese translator via phone, she stated she had no way to communicate with the staff and she felt like the nurses were rude to her. Record review of Resident #16's care plan, dated, dated 06/14/2023, revealed the care plan was not completed and did not address the communication-barrier the resident had. In an interview with RN B on 06/18/2023 at 11:00PM, she revealed she called Resident #16's family member sometimes to talk with the resident and see what she needs. She said Resident #16's Physician Assistant also speaks Vietnamese and is able to talk to her when she visits. In an interview with the family member of Resident #16 on 06/19/23 at 02:08 PM, she stated Resident #16's main complaint was that she often felt ignored by the staff even after pressing the call light and telling them what she needed. In an interview with CNA R on 06/20/2023 at 10:48 AM, she stated Resident #16 spoke Vietnamese and communicated with staff by pointing and making gestures to let them know when she wanted to use the restroom or go to bed. In an interview with the Regional MDS Coordinator on 06/20/23 at 11:26 AM, he stated he worked for multiple facilities. He said the rule for care plans was that it had to be completed within 7 days after the comprehensive MDS assessment is completed. He said care plans were important for informing the team about the resident's special needs and how the resident is to be cared for. He stated communication barriers and ADLs should be care planned for all residents, but the facility did not have an MDS Coordinator to manage all the care plans, so that was a contributing reason as to why Resident #16 did not have a comprehensive care plan. In an interview with the DON on 06/20/23 at 11:36 AM, she stated the facility had one part-time MDS and a regional MDS Coordinator helping with comprehensive assessments and care plans, but the facility was in need of a full-time MDS Nurse for the constant turnover of residents. She stated communication barriers and ADLs need to be included in comprehensive care plans, as they serve as communication for the interdisciplinary team to know necessary interventions to prevent any further decline in the resident. Record review of the facility's policy on comprehensive care plans, dated 08/17/2022, revealed, . The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs . a comprehensive care plan must be- i) developed within 7 days after completion of the comprehensive assessment .

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 13 residents (Resident #16) reviewed for care plans, in that: Resident #16 did not have a comprehensive care plan completed to address her communication-barrier r within 7 days after the completed of her comprehensive assessment. This failure placed residents at risk of not receiving services that could maintain the resident's highest practicable mental, and psychosocial well-being. Findings Included: Record review of Resident #16's face sheet, dated 06/20/2023, revealed a [AGE] year-old female resident who was admitted into the facility on [DATE] and was diagnosed with metabolic encephalopathy, overactive bladder and cognitive communication deficit. Record review of Resident #16's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating the resident's cognition was severely impaired and was assessed to not need or want an interpreter to communicate with staff. In an interview with Resident #16 on 06/18/23 at 9:39AM, surveyor attempted to complete the interview in English but Resident #16 could not respond. With the use of a Vietnamese translator via phone, she stated she had no way to communicate with the staff and she felt like the nurses were rude to her. Record review of Resident #16's care plan, dated, dated 06/14/2023, revealed the care plan was not completed and did not address the communication-barrier the resident had. In an interview with RN B on 06/18/2023 at 11:00PM, she revealed she called Resident #16's family member sometimes to talk with the resident and see what she needs. She said Resident #16's Physician Assistant also speaks Vietnamese and is able to talk to her when she visits. In an interview with the family member of Resident #16 on 06/19/23 at 02:08 PM, she stated Resident #16's main complaint was that she often felt ignored by the staff even after pressing the call light and telling them what she needed. In an interview with CNA R on 06/20/2023 at 10:48 AM, she stated Resident #16 spoke Vietnamese and communicated with staff by pointing and making gestures to let them know when she wanted to use the restroom or go to bed. In an interview with the Regional MDS Coordinator on 06/20/23 at 11:26 AM, he stated he worked for multiple facilities. He said the rule for care plans was that it had to be completed within 7 days after the comprehensive MDS assessment is completed. He said care plans were important for informing the team about the resident's special needs and how the resident is to be cared for. He stated communication barriers and ADLs should be care planned for all residents, but the facility did not have an MDS Coordinator to manage all the care plans, so that was a contributing reason as to why Resident #16 did not have a comprehensive care plan. In an interview with the DON on 06/20/23 at 11:36 AM, she stated the facility had one part-time MDS and a regional MDS Coordinator helping with comprehensive assessments and care plans, but the facility was in need of a full-time MDS Nurse for the constant turnover of residents. She stated communication barriers and ADLs need to be included in comprehensive care plans, as they serve as communication for the interdisciplinary team to know necessary interventions to prevent any further decline in the resident. Record review of the facility's policy on comprehensive care plans, dated 08/17/2022, revealed, . The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs . a comprehensive care plan must be- i) developed within 7 days after completion of the comprehensive assessment .

Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 4 of 8 residents (Resident #1, CR #1, Resident #2 and Resident #4) reviewed for professional standards. - The facility failed to accurately transcribe Resident #1's hospital discharge medications upon admission resulting in the resident receiving the wrong dose of Ethacrynic Acid (a diuretic) from 01/11/23 to 01/20/23 resulting in the resident developing edema (swelling) in her lower leg and discomfort. - The facility failed to monitor Resident #1's weights as ordered by the physician. - The facility administered Ciprofloxacin (an antibiotic) to Resident #1 without an indication or a physician directed order. - The facility failed to enter wound care orders for CR #1 upon admission resulting in the resident not receiving wound care from 01/18/23 to 01/20/23. - The facility failed to enter IV catheter site dressing change orders for Resident #2 upon admission resulting in the resident receiving no dressing changes from 12/30/22 to 01/23/23. - The facility failed to enter IV catheter care and dressing change orders for Resident #4 upon readmission from the hospital resulting in the resident receiving no catheter flushes or dressing changes from 01/17/23 to 01/23/23. - The facility continued to perform NS flushes and Heparin (a blood thinner) locks to Resident #4's IV catheter, that should only be performed when an IV antibiotic is administered , against the MD's orders after IV medications had been discontinued. These failures could place residents at risk of inadequate wound care, infection and, and adverse reactions. Findings Included Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review Resident #1's facility provided Hospital Discharge Instructions dated 01/09/23 revealed, What- Ethacrynic acid 25 mg oral tablet; how much- 2 tab(s) by mouth; When- 2 times daily; Duration- 30 days; Next dose 01/10/23 at 9 AM. Record review of Resident #1's Order Summary dated 01/09/23 revealed Ethacrynic Acid 25 mg- give 1 tablet by mouth every 12 hours for CHF. Order entered by LVN B. Record review of Resident #1's Admission assessment dated [DATE] and signed by LVN B revealed, resident has diagnosis of heart failure- No; Edema Present: No Record review of Resident #1's Medication Reconciliation Form dated 01/09/23 and signed by LVN B revealed, an admission reconciliation was completed and no clinically significant medication issues were identified during reconciliation. Record review of Resident #1's MD Progress Notes dated 01/10/23 revealed, History of Present Illness: Patient was seen sitting up EOB, she is very anxious that her meds were changed at the last hospitalization , and that she is not sure what she is currently on. D/W, that her Lasix (a diuretic) was changed to Ethacrynic acid 2/2 (2 tablets twice a day) to her CKD She says her pain is ok, but her main concerns is the medications. Plan- On Ethacrynic acid, weights MWF, if unable to get ethacrynic acid, cautious use Lasix, would like to first get bmp results back, d/w her that given her previous regiment is what led to her SOB, would be prudent to try and keep on hospital regimen for now . Record review of Resident #1's January 2023 MAR revealed- Ethacrynic acid 25 mg-give 1 tablet by mouth every 12 hours for CHF was administered on: 01/11/23 scheduled for 09:00 PM 01/12/23 scheduled for 09:00 AM and 09:00 PM 01/13/23 scheduled for 09:00 AM and 09:00 PM 01/14/23 scheduled for 09:00 AM and 09:00 PM 01/15/23 scheduled for 09:00 AM and 09:00 PM 01/16/23 scheduled for 09:00 AM and 09:00 PM 01/17/23 scheduled for 09:00 AM and 09:00 PM 01/18/23 scheduled for 09:00 AM and 09:00 PM 01/19/23 scheduled for 09:00 AM and 09:00 PM Record review of Resident #1's January 2023 MAR revealed; Ethacrynic Acid 25 mg- 2 tablet by mouth every 12 hours for swelling for 5 days was first administered on 01/20/22 at 09:00 PM. Record review of Resident #1's Order Summary dated 01/11/23 revealed, Weights MWF- Three times a week every Monday, Wednesday and Friday. Record review of Resident #1's January TAR revealed, resident weight task was documented as performed on 01/11/23, 01/13/23, 01/16/23, 01/18/23, 01/20/23, 01/23/23, 01/25/23. Record review of Resident #1's Physician's Orders dated 01/12/23 at 12:53 PM revealed, Ciprofloxacin 100 mg- give 1 tablet by mouth two times a day related to acute respiratory failure with hypoxia (low blood oxygen). The order was discontinued on 01/13/23 at 12:57 PM. Record review of Resident #1's January 2023 MAR revealed, Ciprofloxacin 100 mg- give 1 tablet by mouth twice a day r/t acute respiratory failure with hypoxia for 10 days was administered for 2 days before the order was discontinued: - 01/12/23 scheduled for 08:00 PM - 01/13/23 scheduled for 08:00 AM. Record review of Resident #1's Weights and Vitals revealed, no weights were documented for Resident #1 for January. Resident #1's vitals indicated no hypoxia, her O2 saturation rate was > 90% during the duration of her residency. Record review of Resident #1's January 2023 Progress Notes revealed, no mention of a prescription for ciprofloxacin, worsening of symptoms, change of conditions, acute respiratory failure, assessments, hypoxia or indication for the use of Ciprofloxacin. Record review of Resident #1's PA Progress Note dated 01/13/23 revealed, Patient is evaluated sitting in WC comfortably. She appears to be no acute distress. Patient notes generally feeling well. No reported coughing, wheezing, shortness of breath. There is no mention of initiating or discontinuing Ciprofloxacin. Record review of Resident #1's MD Progress Note dated 01/17/23 revealed, Physical Exam- no edema. Record review of Resident #1's PA Progress Note dated 01/18/23 revealed, Physical Exam- trace pedal edema (slight swelling due to fluid in the feet). Record review of Resident #1's PA Progress Note dated 01/20/23 revealed. Physical Exam- 1-2+ edema bilateral lower extremity to mid tib (from foot to mid leg). Diagnosis-Assessment-Plan: systemic heart failure- bilateral lower extremity edema noted, cardiopulmonary exam without irregular findings, we will increase Ethacrynic Acid to 50 mg twice a day, Monitor blood pressure. Record review of Resident 1's PA, progress Note dated 01/23/23 revealed, Physical Exam- Trace/1+ bilateral (on both sides) pedal (foot) and ankle edema. Diagnosis-Assessment-Plan: systolic heart failure- lower extremity edema improving with increase of Ethacrynic acid. Record review of Resident #1's MD Progress Note dated 01/24/23 revealed, History of Present Illness- Patient noted to have some increased pedal edema (swelling in the foot); started on increased dose of Ethacrynic acid on 01/20/23. An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she was very concerned because she had not been receiving her diuretic as ordered. She said when she was in the hospital she was changed from Furosemide because it was a strain on her kidneys and placed on another diuretic (Ethacrynic Acid) but the facility did not have it for the first 3 days she was there. Resident #1 said when she admitted to the facility from the hospital she never had swelling in her ankle or feet but her feet started swelling because she had not received her diuretic. She said the doctor changed her medication a few days ago so the swelling had improved, but her feet and ankle were much worse before. Resident #1 said she had not been weighed since she admitted to the facility but denied any shortness of breath. In an interview on 01/24/23 at 11:43 AM, the MD said Resident #1 admitted to the facility with CHF. She said that the resident did not tolerate Furosemide so she was changed to Ethacrynic acid in the hospital. The MD said that she entered orders for weights to be performed on Resident #1 MWF to assess for exacerbation of her CHF but she had not seen any weights in the patients record. The MD said failure to monitor weights could reduce the ability to identify CHF exacerbation. The MD said Resident #1 developed edema while admitted to the facility so the PA increased her diuretic, but she had no chest pain or SOB. The MD said the risk of not receiving a diuretic as ordered placed residents at risk of exacerbation of heart failure, SOB and Hypoxia (low oxygen in the blood). In an interview on 02/02/23 at 4:29 PM, the MD said that besides developing edema Resident #1 had not shown any worsening of symptoms like hypoxia and no signs of an infection. She said that her orthopedic surgeon recommend the resident take a prophylactic antibiotic (doxycycline) but to her knowledge there was no indication for Resident #1 to receive any other antibiotics. She said she did not place an order for the resident to receive ciprofloxacin and was not aware the resident received Cipro. In an interview on 02/03/23 at 03:36 PM, the PA said that he increased Resident #1's Ethacrynic Acid 25 mg to 2 tablets twice daily because the resident developed edema and that he was unaware that the resident was supposed to be receiving Ethacrynic Acid 25 mg 2 tablets twice daily as ordered from the hospital. He said failure to receive a diuretic as ordered would place residents at risk for increased edema or exacerbation of their HF but besides the edema the resident did not have any other s/sx like SOB or abnormal lung sounds. The PA said the resident had no signs or indications of infection and he did not place an order for Ciprofloxacin because there was no need for it and he was unaware Resident #1 received 2 doses of Cipro CR #1 Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, clean bilateral arms sutures with normal saline and cover with DSD, wrap with kerlix and ace wrap twice a day and PRN. Entered by LVN A. There were no orders for wound care or dressing changes entered at admission or before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview of 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. Resident #2 Record review of Resident #2's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis which included; Cellulitis (skin infection) of the left lower limb, and cutaneous abscess of the left lower limb. Record review of Resident #2's Care Plan dated 01/13/23 revealed, Focus- resident has infection, Interventions- administer antibiotics as per MD order. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #2's Order Summary dated 01/25/23 at 04:39 AM revealed, Midline (a catheter inserted in the upper arm used to administer medication) to right arm entered 01/11/23. The resident did not have any orders to monitor the midline, or changed the midline dressing until 01/24/23. Record review of Resident #2's Orders dated 12/30/22 revealed, Ertapenem 1 gm intravenously every 24 hours for infection for 36 days. Record review of Resident #2s December 2022 MAR dated 01/25/23 revealed, no documented dressing change for the resident's midline. Record review of Resident #2's January 2023 MAR dated 01/25/23 revealed, the only day in January Resident #1's midline dressing was changed was on 01/24/23 during the night shift. An observation on 01/24/23 at 01:57 PM revealed, Resident #2 lying in bed. The resident appeared well fed, well dressed, in no immediate distress with an IV site to her left upper arm. The IV dressing appeared in tact, with no visible labeling. Dark old blood could be observed around the site at which the catheter entered the resident's arm. Resident #2 said she was receiving antibiotics via an IV site on her right arm and she could not remember when her dressing was last changed. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and suspected carrier of MRSA (a drug resistant bacteria). Record review of Resident #4's Care Plan printed 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Progress Notes dated 01/10/23 at 6:09 PM revealed, resident discharged to the hospital increased confusion, blood in catheter tubing/urine and an elevated WBC (an indication of infection) of 33.1. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Record review of Resident #4's Progress Notes dated 01/24/23 at 1:48 PM revealed, Double lumen PICC ( an IV catheter with more than one internal [NAME]) line dressing changed to right upper arm and tolerated well. No visible signs of pain noted at this time. Record review of Resident #4's Order Summary Report dated 01/25/23revealed, prior to discharge from the hospital on 01/10/23 the resident had orders for the maintenance of her IV catheter: - Heparin Lock Flush 10 unit/ml- use 5 ml intravenously every shift for antibiotic use, flush line after post medication with NS flush. This order was discontinued on 01/16/23 while Resident #4 was in the hospital. Record review of Resident #4's Physician's Orders dated 01/24/23 revealed, the resident had no PICC line care orders from 01/17/23 until 01/23/23. The following orders were entered on 01/24/23 after the surveyor notified the facility of missing catheter orders: Change PICC line transparent dressing weekly every Wed Measure upper arm circumference (10cm above antecubital). Measure external catheter length. Notify if length has changed since last measurement., Change IV administration tubing every day shift every 24 hours, Change needleless connector as needed, Observe PICC line insertion site every shift for s/s of infection. Notify MD accordingly. Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift Flush PICC line after medication. Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift Flush PICC line before medication. Heparin Lock Flush Solution 10 UNIT/ML Use 5 ml intravenously every shift for flush, Flush PICC line Record review of Resident #4's January 2023 MAR revealed, no dressing changes occurred to Resident #4's IV catheter site from readmission (01/17/23) till after the facility was notified by the surveyor on 01/24/23. No heparin flushes were performed on Resident #4's IV catheter from readmission (01/17/23) until after the facility was notified by the surveyor on 01/24/23. No NS flushes were performed on Resident #4's IV catheter from readmission (01/17/23) until after the facility was notified by the surveyor on 01/24/23. Record review of Resident #4's January 2023 MAR revealed, nursing staff continued to perform a Heparin Lock Flush on Resident #4 IV catheter after the resident completed her IV antibiotic course on 01/24/23 even though the MD order specified the flush was only to be performed after the post-medication NS flush. - 01/25/23 scheduled for the night shift was performed - 01/26/23 scheduled for the night shift was performed - 01/27/23 to 01/29/23 scheduled for the morning and night shifts were performed - 01/30/23 scheduled for the morning shift was performed Record review of Resident #4's January 2023 MAR revealed, nursing staff continued to perform NS flushes on Resident #4's IV catheter after the resident completed her IV antibiotic course on 01/24/23 even though the MD order specified the NS flushes were only to occur before and after medications. - 01/25/23 scheduled for the night shift was performed - 01/26/23 scheduled for the night shift was performed - 01/27/23 to 01/29/23 scheduled for the morning and night shifts were performed - 01/30/23 scheduled for the morning shift was performed An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics and her dressing had not been changed since she readmitted to the facility (01/17/23). In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds or IV catheter sites. She said nurses should immediately enter standard wound care orders for monitoring/cleaning/dressing changes and IV catheter sites should have scheduled dressing changes as well as flushes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care or IV catheter site related orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of the missing IV catheter care orders for Resident #2 and Resident #4 and CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of temporary staff from a staffing agency . The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, or IVs and these orders included tasks needed for care of wounds or IV catheter sites. Record review of the facility provided policy titled Admissions Policy revised 01/05/23 revealed, no specific directions for processing admissions orders. Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for managing catheter sites and surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed: IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN . observe line insertion site every shift for signs and symptoms of infection . flush line with 10 ml NS before medications.

Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and care plans for 2 of 8 resident (Resident #2 and Resident #4) reviewed for parenteral intravenous (IV) antibiotic care and services through a peripherally inserted central catheter (PICC) therapy in that: - The facility failed to provide care or dressing changes to Resident #2's IV catheter site from 12/30/22 to 01/23/23. - The facility failed to provide care or dressing changes to Resident #'s 4 IV catheter site from 01/17/23 to 01/23/23. These failures could place residents at risk for adverse reactions, deterioration of wounds and infection. Resident #2 Record review of Resident #2's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis which included; Cellulitis (skin infection) of the left lower limb, and cutaneous abscess of the left lower limb. Record review of Resident #2's Care Plan dated 01/13/23 revealed, Focus- resident has infection, Interventions- administer antibiotics as per MD order. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #2's Order Summary dated 01/25/23 at 04:39 AM revealed, Midline to right arm entered 01/11/23. The resident did not have any orders to monitor the midline, change the midline or change the midline dressing until 01/24/23. Record review of Resident #2 December 2022 MAR revealed, no documented dressing change for the resident's midline. Record review of Resident #2's January 2023 MAR dated 01/25/23 revealed, between 01/01/23 to 01/23/23 there were no documented dressing changes performed to Resident #2's PICC line. The only day in January Resident #1's midline dressing was changed was on 01/24/23 during the night shift. An observation on 01/24/23 at 01:57 PM revealed, Resident #2 lying in bed. The resident appeared well fed, well dressed, in no immediate distress with an IV site to her left upper arm. The IV dressing appeared in tact, with no visible labeling. Dark old blood could be observed around the site at which the catheter entered the resident's arm. Resident #2 said she was receiving antibiotics via an IV site on her right arm and she could not remember when her dressing was last changed. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, Streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and carrier pr suspected carrier of MRSA (methicillin antibi biotic resistant bacterial infection). Record review of Resident #4's Care Plan saved 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Progress Notes dated 01/10/23 at 6:09 PM revealed, resident discharged to the hospital increased confusion, blood in catheter tubing/urine and an elevated WBC of 33.1. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Record review of Resident #4's Physician's Orders dated 01/24/23 revealed, no PICC line care orders from 01/17/23 to 01/23/23., The following orders were entered after the surveyor notified the facility of missing catheter orders on 01/24/23: Change PICC line transparent dressing weekly every Wed Measure upper arm circumference (10cm above antecubital). Measure external catheter length. Notify if length has changed since last measurement., Change IV administration tubing every day shift every 24 hours, Change needleless connector as needed, Observe PICC line insertion site every shift for s/s of infection. Notify MD accordingly. Record review of Resident #4's Progress Notes dated 01/24/23 at 1:48 PM revealed, Double lumen PICC ( an IV catheter with more than one internal channel) line dressing changed to right upper arm and tolerated well. No visible signs of pain noted at this time. Record review of Resident #4's January 2023 MAR revealed, no dressing changes occurred to Resident #4's IV catheter site from readmission (01/17/23) till after the facility was notified by the surveyor on 01/24/23. An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics and her dressing had not been changed since she readmitted to the facility (01/17/23). In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any IV catheter sites. She said nurses should immediately order standard orders for residents admitting with IVs and IV catheter sites should have scheduled dressing changes as well as flushes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter IV catheter site related orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. The DON said she was unaware of the missing IV catheter care orders for Resident #2 and Resident #4, but the facility had identified issues with admissions orders associated with the use of temporary nurses from staffing agencies. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and she was currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with IVs and these orders included tasks needed for care IV catheter sites. Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for managing catheter sites and surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN .

Based on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 8 residents (Resident#1, Resident #3 and Resident #4) reviewed for pharmaceutical services. - The facility failed to acquire and dispense Ethacrynic Acid 25 mg , a diuretic, to Resident #1 as ordered from 01/09/23 to 01/11/23 . - The facility failed to acquire and dispense Oxycodone 80 mg , a pain medication, to Resident # 4 as ordered from 01/20/23 to 01/22/23 leaving the resident in pain. - The facility failed to acquire and administer IV antibiotic Cefepime and Vancomycin as ordered to Resident #4 for a bone infection with antibiotic resistant bacteria. - The facility failed to timely investigate Resident #3's IV medication error and to timely put measures in place to prevent future medication errors. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review of Resident #1's Order Summary dated 01/09/23 revealed Ethacrynic Acid 25 mg- give 1 tablet by mouth every 12 hours for CHF. Order entered by LVN B. Record review of Resident #1's January MAR revealed, Resident #1 did not receive Ethacrynic Acid on the following days because the medication was not available: 01/09/23 scheduled for 09:00 AM 01/10/23 scheduled for 09:00 AM and 9 PM 01/11/23 scheduled for 09:00 AM An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well fed, well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she was very concerned because she has not been receiving her diuretic as ordered. She said when she was in the hospital she was changed from Furosemide because it was a strain on her kidneys and placed on another medication( Ethacrynic Acid) but the facility did not have it for the first 3 days she was there. Resident #1 said when she admitted to the facility from the hospital she never had swelling in her ankle prior to admission to the facility or feet but her feet started swelling because she had not received her diuretic. She said the doctor changed her diuretic (Ethacrynic Acid) a few days ago so the swelling had improved, but her feet and ankle were much worse before. In an interview on 01/24/23 at 11:43 AM, the MD said Resident #1 admitted to the facility with CHF. She said that the resident did not tolerate Furosemide so she was changed to Ethacrynic acid and when Resident #1 admitted the facility did not have the medication available for administration because it didn't arrive from the pharmacy. The MD said Resident #1 experienced stress due to her missed medications which resulted in her BP being elevated. She said the resident later developed edema while admitted to the facility so the PA increased her diuretic, but she had no chest pain or SOB. The MD said the risk of not receiving a diuretic as ordered placed residents at risk of exacerbation of heart failure, SOB and Hypoxia (low oxygen in the blood). In an interview on 01/25/23 at 1:29 PM, the Pharmacist said the first delivery for Resident #1's Ethacrynic acid was on 01/11/23 and signed by LVN C at 10:18 PM. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, Streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and a suspected carrier of MRSA. Record review of Resident #4's Care Plan printed 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Oxycodone ER 80 mg- give 1 tablet by mouth every 12 hours as needed for pain. Vancomycin 1 gm intravenously at bed time for wound infection until 01/24/23. Record review of Resident #4's January MAR revealed, Resident #4 did not receive her Cefepime antibiotic for 7 out of 14 doses scheduled between 01/18/23 to 01/24/23. - Non administered on 01/19/23 for the 08:00 PM dose. - Non administered on 01/20/23 for the 08:00 PM dose. - Non administered on 01/21/23 for the 08:00 AM dose. - Non administered on 01/22/23 for the 08:00 PM dose. - Non administered on 01/23/23 for the 08:00 PM dose. - Non administered on 01/24/23 for the 08:00 AM and 8:00 PM dose. Record review of Resident #4's Progress Notes dated 01/22/23 at 10:00 AM revealed, Writer went to resident's room to give her scheduled medication and resident requested PRN pain medication at this time. Gave resident PRN oxycodone 5mg and resident stated that she wanted Oxycodone 80mg. Informed resident that medication is unavailable at this time that I will have to call MD. Resident started to yell and curse writer out and calling degrading names. Redirected resident to not yell and degrade and she continues to yell stating I better give her medication right now otherwise she is leaving her and going to report me. Resident started to throw thing in room and says she will continue to yell and throw things if she has to break the window she will. Record review of Resident #4's Progress Notes dated 01/22/23 at 11:10 PM revealed, the PA was notified that Resident #4 did not have her Oxycodone 80 mg . Informed resident that MD is calling her medication into pharmacy and will be available soon. Resident stated that was not good enough. Record review of Resident #4's January MAR revealed, Resident #4 did not receive any Oxycodone 80 mg from 01/20/23 to 01/22/23. Record review of Resident #4's January MAR revealed, Resident #4 did not receive her 11 PM scheduled dose of Vancomycin on 01/19/23. In an interview on 01/23/23 at 12:09 PM, Agency Nurse #1 said she was unable to administer Vancomycin to Resident #4 on 01/19/23 because the medication was not available. She said Resident #4 asked for pain medication but there was non available in the facility. An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident #4 had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics. She said over the weekend (01/20/23 to 01/21/23) she was in intense pain and the facility did not have her Oxycontin 80 mg tablet. Resident #4 said over the weekend the facility had agency nurses who did not understand her pain control regimen. Resident #4 said she was receiving antibiotics but did not know the facility failed to administer any doses of her antibiotics. In an interview on 01/24/23 at 11:25 AM, LVN B said Resident #4 informed her that over the weekend of 01/20-01/21/23 she was in pain because she did not receive her Oxycodone 80 mg. In an interview on 01/24/23 at 11:43 AM, the MD said she was informed that the facility did not have Oxycodone 80 mg for Resident #4 over the weekend because it did not arrive from the pharmacy. She said the resident complained to her about not receiving the medication and being in pain. She said failure to provide pain medication as ordered could place residents at risk for inadequate pain management. In an interview on 01/25/23 at 01:29 PM, the Pharmacist said the pharmacy delivered 14 tablets of Oxycodone 80 mg on 01/24/23 at 11:08 PM. In an interview on 02/02/23 at 04:29 PM, the MD said the facility did not notify her any missed IV antibiotic doses for Resident #4 and it was her expectation that nursing staff inform her or the PA about any medication administration discrepancies. The MD said Resident #4 appeared clinically stable with no elevated temperatures or signs of wound deterioration but failure to administer IV antibiotics as ordered could place the resident at risk of worsening of infection or the development of resistance to the antibiotic being used. In an interview on 02/06/23 at 12:26 PM, the DON said that she was hospitalized during the period in which Resident #1 did not receive her diuretic and she was unaware of the specifics of that incident. She said nursing staff are responsible for entering medication orders into the EMR system which is interconnected to the pharmacy system. She said once an order is entered the pharmacy immediately processes the order for delivery but if the medication is not received, nursing staff can retrieve medication from the EKit or order a stat delivery from the pharmacy. The DON said she was unaware that Resident #4 did not receive her IV antibiotics as scheduled nor was she aware that Resident #4's pain medication was unavailable from 01/20/23 to 01/24/23. The DON said failure to administer IV antibiotics, diuretics and pain medication as ordered places residents at risk of decreased efficacy of the antibiotic treatment leading to infection, uncontrolled pain and exacerbation of CHF. Resident #3 Record review of Resident #3's Face Sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection) unspecified organism, acute respiratory failure with hypoxia, hypertension, pressure ulcer of sacral region and unspecified bacterial pneumonia. Record review of Resident #3's Care Plan dated 01/24/23 revealed, focus- infection sepsis/bacteremia pneumonia; intervention- medication as ordered. Record review of Resident #3's MDS dated [DATE] and completed 01/25/23 revealed, no BIMS assessment, no assessment of cognitive patterns, antibiotic use, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #3's Order Summary Report dated 01/25/23 revealed, Meropenem (antibiotic) intravenous solution- use 500 mg intravenously every 8 hours for sepsis for 42 days. Record review of Resident #3's January MAR revealed, LVN E administered Resident #3's scheduled dose of IV Meropenem antibiotics on 01/16/23 at 06:30 AM. Record review of Resident #3's Progress Notes dated 01/17/23 at 5:07 PM revealed- LVN D found a bag of antibiotics belonging to another resident that was administered by LVN E to Resident #3 on 01/16/23. The resident was on Meropenem but LVN D found Ertapenem was administered to Resident #3. MD notified and she said ok to continue to monitor. Record review of Resident #3's January Clinical Assessments revealed- no assessments were documented following the medication error. Record review of Resident #3's January Progress notes revealed, no further documentation/assessments/notes about Resident #3's medication error. Record review of the Facility Incident Report dated 01/24/23 revealed, Resident #3 had a medication discrepancy incident on 01/17/23 at 04:57 PM. In an interview on 01/24/23 at 11:43 AM, the MD said she was informed that Resident #3 received Ertapenem instead of Meropenem, but she was not informed of whose medication Resident #3 received. The MD said that Resident #3 experienced no side effects or ADRs and she instructed LVN D to submit a report for the medication error. The MD said she had not heard any increase patient concerns about medication errors nor has she observed an increase in medication errors in the facility. An attempt was made to interview LVN D on 01/24/23 at 2:00 PM but staff was out sick. In an interview on 01/25/23 at 3:26 PM, the DON said Resident #3 received another patient's antibiotic on 01/17/23 but she had not completed her investigation of the incident. She said that she did not know whose medication Resident #3 received, nor did she know the individual who administered the medication to Resident #3. The DON could not provide details as to how the error occurred but said she provided an in-service to staff about medication errors. She could not provide further details on what the in-service about medication errors covered and could not state what corrective action was taken since she was still investigating the allegation. The DON said since the antibiotic Resident #3 received was in the same class as what was prescribed she believed the medication error was not a risk to the patient. An attempt was made to interview LVN D on 01/26/23 at 3:07 PM, revealed the facility provided contact number was disconnected. An attempt was made to interview LVN D on 02/06/23 at 11:23 AM, revealed the facility provided contact number was disconnected. In an interview on 02/06/23 at 02:10 PM, the Administrator said medication errors are expected to be investigated promptly within 24 hours to identify what caused the error and to put measures in place to prevent the reoccurrence. Record review of the facility policy titled Incident and Reportable Event Management revised 06/17/22 revealed, to help reduce the risk of an event, all residents receive assistance and supervision as addressed in their care plan. If an event occurs, the facility will follow the 5 Is in an effort to minimize the potential for recurrence. 1- Incident (what happened or was reported as happening), 2- Injury (provide care and document the injury), 3- Interview (who saw the resident last or at the time of the event), 4- Investigated (why did it happen), 5- Intervention (what mitigation effort are we using). Event management includes, but is not limited to, the following type of events: Medication Discrepancy. Record review of the facility policy titled Administration of Medications revised 08/25/22 revealed, The facility will ensure medications are administered safely and appropriately per physician's order to address residents' diagnosis and signs and symptoms. The documented contained no specific instructions on medication acquisition. Record review of the facility policy titled General Dose Preparation and Medication Administration revised 01/01/13 revealed, no specific instructions on medication acquisition. Record review of the facility provided inventory list titled EKit Contents dated 01/18/23 revealed, there was no Ethacrynic Acid or Oxycodone contained in the emergency kit.

Based on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 5 residents (Resident #1 and Resident #4) whose records were reviewed for accuracy and completeness. - The facility failed to document accurately in Resident #1's EMR by documenting the performance of weights that were not performed. - Facility staff failed to document accurately in Resident #1's and #4's EMR by using log in credentials assigned to other users. These failures could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Include: Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review of Resident #1's Order Summary dated 01/11/23 revealed, Weights MWF- Three times a week every Monday, Wednesday and Friday. Record review of Resident #1's January TAR revealed, resident weight task was documented as performed on 01/11/23, 01/13/23, 01/16/23, 01/18/23, 01/20/23, 01/23/23, 01/25/23. Record review of Resident #1's Weights and Vitals revealed, no weights were documented for Resident #1 for the entire month of January An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she had not been weighed since she admitted to the facility In an interview on 02/06/23 at 12:26 PM, the DON said weights are performed by CNAs and not Nurses, so documentation of weights being performed in the nursing MAR would not be an accurate reflection of the task being performed. Credential Use Record review of the facility schedule dated 01/19/23 revealed, Agency Nurse #1 was scheduled to work the 4th floor on the 06:00 PM to 06:00 AM shift. Record review of Agency Nurse #1's payroll punches dated 01/19/23 revealed, she started her shift in at 06:12 PM on 01/19/23 and ended her shift at 06:08 AM on 01/20/23. Record review of the facility schedule dated 01/19/23 revealed, LVN B was scheduled to work the 4th floor on the 06:00 AM to 06:00 PM shift. Record review of LVN B's payroll punches dated 01/19/23 revealed, she started her shift on 06:04 AM and ended her shift at 07:04 PM. Resident #1 Record review of Resident #1's MAR dated 01/19/23 reveled, LVN B was documented as administering medications when she was clocked out and no longer in the building: - Doxycycline 100 mg, 1 tablet every 12 hours- dose scheduled for 09:00 PM administered by LVN B. - Trazodone 50 mg, 1 tablet for insomnia- administered at 10:08 PM by LVN B. - Bio freeze external gel (a topical analgesic)- dose scheduled for 08:00 PM administered by LVN B. - Calcium Carbonate 600 ( a dietary supplement) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Carvedilol 12.5 mg ( for high blood pressure) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Ethacrynic Acid 25 mg (a diuretic) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Nifedipine ER 30 mg ( for high blood pressure) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Senna 8.6 mg ( for constipation) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. Resident #4 Record review of Resident #4's MAR dated 01/19/23 reveled, LVN B was documented as administering medications when she was clocked out and no longer in the building: - Xanax 1 mg (for anxiety) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Apixaban 5 mg (blood thinner) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Nortriptyline 50 mg (for high blood pressure) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Atorvastatin 20 mg (for cholesterol) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Gabapentin 800 mg (for nerve pain) 1 tablet- dose scheduled for 08:00 PM administered by LVN B.- In an interview on 01/23/23 at 12:09 PM, Agency Nurse #1 said she was scheduled to work the evening overnight shift on 01/19/23 and received an email from the administrator sending that included a user name to access the EMR but she never received a password. She said she was informed her password was the same as previously used at another facility but to her knowledge she had not worked at any of the sister facilities. Agency Nurse #1 said she made attempts to contact the DON by phone on multiple occasions during her shift but she was unsuccessful so when she arrived at the facility the day shift nurse (LVN B) provided her log in credentials on a sheet of paper, so she documented under the day shifts nurse credentials for the beginning of the shift. Agency Nurse #1 said that at some point during her shift she lost the sheet of paper with the log in credentials resulting in her having no access to the EMR and being unable to document any tasks completed or administration any medications from 04:00 AM to 06:00 AM. In an interview on 01/24/23 at 11:25 AM, LVN B said the facility has been using a lot of agency staff as of late. She said at the end of the previous week there was an agency nurse (a temporary nurse provided through a staffing agency) who did not have access to the EMR so she had no choice but to provide the agency nurse her log in credentials on a sheet of paper so patient care could be completed. LVN B said that she and the agency nurse attempted to get in touch with management to get the appropriate EMR access but they were unsuccessful. In an interview on 01/25/23 at 03:26 PM, the DON said that facility staff are expected to document timely and accurately. She said documentation should paint a picture of the resident's state and include: vitals, pertinent information, concerns, assessments and communications with physicians. She said that nursing staff must use their own credentials to document in each resident's EMR and failure to do so would result in inaccurate medical records. The DON said she was unaware of a situation in which an agency nurse was forced to use a full time nurse's login credentials or unable to perform medication administration due to not receiving access to the EMR from the Administrator. She said failure to document timely and accurately placed residents at risk of not having a true picture of their status resulting in adequate care. In an interview on 01/25/23 at 03:26 PM, the Administrator said that nursing staff, including agency staff, have individual log ins and are expected to chart with their unique identifiers. She said prior to any agency staff's first shift an EMR access is created and it is emailed to the staff. The Administrator said that she was not aware of agency staff using full time staff log in credentials, and that each user must use their individually assigned credentials because accurate documentation must include the person who actually completed the task. She said by nursing staff using another person's credentials resident would result in inaccurate administration/task completion records and was against facility policy. The Administrator said she was unaware of she was unaware of a situation in which an agency nurse was forced to use a full time nurse's login credentials or unable to perform medication administration due to not receiving access to the EMR. She said that she was responsible for ensuring all agency nurses received access to the EMR and she personally sent the email with their login credentials. The DON said she was available by email or phone and there was a 24 hours line that nursing staff could contact if they had problems accessing the EMR . The Administrator said the inappropriate use of EMR credentials could place residents at risk for inadequate medical records. Record review of the facility policy titled Computer and Electronic Communications with no revision date revealed, Associates must not share their user name or password with anyone, including supervisors, other associates and family members. Record review of the facility policy titled Nursing Documentation revised 05/07/21 revealed, Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs . The medical record must also reflect the resident's condition and the care and services provided across all disciplines . The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress .

Based on observation, interview and record review the facility failed to have physician orders for the resident's immediate care for 1 of 8 (CR #1) of one resident reviewed for admission physician orders. - The facility failed to enter physician's orders for immediate care for CR #1's surgical site throughout her residency from 01/18/23 to 01/20/23. These failure could place residents at risk for adverse reactions, deterioration of wounds and infection. Findings Included: Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, there were no orders for wound care or dressing changes before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. Record review of CR #1's January 2023 Progress Notes revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview on 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds. She said nurses should immediately order standard wound care orders for monitoring/cleaning/dressing changes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of agency staff. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, and these orders included tasks needed for care of wounds or surgical incision sites Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN .

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 8 residents (CR #1) reviewed for quality of care. - The facility failed to provide care to CR #1's surgical site throughout her residency from 01/18/23 to 01/20/23. This failure could place residents at risk for adverse reactions, deterioration of wounds and infection. Findings Included: Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE] with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, there were no orders for wound care or dressing changes before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. Record review of CR #1's January 2023 Progress Notes revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview on 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds. She said nurses should immediately order standard wound care orders for monitoring/cleaning/dressing changes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of agency staff. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, and these orders included tasks needed for care of wounds or surgical incision sites Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care. 1. The facility failed to take appropriate action when Resident #1 experienced falls on [DATE], [DATE], [DATE] and [DATE]. 2. The facility failed to assess Resident #1 following falls on [DATE] and [DATE] and left her unattended after the incident. 3. The facility failed to assess and transfer Resident #1 appropriately and timely following a fall on [DATE] that resulted in a fracture. 4. The facility failed to assess and transfer Resident #1 appropriately after a fall on [DATE] by not assessing her prior to transferring her and by moving her using a fall mat. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with actual harm that was not an immediate jeopardy . These failure could place residents at risk for a delay of care or treatment, pain and suffering. Findings include: Record review of Resident #1's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's Admission Nursing Report, dated [DATE], revealed Resident #1 admitted from an inpatient hospice facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15, nothing was documented for the assessment of assistance of ADLs and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan revised [DATE] revealed Focus- the resident had an actual fall on [DATE], [DATE] and [DATE]. Interventions- Floor mats to both sides of bed, Neuro-checks per protocol, observe/report PRN for 72 hours to MD s/sx : pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, place call light within reach, staff to educate on use of call light. 1. An observation of Resident #1's room video recording of [DATE] at 07:15 revealed Resident #1 restless in bed talking into what appears to be her call light saying can I get my medicine. At 07:18 PM the resident placed her hands over her mouth to make a funnel shape and said can I get my medicine please, hello, can I get my medicine she restlessly moved around in her bed. The resident continued to yell out for her medicine and at 7:39 PM she attempted to stand up from her bed after saying can I get my medicine. After several unsuccessful attempts to stand up and saying hello, can I get my medicine Resident #1 lowers herself to the ground and begins to crawl away from her bed. At 07:48 PM Resident #1 could be seen falling to her side from a crawling position on the ground while letting out a groan. At 07:50 PM Resident #1 screamed for help, saying help me, help me now, help me to get my medicine. Voices can be heard out from outside of the resident's room and then CNA A entered into the resident room. Upon entering the resident room CNA A did not immediately help Resident #1 but instead picked up a plate and cup from the floor to the left of the resident's bed (the opposite side of where the resident laid on the floor) and then walked toward the resident placing the items on the dresser. As CNA A walked toward the Resident #1, the resident said help, I am on the floor again to which CNA A responded what did you do, you were in the bed, why did you get out .I can't carry you. In response Resident #1 said I fell down and in response said no because you were laying in the bed CNA continued to arrange the resident's bed with her back to the resident while the resident remained on the floor talking. Resident #1 continued to say she fell while CNA responded that she did not, at 7:52 PM CNA A walked to Resident #1 and began to move her by herself as the resident groaned, she sat the resident up right on the right side of the bed and walked out of the view of the camera towards the door. At 07:53 PM, CNA A returned to the resident with LVN D who told the resident I hope they saw what you did on camera. Resident #1 was observed sitting upright on the floor, LVN D did not perform any assessments on the resident and with the help of CNA A Resident #1 was lifted into her bed. LVN D left the room and CNA A began to perform incontinence care on the resident and at 07:59 PM CNA left the room after completing incontinence care and covered the resident in bed. At 08:02 PM, LVN D returned to the resident room and administered medication to Resident #2 saying give you medicine for pain. Stop getting out of this bed ok, stop falling, that's not good for you to keep falling, just relax ok, you're alright that is for you pain and left the room. The resident was left unattended after the fall, except the pain medication no head-to-toe assessments or neurological checks were performed. In an interview on [DATE] at 05:13 PM, CNA A said Resident #1 was alert, knew what she was doing and liked to slide to the floor. She said she never saw the resident lower herself to the floor and most times she was just found on the floor. CNA A said per facility policy when a resident was seen on the floor CNA's were expected stay with the patient, call the nurse but couldn't touch the resident . She said once the nurse completed the patient assessment CNA's could assist per the nurses instructions to transfer the resident back into bed. After reviewing the video recording of Resident #1's fall on [DATE] CNA A said she should have stayed with the resident until the nurse arrived instead of making the bed. She said she should not have moved Resident #1 because the resident could have been further injured if moved before a nurse assessed her . She said LVN D was responsible for performing an assessment on Resident #1 but she did not assess her before placing her back in bed. In an interview on [DATE] at 11:41 AM, LVN D said she could not recall Resident #1's fall on [DATE] . Record review of Resident #1's Clinical Progress notes, from [DATE] to [DATE], revealed no clinical notes entered on [DATE]. Record review of Resident #1's Assessments revealed, no Fall Risk Evaluation, Pain Evaluation Tool or Neurological Checklists were completed on [DATE]. 2. An observation of Resident #1's room video recording on [DATE] at 02:02 AM revealed, Resident #1 attempting to get out of bed and then lowering herself to the floor before falling head first to the floor. The resident sat up and then at 02:11 AM said I fell down again and slowly slid herself toward the door at 02:24 AM she was in front of the door and said I fell down again. At 02:29 AM CNA B found Resident #1 on the floor and at 02:31 AM CNA B begins to wipe the resident down while she laid on the floor and then leaves the room to ask for help. When CNA B returned she said she got poo everywhere as she continued to wipe the resident who remained on the floor. At 02:32 AM, CNA C entered into the room and watched CNA B lift up a fall mat from the left side of the resident's bed that had fecal matter smeared across the top and placed it in the bathroom; she then changed the resident's bed linens as the resident remained on the floor. At 02:35 CNA B continued to wipe down the resident who was on the floor, after she prepped a wheelchair by placing a brief of it, CNA B and CNA C lifted Resident #1 and placed her in the wheelchair. At 02:38 AM, CNA B and CNA C transferred Resident #1 into her bed and CNA B left Resident #1's room at 2:49 AM switching off the light on her way out. LVN D was not present from the period in time when Resident #1 was found on the floor up until she was transferred into bed and only entered into the resident's room at 2:52 AM. She checked the residents blood pressure, O2 saturation and then left the room turning the light off on her way out. She did not perform a head-to-toe assessment or even speak to the resident. Resident #1 remained restless in her room unattended until CNA B returned to Resident #1's room at 03:42 AM to help the resident with her oxygen and left at 03:44 AM, the resident was then left unattended until 05:05 AM. At 05:05 AM LVN D entered into the resident room to check the resident's blood pressure and administered medication. No head-to-toe assessment or range of motion assessments was observed on the recordings. No staff entered Resident #1's room from 05:08 AM when LVN D left the resident's room until 06:58 AM when the incoming nurse introduced herself to the resident. In an interview on [DATE] at 11:42 AM, LVN D said when a resident was found on the floor nursing staff must first make sure the patient was ok and then nurses performed a head-to-toe assessment and initiated neurological checks to make sure the resident has not sustained an injury. She said on [DATE] another nurse alerted her the resident fell after Resident #1's family member called to inform the facility staff that the resident was on the floor. She said she performed an assessment and the resident was able to move her arms and feet so the resident was transferred to her bed. LVN D said she checked the resident's vitals but she did not perform neurological checks on the resident while she was sleeping because she did not want to wake her. She said neurological assessments should be done at bedside and could not be done from the door so nursing staff would be seen on the camera if they performed neurological checks. Record review of Resident #1's Neurological Check List, dated [DATE] at 02:58 AM, revealed status- incomplete, started by LVN D. LVN D documented vitals and neurological checks of the right/left pupil, level of consciousness, motor function upper/lower, speech and special cemetery for: 02:58 AM, 03:15 AM, 03:32 AM, 03:49 AM, 04:15 AM and 04:50 AM. Record review of Resident #1's Clinical Progress notes, dated [DATE] at 03:06 AM, revealed CNA informed nurse that patient was on the floor. This nurse entered the room immediately to observe the patient lying on her right side on the side of the bed. V/S taken and is WNL . ROM performed with no abnormalities noted. After carefully assessing patient, no skin issues present or change in mental state noted. CNA assisted this nurse in returning patient back to bed safely. Patient is alert to baseline, this nurse continues to educate patient on the importance of utilizing call light for assistance, patient nodded and stated that she understood the education. No acute distress noted. Patient denies any pain at this time. 3. An observation of Resident #1'sroom video recording on [DATE] at 08:00 PM revealed, staff talked through an intercom asking Resident #1 what is it that you need to which she responded I need to do number 2, and at 08:01 PM the resident pressed her call button. Resident #2 at different intervals said she needed to go to the restroom then at 08:38 PM she stood up and walked unbalanced away from her bed, leaning on furniture in her room and at 08:39 PM she says I am going to fall and shortly after she fell face first to the ground. A loud thud and groaning were heard as the resident fell to the floor, and Resident #1 said I really hurt myself this time. As she pulled herself on the floor and tried to pull herself up holding on to the bed she said I really hurt myself this time and let out a loud groan. Which point she fell face first into the floor. At 8:43 PM, RN B found Resident #1 on the floor and asked what are you doing, what happened to which the resident replied I fell and I hurt myself this time. Resident #1 said she hurt her hip when asked where she hurt. RN B did not call for help but instead left the room, while unattended the resident continued to call for help and groaned in pain and RN B returned to the room [ROOM NUMBER] minutes later. As Resident #1 laid on the floor RN B sat in a chair beside her looking down on her and asked again where do you hurt to which the resident said in my hip I told you. RN B sat in the chair waited for assistance and she reminded the resident to not move, at 8:49 PM she left the resident unattended on the floor and the resident can be heard groaning about her hip pain. At 8:52 PM, RN B returned to the resident room with a CNA and together they picked Resident #1 up and placed her in a chair, the resident can be heard groaning in pain and complained about her hip as the staff moved the chair closer to her bed in the chair before transferring her into bed . At 08:56 PM, RN B returned and administered Resident #1 medication for pain, the resident was then left unattended restless in bed, appeared in pain, called out for help. She did not check the resident's vitals and no assessments were observed. At 9:35 PM, RN B returned to the room and informed the resident she would be going to the hospital and left the room, she did not perform any further assessments on the resident but returned to administer some more medication. Resident #1 could be heard groaning on occasion and appeared restless as she awaited transport to the hospital. Resident #1 remained unattended from 09:37 PM until 12:46 AM, at which point the transport agency arrived to take her to the hospital. When the EMS asked the resident, what hurt she said my hip. In an interview on [DATE] at 4:55 PM, RN B said on [DATE] she remembered seeing Resident #1's call light on so she went to check on her and she found her on the floor. She said she assessed her, and the resident told her she broke her hip. RN B said she didn't observe any breaks in her skin, but the resident tried to get up and kept moving so she called the doctor and the doctor said Resident #1 should be sent to the hospital for evaluation. She didn't remember if she performed any neurological assessments, but these assessments were done at a particular frequency and had to be done face to face with the resident. RN B said she did not remember if she checked Resident #1's vitals after the fall and after watching the video, RN B said a Hoyer lift should have been used instead of a chair and she didn't remember why the chair was used. She said since she suspected a fractured their hip, the resident should not be transferred into a weight bearing sitting position, such as sitting in a chair, because it could cause further injury and pain . RN B said that she did not contact 911 and used the facility contracted transport service because the doctor did not specify that the transfer was an emergency and 911 should be called In an interview on [DATE] at 01:10 AM, the Physician said that she was not working on [DATE] and the on-call doctor should have addressed and calls to the facility but Resident #1 and any resident who received orders to send to the hospital should be send out as 911 and a 4 hour wait time was not appropriate because it delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's assessments, dated [DATE], revealed no Pain Evaluation Tool, Fall Risk Evaluation and Neurological Check List were completed. Record review of Resident #1's Clinical Progress Notes, dated [DATE] at 01:00 AM, revealed On [DATE] at approximately 2040 [8:40 PM] this nurse found the patient on the floor. Assisted patient back into bed with assistance of the CNA on duty. HTT assessment completed. Patient c/o pain to her left hip and stated I think I might have broke my hip. Notified Hospice Nurse and spoke to the on-call nurse - RN. Received orders to send patient to hospital for evaluation of left hip. At 2115 called EMS for transport to hospital. Resident transported via stretcher to Hospital at 0050 in stable condition. Medical documentation given to transport personnel. Patient's family notified and aware of situation . Record review of Resident #1's Hospital Discharge Records, dated [DATE] at 07:19 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Clinical Progress Notes, dated [DATE] at 10:53 AM revealed patient readmitted from [hospital[, with new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was stable during readmission, no compliant of pain, vital signs was with in normal level. 4. An observation of Resident #1's room video recording on [DATE] at 06:40 AM revealed Resident #1 restless in bed letting out an occasional grown and at 06:55 AM while yelling she slid headfirst to the floor on the right of the bed as the rest of her body slowly followed. At 07:11 AM, RN B walked into the room to find Resident #1 on the floor, she attempted to arouse the resident, but she would not respond. At 07:12 AM, RN B left Resident #1 unattended and left the room and returned with RN C. Together RN B and RN C attempted to lift the resident from the floor by her arms and legs as the resident screamed but were unable to so they lifted her with the floor mat and dropped her into her bed. No assessments, vitals or neurological checks were performed on the resident prior to or after the resident was transferred into bed and at 07:19 AM the resident was left unattended as the staff switched off the lights on their way out. As the resident lay unattended in her room she appeared restless and let out an occasional moan, RN B and RN C returned to the resident's room to readjust her position in bed at 07:47 AM. At 07:59 AM, RN C returned with Resident #1's breakfast tray, placed it out of reach of the resident and left the room. Resident #1 remained unattended until 08:45 AM when facility staff returned to assist her with breakfast. From the period reviewed from 07:11 to 08:45, no vitals or assessments were performed on Resident #1. In an interview on [DATE] at 04:55 PM, RN B said once a resident was found on the floor a nurse must first perform a head-to-toe assessment, check for injuries and if appropriate the resident can be transferred off the floor. She said if the resident was in pain, experienced excessive bleeding and/or a lack of consciousness the nurse must call 911 . RN B said all un-witnessed falls triggered neurological checks which involved assessing if the resident's pupils were equal, their level of consciousness and any change in the ability to move and respond to commands. She said the resident's physician should be contacted with every fall and if the doctor said the resident should be sent out, 911 should be called. RN B said she was not the assigned nurse for Resident #1 on [DATE] but when she was walking down the hall she observed the resident on the floor next to the bed so she went to get RN C. She said she did not remember doing any assessments on the resident and didn't remember how the resident was transferred, but a safe method should have been used to not cause further injury. After reviewing the video, RN B said she should have further assessed Resident #1 before she was transferred to the bed and the method of transfer was not appropriate. She said Resident #1 should not have been transferred using the fall mat because the resident could slip off the mat causing further injury. RN B said following the fall the resident should not have been put in bed and left unattended because that placed the resident at risk of a decline in health due to a failure to identify a change of condition. In an interview on [DATE] at 12:18 PM, RN C said on [DATE] she was still in training so she was shadowing RN B when Resident #1 fell . She said she assisted RN B to transfer the resident to the floor using the floor mat because there was no other way to get her off the floor at that time. RN C said if she had been moved by her arms and legs not the fall mat Resident #1 would have had further injuries because she was very fragile, and when the resident's legs were touched she would hurt but using the fall mat was not appropriate because it could cause further injuries or falls. She said the safest way to transfer Resident #1 from the floor would have been to use a Hoyer lift but she just followed RN B's instructions. She said she did not know if RN B assessed the resident when she was on the floor. In an interview on [DATE] at 10:10 AM, the DON said once a resident fell , nursing staff should call for help and should not leave the resident unattended. She said nurses should assesses the resident physically, then perform neurological checks at specified intervals and the resident should be monitored for changes in consciousness and pain continuously for 3 days. She said prior to moving the resident the nurse should make sure the resident didn't suffer any injuries, assess for range of motion in the arm and head, skin tears and if ok the resident could be transferred. The DON said if the resident could move themselves they could be assisted onto the bed but if not a Hoyer lift should be used but if the resident was screaming in pain, they should not be moved because it could cause further injury and their attending physician should be called. The DON said if the physician said a resident should be sent to the hospital for evaluation the resident should be sent out using 911 . In an interview on [DATE] at 11:06 AM, the Administrator said when a resident had an unwitnessed fall nurses must first assess the resident to determine it the resident could be transferred into bed . He said if necessary a Hoyer lift could be used to transfer the resident into bed and the facility had 3 lifts located on each resident floor . Record review of Resident #1's Clinical Progress notes, from [DATE] to [DATE], revealed no clinical notes about the fall entered on [DATE]. Record review of Resident #1's Assessments revealed, no Fall Risk Evaluation, Pain Evaluation Tool or Neurological Checklists were completed on [DATE]. Record review of Resident #1's Clinical Progress notes, dated [DATE] signed by LVN D at 03:30 PM, revealed All needs met, at this time hospice nurse visited and asked if the patient fell on shift, that someone called and reported patient fell . At this time writer told hospice nurse that patient did not fall on this shift and no body reported to the writer about any fall. Record review of the facility procedure titled Fall Management, Long-term Care revealed, Implementation- .if you weren't with the resident during the fall, confirm the resident's identity using at least 2 identifiers and verify that the environment is safe . perform hand hygiene . assess the resident for responsiveness . fully evaluate the resident's status before moving the resident. To determine the extent of the resident's injuries, look for lacerations, abrasions, and obvious deformities. Not any deviations from the resident's baseline condition and notify the practitioner. Determine the whether the resident suffered any head trauma, which requires further diagnostic evaluation to rule out subdural hematoma . Assess the resident's limb stress and motion, do not perform range of motion exercises if you suspect a fracture or if the resident complains of any odd sensations or limited movement. If you suspect an injury, do not move the resident until a practitioner examines the resident . If you don't detect any injuries return the resident to bed with the help of another staff member. Never try to life a resident alone because you may injure yourself or the resident. Even if the resident shows no signs of distress or has sustained only minor injuries, increase the frequency of monitoring of blood pressure, pulse, and respirations for the next 72 hours . Record of the facility policy titled Neurological Assessment, revised [DATE], revealed a neurological assessment is an indispensable tool for quickly checking a resident's neurologic status. This procedure supplements the routine measurement of vital signs by evaluating a resident's level of consciousness (LOC), pupil activity, motor response, and orientation to time, place, and person. The Neurological check list use define assessment in the EMR shall be initiated by a written physicians order for neurological checks or when indicated by a resident assessment ( e.g ., head injury, post fall , . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:45 PM. The Administrator was notified The Administrator was provided with the IJ template on [DATE] at 4:22 PM . The following Plan of Removal was submitted by the facility and was accepted on [DATE] at 2:38 PM: -Resident #1 was no longer in the facility and would no longer be returning. -The Regional Director of Quality Services (RDCS ) is in the facility and directing the corrective actions with the Administrator and DON . -Residents at risk for fall, fall risk assessments, care plans were re-reviewed and rounds were completed to ensure appropriate individualized interventions were present and remained in place. It was completed on [DATE] by the RDCS. -Head to toe assessments for competencies were provided to licensed nurses starting [DATE] and skills checklists were completed. Licensed nurses in the facility would have competencies completed prior to working. New hire will have competencies completed at the time of orientation. This was completed by the DON with all full-time nurses completed on [DATE]. -Neurological competencies were completed for licensed nursing staff starting [DATE] and skills checklists were completed. Licensed nursing staff in the facility will have competencies completed prior to working. New hires will have competencies completed at the time of orientation. This was completed by the DON with all full-time nurses completed on [DATE]. -Interviewable residents were interviewed to determine if they had experienced a fall without being assessed or if they had ever witnessed this with other residents. This was completed on [DATE]. -Associates on-site were interviewed to determine if they were aware of any residents that experienced falls were not assessed or assisted timely or properly. This was completed on [DATE]. -Residents who fell in the last 30 days were reviewed to determine if any of the events met the requirements for self-reporting. This was completed on [DATE] by the Regional Clinical Director. -Return to hospital data for the last 30 days were reviewed to identify if there were any residents sent to the hospital with injuries consistent with a fall. No instances were found that indicated injuries consistent with a non-reported fall. This was completed by the Regional Clinical Director on [DATE]. - Progress notes and risk management reports for 100% of current residents were reviewed for the last 30 days to determine if the falls process, including assessments and documentation. This was completed on [DATE] by the RDCS and findings were compiled and a Process Improvement Plan was developed. Systemic Education Completed: - Education was provided to CNA on the facility Fall Management Policy and Procedure by the DON starting on [DATE] and completed on [DATE]. - DON conducted on-site education to nursing staff regarding from [DATE] to [DATE] on: - Care plan implementation - Head to toe assessments for residents after incidents - Notification of family and physician after an incident - Timely transfers to the hospital after incidents and expectations - Accurate documentation of incidents and the fall management system - Accurate competition of neurological checks - Abuse and neglect -Education was provided to Nurses, Administrator and DON regarding the facility policy and procedure for reporting significant injuries and events that meet the criteria for neglect. This was completed by the Regional Clinical Director on [DATE]. - The Administrator and DON were in-serviced on reporting guideline regarding injuries of unknown origin on [DATE] Monitoring: An observation on [DATE] at 04:20 AM revealed, 2nd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. An observation on [DATE] at 10:10 AM revealed, 2nd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. Resident in room [ROOM NUMBER] with bed in lowest position with bilateral fall mats, call bell within reach. Resident in room [ROOM NUMBER] with bed in lowest position, fall mats and call bell within reach. An observation on [DATE] at 07:48 AM revealed 3rd floor nurses passed medications and completed treatments with CNAs providing care and Residents eating breakfast. Resident in room [ROOM NUMBER] well-groomed in no immediate distress with bed in low position, eating breakfast with bed tray over bed. An observation on [DATE] at 01:15 PM revealed, 3rd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. An observation on [DATE] at 12:50 PM revealed, 3rd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. An observation on [DATE] at 12:58 PM revealed, 2nd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. An observation on [DATE] at 10:40 AM revealed, 3rd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. An observation on [DATE] at 10:45 AM revealed, 2nd floor nurses passed medications and completed treatments with CNAs providing care. No prolonged call bells, no injuries/incidents, no residents call out for help. In an interview on [DATE] at 04:40 PM, LVN I said the facility abuse coordinator was the Administrator and the last in-service on abuse/neglect and falls was on [DATE]. She said if a resident fell the nurse must assess the residents vitals, pupils, level of consciousness and range of motion. She said if the resident could be moved they should be transferred into bed and if the resident was unable to move they should be sent to the hospital for evaluation. LVN I said nursing staff must call the RP and physician as well as document what happened. In an interview on [DATE] at 04:45 PM, a family member said Resident #3 had a fall last week when she tried to take her to the bathroom. She said it wasn't a real fall that she and the resident had slowly gotten down to the floor but the staff responded promptly and continued to check on the resident. In an interview on [DATE] at 10:22 AM, LVN E said when a resident fell nurses performed a head to toe assessment, neuro-vital assessment, pain assessment, call the MD, RP, DON, and administrator. She said all residents were treated as a high risk, and they should be kept close to the station where the staff was to keep an eye on them . In an interview on [DATE] at 10:31 AM, LVN C said if a CNA reported a resident fall, nurses assessed the resident for pain, injury, and neuro-vital signs. She said if there was an injury or suspected injury the resident should not be moved and 911 should be called. LVN V said the incident should be reported using the 24 hour report and shift change report. In an interview on [DATE] at 10:42 AM, CNA E said if a resident was found on the floor CNA's stayed with the resident and called for help . She said they should not move them until the nurse assessed them . In an interview on [DATE] at 11:00 AM, CNA D said if a resident was found on the floor CNA's stated with the resident an [TRUNCATED]

Based on interview, and record review the facility failed to ensure residents were offered a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 3 of 3 residents (Residents #1, #5 and #6 ) reviewed for therapeutic diets. 1. The facility failed to provide Resident #1 and Resident #5's supplement, Med Pass, as recommended by the Dietician. 2. The facility failed to provide Resident #'6's liquid protein as recommended by the Dietician. These failures could place resident's at risk of inadequate nutritional intake. Findings include: 1. Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15. Nothing was documented for the assessment of assistance of ADL's and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan revised [DATE] revealed: no mention of Resident #1's dietary prefrences, orders and needs. Record review of Resident #1's Dietary Recommendation, dated [DATE], revealed an initial assessment, wound, on hospice, low [MEDICATION(S)] and poor intake. Recommend Med Pass 120 ml three times daily. Record review of Resident #1's Nutrition Assessment/Nutritional Data Collection, dated [DATE] signed by the Dietician, revealed inadequate oral intake, poor intake and [MEDICATION(S)] of 2.3 (a sign of possible malnutrition), increased nutrient needs related to skin breakdown and a stage III pressure ulcer. Recommend 120 ml Med Pass three times daily. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 01:38 PM, the Dietician said she recommended Med Pass for Resident # 1 due to her lab work showing low [MEDICATION(S)] as well as poor oral intake. She said it would be difficult to supplement the resident's meal with changes to her diet so Med Pass was a great option because it would be administered like medication. 2. Record review of Resident #5's face sheet, printed [DATE], revealed a [AGE] year old woman admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She discharged on [DATE]. Record review of Resident #5's electronic chart revealed, the resident did not have a comprehensive care plan for her current admission. The care plan provided by the facility was cancelled on [DATE]. Record review of Resident #5's Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 09 out of 15. The resident needed extensive assistance with most ADLs, received a mechanically altered diet and was frequently incontinent of both bladder and bowel. Record review of Resident #5's Dietary Recommendation, dated [DATE], revealed initial assessment, poor intake and low [MEDICATION(S)], recommend Med Pass 120 mg three times a day. Record review of Resident #5's Nutrition Assessment/Nutritional Data Collection, dated [DATE] signed by the Dietician, revealed poor oral intake, poor intake and [MEDICATION(S)] of 2.3 recommend Med Pass 120 ml three times daily. Record review of Resident #5's Letter titled Communication Between the Dietician and The Attending Physician, dated [DATE], revealed a Problem or concern: Inadequate oral intake, abnormal eating behaviors, poor intake and [MEDICATION(S)] of 2.3. Recommendation: Med Pass 120 ml three times daily. The comment from the attending physician lines with agree or disagree lines are left blank and the attending physician's signature and date are left blank. Record review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 01:38 PM, the Dietician said she recommended Med Pass for Resident # 5 due to her lab work showing low [MEDICATION(S)] as well as poor oral intake. 3. Record review of Resident #6's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15 and worsening of a change of behavior and frequent incontinence of both bladder and bowel. Record review of Resident #6's Laboratory Records, dated [DATE], revealed Test- [MEDICATION(S)] LOW Test Total Protein- LOW Record review of Resident #6's Dietary Recommendation, dated [DATE], revealed initial assessment, wound pending, poor intake, low [MEDICATION(S)]. Recommend liquid protein 30 ml daily for 20 days, Vitamin C 500 mg twice daily for 30 days and Ensure twice daily. Record review of Resident #6's care plan, initiated [DATE], revealed Focus- at risk for weight fluctuation related to current health status, goal- resident wishes to maintain current weight through next review, intervention- assistance with meals as needed. Record review of Resident #6's Letter titled Communication Between the Dietician and The Attending Physician, dated [DATE], revealed a Problem or concern: Increased nutrient needs r/t skin breakdown AEB Stage II to Sacrum and low [MEDICATION(S)] of 2.8. Recommendation: 1) Rec liquid protein 30cc QD x 30 days. 2) Rec 500 mg Vit C BID x 30 days. The comment from attending physician lines with agree or disagree lines are left blank and the attending physician's signature and date a left blank. Record review of Resident #6's Letter titled Communication Between the Dietician and The Attending Physician, dated [DATE], revealed a Problem or concern: Inadequate oral intake, abnormal eating behaviors, poor intake and [MEDICATION(S)] of 2.3. Increased nutrient needs related to a skin breakdown, stage III to sacrum. Recommendation: 1) Med Pass 120 ml three times daily, 2) 500 mg Vit C BID x 30, 220 mg Zinc daily for 14 days and multivitamin with minerals. The comment from attending physician lines with agree or disagree lines were left blank and the attending physician's signature and date were left blank. Record review of Resident # 6's weight records revealed [DATE] at 12:53 PM 127.6 Lbs on the wheelchair scale and 122.6 Lbs on [DATE] at 10:35 on the Hoyer lift scale . Record review of Resident #6's Nutrition Assessment/Nutritional Data Collection, dated [DATE] and singed by the Dietician, revealed inadequate oral intake, slight weight low and low [MEDICATION(S)] of 3.3, increased nutrient needs related to recent surgical wound. Record review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 01:38 PM, the Dietician said she recommended liquid protein for Resident # 6 due to her lab work showing low [MEDICATION(S)] as well as poor oral intake. In an interview on [DATE] at 10:10 AM, the DON said nursing staff should enter/[MEDICATION(S)] on any dietary recommendations within ,d+[DATE] hours. She said unentered dietary orders placed residents at risk for insufficient caloric intake and nutrition, weight loss, weakness, decreased activity . In an interview on [DATE] at 11:06 AM, the Administrator said once the nurse received a dietary recommendation, they should enter it in the system as timely as possible a few days at most. He said nursing administration was responsible for ensuring dietary orders were entered, and once entered the kitchen received a copy of the order. The Administrator said failure to enter dietary orders could result in insufficient caloric intake and weakness. In an interview on [DATE] at 01:35 PM, the Dietician said she monitored resident's monthly that were triggered due to weight loss, abnormal lab values and wounds. She said after recommendations were made , changes should be implemented within ,d+[DATE] days but since she didn't monitor patients once they discharged and the facility had a lot of short term residents she could not follow up if some of her recommendations were acted on. She said along with the recommendations she provided the facility with doctor letters for the provider to indicate if they agreed or disagreed with her recommendations . She said the risk of not acting on dietary recommendations placed resident's at risk of weight loss, poor wound healing, weakness, and increased falls. In an interview on [DATE] at 02:00 PM, the Administrator said the former interim DON was responsible for entering the missed dietary orders for Resident #1, Resident #5, and Resident #6 . He said she was also responsible for making sure that the residents' dietary orders were communicated to the physician and acted upon

Based on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 5 residents (Resident #1 and Resident #4) whose records were reviewed for accuracy and completeness. 1. The facility failed to ensure LVN D documented Resident #1's falls on [DATE]. 2. The facility failed to ensure LVN D completely and accurately documented Resident #1's fall on [DATE] by documenting assessments that were never completed. 3. The facility failed to ensure RN D documented Resident #1's refusal of medications on [DATE]. 4. The facility failed to ensure RN B documented Resident #1's fall on [DATE]. 5. The facility failed to record Resident #4's injury that resulted in a fracture that occurred on [DATE]. These failures could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Include: 1. Record review of Resident #1's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15. Nothing was documented for the assessment of assistance of ADL's and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan, revised [DATE], revealed Focus- the resident had an actual fall on [DATE], [DATE] and [DATE]. Interventions- Floor mats to both sides of bed, Neuro-checks per protocol, observe/report PRN for 72 hours to MD s/sx : pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, place call light within reach, staff to educate on use of call light. Record review of Resident #1's Clinical Progress notes from [DATE] to [DATE] revealed no clinical notes entered on [DATE]. Record review of Resident #1's Assessments revealed, no Fall Risk Evaluation, Pain Evaluation Tool or Neurological Checklists were completed on [DATE]. Record review of Resident #1's Neurological Check List, dated [DATE] at 02:58 AM, revealed, status- incomplete, started by LVN D. LVN D documented vitals and neurological checks of the right/left pupil, level of consciousness, motor function upper/lower, speech and special cemetery for: 02:58 AM, 03:15 AM, 03:32 AM, 03:49 AM, 04:15 AM and 04:50 AM. Record review of Resident #1's Clinical Progress notes, dated [DATE] at 03:06 AM, revealed CNA informed nurse that patient was on the floor. This nurse entered the room immediately to observe the patient lying on her right side on the side of the bed. V/S taken and is WNL . ROM performed with no abnormalities noted. After carefully assessing patient, no skin issues present or change in mental state noted. CNA assisted this nurse in returning patient back to bed safely. Patient is alert to baseline, this nurse continues to educate patient on the importance of utilizing call light for assistance, patient nodded and stated that she understood the education. No acute distress noted. Patient denies any pain at this time. Record review of Resident #1's MAR, for [DATE], revealed the following medications were administered for the residents 08:00 AM medication pass, [MEDICATION(S)] 2.5 mg 1 tablet, [MEDICATION(S)] 500 mg 1 tablet, Calcitriol 0.25 mg 1 capsule, [MEDICATION(S)] 20 mg 1 tablet, Multi-vitamin/Minerals 1 tablet, [MEDICATION(S)] 25 mg 1 tablet, [MEDICATION(S)] 220 mg 1 capsule and [MEDICATION(S)] 2mg 1 tablet. Record review of Resident #1's Assessments revealed, no Fall Risk Evaluation, Pain Evaluation Tool or Neurological Checklists were completed on [DATE]. Record review of Resident #1's Clinical Progress notes, dated [DATE] signed by LVN D at 03:30 PM, revealed, All needs met, at this time hospice nurse visited and asked if the patient fell on shift, that someone called and reported patient fell . At this time writer told hospice nurse that patient did not fall on this shift and no body reported to the writer about any fall. An observation of Resident #1's room video recording of [DATE] at 07:51 PM revealed, Resident #1 was found on the floor by CNA A . CNA A stepped out of the room and returned with LVN D and together they transferred Resident #4 into bed. An observation of Resident 1's room video recording of [DATE] at 02:29 AM revealed, CNA B found Resident #1 on the floor. She left the room and returned with CNA C, after starting incontinence care while the resident lie on the floor, together they transferred the resident back into her bed at 02:40 AM. CNA C left Resident's room and after completing incontinence care CNA B left Resident #1's room at 2:49 AM, switching off the light on her way out. LVN D was not present from the period in time when Resident #1 was found on the floor up until she was transferred into bed (02:29 AM to 02:49 AM) and entered into the resident's room at 2:52 AM. LVN D checked the residents blood pressure, O2 saturation, she did not administer any medication and then left the room turning the light off on her way out. She did not perform a head-to-toe assessment or even speak to the resident. CNA B returned to Resident #1's room at 03:43 AM to help the resident with her oxygen and left at 03:44 AM, the resident was left unattended until 05:05 AM. At 05:05 AM, LVN D entered into the resident room, checked the resident's blood pressure, and administered medication. No head-to-toe assessment or range of motion assessments were observed on the recordings. No staff entered Resident #1's room from 05:08 AM when LVN D left the resident's room until 06:58 AM when the incoming nurse introduced herself to the resident. An observation of Resident 1's room video recording of [DATE] at 07:11 AM revealed, Resident #1 was found on the floor by RN B. RN B was assisted by CNA B to transfer the resident back into the bed. In an interview on [DATE] at 05:13 PM, after reviewing the video recording of Resident #1's fall on [DATE], CNA A said she found Resident #1 on the floor and she alerted RN B. She said it was RN B's responsibility to complete the assessment and the documentation associated with the fall. In an interview on [DATE] at 11:41 AM, LVN D said she could not recall Resident #1's fall on [DATE]. An observation and interview on [DATE] at 01:15 PM with RN D revealed the 2nd Floor Nursing Cart was unlocked with a medication cup which contained 8 solid forms (tablets and capsule) of medication in the top drawer; the cup containing the medication was not labeled. RN D said the pills in the cup were Resident #1's scheduled 8:00 AM medications. She said after she prepared the medication, the resident refused administration. RN D said if a resident refused medications it must be documented as not administered with the reason of the refusal. She said that morning she documented administration and then the resident refused the medication . In an interview on [DATE] at 10:10 AM, the DON said if the resident refused medication after they have been prepped then the medication must be destroyed by placing them in the sharps container. She said nursing staff responsible for medication administration must document any medications that were not administered in the patient chart with a reason. In an interview on [DATE] at 11:06 AM, the Administrator said if a resident declined a medication then the denial should be recorded in the resident's chart . In an interview on [DATE] at 01:22 PM, the DON said she could not explain the discrepancy between the nursing notes and the videos of Resident #1's falls on [DATE] and [DATE] . In an interview on [DATE] at 04:55 PM, RN B said she was not the assigned nurse for Resident #1 on [DATE] but when she was walking down the hall when she observed the resident on the floor. RN B said she was not responsible for documenting the resident's fall since she was not her assigned nurse even though she was the one who found her on the floor . In an interview on [DATE] at 12:18 PM, RN C said when a resident fell the nurse was responsible for completing documentation for the incident. RN C said she assisted RN B to transfer the resident to the floor and RN B was responsible for completing any and all documentation associated with the incident. 2. Record review of Resident #4's face sheet, dated [DATE], revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She discharged from the facility on [DATE] at 5:00 PM. Record review of Resident #4 MDS, dated [DATE], revealed resident admitted from an acute hospital stay, needed limited to extensive assistance with all ADLs, used a wheelchair and a walker, occasionally incontinent of bladder, always continent of bowel, received occupational and physical therapy. Record review of Resident #4's care plan, revised [DATE], revealed Focus- resident had an actual fall on [DATE] related to unsteady gate and risk for falls r/t impaired balance and occasional bladder incontinence. Interventions- call light within reach at all times, remind resident to call for assistance for transfers. Record review of Resident #4's Clinical Progress Notes, dated [DATE], revealed no notes or documentation of how the injury occurred. Record review of Resident #4's Clinical Progress Notes, dated [DATE] at 9:31 PM written by RN A ,revealed X-ray of left foot ordered pending tech arrival. Scheduled medications administered as ordered, call lights within reach, no acute distress. Record review of Resident #4's Clinical Records revealed no accident/incident report on [DATE]. Record review of Resident #4's Physicians Orders, dated [DATE] signed by LVN B, with no time listed, revealed X-ray of left foot, indication- trauma, dropped ice on foot. Record review of Resident #4's Radiology Report, received on [DATE] at 01:10 AM, revealed, ALERT result: acute distal fifth metatarsal fracture . no dislocation.' Electronically signed on [DATE] at 12:03 AM by the radiologist, physically signed by the Physician on [DATE]. Resident review of Resident #4's Incident report, dated [DATE] at 01:55 PM, revealed patient sustained an acute distal fifth metatarsal fracture after a container that she was obtaining ice from, fell on her foot. Agencies/People notified: DON on [DATE] at 01:10 PM, Physician on [DATE] at 01:00 PM, and State Survey Agency on [DATE] at 12:37 PM. In an interview on [DATE] at 10:10 AM, the DON said that nursing staff were expected to chart significant events and the documentation should be accurate and must be completed prior to the end of their shift. She said that Resident #4's incident occurred on [DATE] but an accident/incident report was not completed until [DATE]. The DON said that failure to chart accurately or timely placed residents at risk for missed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on [DATE] at 11:05 AM, the Administrator said staff were required to complete documentation timely and accurately. He said the nurses who had the first encounter with the resident should initiate the investigation and failure to document timely and accurately in a resident's EMR placed residents at risk for improper follow up and adverse events or reactions. Record review of the facility policy titled Nursing Documentation, revised [DATE], revealed Medical Records- Staff must document a resident's medical and no-medical status when any positive or negative condition change occurs, at a periodic reassessment and during the annual comprehensive assessment. The medical record must also reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions. Record review of the facility policy titled 6.0 General Dose Preparation and Medication Administration, revised [DATE], revealed 5.1 Identify the resident per facility policy; 5.2 position the resident properly , 5.4 administer medications within timeframes specified by facility policy; 5.5 document the administration of controlled substances in accordance with applicable law. 6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 document necessary medication administration/treatment information (e.g., when medication are opened, when medications are given .) on appropriate forms; 6.2 dispose of unused medication portions in accordance with facility policy.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a change in condition for 1 of 5 residents (Resident #1 ) reviewed for change of condition. - The facility failed to immediately notify Resident #1's physician following falls on [DATE], [DATE] and [DATE]. This failure could place residents at risk for not receiving appropriate care and interventions. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15. Nothing was documented for the assessment of assistance of ADL's, and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan, revised [DATE], revealed Focus- the resident had an actual fall on [DATE], [DATE] and [DATE]. Interventions- Floor mats to both sides of bed, Neuro-checks per protocol, observe/report PRN for 72 hours to MD s/sx : pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, place call light within reach, staff to educate on use of call light. Record review of Resident #1's Clinical Progress notes, from [DATE] to [DATE], revealed no documentation of clinical notes entered on [DATE] regarding contact to the physician regarding the fall that occurred on [DATE]. Record review of Resident #1's Clinical Progress notes, dated [DATE] at 03:06 AM, revealed CNA informed nurse that patient was on the floor. This nurse entered the room immediately to observe the patient lying on her right side on the side of the bed. V/S taken and is WNL . ROM performed with no abnormalities noted. After carefully assessing patient, no skin issues present or change in mental state noted. CNA assisted this nurse in returning patient back to bed safely. Patient is alert to baseline, this nurse continues to educate patient on the importance of utilizing call light for assistance, patient nodded and stated that she understood the education. No acute distress noted. Patient denies any pain at this time. There was no documentation regarding contact to Resident #1's attending physician. Record review of Resident #1's Clinical Progress notes, dated [DATE] and signed by LVN D at 03:30 PM, revealed All needs met, at this time hospice nurse visited and asked if the patient fell on shift, that someone called and reported patient fell . At this time writer told hospice nurse that patient did not fall on this shift and no body reported to the writer about any fall. There is no note stating that the resident's physician was contacted. Record review of the facility Incidents by Incident Type report, dated [DATE], revealed during the review period on [DATE] to [DATE] Resident # 1 had documented un-witnessed falls on [DATE], [DATE] and [DATE]. There were no record of the residents falls on [DATE] and [DATE]. Record review of the facility Incidents by Incident Type report, dated [DATE], revealed during the review period on [DATE] to [DATE], Resident #1 had no documented falls, there was no record of the residents fall on [DATE]. An observation of Resident #1's room video recording of [DATE] at 07:51 PM revealed, Resident #1 was found on the floor by CNA A. CNA A stepped out of the room and returned with LVN D and together they transferred Resident #4 into bed . An observation of Resident #'2 room video recording on [DATE] at 02:29 AM revealed, CNA B found Resident #1 on the floor. She left the room and returned with CNA C, after starting incontinence care while the resident lie on the floor, together they transferred the resident back into her bed at 02:40 AM. CNA C left Resident's room and after completing incontinence care CNA B left Resident #1's room at 2:49 AM, switching off the light on her way out. LVN D was not present from the period in time when Resident #1 was found on the floor up until she was transferred into bed (02:29 AM to 02:49 AM) and entered into the resident's room at 2:52 AM. LVN D checked the residents blood pressure, O2 saturation, she did not administer any medication and then left the room turning the light off on her way out. She did not perform a head to toe assessment or even speak to the resident. CNA B returned to Resident #'2 room at 03:43 AM to help the resident with her oxygen and left at 03:44 AM, the resident was left unattended until 05:05 AM. At 05:05 AM LVN D entered into the resident room, checked the resident's blood pressure, and administered medication. No head to toe assessment or range of motion assessments was observed on the recordings. No staff entered Resident #1's room from 05:08 when LVN D left the resident's room until 06:58 AM when the incoming nurse introduced herself to the resident. An observation of Resident #1's room video recording on [DATE] at 07:11 AM revealed, Resident #1 was found on the floor by RN B. RN B was assisted by CNA B to transfer the resident back into the bed. In an interview on [DATE] at 05:13 PM, after reviewing the video recording of Resident #1's fall on [DATE] CNA A said she found Resident #4 on the floor and she alerted LVN D. She said it was LVN D's responsibility to complete the assessment, documentation associated with the fall as well as contact the physician. In an interview on [DATE] at 11:41 AM, LVN D said she could not recall Resident #1's fall on [DATE] . LVN D was not onsite to review the video. In an interview on [DATE] at 11:42 AM, LVN D said on [DATE] another nurse alerted her the resident fell after Resident #1's family member called to inform the facility staff the resident was on the floor. She said she performed an assessment and the resident was able to move her arms and feet so the resident was transferred to her bed. LVN D said that she checked the resident's vitals but she did not perform neurological checks on the resident while she was sleeping. She said neurological assessments should be done at bedside and could not be done from the door so nursing staff would be seen on the camera if they performed neurological checks. She said she did not remember if the attending physician was contacted . In an interview on [DATE] at 04:55 PM, RN B said the resident's physician should be contacted with every fall and if the doctor says the patient should be sent out, 911 should be called. She said she was not the assigned nurse for Resident #1 on [DATE] but when she was walking down the hall when she observed the resident on the floor. RN B said she did not remember performing any assessments on the resident and she was not responsible for documenting the resident's fall or contacting the physician since she was not her assigned nurse even though she was the one who found her on the floor . In an interview on [DATE] at 12:18 PM, RN C said when a resident fell the nurse was responsible for assessing the resident, notifying the family/doctor, and completing documentation for the incident. She said on [DATE] she was still in training so she was shadowing RN B when Resident #1 fell . RN C said she assisted RN B to transfer the resident to the floor and RN B was responsible for completing any and all documentation associated with the incident as well as contacting the resident's physician. In an interview on ,d+[DATE] at 2:00 PM, the Administrator said the only call the attending physicians practice received was the incident on [DATE] in which the resident was sent to the hospital. There were no calls on record for the falls on [DATE], [DATE] and [DATE] . In an interview on [DATE] at 10:10 AM, the DON said after an incident such as a fall nursing staff must contact the resident's responsible party, the clinician, and the state survey agency if necessary . In an interview on [DATE] at 11:06 AM, the Administrator said following a fall nursing staff should contact the resident's family, physician, the facility DON and then document the incident and their contact. He said the nurse who witnessed the incident or made the first encounter was responsible for documenting the incident and contacting all those necessary. Record review of the facility policy titled Changes in Resident's Condition or Status, revised [DATE], revealed The facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. Notification of Changes: I- A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- a) an accident involving the resident which results in injury and has the potential for requiring physician intervention; b) a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, or psychosocial status in either life threatening conditions or clinical complications); d) a decision to transfer or discharge the resident from the facility. Record review of the facility policy titled Fall Management, revised [DATE], revealed Falls refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force . A fall without an injury is still a fall, unless there is evidence suggesting otherwise, when a resident is found on the floor a fall is considered to have occurred.

Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source, were was reported immediately, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1 ) reviewed for neglect. The facility failed to report Resident #1's unwitnessed fall with serious injury on [DATE], that resulted in a fracture. This failure could place residents at risk for abuse and neglect. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15, nothing was documented for the assessment of assistance of ADLs and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan, revised [DATE], revealed Focus- the resident had an actual fall on [DATE], [DATE] and [DATE]. Interventions- Floor mats to both sides of bed, Neuro-checks per protocol, observe/report PRN for 72 hours to MD s/sx : pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, place call light within reach, staff to educate on use of call light. Record review of the facility's TULIP account revealed an incident for Resident #1's fall was not submitted to the State Survey Agency. Record review of Resident #1's Clinical Progress Notes, dated [DATE] at 01:00 AM, revealed On [DATE] at approximately 2040 this nurse found the patient on the floor. Assisted patient back into bed with assistance of the CNA on duty. HTT assessment completed. Patient c/o pain to her left hip and stated I think I might have broke my hip. Notified Hospice Nurse and spoke to the on call nurse - RN . Received orders to send patient to hospital for evaluation of left hip. At 2115 called EMS for transport to hospital. Resident transported via stretcher to Hospital at 0050 in stable condition. Medical documentation given to transport personnel. Patient's family notified and aware of situation. Record review of Resident #1's Hospital Discharge Records, dated [DATE] at 07:19 AM, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Clinical Progress Notes, dated [DATE] at 10:53 AM, revealed patient readmitted from [the hospital], with new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient was stable during readmission, no compliant of pain, vital signs was with in normal level. Record review of the facility Incidents by Incident Type report, dated [DATE], revealed during the review period on [DATE] to [DATE] Resident # 1 had documented un-witnessed falls on [DATE], [DATE] and [DATE]. There were no record of the residents falls on and [DATE]. An observation of Resident #1's room video recording on [DATE] at 08:00 PM revealed, staff asked Resident #1 what is it that you need to which she responded I need to do number 2, and at 08:01 PM the resident pressed her call button. Resident #2 at different intervals said she needed to go to the restroom then at 08:38 PM she stood up and walked unbalanced away from her bed, leaned on furniture in her room. At 08:39 PM she says I am going to fall and shortly after she fell face first to the ground. A loud thud and groaning were heard as the resident fell to the floor, and Resident #1 said I really hurt myself this time. As she pulled herself on the floor and tried to pull herself up holding on to the bed she said I really hurt myself this time and let out a loud groan,. which point she fell face first into the floor. At 8:43 PM, RN B found Resident #1 on the floor and asked what are you doing, what happened to which the resident replied I fell and I hurt myself this time. Resident #1 said she hurt her hip when asked where she hurt. RN B did not call for help but instead left the room, while unattended the resident continued to call for help and groaned in pain and RN B returned to the room [ROOM NUMBER] minutes later. As Resident #1 lay on the floor RN B sat in a chair beside her looking down on her and asked again where do you hurt to which the resident said in my hip I told you. RN B waited for assistance and she sat in the chair reminding the resident to not move, at 8:49 PM she left the resident unattended on the floor and the resident could be heard groaning about her hip pain. She did not check the resident's vitals and no assessments were observed. At 8:52 PM RN B returned to the resident room with a CNA and together they picked Resident #1 up and place her in a chair, the resident could be heard groaning in pain and complained about her hip as the staff moved the chair closer to her bed in the chair before they transferred her into bed. At 08:56 PM, RN B returned and administered Resident #1 medication for pain, the resident was then left unattended restless in bed, appeared in pain, called out for help. At 9:35 PM, RN B returned to the room and informed the resident she would be going to the hospital and left the room, she did not perform any further assessments on the resident but returned to administer some more medication. Resident #1 could be heard groaning on occasion and appeared restless as she awaited transport to the hospital. Resident #1 remained unattended from 09:37 PM until 12:46 AM, at which point the transport agency arrived to take her to the hospital. When the EMS asked the resident, what hurt she said my hip. In an interview on [DATE] at 12:09 PM, the Administrator said the Resident #1's fall on [DATE] was not reported to the state survey agency and he could not explain why it was not reported. In an interview on [DATE] at 10:10 AM, the DON said incidents that involved suspicion of abuse, neglect and falls with major injuries such as hematomas or fracture should be reported. She said per the facility policy Resident #1's fall on [DATE] that resulted in a fracture should have been reported to the State Survey Agency . She said the facility abuse coordinator is responsible for making reports to the State Survey Agency. Record review of the facility policy Incident and Reportable Event Management, issued [DATE], revealed ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to State Survey Agency and adult protective services where the state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. Falls . unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Immediately means as soon as possible, in the absence of a shorter state time frame requirement, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 Residents (Resident #5) reviewed for care plans. - The facility failed to create a comprehensive care plan for Resident #5. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings include: Record review of Record review of Resident #5's face sheet, printed 12/31/21, revealed a [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She discharged on [DATE], 24 days after admission . Record review of Resident #5's electronic chart revealed, the resident did not have a comprehensive care plan for her current admission. The care plan provided by the facility was cancelled on 10/30/19, the date of her previous discharge. Record review of Resident #5's Admission MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 09 out of 15, resident needed extensive assistance with most ADLs, received a mechanically altered diet and was frequently incontinent of both bladder and bowel. In an interview on 02/25/21 at 10:10 AM, the DON said the comprehensive care plan was created based on the triggered care plan areas and information from the interdisciplinary team. She said failure to complete care plans placed residents at risk of not having their needs met. She said the former DON was responsible for making sure the comprehensive care plans were completed and she did not know why Resident #5 did not have a comprehensive care plan . In an interview on 02/25/21 at 11:06 PM, the Administrator said the comprehensive care plans should include the initial areas, goals, interventions as well as help with feeding. He said failure to complete care plans could leave the staff unable to care for the residents. The Administrator could not determine why Resident #5 did not have a comprehensive care plan . In an interview on 02/25/22 at 2:22 PM the Regional Clinical Director said Resident #5 did not have comprehensive care plans . Record review of the facility policy titled Resident Assessment Instrument & Care Plan, revised 05/10/21, revealed a comprehensive care plan must be developed within 7 days of completion of the comprehensive assessment, prepared by an interdisciplinary team, . Reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessment.

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, which included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 out of 1 medication carts ( 2nd Floor Back Nursing Cart) reviewed for medication storage. 1. The facility failed to ensure medications stored in the 2nd Floor Back Nursing Cart were labeled. 2. The facility failed to ensure Resident #1's narcotic medication, in the 2nd Floor Back Nursing Cart, was locked in a separate compartment used to store controlled substances. 3. The facility failed to ensure the 2nd Floor Back Nursing Cart was locked. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications and drug diversion. Findings Include: Record review of Resident #1's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired in the facility on [DATE]. Record review of Resident #1's incomplete Admission MDS, dated [DATE], revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15. Nothing was documented for the assessment of assistance of ADLs and nothing was documented for Resident #1's urinary or bowel continence. Record review of Resident #1's care plan revised [DATE] revealed, Focus- the resident had an actual fall on [DATE], [DATE] and [DATE]. Interventions- Floor mats to both sides of bed, Neuro-checks per protocol, observe/report PRN for 72 hours to MD s/sx: pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation, place call light within reach, staff to educate on use of call light. Record review of Resident #1's MAR for [DATE]: revealed the following medications were administered for the residents 08:00 AM medication pass, [MEDICATION(S)] 2.5 mg 1 tablet, [MEDICATION(S)] 500 mg 1 tablet, Calcitriol 0.25 mg 1 capsule, [MEDICATION(S)] 20 mg 1 tablet, Multi-vitamin/Minerals 1 tablet, [MEDICATION(S)] 25 mg 1 tablet, [MEDICATION(S)] 220 mg 1 capsule and [MEDICATION(S)] 2mg 1 tablet. An observation and interview on [DATE] at 01:15 PM with RN D revealed the 2nd Floor Nursing Cart was unlocked with a medication cup which contained 8 solid forms (tablets and capsule of assorted sizes and colors) of medication in the top drawer; the cup which contained the medication was not labeled. RN D said that the pills in the cup were Resident #1's scheduled 8:00 AM medications. She said after she prepared the medication, the resident refused administration so she placed it in the cart to attempt to administer the medication at a different time. RN D said one of the medications was Resident #1's tablet of [MEDICATION(S)] 2mg , a strong pain killer, and the rest were her other chronic medications and dietary supplements. She said normally nursing staff should first introduce themselves to the resident and inform them that staff would be administrating medication to them prior to preparing the medication for administration. RN D could not say why she prepared the medication prior to confirming if the resident would be able to take the medication. She said all medications were required to be stored in their original pharmacy containers which were labeled with the medication and resident information, controlled medications should be stored in a separate locked compartment and nursing carts must be locked when not in use. She said if a medication is not administered to a resident after it has been removed from the original packaging it must be wasted and placed in the sharps container with another nurse as a witness. She said loose pills placed in unsecured carts place residents at risk for medication errors and adverse effects if the wrong medication was administered and drug diversion of controlled substances. In an interview on [DATE] at 10:10 AM, the DON said all medications should be labeled with the drug name, and resident information, nursing carts should be locked and controlled medications should be behind a double lock (a locked compartment in a locked cart). She said prior to administrating medication the staff should go in and tell the resident it was time for medication, evaluate the resident for administration related parameters, and then retrieve the medication verifying the package against the order. The DON said by following these steps staff could avoid prepping medication when the resident was unable or unwilling to take the medication. She said if the resident refused medication after they have been prepped then they must be destroyed by placing them in the sharps container with a nurse as a witness. She said loose pills, unlocked controlled substances and unlocked nursing carts placed residents at risk of medication errors and drug diversion. In an interview on [DATE] at 11:06 AM, the Administrator said prior to administering medication staff must inform the resident they would be receiving medication then read the order making sure it matched the medication being administered and once administered documentation should be completed in the resident's chart. He said if a resident declined a medication then the denial should be recorded in the resident's chart. The Administrator said all medication should be labeled per facility policy (resident name, drug name and frequency of administration), loose pills should not be kept in the nursing cart, controlled substances must be locked in a separate compartment and carts should be locked when not in use. He said loose pills and unsecured carts placed residents at risk for medication error and drug diversion. Record review of the facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles with revision date ,d+[DATE] revealed 3.1 Facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device. 3.2 Facility should ensure that all mediations and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 6 Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions. Record review of the facility policy titled 6.0 General Dose Preparation and Medication Administration revised [DATE] revealed, 6- After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 document necessary medication administration/treatment information (e.g., when medication are opened, when medications are given .) on appropriate forms; 6.2 dispose of unused medication portions in accordance with facility policy.

Based on interview and record review the facility failed to promptly notify the ordering physician of results that fell outside of clinical procedures for notification of the ordering physician orders for 1 of 1 resident (Resident #4) reviewed for diagnostic services. The facility failed to timely report Resident #4's radiology findings of an acute distal fifth metatarsal fracture, the long bone on the outside of the foot that connects to the little toe, resulting in a failure to treat prior to discharge. This failure could place residents at risk for delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Record review of Resident #4's face sheet, dated 02/25/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She discharged from the facility on 02/19/22 at 5:00 PM. Record review of Resident #4 MDS, dated [DATE], revealed the resident admitted from an acute hospital stay, needed limited to extensive assistance with all ADLs, used a wheelchair and a walker, occasionally incontinent of bladder, always continent of bowel, received occupational and physical therapy. Record review of Resident #4's care plan, revised 02/17/22, revealed Focus- resident had an actual fall on 02/06/22 related to unsteady gate and risk for falls r/t impaired balance and occasional bladder incontinence. Interventions- call light within reach at all times, remind resident to call for assistance for transfers. Record review of Resident #4's Clinical Progress Notes, dated 02/18/22, revealed no notes or documentation of how the injury occurred. Record review of Resident #4's Clinical Progress Notes, dated 02/18/22 at 9:31 PM written by RN A, revealed X-ray of left foot ordered pending tech arrival. Scheduled medications administered as ordered, call lights within reach, no acute distress. Record review of Resident #4's Clinical Records revealed no accident/incident report on 02/18/22. Record review of Resident #4's Physicians Orders, dated 02/18/22 signed by LVN B, with no time listed revealed X-ray of left foot, indication- trauma, dropped ice on foot. Record review of Resident #4's Radiology Report, received on 02/19/22 at 01:10 AM, revealed ALERT result: acute distal fifth metatarsal fracture . no dislocation. Electronically signed on 02/19/22 at 12:03 AM by the radiologist, physically signed by the Physician on 02/21/22. Resident review of Resident #4's Incident report, dated 02/21/22 at 01:55 PM, revealed, patient sustained an acute distal fifth metatarsal fracture after a container that she was obtaining ice from, fell on her foot. Agencies/People notified: DON on 02/21/22 at 01:10 PM, Physician on 02/21/22 at 01:00 PM, and State Survey Agency on 02/21/22 at 12:37 PM. In an interview on 02/25/22 at 10:07 AM, the DON said events that involved a suspicion of abuse/neglect, fall with major injury or fracture should be reported to the state agency. She said at the time Resident #4 discharged from the facility on 02/19/22 the X-ray results were not available. The DON said the risk of reporting/receiving X-rays and other diagnostics late was delay of treatment and failure to identify injuries . In an interview on 02/25/22 at 11:06 AM, the Administrator said the facility received the results for Resident #4's fracture on 02/19/22 but it was only brought to his attention on 02/21/22 by the Physician. He said the results were faxed in on Saturday 02/19/22 but it was missed until 02/21/22 and the facility was currently completing the investigation. The Administrator said floor nurses on duty were responsible for checking the fax machine for incoming radiology reports. He said the facility was required to report major injuries like fractures within 2 hours of when the facility was made aware of the fracture . In an interview on 02/25/22 at 12:55 PM, LVN A said nursing staff entered x-ray orders with the radiology company and results were normally faxed in but they could be accessed on the online portal . She said the expectation was nursing staff checked the fax to see if any results came in and once received the patients doctor must be notified of abnormal findings . LVN A said failure to receive and communicate abnormal lab/x-ray results timely to the ordering practitioner placed residents at risk of not identifying a problem, failure to initiate treatment and pain to identify a problem, initiate treatment, and pain. She said LVN B and RN A were the nurses that worked over the weekend from 02/19/22-02/21/22. In an interview on 02/25/22 at 01:18 PM, the DON said on 02/18/22, the day before Resident #4 discharged , she went to see the resident who then reported she had dropped a jug of ice on her foot. She said an x-ray was ordered on 02/18/22 and the resident discharged with a fracture on 02/19/22 but the facility was unaware of the fracture at that time. The DON said on Monday 02/21/22 she called Resident #4 to inform her of the baby toe fracture and to inquire if she wanted an appointment with a physician assistant or orthopedics but Resident #4 didn't want anything. She said she also called on 02/22/22 but Resident #4 said she wasn't worried about it. An attempt was made to contact RN A on 02/25/22 at 01:19 PM by telephone, she was not available for interview. In an interview on 02/25/22 at 01:27 PM, LVN B said when she left her shift on Saturday 02/19/22 at 7 AM, the X-ray results for Resident #4 had not come in the incoming RN, RN A, was aware of the pending results because she was the person who entered the original X-ray order on 02/18/22. She said over her weekend shift she checked and nothing had come across the fax. LVN B said normally, when a resident reported an injury and a fracture was suspected, the nurse was responsible for calling the doctor to receive an order and immediately when the results come in the doctor should be notified. She said since it was the weekend she would have notified the on-call doctor but Resident #4's results didn't come in on her weekend shift. LVN B said she did not have access to the online portal so she was unable to check the results and was waiting for the fax and the x-ray company normally called the facility to report any abnormal test results. LVN B said the risk of not communicating x-ray results on time was delayed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the facility policy titled Changes in Resident's Condition or Status revised 04/02/21 revealed, The facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. Notification of Changes: I- A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- a) an accident involving the resident which results in injury and has the potential for requiring physician intervention; b) a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, or psychosocial status in either life threatening conditions or clinical complications); d) a decision to transfer or discharge the resident from the facility.

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 1 resident (Resident #1) reviewed for accurate acquiring, receiving, dispensing, and administering of all drugs, in that: -Resident #1 was not administered Lorazepam as ordered by the physician. This failure could place residents at risk of not getting the anti-anxiety effects of the medication, decline in quality of life, decline in comfort and health. The findings included: Record review of Resident #1's admission record revealed an admitted [DATE] and initial admitted [DATE]. His diagnoses included anxiety disorder, dementia, diabetes, [CONDITION(S)] (narrowing of arteries resulting in reduced blood flow to head, arms, stomach and legs)open wound to left foot, [CONDITION(S)] and [CONDITION(S)](bone infection). Record review of Resident #1's admission MDS record, revealed a BIMS score of 15 out of 15 indicating he had no cognitive impairment. He required extensive, one-person physical assistance with most activities of daily living. Record review of Resident #1's active physician orders as of 12/02/2021 revealed Lorazepam tablet 0.5mg, give 1 tablet by mouth three times a day for anxiety. Order date 11/29/2021 and start date 11/29/2021. Record review of Resident #1's MAR for November 2021, revealed he did not receive Lorazepam 0.5 mg tablet on the following dates and times: 11/29/2021 - 8:00PM 11/30/2021 - 8:00AM, 2:00PM and 8:00PM The dates were coded with the number 10 (meaning: Other/see progress note). Record review of Resident #1's MAR for December 2021, revealed he did not receive Lorazepam 0.5 mg tablet on the following dates and times: 12/01/2021- 8:00AM, 8:00AM, 2:00PM and 8:00PM 12/02/2021- 8:00AM The dates were coded with the number 10 (meaning: Other/see progress note). Record review of Resident #1's progress notes did not have entries to correspond with dates coded with number 10. Record review of Resident #1's hospital records, date of service 11/07/2021 read in part: .Psychiatry consult given, concern for compliance and poor insight. Suspect underlying mood disorder, anxiety, paranoia traits and intellectual disability. Record review of Resident #1's Psychiatry physician progress note dated 11/18/2021 read in part: .Nurses and staff say behavior very difficult but tolerable. Can safely manage patient here. Record review of Resident #1's physician progress note dated 11/29/2021 read in part: Psychiatry: Nurses reported needy, demanding, repetitive with yelling and have to say things over and over to get him to listen. DON reported he's resistant to care, angry and verbally aggressive .I added [MEDICATION(S)] (generic name for Lorazepam) 0.5mg PO TID. Observation and interview on 12/02/2021 at 10:30AM, Resident #1 was lying in bed watching TV. He had an ace wrap to his left foot. He said he had been in the facility about one week and had some set-backs due to going to the hospital about 2-3 times then returning to facility. Interview on 12/02/2021 at 12:25PM, LPN A said a code number 10 on the MAR meant the medication was unavailable. LPN A said Resident #1's Lorazepam had not arrived, and she was just about to check when the Surveyor asked her. LPN A said she would first check with the Pharmacy to see about the delay. LPN A said if a drug was needed from the E-kit, the doctor would need to write an order in triplicate first. LPN A said Resident #1 was easily agitated and had a mind like a child if he does not get things done a certain way and he may take things the wrong way too. LPN A said in the last 2 days Resident #1 had not had any behaviors. LPN A said it was the nurse's responsibility to find out why meds have not been given or why meds were unavailable. In an interview on 12/02/2021 at 1:35PM, the SW said she had seen Resident #1 agitated and it was because he didn't want the wound vac anymore. He said he hated it. At the time he was talking to his brother on the telephone. SW said when she would speak with Resident #1, his conversations would have a mind of their own. His train of thought would wander and never return to the initial topic of conversation. In an interview on 12/02/2021 at 3:00PM, the DON said when the nurse called pharmacy regarding the Lorazepam, they gave her incorrect information. When ordering scheduled drugs, it is not enough for the nurse to enter the order in PCC and for the physician to do the same. The physician must order through a secure site in order for the pharmacy to fill the prescription. This is how it had always been done. The MD will call in the order/order through secure website and it is the charge nurse responsibility to ensure a follow-up. The DON said she had just discussed this with one of the doctors in the building who was unfamiliar with the process, so it was fresh in her mind and that she will be contacting the pharmacy to help educate the doctors and nursing staff. The missing link in ordering has to do with the MD ordering through secure website. What we also need to include in the process is for nurses to notify the medical director as medical director is aware of the proper procedure and would be able to guide in the process. The DON agreed that there was a system failure due to the missing link. DON said the staff will be educated. In an interview on 12/02/202 at 4:00PM, the Administrator said the nurses should call the doctor and get guidance from the physician if a medication was unavailable. It could mean the need to order a new med or a substitution. It is the responsibility of the nurse taking the pharmacy order to ensure the resident receives meds as ordered. We have never had issues like this. In an interview on 12/02/2021 at 4:30PM, the DON said Lorazepam is available in the E-kit, the nurses did not understand the process. First the MD had to order through secure website, the nurse will then call the pharmacy who will then send a one-time code to access the E-kit safe. The issue is when nurses order through PCC and don't communicate with the following shift. DON said she did not know what happened in Resident #1's case with the Lorazepam and would have to look into it. She did not think the process for ordering Scheduled drugs was complicated for the nurses or the physicians. In an interview on 12/02/2021 at 4:49PM, the DON said the consent for Lorazepam had just now been signed by Resident #1's Responsible Party (RP), a call out to Pharmacy had been made and Resident #1 will get his Lorazepam. Record review of the facility training letter from the DON titled Control Substance Order Training read: Concern - Unable to receive control medication timely. Resolution: Medical Director or Pharmacist will train all attending and consulting physicians how to order control substance via secure website with Pharmacy. Controlled medication cannot be confirmed through PCC, must be ordered through a secure website. Controlled medication needing triplicate, must have e-script transmitted to pharmacy. DON or Designee will train all charge nurses how to, 1)order control substance, 2)how to get approval to remove control substance from the emergency narcotic box and 3)whom to contact or how to troubleshoot when unable to acquire prescribed control substance. Training started 12/02/2021. Record review of the facility Policy and Procedure titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, revised on date 10/31/2016, read in part, .4. Hard copy physician/prescriber orders should be faxed to the pharmacy .5.1 An electronic medication administration record entry is created once the order is finalized 6. Authorized Physician/Prescribers may electronically prescribe controlled substances and non-controlled medications using an electronic prescription Record review of the facility Policy and Procedure titled Administration of Medications revised on 07/14/2021 read in part, .Standard: All medications are administered safely and appropriately per physician orders to address residents' diagnosis and signs and symptoms

The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control; in that: The Staff Development Coordinator (SDC) failed to don a gown when she administered a COVID-19 nasal swab test to Resident #1 who had unknown COVID-19 status. This failure could affect all residents, placing at risk contracting and spreading. Findings include: Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's annual MDS assessment dated [DATE] revealed a staff assessment for mental status score of 3 out of 15, indicating severe impairment. She required extensive assistance of 1-2 staff for bed mobility and transfers. Interview on 10/20/20 at 9:39 a.m. with RN A on the 200-hall, she said all 8 residents on her hall were on contact precautions. She said when entering the resident's room, you had to don a face shield, N95 mask, gown and gloves. She said the residents were on precaution because a part time employee recently tested positive for COVID-19. Interview on 10/20/20 at 12:31 p.m. with the SDC, she said she was testing all residents today for COVID-19. Observation and interview on 10/20/20 at 12:57 p.m. with the SDC on the 200 hall, she entered Resident #1's room without donning a gown. Resident #1 was lying in bed, the SDC leaned over the resident to administer a COVID-19 test via the nasal passage. The SDC said residents on the 200-hall did not require the use of a gown. Interview on 10/20/20 at 1:19 p.m. with the Administrator, he said the 200-hall was changed to a suspected COVID-19 floor because an employee tested positive. He said effective 10/19/20, staff were to don a gown when entering residents' rooms. Interview on 10/20/20 at 1:58 p.m. with the SDC, she said a N95 mask and gloves were required when working with residents on the 200-hall, not a gown. She said she was not directly notified of a case of COVID-19 amongst the staff and was not sure if it was a rumor or the real thing. She said she was not aware that she had to wear a gown. Interview on 10/20/20 at 2:03 p.m. with the Administrator, he said as of 10/19/20 all residents on that hall were designated as unknown COVID-19 status because a nurse who worked on the 200-hall tested positive for COVID-19 on 10/16/20. He said the nurse wore a surgical mask while working. He said the SDC was notified of the positive COVID-19 case during morning meeting and was told that staff must don a gown when entering all rooms. Record review of the facility's Transmission-based Precautions and Isolation Procedures dated 3/24/20 read in part, .don appropriate PPE upon entry into the environment of resident on transmission-based precautions (e.g., contact precautions) . For a resident with known or suspected COVID-19: Associates should wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #1) reviewed for infection control. -RN R failed to perform hand hygiene during medication administration to Resident #1 who was in reverse isolation (the purpose of reverse isolation is to protect the patient from any germs the staff or visitors are carrying). -This failure could affect any resident who is on reverse isolation. Findings Include: Resident #1 Record review of Resident #1's admission record revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's care plans revealed a focus: The resident has impaired immunity related to [MEDICAL CONDITION] dated on 03/09/2020. Interventions included; Maintain reverse isolation related to [DIAGNOSES REDACTED]. During an observation on 03/11/2020 at 1040 AM, there was an isolation cart outside Resident #1's room. On top was a box of gloves, a box of masks, contact isolation and respiratory isolation instructions. The drawers had yellow gowns. During an observation on 03/11/2020 at 1045 AM RN R entered room with portable electronic BP machine, gloves and mask. He donned gloves and mask just inside the door. He walked out of room, removed gloves and mask and deposited in the trash at med cart. He said he will hold the Mitodrine. He opened med cart, gathered medications, put gloves and mask on, entered resident room and administered meds. RN R exited room, removed mask and gloves at the med cart. He opened a door to a storage room near by, returned to cart and began using the computer key board. In an interview on 03/05/2020 at 11:15 AM RN R said he should have put gown on as well as the gloves when entering Resident #1's room. He said she was in reverse isolation and the gown would be to prevent any splashes from getting onto scrubs. He said hand hygiene was done to remove unwanted microorganisms from hands. He said he did not perform hand hygiene before donning clean gloves and after removing gloves. He said he forgot to do this. In an interview on 03/11/2020 at 2:30 PM, the Regional Nurse said there was no policy and procedure for reverse isolation. Record review of facility policy on Hand Hygiene, Life Care Centers of America, last reviewed 07/25/19 revealed Purpose: to decrease the risk of transmission of infection by appropriate hand hygiene .Introduction using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; .after removing gloves Special considerations .Keep in mind that glove use doesn't eliminate the need for hand hygiene. Record review of facility policy on Transmission-based Precautions and Isolation Procedures, revised 02/11/2020 did not include procedure for Reverse Isolation.

Based on interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 14 residents (CR #1) reviewed for accidents and supervision, in that; CR#1 known to have history of substance abuse was not provided adequate supervision to prevent continued use of illicit drugs. CR#1's baseline care plan and admission comprehensive assessment care plan did not address CR#1's history of illicit drug use and smoking. CR#1 was not adequately monitored and supervised after incidents of smoking in his room and possible illicit drug paraphernalia. CR#1 was found dead in his bathroom with syringe, needle and heroin on his bathroom sink. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was continuing to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one closed record who died . Findings include: CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the facilities Pre-Admission Assessment for CR #1 dated [DATE] revealed he was admitted to local hospital on [DATE]. The assessment revealed the resident was homeless living in his car before admission to the hospital. His admitting [DIAGNOSES REDACTED]. Further review of the assessment revealed the resident was accepted into the facility. There were no additional notes on the assessment addressing the substance abuse or use of cigarettes. Record review of CR #1's History and Physical (H&P) dated [DATE] completed by NP, revealed a social history stating, current every day smoker, drinks beer ,[DATE] times per week, no illicit drug abuse. CR#1's H&P revealed review of Miscellaneous labs stating, urine drug screen [DATE] positive with opiates. The H&P summary of Plans did not address the resident's positive drug screen, history of drug use, or current cigarette use. Record review of CR #1's Admissions Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed CR #1 had no current Tobacco use. Record review of CR #1's hospital record dated [DATE] revealed a social history - He uses heroin and has a history of [MEDICATION NAME] use in the past. He smokes cigarettes. He denies alcohol use. Urine drug screen was positive for opiates. The Impression was At this time, I strongly suspect the fever is related to the fracture and also possible drug fevers. Record review of CR #1's record revealed no baseline care plan on admission on file. Record review of CR #1's record revealed no care plan addressing the resident's history or risk of substance abuse and smoking following admission. Record review of CR #1's progress notes dated [DATE] at 11:14AM revealed, Doctor here to see resident with new orders for Intravenous Antibiotics (IVABT) and labs. Pharmacy notified of peripherally inserted central catheter (PICC) placement and orders faxed to pharmacy. Resident was informed of IVABT for [MEDICAL CONDITION] lower extremities. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] at 10:16AM revealed, Attempted to flush and hang IVABT via PICC at 7:00AM. Unable to flush. Assessed IV and noted rubber cap off PICC line site. Unit manager assessed also and noted. PICC line dislodged right upper arm. Call placed to pharmacy and request for PICC line reinsertion and will send nurse out. Resident informed IVABT will be given after insertion. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] at 2:05PM revealed, RN here to reinsert PICC line at 12:00PM. Orders for STAT chest x-ray for placement prior to restarting IVABT. Doctor here and informed of PICC line out and residents Physician also notified. X-ray ordered with number 011. Resident aware. [MEDICATION NAME] with-held d/t bleeding at insertion site. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] referred to a late entry from [DATE] 10PM-6AM. The note revealed on [DATE] around 2:30AM, LVN #2 smelled a cigarette odor. She followed the smell and went to CR #1's room where she observed him sitting on his bed smoking a cigarette. She politely informed him that smoking was not permitted in residents' room. The resident responded by cursing and yelling at her saying, What the [***] you going to do. [***] you. Get out of my room. LVN #2 called the unit manager and she instructed her to get another nurse and get the cigarettes away from the resident. She returned to the room with a second nurse who also said he could smell smoke and informed CR #1 they had to quickly check his drawer for cigarettes and lighter to avoid accidents and danger. The other nurse reached for the drawer and CR #1 punched the nurse and began hitting him in the head with the phone. The resident continued to curse and hit the nurse with objects while they were asking the resident to stop and calm down. The nurse was able to discover a pack of cigarettes and some medication that were in the drawer. The staff left out of the room and the resident followed them to the nurse's station while continuing to yell and curse. LVN #2 called the Physician and the family. Note was written by LVN#2. Phone interview on [DATE] at 9:08AM, LVN #2 confirmed she was the nurse who observed CR #1 smoking in his bedroom on [DATE] around 2:30AM during the 10PM - 6AM shift. She said she smelled smoke and walked down the hall to see where it was coming from and observed CR #1 sitting on the end of the bed with a cigarette butt in his mouth. She asked him what he was doing and told him he could not smoke in the facility and he began to yell and curse at her. She then called the unit manager and stood in the doorway while telling her what was going on. The unit manager attempted to talk to the resident over the phone, but he would not stop yelling and cursing. The unit manager instructed her to go get another nurse and remove the cigarettes and lighter. She got another male nurse (RN#2) and they attempted to remove the cigarettes and the resident began to fight the male nurse and hit him with the phone and other objects nearby. They recovered some cigarettes and [MEDICATION NAME] pills. She later wrote up what happened and was told by the DON they shouldn't go to the room again and another nurse should take over the room. Record review of RN #1's written statement dated [DATE] revealed when she arrived for her shift (6am - 10pm) on [DATE] she was immediately informed of a smoking incident that had taken place with CR #1 and had led to combative behavior. The night nurse (LVN#2) told her the resident was still there and per the 6AM -2PM nursing staff the resident did not present anymore behaviors at that time. Later during the 6AM -2PM shift it was brought to her attention that an unfamiliar needle, syringe device was retrieved from CR #1's bathroom floor. RN #1 confirmed in her statement it was not a needle used at the facility. The nurse assigned to the resident (LVN #3) also confirmed the syringe was not used by her or on her cart. She called the DON and left a voicemail. RN#1 instructed LVN #3 to call the physician and request for labs for a drug panel or to have the resident sent out to be evaluated or treated. She further noted LVN #3 denied the resident presented any violent behaviors or change in condition during her shift. RN #1 wrote she then texted the DON to inform her of the needle device found in room due to her not answering the phone. During this time the on-call provider returned the phone call, and she witnessed LVN #3 suggest a drug panel or for the resident to be sent out to the hospital. The on-call provider gave directives to monitor for change in condition and if so to discharge to the hospital. During that time the resident was noted to be stable with no behaviors. Shortly after staff spoke with the on-call provider the DON replied to the text and said she was out of town and asked if the device was removed, use caution entering his room, go in pairs, see what his intentions were, and to get family involved. The resident was closely monitored for the rest of the weekend and did not present any cause for concern. On Sunday morning [DATE] the Administrator was notified when he was noted in the building and he also said to monitor resident, report change, and send out if needed. Record review of CR #1's progress notes dated [DATE] at 2:27PM, revealed the DON spoke with the resident regarding his behavior- smoking in his room. The Resident denied hitting anyone and said they found a pack of cigarettes that were not open, and some [MEDICATION NAME] pills he kept for his own use. The resident was educated about the facility being smoke-free and he was not allowed to smoke anywhere on the premises and failure to follow the policy could result in discharge. Resident denied smoking in the room and said he had just come from smoking outside and that's why he smelled of smoke. He was also told he could not keep medications in room and if he felt he needed something the Physician would order it. The resident said he was preparing to discharge next week, and he wanted to be with his family in another town. The DON informed social services of his wishes. Residents care plan was updated to reflect non-compliant behavior in smoking, combativeness towards staff and taking medication not prescribed by the Physician. Record review of CR #1's Care Plan dated [DATE] revealed resident is at risk for non-compliancy with smoking in the room, exhibiting periods of manipulation combativeness and verbal aggression towards staff, as reported by nursing staff. The goal was, Resident will experience minimal adverse effects from non-compliance through next review, with a target date of [DATE]. The approaches were to, anticipate care needs and provide them before the resident becomes overly stressed, if reasonable, discuss behavior with resident. Explain/reinforce why behavior is unacceptable. Intervene as needed to protect the rights and safety of other. Investigate/observe need for psychological/psychiatric support. Provide services if desired by resident/responsible party as ordered by the physician. Report to physician changes behavioral status. Attempt to provide a safe living environment for resident daily. Discuss compliancy and potential results of non-compliancy with patient. Further review of above care plan revealed it did not address CR#1's drug use history and it did not address nursing staff's concern regarding CR#1's PICC line. Record review of CR #1's progress notes dated [DATE] at 10:18PM revealed in part, Resident appetite has decreased, and he has not been eating his meals. Resident was observed by a Physical Therapy assistant sitting on the toilet for an extended period of time with a syringe and needle on the floor next to him. Resident was asked where the syringe came from by charge nurse and resident stated he did not know what the charge nurse was talking about. Resident appeared to have slight change in mental status, he was slurring his speech and stated that he was feeling dizzy. Resident vitals were obtained ,[DATE], 88, 20, 97.5, 98%. Resident breathing was even and unlabored with no complaints of shortness of breath. Resident received Physical therapy services. Resident left off premises at 7:32PM, stated he was going out with his family member to get something to eat, as of 10:30PM resident still has not returned. Informed 10PM-6AM shift nurse that resident had not returned. Resident did not receive any 8:00PM medications. Will continue to monitor. Progress note was signed by LVN #3. Further review of CR#1's record revealed there was no further follow up on this incident by the facility administrator and DON. Interview on [DATE] at 1:00PM, LVN #3 confirmed she completed the note about the syringe being found in CR #1's room on [DATE]. She said she was on break around noon and when she returned another nurse told her about the needle being found in the restroom with the resident and she had placed it in the med room for her to examine. She examined the needle and confirmed it was not a needle that was used in the facility and said it appeared to be old due to the numbers being worn off. LVN #3 began to get emotional as she explained how she had a close relationship with the resident and was unaware of his history of drug use. She said after she examined the needle she went to CR #1's room and observed him coming out of the restroom and he complained of being dizzy and was slurring his speech. She assisted him to the bed and asked him what was going on. He denied having the syringe and said he didn't know what she was talking about. She took his vitals and she felt they were normal for him. She went to the nurse's station and the weekend unit manager (RN #1) was there and already knew of the incident. She said they then called the on-call NP and was instructed not to do any labs and to monitor the resident for changes and if there are changes to send to the hospital. LVN #3 reported she worked 6AM - 10PM on Saturday and Sunday and did not observe any changes or concerns in the resident during that time. She revealed she was very concerned about him after the incident, so she closely monitored him and kept track of where he was. Record review of CR #1's written physician's orders [REDACTED]. [DIAGNOSES REDACTED]. Record review of CR #1's transcribed physician's orders [REDACTED]. Record review of CR #1's progress notes dated [DATE] at 10:43PM revealed in part, Resident receiving IVABT [MEDICATION NAME] for osteo[DIAGNOSES REDACTED], heel wound and amputated great toe. No adverse reactions noted (NARN). Afebrile. PICC line to upper right arm, dressing dirty with blood, will need to be changed. PICC line is patent, with [MEDICATION NAME] lock. Resident complained of abdominal pain and diarrhea, gave Questran to aid with loose stools. Resident is continent of bowel and bladder and a one person assist when needed. Resident receiving PT/OT skilled services, resident is able to ambulate with aid of walker. Record review of CR #1's progress notes dated [DATE] at 3:55pm revealed the resident was visited for an admission evaluation by another facility representative. Note further revealed per evaluation the resident was clinically accepted for admission, insurance authorization was pending. Record review of the facility's incident report dated [DATE] revealed CR #1 was found unresponsive on his bathroom floor around 6:30AM on [DATE]. Code Blue was initiated and 911 was called. Cardiopulmonary resuscitation (CPR) was started. Emergency Medical Services (EMS) arrived and took over and pronounced the resident at 7:07AM. The EMS note syringe with clear substance next to sink and black plastic spoon with small brown colored rock like substance in front of sink. Houston Police Department (HPD) was notified and on scene at 7:35AM as well as Medical Examiner as of 9:19AM. Incident was observed on day shift 6am - 2pm. Record review of LVN #4's written statement dated [DATE] revealed she came to the 2nd floor on [DATE] around 2:00AM to make rounds on CR #1 in room [ROOM NUMBER] and LVN #2 stated she saw him go down in the elevator to go outside and smoke. She went back to the 5th floor where she was assigned. She returned to the 2nd floor to administer any 6:00AM meds for CR #1 but noted the Medication Administration Record [REDACTED]. The night nurse and morning nurse were notified the patient did not have 6:00AM meds and went back to her 5th floor station. Interview on [DATE] at 5:47AM, LVN #1 confirmed she was the nurse to discover CR #1 unresponsive in his restroom on [DATE] around 6:30AM. LVN #1 said she had just come onto her shift and was headed to CR #1's room when CNA #1 came out of the room and told her the resident was on the floor. She went into the room and found the resident unresponsive on the bathroom floor lying in fetal position. She called out to the resident and he did not respond, she checked his pulse and called a code blue. Resident was pulled out into room area, CPR was started and 911 was called. LVN #1 said the resident body presented signs as if he had been lying there for a while, she did not elaborate. She further said she raised up the resident's shirt in attempts to find his cell phone to notify family and found a syringe. She said there was also a black plastic spoon and some brown rock like substance that she suspected to be heroin. There was also a paper towel with a nickel size blood spot on it and the hot water was running in the sink when she entered the room. She felt something was wrong when she saw the light on in the resident's room because the resident was not usually awake at that time, he usually slept in until around 11:00AM. LVN #1 said she had no idea the resident had a history of [REDACTED]. The nurse from the night shift did not give her a report of any concerns or incidents for CR #1. She added the resident was a smoker and would often leave out of the facility to go and smoke. Interview on [DATE] at 5:59AM, CNA #2 said she worked 10PM - 6AM shift on the 2nd floor the night before CR #1 was found ([DATE]). CNA #2 said she made rounds around 10:00PM and the resident was not in his room and she assumed he was out smoking because he often left out the facility to go and smoke. The next time she saw the resident he was coming out the elevator between the time of 1:30AM - 2:30AM. CR #1 did not greet them at the nurses' station as he sometimes did and went into his room and closed the door. She did not see the resident for the rest of the night. She did not go into the resident's room the rest of the night because he does not like to be bothered when his door was closed. She said she could not speak on the resident's personality due to him being a quiet person. CNA #2 was unaware of resident having any current or past issues with drugs. CNA #2 added the resident would often leave out of the facility throughout the night to go smoke. Interview on [DATE] at 7:30AM, the social worker said CR #1 did not self-disclose a history of drug use to her during her assessment. The social worker said the resident did not present behaviors for her to suspect current issues with substance abuse, therefore it was not addressed. She had spoken with the resident on [DATE] concerning his request to discharge to a non-smoke free facility. The social worker found a smoking facility to accept the resident and the Interdisciplinary Team (IDT) and Nursing Services were aware. The incident on [DATE] with CR #1 being found with a syringe and needle was not brought to her attention until their morning meeting after he had passed on [DATE]. Due to her being unaware of the incident she did not reassess the resident for drug abuse or make any referrals. Phone interview on [DATE] at 9:15AM, LVN #2 said she came to work Monday night ([DATE]) and did not go into CR #1's room as the DON instructed her to do but did make observations of him in his room while walking the halls. She observed CR #1 in his room around 10:05PM sitting on his bed due to his door being open. She observed CR #1 leaving out of the elevator between 2:00AM - 2:30AM. She did med pass around 4:00AM and saw CR #1 lying in his bed due to the door being open. LVN #2 said she then called the nurse assigned to him (LVN #4) to give him his meds and LVN #4 said she would be down in a minute. LVN #2 added she was not aware of resident having history of substance abuse, the incident of resident being found with a syringe on [DATE], or the orders for the resident to be monitored for suspicions of drug use. LVN #2 added the resident would often leave out of the facility throughout the night without signing out, it was always assumed he was smoking outside. Interview on [DATE] at 9:50AM, the Unit Manager said LVN #2 had called her around 3:00AM and told her about CR #1 smoking in his room and his behavior when she confronted him. She had LVN #2 put her on speaker and attempted to talk to CR #1, but the resident was yelling and screaming refusing to listen. She told LVN #2 to leave the room and get another nurse to remove the cigarettes and lighter. She texted the DON and Administrator to determine if the police should be called. Before they could respond she heard back from the nurses they were able to retrieve the cigarettes and medications and was told about his fighting the staff. She came in shortly after 3:00AM to see the resident and address the situation but the resident had already fallen asleep. The DON spoke with the resident when he woke up later in the day. The Unit Manager added she was shocked by his behavior and she had never saw the resident act in that way. She also confirmed CR #1 would often go outside to smoke or leave the premises with a woman. She said CR #1 was non-compliant with signing out and she would often get onto him about signing out. Interview on [DATE] at 10:20AM, the Unit Manager said she was aware CR #1 had a history of [REDACTED]. She said the resident had a few issues with his PICC line and she wondered if he was messing with it but did not want to assume or accuse without evidence. She questioned the resident on one occasion where she found the PICC line bloody as if it had been tampered with and CR #1 claimed the nurse who came in earlier had flushed the line and caused the mess. The Unit Manager said she was not aware of the incident that happened over the weekend ([DATE]) with the resident being found with a syringe and needle until after he was found deceased on [DATE]. Interview on [DATE] at 12:45PM, CNA #3 said around 12:00PM on [DATE] she was in a room assisting with feeding when a nurse asked her to step out to the hall. The nurse asked where CR #1 was when she went to pass his lunch tray. They both went into CR #1's room and opened the bathroom door and observed him on the toilet with a syringe on the floor wrapped in toilet paper with blood on it. CR #1 told them to get out because he had diarrhea. The nurse (LVN#5) was able to grab the syringe from off the floor before they left the room. She added that when she went to pass the lunch tray earlier the resident was not in the room and she assumed he had gone downstairs to smoke. Attempts were made to contact LVN #4 via phone on [DATE] at 1:20PM and [DATE] at 5:00PM, there was no response and voicemail was left with no return phone calls. Attempt was made to contact LVN #5 via phone on [DATE] at 1:25PM, there was no response and voicemail was left with no return phone calls. Record review of CR #1's clinical record revealed no documentation of labs, assessments, or referrals addressing substance abuse or resident's ability to smoke outside the facility since his admission. There was also no check out log to indicate when the resident had left and returned to the facility or evidence the resident had been counseled about it. Interview on [DATE] at 4:00PM, the Administrator and DON said the company had Liaisons who go into hospitals to assess resident and clear them to be admitted to the facility. The Administrator and DON when asked said CR#1 was admitted to the facility despite his history of substance abuse due to no indication the resident was currently using drugs. The Administrator and DON when asked said CR#1 had no care plan for risks of substance abuse upon his admission because facility did not feel the resident presented concerns. There were also no smoking assessments completed or care plan addressing smoking for the resident because the facility was non-smoking. The Administrator said staff were aware of the resident leaving the facility to smoke and him leaving the facility for extended periods of time. The DON said she attempted to counsel with the resident on checking out of the facility, but he continued to be non-compliant. The Administrator and the DON said after the incident on [DATE] when CR #1 was found with a syringe and needle, they responded accordingly by notifying the Physician and following the orders to monitor the resident. They confirmed CR #1's care plan was not updated to reflect the incident, there were no assessments or referrals made, and there were no additional interventions put in place for the resident. The DON said there were no in-services completed for staff concerning signs of substance abuse or how to monitor for substance abuse issues. The DON said the resident was being monitored and there were no further concerns, signs, or changes after the incident that prompted them to do anything else. The DON gave no specifics on how the staff were monitoring the resident and she said the Physician did not specify that in her order. The DON said she knew the resident's vitals were taken every day and there was a nurse (LVN #3) on the weekend shift who closely monitored the resident by keeping track of where he was going and his status when he returned. The DON agreed there was a break in communication from the weekend staff and the week day staff. The weekday staff were not aware of CR#1's incidents and possible drug use which required staff to monitor him. The DON said the shift change report should have told the in-coming staff what was going on. The DON and Administrator reported even though staff were unaware of the incident with the syringe and the residents drug history, the resident was properly monitored and presented no changes to cause them to initiate any other interventions. Interview on [DATE] at 3:00PM, CR #1's Physician said she came into the facility on [DATE] and discontinued an order for [REDACTED]. She did not address the situation that happened on [DATE] with the syringe during her visit because she was unaware of the incident. She was not told about the incident until the morning meeting on [DATE] after the resident had passed. She confirmed she had now talked to her on-call NP who was contacted about the incident on [DATE] and she confirmed she gave orders to monitor the resident for changes and send out if there were changes. She added she was also not aware of the resident combative behavior with staff when he was found to be smoking in his room on [DATE], she was only told the resident was smoking cigarettes and [MEDICATION NAME] were retrieved from his room. Record review of Houston Police Department Report dated [DATE] at 7:11AM revealed an offense titled Death - Poison/Drugs. CR #1 was identified as the complainant in the report. The Brief Summary revealed, The complainant was found deceased in nursing home by the attending nurse. A syringe with needle and a small amount of heroin was also found near the body. The report further revealed Houston Fire Department was on the scene and announced time of the death at 7:07AM, the complainant appeared to have been deceased for at least 2 hours because he was stiff and rigor mortis had started to set in. The reportee was listed as LVN #1, her statement revealed she found the resident deceased in bathroom around 6:30AM. She alerted other staff to come help her, so they could initiate CPR and 911 was called. She stated she found a syringe with needle and a small amount of heroin on the sink of the bathroom and she suspected the complainant was shooting heroin prior to his death. Record review of the facility's Non-Smoking Facility policy (Last Revised [DATE]) revealed in part, smoking is not allowed, at any time, inside or outside the building or on the property by resident, staff, or visitors. Record review of the facility Safety Management Program policy (Last revised [DATE]) revealed in part, The facility is committed to a safety management program designed to provide a physical environment free of hazards, manage staff activities, and minimize the risk of human injury. It shall be directed to the safety of all associates, residents, and visitors interacting with the facility. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 4:15PM due to the above failures. A Plan of removal was requested. After revisions, the Plan of Removal was accepted on [DATE] at 12:00PM. Immediate Jeopardy Plan of Removal Completed [DATE] 1. Medical Director notified, and QA set for 3pm on [DATE] 2. Education began with Staff related to (completed by ED, DON, Unit Managers, RN Supervisor, Regional Nurse): a. Sharps containers needing to be locked. Safe disposal of sharps. b. Ensure areas free from hazardous materials c. Immediate Notification of unusual occurrences or behaviors to MD, DON, ED- d. Clinical assessments and recognizing signs and symptoms of illegal drug use e. Residents Rights -v- Safety (check on but do not disturb unless necessary) 3. Residents educated on (Completed by Social services Director, Social Services Assistant): a. Residents Rights -v Safety (will be checked on but not disturbed unless necessary) b. Facility is non-smoking (except for the grandfathered in people in facility as of ,[DATE]) c. Requirements to sign in and out when leaving the property 4. Audits completed: a. Sharps containers locked (Audits by Nurses) b. Current residents (,[DATE]) checked for smoking history/activity and/or history of illegal substance abuse (audits by DON, SDC, Case Manager, MDS nurses, Unit Managers) Any residents identified with a smoking history or substance abuse history the care plan was reviewed and revised as needed. c. Room rounds completed by department heads and no potentially hazardous items were identified. Rounds will be completed ,[DATE] times weekly. Completed [DATE] 1. Continued Education of Staff as above 2. Completed current resident education as per above 3. Audited new admission charts for history of smoking or substance abuse 4. Audited Sharps containers 5. Staff will not be allowed to return to work until education has been completed Facility practice: 1. Facility liaisons conduct bed side screenings and follow the facility capability grid to determine the appropriateness of the patient for the facility and the facilities ability to meet their needs. 2. At the time of the bed side screening the information is forwarded to the facility to the unit staff and information is placed on the 24 hour report and in shift to shift communication/report. If the referral has known use of or history of drug use, alcohol use, smoking or a positive toxicology for these, then the referral will be sent to DON and ED for further evaluation to determine if facility can meet the needs of the patient. 3. Resident specific needs will be communicated to appropriate clinical staff at the time of admission and through shift to shift reporting. 4. The base line care plan is initiated at the time of admission and completed within 48 hours by the nursing staff and IDT. The base line care

Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 14 residents (CR #1) reviewed for resident administration in that: The Administrator failed to develop and implement policy and procedure for a resident admitted to the facility who was non-compliant with smoking in a non- smoking facility The Administrator failed to have policy and procedure in place for suspected illicit drug use in the facility. The DON failed to train nursing staff on how to monitor and supervise resident with a possible illicit drug use in the facility. The DON failed to ensure nursing staff were made aware of CR#1's history of illicit drug use and failed to ensure staff received adequate communication of recent incident of suspected drug use in the facility by CR#1 for which supervision/monitoring was required and ordered. CR #1 was found dead in his bathroom with a syringe and needle next to him and heroin on the bathroom sink. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was continuing to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one closed record who died . Findings include: TX 779/Intake # Interview on [DATE] at 4:00PM, the Administrator and DON said the company had Liaisons who go into hospitals to assess resident and clear them to be admitted to the facility. The Administrator and DON when asked said CR#1 was admitted to the facility despite his history of substance abuse due to no indication the resident was currently using drugs. The Administrator and DON when asked said CR#1 had no care plan for risks of substance abuse upon his admission because facility did not feel the resident presented concerns. There were also no smoking assessments completed or care plan addressing smoking for the resident because the facility was non-smoking. The Administrator said staff were aware of the resident leaving the facility to smoke and him leaving the facility for extended periods of time. The DON said she attempted to counsel with the resident on checking out of the facility, but he continued to be non-compliant. The Administrator and the DON said after the incident on [DATE] when CR #1 was found with a syringe and needle, they responded accordingly by notifying the Physician and following the orders to monitor the resident. They confirmed CR #1's care plan was not updated to reflect the incident, there were no assessments or referrals made, and there were no additional interventions put in place for the resident. The DON said there were no in-services completed for staff concerning signs of substance abuse or how to monitor for substance abuse issues. The DON said the resident was being monitored and there were no further concerns, signs, or changes after the incident that prompted them to do anything else. The DON gave no specifics on how the staff were monitoring the resident and she said the Physician did not specify that in her order. The DON said she knew the resident's vitals were taken every day and there was a nurse (LVN #3) on the weekend shift who closely monitored the resident by keeping track of where he was going and his status when he returned. The DON agreed there was a break in communication from the weekend staff and the week day staff. The weekday staff were not aware of CR#1's incidents and possible drug use which required staff to monitor him. The DON said the shift change report should have told the in-coming staff what was going on. The DON and Administrator reported even though staff were unaware of the incident with the syringe and the residents drug history, the resident was properly monitored and presented no changes to cause them to initiate any other interventions. Interview on [DATE] at 9:32AM the Administrator said the facility has liaison's in who go to hospitals to evaluate residents for admission to the facility. If the liaisons approve the resident for admission, the file is sent to the facility for facility staff to review. After a resident is admitted the facility has interdisciplinary team (IDT) meetings to evaluate the resident and establish a care plan in conjunction with the medical physician. The Administrator said he monitors staff through morning meetings, weekly meetings with department heads, and doing monitoring rounds. He ensures the competency of staff with skill check offs and annual review of job descriptions and performance review. The facility ensures the effectiveness of the facility process through Quality Assurance committee meetings that meet monthly. The Administrator identified the medical physician, medical director, psychiatric services, psychological services, and corporate personnel as facility resources. The Administrator when asked what he thought lead to the immediate jeopardy said he could not speak on what led to the incident with CR #1 because it had just happened on [DATE]. He said the situation was still being investigated so he is not able to say if and how there was a failure. Interview on [DATE] at 9:46AM, the DON said the staff were not previously in-serviced on signs or symptoms of drug use. After the incident the staff were in-serviced over reviewing resident clinical record for history, 24-hour report, abuse/neglect, signs and symptoms of drug use, monitoring residents, and checking out process. The DON said residents will now be evaluated when they return to the facility and checked for paraphernalia being brought in. Residents who come in with substance abuse issues should have been identified before admission and presented to the circle of service. The IDT team then should have gone to the resident's bedside and addressed the identified history and came up with a plan of care. The DON was not sure how the incident came about because the situation was still under investigation. She added the facility are evaluating our understanding or resident rights while putting safety first. CR #1 Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the facilities Pre-Admission Assessment for CR #1 dated [DATE] revealed he was admitted to local hospital on [DATE]. The assessment revealed the resident was homeless living in his car before admission to the hospital. His admitting [DIAGNOSES REDACTED]. Further review of the assessment revealed the resident was accepted into the facility. There were no additional notes on the assessment addressing the substance abuse or use of cigarettes. Record review of CR #1's History and Physical (H&P) dated [DATE] completed by NP, revealed a social history stating, current every day smoker, drinks beer ,[DATE] times per week, no illicit drug abuse. CR#1's H&P revealed review of Miscellaneous labs stating, urine drug screen [DATE] positive with opiates. The H&P summary of Plans did not address the resident's positive drug screen, history of drug use, or current cigarette use. Record review of CR #1's Admissions Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed CR #1 had no current Tobacco use. Record review of CR #1's hospital record dated [DATE] revealed a social history - He uses heroin and has a history of [MEDICATION NAME] use in the past. He smokes cigarettes. He denies alcohol use. Urine drug screen was positive for opiates. The Impression was At this time, I strongly suspect the fever is related to the fracture and also possible drug fevers. Record review of CR #1's record revealed no baseline care plan on admission on file. Record review of CR #1's record revealed no care plan addressing the resident's history or risk of substance abuse and smoking following admission. Record review of CR #1's progress notes dated [DATE] at 11:14AM revealed, Doctor here to see resident with new orders for Intravenous Antibiotics (IVABT) and labs. Pharmacy notified of peripherally inserted central catheter (PICC) placement and orders faxed to pharmacy. Resident was informed of IVABT for [MEDICAL CONDITION] lower extremities. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] at 10:16AM revealed, Attempted to flush and hang IVABT via PICC at 7:00AM. Unable to flush. Assessed IV and noted rubber cap off PICC line site. Unit manager assessed also and noted. PICC line dislodged right upper arm. Call placed to pharmacy and request for PICC line reinsertion and will send nurse out. Resident informed IVABT will be given after insertion. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] at 2:05PM revealed, RN here to reinsert PICC line at 12:00PM. Orders for STAT chest x-ray for placement prior to restarting IVABT. Doctor here and informed of PICC line out and residents Physician also notified. X-ray ordered with number 011. Resident aware. [MEDICATION NAME] with-held d/t bleeding at insertion site. Note was written by LVN#1. Record review of CR #1's progress notes dated [DATE] referred to a late entry from [DATE] 10PM-6AM. The note revealed on [DATE] around 2:30AM, LVN #2 smelled a cigarette odor. She followed the smell and went to CR #1's room where she observed him sitting on his bed smoking a cigarette. She politely informed him that smoking was not permitted in residents' room. The resident responded by cursing and yelling at her saying, What the [***] you going to do. [***] you. Get out of my room. LVN #2 called the unit manager and she instructed her to get another nurse and get the cigarettes away from the resident. She returned to the room with a second nurse who also said he could smell smoke and informed CR #1 they had to quickly check his drawer for cigarettes and lighter to avoid accidents and danger. The other nurse reached for the drawer and CR #1 punched the nurse and began hitting him in the head with the phone. The resident continued to curse and hit the nurse with objects while they were asking the resident to stop and calm down. The nurse was able to discover a pack of cigarettes and some medication that were in the drawer. The staff left out of the room and the resident followed them to the nurse's station while continuing to yell and curse. LVN #2 called the Physician and the family. Note was written by LVN#2. Phone interview on [DATE] at 9:08AM, LVN #2 confirmed she was the nurse who observed CR #1 smoking in his bedroom on [DATE] around 2:30AM during the 10PM - 6AM shift. She said she smelled smoke and walked down the hall to see where it was coming from and observed CR #1 sitting on the end of the bed with a cigarette butt in his mouth. She asked him what he was doing and told him he could not smoke in the facility and he began to yell and curse at her. She then called the unit manager and stood in the doorway while telling her what was going on. The unit manager attempted to talk to the resident over the phone, but he would not stop yelling and cursing. The unit manager instructed her to go get another nurse and remove the cigarettes and lighter. She got another male nurse (RN#2) and they attempted to remove the cigarettes and the resident began to fight the male nurse and hit him with the phone and other objects nearby. They recovered some cigarettes and [MEDICATION NAME] pills. She later wrote up what happened and was told by the DON they shouldn't go to the room again and another nurse should take over the room. Record review of RN #1's written statement dated [DATE] revealed when she arrived for her shift (6am - 10pm) on [DATE] she was immediately informed of a smoking incident that had taken place with CR #1 and had led to combative behavior. The night nurse (LVN#2) told her the resident was still there and per the 6AM -2PM nursing staff the resident did not present anymore behaviors at that time. Later during the 6AM -2PM shift it was brought to her attention that an unfamiliar needle, syringe device was retrieved from CR #1's bathroom floor. RN #1 confirmed in her statement it was not a needle used at the facility. The nurse assigned to the resident (LVN #3) also confirmed the syringe was not used by her or on her cart. She called the DON and left a voicemail. RN#1 instructed LVN #3 to call the physician and request for labs for a drug panel or to have the resident sent out to be evaluated or treated. She further noted LVN #3 denied the resident presented any violent behaviors or change in condition during her shift. RN #1 wrote she then texted the DON to inform her of the needle device found in room due to her not answering the phone. During this time the on-call provider returned the phone call, and she witnessed LVN #3 suggest a drug panel or for the resident to be sent out to the hospital. The on-call provider gave directives to monitor for change in condition and if so to discharge to the hospital. During that time the resident was noted to be stable with no behaviors. Shortly after staff spoke with the on-call provider the DON replied to the text and said she was out of town and asked if the device was removed, use caution entering his room, go in pairs, see what his intentions were, and to get family involved. The resident was closely monitored for the rest of the weekend and did not present any cause for concern. On Sunday morning [DATE] the Administrator was notified when he was noted in the building and he also said to monitor resident, report change, and send out if needed Record review of CR #1's progress notes dated [DATE] at 2:27PM, revealed the DON spoke with the resident regarding his behavior- smoking in his room. The Resident denied hitting anyone and said they found a pack of cigarettes that were not open, and some [MEDICATION NAME] pills he kept for his own use. The resident was educated about the facility being smoke-free and he was not allowed to smoke anywhere on the premises and failure to follow the policy could result in discharge. Resident denied smoking in the room and said he had just come from smoking outside and that's why he smelled of smoke. He was also told he could not keep medications in room and if he felt he needed something the Physician would order it. The resident said he was preparing to discharge next week, and he wanted to be with his family in another town. The DON informed social services of his wishes. Residents care plan was updated to reflect non-compliant behavior in smoking, combativeness towards staff and taking medication not prescribed by the Physician. Record review of CR #1's Care Plan dated [DATE] revealed resident is at risk for non-compliancy with smoking in the room, exhibiting periods of manipulation combativeness and verbal aggression towards staff, as reported by nursing staff. The goal was, Resident will experience minimal adverse effects from non-compliance through next review, with a target date of [DATE]. The approaches were to, anticipate care needs and provide them before the resident becomes overly stressed, if reasonable, discuss behavior with resident. Explain/reinforce why behavior is unacceptable. Intervene as needed to protect the rights and safety of other. Investigate/observe need for psychological/psychiatric support. Provide services if desired by resident/responsible party as ordered by the physician. Report to physician changes behavioral status. Attempt to provide a safe living environment for resident daily. Discuss compliancy and potential results of non-compliancy with patient. Further review of above care plan revealed it did not address CR#1's drug use history and it did not address nursing staff's concern regarding CR#1's PICC line. Record review of CR #1's progress notes dated [DATE] at 10:18PM revealed in part, Resident appetite has decreased, and he has not been eating his meals. Resident was observed by a Physical Therapy assistant sitting on the toilet for an extended period of time with a syringe and needle on the floor next to him. Resident was asked where the syringe came from by charge nurse and resident stated he did not know what the charge nurse was talking about. Resident appeared to have slight change in mental status, he was slurring his speech and stated that he was feeling dizzy. Resident vitals were obtained ,[DATE], 88, 20, 97.5, 98%. Resident breathing was even and unlabored with no complaints of shortness of breath. Resident received Physical therapy services. Resident left off premises at 7:32PM, stated he was going out with his family member to get something to eat, as of 10:30PM resident still has not returned. Informed 10PM-6AM shift nurse that resident had not returned. Resident did not receive any 8:00PM medications. Will continue to monitor. Progress note was signed by LVN #3. Further review of CR#1's record revealed there was no further follow up on this incident by the facility administrator and DON. Interview on [DATE] at 1:00PM, LVN #3 confirmed she completed the note about the syringe being found in CR #1's room on [DATE]. She said she was on break around noon and when she returned another nurse told her about the needle being found in the restroom with the resident and she had placed it in the med room for her to examine. She examined the needle and confirmed it was not a needle that was used in the facility and said it appeared to be old due to the numbers being worn off. LVN #3 began to get emotional as she explained how she had a close relationship with the resident and was unaware of his history of drug use. She said after she examined the needle she went to CR #1's room and observed him coming out of the restroom and he complained of being dizzy and was slurring his speech. She assisted him to the bed and asked him what was going on. He denied having the syringe and said he didn't know what she was talking about. She took his vitals and she felt they were normal for him. She went to the nurse's station and the weekend unit manager (RN #1) was there and already knew of the incident. She said they then called the on-call NP and was instructed not to do any labs and to monitor the resident for changes and if there are changes to send to the hospital. LVN #3 reported she worked 6AM - 10PM on Saturday and Sunday and did not observe any changes or concerns in the resident during that time. She revealed she was very concerned about him after the incident, so she closely monitored him and kept track of where he was. Record review of CR #1's written physician's orders [REDACTED]. [DIAGNOSES REDACTED]. Record review of CR #1's transcribed physician's orders [REDACTED]. Record review of CR #1's progress notes dated [DATE] at 10:43PM revealed in part, Resident receiving IVABT [MEDICATION NAME] for osteo[DIAGNOSES REDACTED], heel wound and amputated great toe. No adverse reactions noted (NARN). Afebrile. PICC line to upper right arm, dressing dirty with blood, will need to be changed. PICC line is patent, with [MEDICATION NAME] lock. Resident complained of abdominal pain and diarrhea, gave Questran to aid with loose stools. Resident is continent of bowel and bladder and a one person assist when needed. Resident receiving PT/OT skilled services, resident is able to ambulate with aid of walker. Record review of CR #1's progress notes dated [DATE] at 3:55pm revealed the resident was visited for an admission evaluation by another facility representative. Note further revealed per evaluation the resident was clinically accepted for admission, insurance authorization was pending. Record review of the facility's incident report dated [DATE] revealed CR #1 was found unresponsive on his bathroom floor around 6:30AM on [DATE]. Code Blue was initiated and 911 was called. Cardiopulmonary resuscitation (CPR) was started. Emergency Medical Services (EMS) arrived and took over and pronounced the resident at 7:07AM. The EMS note syringe with clear substance next to sink and black plastic spoon with small brown colored rock like substance in front of sink. Houston Police Department (HPD) was notified and on scene at 7:35AM as well as Medical Examiner as of 9:19AM. Incident was observed on day shift 6am - 2pm. Record review of LVN #4's written statement dated [DATE] revealed she came to the 2nd floor on [DATE] around 2:00AM to make rounds on CR #1 in room [ROOM NUMBER] and LVN #2 stated she saw him go down in the elevator to go outside and smoke. She went back to the 5th floor where she was assigned. She returned to the 2nd floor to administer any 6:00AM meds for CR #1 but noted the Medication Administration Record [REDACTED]. The night nurse and morning nurse were notified the patient did not have 6:00AM meds and went back to her 5th floor station. Interview on [DATE] at 5:47AM, LVN #1 confirmed she was the nurse to discover CR #1 unresponsive in his restroom on [DATE] around 6:30AM. LVN #1 said she had just come onto her shift and was headed to CR #1's room when CNA #1 came out of the room and told her the resident was on the floor. She went into the room and found the resident unresponsive on the bathroom floor lying in fetal position. She called out to the resident and he did not respond, she checked his pulse and called a code blue. Resident was pulled out into room area, CPR was started and 911 was called. LVN #1 said the resident body presented signs as if he had been lying there for a while, she did not elaborate. She further said she raised up the resident's shirt in attempts to find his cell phone to notify family and found a syringe. She said there was also a black plastic spoon and some brown rock like substance that she suspected to be heroin. There was also a paper towel with a nickel size blood spot on it and the hot water was running in the sink when she entered the room. She felt something was wrong when she saw the light on in the resident's room because the resident was not usually awake at that time, he usually slept in until around 11:00AM. LVN #1 said she had no idea the resident had a history of [REDACTED]. The nurse from the night shift did not give her a report of any concerns or incidents for CR #1. She added the resident was a smoker and would often leave out of the facility to go and smoke. Interview on [DATE] at 5:59AM, CNA #2 said she worked 10PM - 6AM shift on the 2nd floor the night before CR #1 was found ([DATE]). CNA #2 said she made rounds around 10:00PM and the resident was not in his room and she assumed he was out smoking because he often left out the facility to go and smoke. The next time she saw the resident he was coming out the elevator between the time of 1:30AM - 2:30AM. CR #1 did not greet them at the nurses' station as he sometimes did and went into his room and closed the door. She did not see the resident for the rest of the night. She did not go into the resident's room the rest of the night because he does not like to be bothered when his door was closed. She said she could not speak on the resident's personality due to him being a quiet person. CNA #2 was unaware of resident having any current or past issues with drugs. CNA #2 added the resident would often leave out of the facility throughout the night to go smoke. Interview on [DATE] at 7:30AM, the social worker said CR #1 did not self-disclose a history of drug use to her during her assessment. The social worker said the resident did not present behaviors for her to suspect current issues with substance abuse, therefore it was not addressed. She had spoken with the resident on [DATE] concerning his request to discharge to a non-smoke free facility. The social worker found a smoking facility to accept the resident and the Interdisciplinary Team (IDT) and Nursing Services were aware. The incident on [DATE] with CR #1 being found with a syringe and needle was not brought to her attention until their morning meeting after he had passed on [DATE]. Due to her being unaware of the incident she did not reassess the resident for drug abuse or make any referrals. Phone interview on [DATE] at 9:15AM, LVN #2 said she came to work Monday night ([DATE]) and did not go into CR #1's room as the DON instructed her to do but did make observations of him in his room while walking the halls. She observed CR #1 in his room around 10:05PM sitting on his bed due to his door being open. She observed CR #1 leaving out of the elevator between 2:00AM - 2:30AM. She did med pass around 4:00AM and saw CR #1 lying in his bed due to the door being open. LVN #2 said she then called the nurse assigned to him (LVN #4) to give him his meds and LVN #4 said she would be down in a minute. LVN #2 added she was not aware of resident having history of substance abuse, the incident of resident being found with a syringe on [DATE], or the orders for the resident to be monitored for suspicions of drug use. LVN #2 added the resident would often leave out of the facility throughout the night without signing out, it was always assumed he was smoking outside. Interview on [DATE] at 9:50AM, the Unit Manager said LVN #2 had called her around 3:00AM and told her about CR #1 smoking in his room and his behavior when she confronted him. She had LVN #2 put her on speaker and attempted to talk to CR #1, but the resident was yelling and screaming refusing to listen. She told LVN #2 to leave the room and get another nurse to remove the cigarettes and lighter. She texted the DON and Administrator to determine if the police should be called. Before they could respond she heard back from the nurses they were able to retrieve the cigarettes and medications and was told about his fighting the staff. She came in shortly after 3:00AM to see the resident and address the situation but the resident had already fallen asleep. The DON spoke with the resident when he woke up later in the day. The Unit Manager added she was shocked by his behavior and she had never saw the resident act in that way. She also confirmed CR #1 would often go outside to smoke or leave the premises with a woman. She said CR #1 was non-compliant with signing out and she would often get onto him about signing out. Interview on [DATE] at 10:20AM, the Unit Manager said she was aware CR #1 had a history of [REDACTED]. She said the resident had a few issues with his PICC line and she wondered if he was messing with it but did not want to assume or accuse without evidence. She questioned the resident on one occasion where she found the PICC line bloody as if it had been tampered with and CR #1 claimed the nurse who came in earlier had flushed the line and caused the mess. The Unit Manager said she was not aware of the incident that happened over the weekend ([DATE]) with the resident being found with a syringe and needle until after he was found deceased on [DATE]. Interview on [DATE] at 12:45PM, CNA #3 said around 12:00PM on [DATE] she was in a room assisting with feeding when a nurse asked her to step out to the hall. The nurse asked where CR #1 was when she went to pass his lunch tray. They both went into CR #1's room and opened the bathroom door and observed him on the toilet with a syringe on the floor wrapped in toilet paper with blood on it. CR #1 told them to get out because he had diarrhea. The nurse (LVN#5) was able to grab the syringe from off the floor before they left the room. She added that when she went to pass the lunch tray earlier the resident was not in the room and she assumed he had gone downstairs to smoke. Attempts were made to contact LVN #4 via phone on [DATE] at 1:20PM and [DATE] at 5:00PM, there was no response and voicemail was left with no return phone calls. Attempt was made to contact LVN #5 via phone on [DATE] at 1:25PM, there was no response and voicemail was left with no return phone calls. Record review of CR #1's clinical record revealed no documentation of labs, assessments, or referrals addressing substance abuse or resident's ability to smoke outside the facility since his admission. There was also no check out log to indicate when the resident had left and returned to the facility or evidence the resident had been counseled about it. Interview on [DATE] at 3:00PM, CR #1's Physician said she came into the facility on [DATE] and discontinued an order for [REDACTED]. She did not address the situation that happened on [DATE] with the syringe during her visit because she was unaware of the incident. She was not told about the incident until the morning meeting on [DATE] after the resident had passed. She confirmed she had now talked to her on-call NP who was contacted about the incident on [DATE] and she confirmed she gave orders to monitor the resident for changes and send out if there were changes. She added she was also not aware of the resident combative behavior with staff when he was found to be smoking in his room on [DATE], she was only told the resident was smoking cigarettes and [MEDICATION NAME] were retrieved from his room. Record review of Houston Police Department Report dated [DATE] at 7:11AM revealed an offense titled Death - Poison/Drugs. CR #1 was identified as the complainant in the report. The Brief Summary revealed, The complainant was found deceased in nursing home by the attending nurse. A syringe with needle and a small amount of heroin was also found near the body. The report further revealed Houston Fire Department was on the scene and announced time of the death at 7:07AM, the complainant appeared to have been deceased for at least 2 hours because he was stiff and rigor mortis had started to set in. The reportee was listed as LVN #1, her statement revealed she found the resident deceased in bathroom around 6:30AM. She alerted other staff to come help her, so they could initiate CPR and 911 was called. She stated she found a syringe with needle and a small amount of heroin on the sink of the bathroom and she suspected the complainant was shooting heroin prior to his death. Record review of the facility's Administrative Responsibility Policy (Revised ,[DATE]) revealed in part, 2. The Executive Director will be responsible for supervision of policy implementation and formulation of new policies and programs as advised by the governing body, consultants, staff, and members of the board of directors. 3. The Executive Director will be responsible for implementing facility policies and formulating departmental policies with advice and counsel from the consultants, medical staff, and departmental staff. He/she will administer and conduct all aspects of the policies and programs with the framework provided. 4. The Executive Director will be responsible for all implications of the program operations as it effects the residents, staff, families, and community. 8. The Executive Director is delegated by the Governing Body to have full responsibility for the daily operations of the facility. Record r

Based on interview and record review the facility failed to provide necessary care and services to attain or maintain the highest practicable mental and physical well-being for one of seven residents (CR #1) reviewed for quality of care. The facility failed to thoroughly and promptly assess CR #1 and obtain proper medical treatment when CR #1 had a change in his physical and mental condition which led to his hospital admission on 11/29/15 where he was diagnosed with [REDACTED]. This failure affected one resident who required hospitalization following a significant change of condition on 11/27/15 until 11/29/15 and placed 3 other residents with indwelling catheters at risk of not receiving timely medical care and services, which would have a negative impact on their health and wellbeing. Findings include: Intake # 6 Record review of CR #1's face sheet revealed an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's MDS dated [DATE] revealed a BIMS score of 8 indicating he was moderately impaired for daily decision making skills. Further review of this MDS revealed CR #1 had no signs or symptoms of delirum. CR#1 required extensive assistance for all ADLs, had an indwelling urinary catheter, was frequently incontinent of bowel, and received nutrition via feeding tube. Further review of this MDS revealed CR#1 had no history of falls prior to admission or while he was a resident at the facility. Record review of CR #1's care plan dated 11/03/15 revealed CR #1 had a urinary tract infection, goal was the resident would have no complications related to urinary tract infection and infection would resolve by the next review date (02/13/15), approaches included: administer medication as ordered, monitor side effects or adverse reactions related to medication/antibiotic every shift until resolved, encourage fluid unless contraindicated by MD or medical status, obtain labs as ordered by MD, report results to MD, monitor and document urine for clarity, output, color and odor, notify MD and responsible party of any change in condition related to current infection. Record review of CR #1's nurse's notes dated 11/27/15 at 6:40a.m. revealed CR#1 was noted with bleeding from penis site moderate amount, blood tinged urine noted in Foley catheter for few minutes and then subsided. Called (on-call healthcare provider) received order to irrigate catheter and was done and if the bleeding does not stop, send patient to ER. No bleeding noted after irrigation. Did not receive order to hold blood thinners but notified AM nurse to monitor for bleeding and call (on-call healthcare provider) if any change in condition occurs. Record review of CR #1's physicians' order revealed the following: 11/27/15: irrigate Foley catheter with 60ml of normal saline and monitor for bleeding, if it continues send to ER. Indication was bleeding at the penis site. Change free water to 200 ml via peg tube every 4 hours, UA with CBC and CMP and [MEDICATION NAME] today to rule out UTI. Record review of CR #1's MAR indicated [REDACTED] [MEDICATION NAME] 5,000 unit subcutaneous every 12 hours, ordered 11/9/15. Further review between 11/27/15 until 11/29/15 revealed the [MEDICATION NAME] was administered 11/27/15 at 4a.m., but held at on 11/27/15 at 4p.m.; held 11/28/15 at 4a.m. and 4p.m.; administered 11/29/15 at 4a.m. and 4p.m. Aspirin 81 mg tablet per gtube daily. Further review revealed this medication was administered at 4a.m. daily. Record review of CR #1's physician's orders revealed no physician's order to hold the [MEDICATION NAME]. Interview on 12/1/15 at 12:46p.m., LVN #1 said Friday morning (11/27/15) CR#1 was alert and oriented to time, place and person. She was informed by the outgoing nurse CR#1's Foley catheter was irrigated because the resident had some blood in his urine and around his penis. LVN #1 stated she noticed blood around CR #1's penis and some in his brief. She stated the NP was around and he went and saw it. LVN #1 further stated when CR#1 went to use the toilet, a family member saw blood in his penis area again. LVN #1 stated she notified his NP who gave an order for [REDACTED]. Record review of CR #1's progress notes revealed no documentation from LVN #1 on 11/27/15 for the morning shift. Record review of CR #1's NP progress note dated 11/27/15 (no time documented) revealed reason for visit was periuretheral bleeding likely secondary to minor trauma and bladder fullness. CR #1 was lying in bed, his oropharynx was clear and tongue had thrush. A small amount, less than 0.5ml, of dried blood was noted without active bleeding. His assessment and plan revealed severe weakness secondary to squamous cell [MEDICAL CONDITION] status [REDACTED]. The NP ordered a change to water flushing to 200ml every 4 hours. The NP noted update on hospice-per staff he does not qualify for hospice. Record review of CR#1's urinalysis result dated 11/27/15 revealed the following: Color of urine was amber (normal range yellow). Appearance was cloudy (normal range clear). Blood was large (normal range negative). Protein was 100 (normal range negative). Bacteria was moderate (normal range few). Red blood count was 50 plus (normal range 0-2). Record review of CR #1's nurse's notes dated 11/27/15 on the 2p.m.-10p.m. shift revealed: resident supine in bed awake, alert and oriented 2-3, (family member) at bed side about 3:30p.m., oxygen saturation was 93%. He had some bleeding around his penis meatus (point of catheter insertion site) today [MEDICATION NAME] Subcutaneous held and awaiting to hear from (on-call healthcare provider). Further review of above notes revealed at 9:30p.m., CR #1 was alert and oriented X2, trying to get out of bed, aide assisted him out of bed and he was re-oriented. Labs called. (On-call healthcare provider) and family notified CR #1 was also disoriented at 10:15p.m., stating there was a lady in his room. No new orders were given. Record review of CR #1's SBAR communication forms revealed no SBAR form was completed for 11/27/15 when his change in condition was first identified. Record review of CR #1's nurse's notes dated 11/28/15 revealed the following: At 7a.m., resident was noted very agitated pulling at Foley catheter and he was redirected. At 8a.m. no change was noted. Rehab therapy went to CR #1's room to give him therapy which was unsuccessful. His bed was at the lowest position. At 9a.m. resident was observed flopping from head to foot of bed and staff continued to monitor him due to his high risk of falls. CR #1 remained on [MEDICATION NAME] (Antibiotic) for pneumonia. An addendum at 10:00a.m. revealed CR #1's family was at his bedside until 8:30p.m. He was observed fine alert and oriented X2 at 10:00a.m. Around 4:45p.m., CR#1 became restless, speaking about things not there and grabbing at the air. Family witnessed this. Staff continued to monitor Resident due to huge fall risk. CR #1 was noted at times with eyes closed during rounds and other times conversing with himself. An addendum to the nurses' notes dated 11/28/15 with no time revealed CR#1 was observed out of bed crawling on the floor. A head to toe assessment was completed and abrasions to bilateral knee area were noted. CR #1's NP and family member were called. Record review of CR #1's SBAR communication forms revealed no SBAR form was completed for 11/28/15 for his change in condition. Record review of CR #1's Nurse's notes dated 11/29/15 revealed the following: At 1:18a.m., resident asleep at this time, easily aroused, patient look confused and disoriented, trying to come out of bed. At 3:40a.m., revealed CR #1 was awake talking to himself, confused trying to reach for things around him. He was redirected but very confused. CR #1 was repositioned, turned and made comfortable. At 4:30a.m., on rounds, met patient in bed with Kangro pump machine on his bed with tube around his neck, neck observed with no injury noted. Patient talking to self and very confused. Foley catheter pulled across the other side of bed of patient, he was repositioned, turned and redirected. At 6:00a.m., report received from outgoing nurse, patient had been restless, hallucinating, uncooperative all night, had a fall last night, MD and DON notified. Patient seen by the nurses' station restless, trying to get up and noted blood in the Foley catheter at this time. At 6:10a.m., patient still restless and wanting to get up, instructed patient to sit still educated patient on the risk of falling if he gets up without assistance, patient verbalized understanding at this time, will continue to monitor patient. At 6:55a.m., patient continued to talk to self, confused, continue to be monitored by the nurses' station. DON called to notify the condition of the patient who instructed to call (on-call healthcare provider), writer called and explained the condition of the patient and NP received call, tried to give order for STAT CBC and BMP but said hold on, I have not finished, I will call you back, waited for return call from NP but did not call back. At 7:05a.m., staff called DON back who said do order given to you and give report to 6-2 staff and go home and let her follow up with the NP. At 7:16a.m., revealed CR #1 was confused and restless, talking to himself and was uncooperative. His vital signs were taken and the DON was called and notified of the condition of CR #1. The DON instructed the nurse to call the (on-call healthcare provicer). The nurse called and explained the condition of CR #1 and while the nurse was trying to take the order the (on-call healthcare provider) said she would call back to complete the order, report given to incoming nurse to follow up. At 8:40a.m., revealed (family member) called primary nurse that patient is having [MEDICAL CONDITION], upon getting to the patient, patient is awake and talking, (family member) asked the nurse to call 911 or else he will call 911 himself. Primary nurse tried to assess patient first but (family member) already calling 911, EMS arrived at 8:50a.m., patient's (family member) stated patient had [MEDICAL CONDITION] for 15 seconds; EMS took patient to hospital about 8:55am. Record review of CR #1's ER record dated 11/29/15 revealed chief complaint: [MEDICAL CONDITION], this occurred today, is still seizing and worsening, [MEDICAL CONDITION] was witnessed and brief, experienced repeated [MEDICAL CONDITION] occasionally of 5-10 seconds and lost consciousness. Neurological assessment revealed patient looks as if he is grabbing something that isn't there and then started having a small [MEDICAL CONDITION]. Further review of CR #1's ER record revealed assessment: [MEDICAL CONDITION], likely multifactorial, [MEDICAL CONDITION]/[DIAGNOSES REDACTED], hypercapnic [MEDICAL CONDITION] necessitating intubation/vent, possible hyperactive airway disease,[MEDICAL CONDITION] urological origin, urinary tract infection with hematuria, [MEDICAL CONDITION], respiratory acidosis and dysphagia. CR #1 was critical and was admitted to the intensive care unit. Record review of the facility's incident report dated 11/29/15 (no time) revealed CR#1 was observed on 11/28/15 (no time given) by nurse crawling on the floor in his room. Resident noted with abrasion to both knees. Action taken was bed in low position therapy evaluation, neurological checks in progress. Record review of CR #1's neurological assessment flow sheet dated 11/29/15 revealed CR #1 was alert and confused. Record review of CR #1's SBAR communication form dated 11/29/15 revealed a change in condition of restlessness and Resident talking to himself. Resident's mental evaluation revealed increased confusion or disorientation, while functional status evaluation revealed weakness and falls. Behavioral evaluation revealed restless and talking to self. Interview on 12/1/15 at 10:25a.m., Unit manager #1 said CR #1 had hematuria (blood in urine) on Friday (11/27/15), staff called MD who ordered UA, CBC and CMP lab, which were done the same day. Unit Manager #1 stated lab results had some abnormal values that were called to his MD and no new orders were given. Unit manager #1 said she was told CR #1 had a fall on Saturday night (11/28/15) and sustained abrasions to his bilateral knees and was found crawling on the floor. She stated she was unsure of the size of the abrasion. Interview on 12/1/15 at 12:00p.m., DON said CR #1 admitted to the facility with an indwelling urinary catheter, [DEVICE], on intravenous antibiotics and had a [DIAGNOSES REDACTED].#1 also had a urinary tract infection on admission. She stated CR #1 had a change in condition over the weekend which was communicated to the MD and NPs. She further said the staff followed the physician's orders. The DON said CR #1 was on antibiotics for pneumonia, and the ordered labs were done which did not reveal any abnormality. She said CR #1 [MEDICAL CONDITION] and was deteriorating very quickly. She stated a Hospice evaluation was done on Friday but the family declined Hospice. The DON agreed the facility's NP called by staff did not promptly give orders to address the resident's needs. She further stated staff made attempts to notify CR #1's MD and NP of the resident's condition but she had no response when asked what she expected her staff to do when MDs and NPs did not call back or respond. The DON agreed staff identified CR#1's change in condition on Friday (11/27/15) and continued to document disorientation, confusion, changes in his behaviors and a fall from 11/27 until 11/29/15 without sufficient interventions. She further agreed CR#1's fall on11/28/15, which resulted in abrasions to his bilateral knees, was avoidable. The DON stated an SBAR communication form was completed on 11/29/15 for CR #1's fall on 11/28/15, but she did not know why an SBAR was not completed for his change of condition on 11/27/15 or 11/28/15. When asked why the resident was not sent to the hospital for evaluation when he continued to show significant changes in his physical and mental status, the DON said they were going to send him out Sunday morning (11/29/15) for a CT scan. The DON at this time was asked for any evidence that the facility had plans to have CR#1 sent to hospital for evaluation but she provided none. The DON stated she was told by staff that the family witnessed the resident having a [MEDICAL CONDITION] on 11/29/15 around 8:30a.m. and the family called 911. Interview with facility administrator during exit conference on 12/1/15 about 4:00p.m., he stated he just assumed duties at this facility. He stated the facility would be adding more physicians to their network to enhance patient care. Interview on 11/30/15 at 3:58 P.M., CR #1's family member said she visited CR #1 on 11/26/15 and noted he had blood in his urine which she showed the nursing staff. She stated facility staff did not think it was a problem. The family member said it continued on 11/28/15 combined with dis-orientation and unusual behavior of seeing things and hallucinating but facility did not intervene. She stated staff sat at the nurses' station and did not want to be bothered. The family member said CR#1 had a fall on the night of 11/28/15 and facility staff called the family to notify them of his fall. She stated family members arrived at the facility the morning of 11/29/15 to see how CR #1 was doing, and he was still out of it and confused. The family member stated while family was visiting, CR #1 had a [MEDICAL CONDITION]. She stated family called the nurse who did not seem to know what to do, so the family asked the nurse to call 911. The family member stated the nurse said she would call the physician first and then follow orders. The family member stated family called 911 and CR #1 was transferred to the hospital. The family member stated the hospital found CR #1 had severe dehydration and a urinary tract infection and he was admitted to the hospital. The family member stated she could not understand how CR#1 got a UTI because he was dependent on a gastrostomy tube for nutrition and hydration. Record review of facility's policy on changes in a Resident's condition or status (not dated) did not address staff expectations and responsibilities when a resident's physicians was called without success, or what staff should do when a change of unknown condition was identified. The DON reported a census of 3 residents with indwelling catheters in the facility on 12/1/15.

Based on interview and record review the facility failed to ensure 1 of 5 residents (CR #1) reviewed for care and services received services to maintain or maintain the highest practicable physical, mental and psychosocial well being as evidenced by: -CR #1 was not transported to her [MEDICAL TREATMENT] appointment on 05-26-15. CR #1 was hospitalized on [DATE] for emergency [MEDICAL TREATMENT] due to abnormal lab results. This failure affected 1 discharged resident and placed 2 other residents receiving [MEDICAL TREATMENT] at risk of decline in health, abnormal labs and hospitalization . Complaint # 9 Findings included: Record review of CR#1 clinical record revealed she was a [AGE] year old female that was admitted to the facility on [DATE]. CR #1 had a [DIAGNOSES REDACTED]. CR #1 was discharged to a local hospital on [DATE] and did not return to the facility. Record review of CR #1's admission sheet revealed that she requeired [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. Record review of CR #1's admission MDS dated [DATE] revealed a [DIAGNOSES REDACTED]. In an interview on 06/17/15 at 12:35 PM LVN B stated, the facility could not get transportation for CR #1 to go to [MEDICAL TREATMENT] on 5/27/15 due to the van driver could not make it to work due to the rain and flooding. LVN B stated the facility contacted a local transportation company about picking up CR#1 to take her to [MEDICAL TREATMENT], but they stated they were only transporting medical emergencies. LVN B further stated, the facility called the [MEDICAL TREATMENT] clinic on 05/26/15 to see if they were open but they did not get an answer, although she stated she was not sure who from the facility contacted the [MEDICAL TREATMENT] clinic. She stated, the whole situation was just bad communication between the two parties. In an interview on 06/17/15 at 12:37 PM LVN A said that CR #1's labs were usually abnormal but due to her not going to [MEDICAL TREATMENT] on 05/26/15 her labs were more abnormal than usual. Record review of CR #1's lab results dated 05/19/15 revealed that the potassium level was 4.9 (normal range from 3.5-5.3), BUN was 18 (normal range was 7-25) and [MEDICATION NAME] was 3.0 (normal range was 0.6-1.2). Record review of lab results for CR#1 dated 05/27/15 revealed a potassium level of 6.2 (normal range is 3.5 - 5.3); creatinine level of 6.2 (normal level is 0.6 - 1.2) and BUN (blood urea nitrogen-test to evaluate kidney function) level of 55 (normal level is 7 - 25). A note located by the potassium leve indocated that this was a critical value. In a telephone interview on 06/17/15 at 1:00 PM the Administrator said the [MEDICAL TREATMENT] clinic contacted the facility on 05/26/15 to inquire as to why CR#1 did not come to her [MEDICAL TREATMENT] appointment that morning and that the [MEDICAL TREATMENT] clinic was open on time that day and CR#1 did not have to miss her appointment. The Administrator stated the [MEDICAL TREATMENT] clinic does have a voicemail so the facility could have left a voicemail if no one had answered the phone when they were contacted. The Administrator further stated, when the [MEDICAL TREATMENT] clinic contacted the facility on 05/26/15 they stated they were closing at 4:00 PM so they offered to see CR#1 on 05/27/15, but on 05/27/15 CR#1 was admitted to the hospital for abnormal lab results. In an interview on 06/17/15 at 1:40 PM the Executive Director stated the facility did everything they could to find transportation for CR#1 for the [MEDICAL TREATMENT] appointment. The Executive Director stated there was no documentation on record that the facility made attempts to get the resident to [MEDICAL TREATMENT] or who spoke with staff at the [MEDICAL TREATMENT] clinic on 5/26/15. In an interview on 06/17/15 at 1:43 PM Staff B (Business Offie Manager) stated she contacted 3 different [MEDICAL TREATMENT] clinics because she was not sure which clinic CR#1 went to for treatment. Staff B stated she was not sure who she spoke with at the clinic but they stated it would be alright if the resident missed a day. Staff B stated CR#1 was re-scheduled for [MEDICAL TREATMENT] treatment the next day. In an interview on 06/17/15 at 2:23 PM the ADON stated the facility had nothing documented on the 24 hour report, nursing notes, or chart notes describing the reason for the resident missing the appointment or anyone contacting the [MEDICAL TREATMENT] clinic to see if they were open. Record review of the Nursing Notes for CR#1 on 05/27/15 revealed pt (patient) was transferred to a local hospital for emergency [MEDICAL TREATMENT] due to elevated K (potassium) (6.2). Record review of CR #1's transportation form dated 05/26/15 revealed CR#1 was scheduled for [MEDICAL TREATMENT] pick up at 9:30 AM via the facility bus/van. Further review revealed no documentation indicating why the resident was not taken to the appointment. According to the facility 672, there were 2 residents receiving [MEDICAL TREATMENT] in the facility.