Every finding on record at Villa Vista Royale LLC

Based on record review, interview and facility policy review, the facility failed to update a resident's Pre-admission Screening and Resident Review (PASARR) with changes to the resident medical diagnosis This deficient practice affected one resident (Resident #5) of one resident reviewed for PASARR. The facility census was 46.Findings Include: Review of Resident #5's medical record revealed an admission date of 07/01/24 with diagnoses including but not limited to high blood pressure, anxiety disorder, post traumatic stress disorder (PTSD), and history of falls.Review of Resident #5's physician orders revealed an order dated 04/01/25 for the antidepressant medication, Zoloft Oral Tablet 50 milligrams (mg). Give one (1) tablet by mouth one time a day for depression, sadness, tearfulness, self-isolation related to anxiety disorder, and an order dated 09/29/25 for the antianxiety medication Vistaril Oral Capsule, 50 mg. Give 50 mg by mouth at bedtime related to insomnia and anxiety disorder.Review of Resident #5's PASARR dated 05/06/24 revealed mood disorder, panic or other severe anxiety disorder was marked no. Additionally, the PASARR asked if in the last six months, the individual was prescribed any psychotropic medications, including antidepressants or anti-anxiety medications. The assessment was marked no. This was the only PASARR to review for the resident.An interview on 02/23/26 at 2:17 P.M. with Social Services (SS) #264 confirmed Resident #5 did not have an updated PASARR to reflect the new medications and diagnoses. SS #264 stated the PASARR should be updated when there is a new psychotropic diagnosis or medication is ordered.Review of the facility's policy titled Pre-admission Screening and Resident Review revised date 01/2026 revealed PASARR will be completed with a significant change or with a new psychotropic medication and appropriate diagnoses.

Based on record review, observation, interview, review of manufacturer operating guidelines, and facility policy review the facility failed to ensure pressure relieving interventions were appropriate based on resident weight and the location of the resident's pressure ulcer was accurately documented. This affected one resident (Resident #24) of two residents reviewed for pressure ulcers. The facility census was 46.Findings Include: Review of Resident #24's medical record revealed an admission date of 04/28/23 with diagnoses including but not limited to dysphagia, dementia, hypokalemia, depression disorder, and high blood pressure.Review of Resident #24's physician orders revealed an order dated 12/23/25 for an air mattress to the bed to prevent skin breakdown, check placement and function every shift and a treatment order dated 02/03/26 for a left buttock wound - irrigate with normal saline, pack with calcium alginate with silver ribbon, cover with foam dressing daily and as needed (PRN) if soiled or loose every day shift for wound healing.Review of Resident #24's weekly wound/skin grid documentation revealed the resident had a pressure ulcer to the coccyx or left buttock. Further review of the medical record revealed the resident weighed 97 pounds.Observation on 02/24/26 from 11:15 A.M. to 11:35 A.M revealed Assistant Director of Nursing (ADON) #208 provided wound care to Resident #24's pressure ulcer located on the coccyx. The low air loss (LAL) mattress control unit, located at the foot of the bed, was observed to be on the weight setting for a person weighing 350 pounds.Interview on 02/24/26 at 11:30 A.M. with ADON #208 confirmed the location of Resident #24's pressure ulcer was on the coccyx and not on the left buttock. ADON #208 stated the pressure ulcer had always been on the coccyx. ADON #208 also confirmed the LAL mattress control knob was set at 350 pounds. ADON #208 stated Resident #24 weighed 97 pounds and someone must have changed the control knob setting to 350 pounds instead of the 100 pound setting which would be appropriate for Resident #24.Review of the manufacturer operating guidelines for the Proactive low air loss mattress undated revealed in the operating instructions, step #6- determine the patient's weight and set the control knob to that weight setting on the control unit.Review of the facility's policy titled Pressure Ulcer Prevention dated 01/16/07 revealed place the at-risk resident on a pressure reducing mattress and or a pressure reducing chair pad.

Based on observation, interviews, record review, and policy review the facility failed to assess and monitor a resident's edema while having a sling and brace in place for a humerus fracture. This affected one resident (#249) of 24 resident records reviewed for assessments. Findings include: Review of record revealed Resident #249 was admitted to the facility on [DATE] with diagnoses including left humerus fracture, hypertension (HTN) atrial fibrillation, generalize anxiety disorder, major depressive disorder, Gastrointestinal reflux disease (GERD), type 2 diabetes, heart failure, cerebrovascular disease, hyperlipidemia, anemia, mitral stenosis, lymphedema, atherosclerotic heart disease, abnormal weight loss, Transient ischemic attack (TIA), breast cancer, hypothyroid, dry eyes, cataracts, polyarthritis, hyponatremia, diverticulitis left breast lumpectomy with lymph node sampling, lumpectomy of right breast. Review of baseline care plan completed 03/25/25 revealed Resident #249 required two assist with ambulation and transfers, one assist with bathing and hygiene, and a one assist with dressing and grooming. Resident #249 needed assistance with setup for meals, two assist for toileting, and used a wheel chair. Goals included observing pain and report as indicated, administer pain medication as ordered, and attempt non-medication interventions. Resident is able to communicate wants and needs. Visual ability indicates Resident #249 used glasses and will have adequate vision. Resident was alert to person, place, and time. Resident has anxiety and depression and will have a safe comfortable environment, social service visit and encouraged to ventilate feelings, provide redirection for episode behavior, monitor for medication effectiveness and side effects, and provide emotional support. Consult physical therapy (PT) and occupational therapy (OT) as ordered, evaluate for unsteady gate, ambulation devices as necessary, call bell within reach, observe footwear and non-skid socks. Prevent pressure ulcer and skin break down by following facility skin protocol, turn and position PRN, weekly skin evaluation, report any redness to medical director (MD), keep linens dry and wrinkle free, do prescribed treatment as ordered, notify MD is treatment is ineffective. Record review of Emergency department physician notes dated 03/23/25 revealed Resident #249 arrived from home due to a fall from ground level from standing position onto her left side, states she has left shoulder pain. Left arm x-ray revealed an acute humerus fracture. Left humeral sugar-tong splint placed to left humerus for stabilization. Record review of progress notes revealed a note on 03/25/25 at 6:00 P.M. by Licensed Practical Nurse (LPN) that identified Resident #249 had a brace and sling to left upper extremity (LUE) with pitting +2 edema to left hand. States brace/ sling can be removed for care. Resident is in good spirits with pain upon movements. Record Review of a comprehensive nursing note written on 03/26/25 by Registered Nurse (RN) #123 at 5:47 P.M. revealed nonpitting edema to LUE due to lymphedema. Sling in place per order to LUE. Record review of comprehensive nursing notes revealed no documentation of Resident #249's edema to the LUE on comprehensive nursing notes completed on 03/25/25, 03/27/25, 03/28/25, 03/29/25, 03/30/25, 03/31/25, 04/01/25, and 04/02/25. Record review revealed no documentation of monitoring or evaluation of Resident #249's LUE edema. Record review revealed no documentation of interventions ordered or being implemented for Resident #249 LUE edema. Observation on 03/31/25 at 11:10 A.M. revealed Resident #249's arm in a brace and sling, only able to visualize Resident #249's hand with swelling to the left hand. Observation on 4/01/25 at 11:21 A.M. revealed Resident #249 moving herself down the hallway in her wheelchair with a brace and sling applied to the LUE. Unable to visualize LUE from the wrist up. Swelling noted to the left hand of Resident #249. Observation on 04/02/25 at 9:05 A.M. revealed Resident #249 and RN #123 speaking. Observed sling and brace to Resident #249's LUE. Unable to visualize Resident #249's LUE from wrist up. Resident #249 had swelling to the left hand. Interview on 04/02/25 at 10:26 A.M. with Registered Nurse (RN) #123 revealed that Resident #249's arm had been swollen due to her lymphedema and was swollen on previous admissions. RN#123 stated before they were able to elevate her arm, but therapy has Resident #249 limited on what she can do with her left arm and they are only able to take the brace off for care. RN #123 stated the edema should be documented in the comprehensive nursing assessment. Interview on 04/02/25 at 10:13 A.M. with Occupational Therapy Assistant (OTA) #555 revealed Resident #249 is coming to therapy 3-5 times a week, they've had a few sessions and are working on exercises Resident #249 can do while seated, improving range of motioning to her left upper extremity, and hand exercises to help with the edema in that arm. Interview with RN #111 on 04/02/25 at 2:20 P.M. stated that the edema on the arm should be documented. RN #111 stated she understands it is necessary to evaluate the swelling to monitor for any changes especially with the sling and the fracture to the extremity. Review of policy Charting and Documentation (revised July 2017) revealed treatments or services performed must be documented in the medical record, documentation will be objective (not opinionated or speculative), complete, and accurate. Documentation will include care specific details including the assessment data and any unusual findings obtained during the procedure/treatment.

Based on medical record review, observation, restorative master log, review of the therapy log, and interview the facility failed to ensure a newly admitted resident was accurately assessed for range of motion (ROM) and failed to ensure an individualized restorative program was implemented to ensure the resident maintained range of motion. This affected one resident (#399) of three reviewed for ROM. Findings included: Medical record review revealed Resident #399 was transferred to the facility on [DATE] from another skilled nursing facility located in another state. The resident diagnoses included stiffness of unspecified joint, absence of right leg above knee, diabetes type two, hemiplegia and hemiparesis following cerebral infarction affecting right dominating side, lack of coordination, weakness, and difficulty walking. Review of Resident #399's base line care plan dated 03/01/25 revealed the resident's bilateral hands the fingers (last two) only opened 50-75%. There were no goals or interventions documented. Review of Resident #399's comprehensive plan of care revealed no evidence of a plan of care for limited ROM/contractures. Review of admission Minimum Data Set (MDS) dated [DATE] revealed the resident had no impairment of the upper extremity and impairment one side of the lower extremity. Review of Resident #399's mobility evaluation dated 03/07/25 revealed the resident had full range of motion of right and left fingers. Review of Resident #399's orders and task (CNA documentation) revealed no evidence the resident had orders for splints, braces, or restorative therapy. Review of restorative master log sheet dated 04/2025 revealed no evidence Resident #399 was receiving restorative services. Review of the Therapy log dated 04/2025 revealed no evidence Resident #399 was receiving therapy services. Interview and observation with Resident #399 on 03/31/25 at 10:29 A.M. and 04/01/25 at 8:25 A.M., revealed the resident had contractures noted right pinky and left ring finger and pinky. The resident confirmed he had not received therapy, splints, or any type of treatment to prevent contractors in his fingers from getting worse since he had been admitted to the facility a month ago. The resident reported he was in a skilled nursing home in another state and was not receiving good care which resulted in his fingers being contracted. The resident reported he was hoping to have therapy and they would put something in place but he has not seen therapy yet. Interview and observation on 04/01/25 at 1:25 P.M. of Resident #399 with Licensed Practical Nurse (LPN) #110 and Certified Nursing Assistant (CNA) #148 confirmed Resident #399's right pinky and left ring finger and pinky were contracted. The LPN attempted to straighten out the resident fingers, however, was not able due to the extent of the contractures and the resident was experiencing pain. The LPN was not able to open fingers more than halfway on the right and less than halfway one the left. The CNA (who was related to Resident #399) and resident confirmed the contractures had not worsened in the last 30 days. Interview on 04/01/25 at 1:42 P.M., with LPN/Restorative Nurse #300 confirmed Resident #399's admission MDS and mobility evaluation were inaccurate due to the resident having limited ROM/contracture with his fingers on admission per the baseline plan of care and resident interview. The LPN confirmed the resident did not have a comprehensive plan of care for the limited range of motion/contractors nor was in a restorative program/therapy initiated, however a program should have been initiated. LPN #300 confirmed the resident was not receiving therapy services. Review of Resident #399's MDS note dated 04/01/25 (after surveyor confirming findings with staff) revealed the resident stated he would enjoy having exercise to his joints. The resident stated his ROM had not declined since admission. The resident had noted limitation to his pink finger on the right hand and last two fingers on the left hand. The resident reported the limitation happened at the place he was prior to coming to the facility. Will add ROM program.

Based on record review, staff interview and policy review, the facility failed to identify, monitor and measure targeted behaviors with the use of antipsychotic medication. This affected one resident (#14) of five residents reviewed for unnecessary medication. The facility census was 50 residents. Findings include: Review of Resident #14's medical record revealed a 08/21/23 admission with diagnoses including severe protein calorie malnutrition, magnesium deficiency, hypo-osmolality an hyponatremia, age related physical disability, pain, lack of coordination, muscle wasting and atrophy, peripheral vascular disease, Vitamin D deficiency, neuropathy, bipolar disorder, major depressive disorder, Vitamin B 12 deficiency anemia, dizziness and giddiness, gastroesophageal reflux disease, insomnia, dysphagia, anxiety disorder, hypokalemia, hypothyroidism, hypertension, orthostatic hypotension, and diverticulosis, Review of the Quarterly 01/02/25 Minimum Data Set assessment revealed the resident was independent for daily decision making with little interest or pleasure in doing things, feeling down, depressed, or hopeless. The resident was feeling tired or having little energy, having trouble falling or staying asleep, or sleeping too much, She had a poor appetite. She had trouble concentrating on things, such as reading the newspaper or watching television. She was on antipsychotics, antianxiety, opioid, antiplatelet, and anticonvulsant mediations. She had not started on hospice yet. A review of physician orders included Ativan, antianxiety medication, 0.5 milligram (mg) tablet TID, three times a day for anxiety ordered 08/24/23. Remeron, an antidepressant, 15 mg daily for major depressive disorder since 01/23/24. Lamictal, an antipsychotic, 150 mg tablet at bedtime for bipolar disorder current episode manic severe with psychosis, Risperdal 1 mg daily ordered 06/07/22. Abilify, an antidepressant, 5 mg at bedtime was ordered 08/28/24 for depression. Review of the 06/06/19 psychotropic drug care plans included an anti-depressant plan of care revealed the resident would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. The goal was the resident will be free of signs and symptoms of depression, anxiety or sad mood. The plan did not identify what behaviors the resident exhibited while depressed. There were no behaviors identified to monitor for the use of antidepressants. Review of the 11/03/22 plan of care for psychotropic drug use included the resident was at risk for adverse consequences related to receive an antipsychotic medication for psychosis. The long-term goal was the resident will not exhibit signs and drug related side effects or adverse drug reaction. The plan did not identify what behaviors the resident exhibited while psychotic. There were no behaviors identified to monitor for the use of antidepressants. Review of the Certified Nurse Aide TASK documentation revealed there was not a behavior section included in their documentation. Review of the Medication Administration Record (MAR) and the Treatment Record (TAR) revealed there were no sections related to the documentation of targeted behaviors for the use of psychotropic medication. Interview on 04/01/25 on 11:59 A.M. with the Director of Nursing verified the resident had no identified targeted behaviors being monitored and measured for the use of psychotropic medications. Further verified behavior monitoring would assist with the justification to increase or titrate medications. Review of the facility 08/30/24 Psychotropic Medication policy included if behaviors are displayed to document the behaviors in the Nurse Notes and interventions used.

Based on medical record review, interview, and policy review the facility failed to ensure laboratory testing was completed per physician order. This affected one resident (#28) of five residents reviewed for medication review. Findings included: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including history of hypertension, grade I diastolic dysfunction, and dementia. Review of Resident #28's orders dated 03/2025 revealed on 10/28/22 the physician ordered lipid profile to be obtained every six months (April/October). Review of laboratory results dated [DATE] to 04/01/25 revealed no evidence a lipid profile was obtained per orders in October 2024. Further review of laboratory results revealed the last lipid profile was obtained on 04/05/24. The resident's cholesterol was 250 (high) (normal less than 200 milligram (mg) / deciliters (dL), triglyceride 234 high (normal less 150 mg/dl), HDL 36.0 low (higher than desirable 40 mg/dl), LDL 167 high (less than 100 if desirable if clinical atherosclerotic disease or diabetes had been diagnosed ). Review of the facility policy titled Lab Draw dated 01/2025 revealed labs would be drawn as ordered by the physician.

Based on medical record review, policy review and staff interview the facility failed to ensure residents had appropriate indications for use of antibiotics. This affected one resident (#20) of five residents reviewed for antibiotic use. The facility census was 50. Findings include: Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses that included diabetes mellitus, hypertension and peripheral vascular disease. Review of Resident #20's nursing notes revealed on 11/01/24 the resident sustained a fall and was sent to the local emergency department for evaluation. Upon return to the facility on [DATE], Resident #20 was diagnosed at the emergency department with a urinary tract infection (UTI) and prescribed Cephalexin (antibiotic) 500 milligrams (mg) every six hours for five days due to a UTI. Nursing staff advised Resident #20's physician of the returning diagnosis and antibiotic order. Nursing staff also advised the physician the resident's urinalysis was negative and resident asymptomatic for a UTI. Resident #20's physician advised staff to continue the antibiotic. On 11/04/24, after receiving the final urinalysis results, the physician was notified Resident #20 did not meet criteria and advised to continue the antibiotic as ordered. Review of the physician's medication orders revealed on 11/02/24 Resident #20 was prescribed the use of Cephalexin (antibiotic) 500 milligrams (mg) every six hours for five days due to a urinary tract infection (UTI). Review of the antibiotic assessment completed on 11/02/24 revealed Resident #20 did not meet McGeer's criteria for appropriate indication for antibiotic use. The assessment indicated Resident #20 had a urinalysis and culture that final results returned on 11/03/24 which indicated a bacteria growth of proteus mirabilis of >100,000 colonies per million (cfu/ml). The resident had no additional symptoms of a UTI. Review of facility policy titled Antibiotic Stewardship with a reviewed date of December 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Additional policy review titled Infection Prevention and Control; Antibiotic Stewardship with a review date of June 2024 revealed the facility administration and medical director should ensure that current standards of practices based on recognized guidelines are incorporated in the residents care policies and procedures. Interview with the Director of Nursing on 04/02/25 at 2:25 P.M. verified the antibiotic for Resident #20 on 11/02/25 did not meet criteria for appropriate indication for use.

Based on record review, facility policy and procedure review and interview the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 42 residents residing in the facility. Findings include: Review of the facility assessment, dated 02/02/22 revealed no evidence of RN requirements, however the assessment revealed nursing was available 24 hours a day. Review of the staffing schedule, daily posting, and timecards dated 08/29/22 to 09/25/22 revealed there was no consecutive RN coverage for eight hours as required on 09/03/2, 09/10/22, or 09/11/22. Interview on 10/05/22 at 9:23 A.M. with Human Resource (HR)/Scheduler #42 verified there was only six hours RN coverage on 09/03/22 and there was no RN coverage on 09/10/22 or 09/11/22 due to call offs and no RNs to cover the shifts. Interview on 10/05/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed there was not eight hours of consecutive RN coverage on 09/03/22, 09/10/22, or 09/11/22. Review of the Staffing policy, dated 2017 revealed the facility would provide enough staff with the skills and competency necessary to provide care services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #31 was provided a dignified dining experience. This affected one resident (#31) of thirteen residents observed for dining. Findings include: Review of Resident #31's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Assessment (MDS) 3.0 assessment, dated 08/30/22 revealed the resident had severe cognitive impairment and required extensive assistance of one staff member with eating. On 10/11/22 at 8:22 A.M. Resident #31 was observed seated in her chair while State tested Nursing Assistant (STNA) #44 was observed standing next to Resident #31, feeding the resident her breakfast meal. The STNA continued to stand through completion of the meal at 8:40 A.M. On 10/11/22 at 8:35 A.M. the Director of Nursing (DON) entered the dining room and spoke with residents eating as well as STNA #44. No mention was made to the STNA regarding her standing while assisting the resident with her breakfast meal. On 10/11/22 at 8:42 A.M. STNA #44 was observed to remove Resident #31 from the dining room. On 10/11/22 at 8:47 A.M. interview with STNA #44 verified she stood while feeding Resident #31 her breakfast. The STNA acknowledged she should be seated next to the resident while assisting the resident with her meal and this was not a dignified dining experience for the resident. On 10/11/22 at 10:30 A.M. interview with the DON verified the STNA should have been seated next to the resident while assisting the resident with her meal. Review of the Quality of Life- Dignity Policy, dated 2001 and revised 11/2017 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on record review, shower schedule review and interview the facility failed to ensure residents were provided the opportunity to choose their shower schedule and/or failed to ensure residents were offered choices related to meals. This affected one resident (#32) of one resident reviewed for choices and one resident (#11) of one resident reviewed for [CONDITION(S)]. Findings include: 1. Review of Resident #32's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the undated document titled MDS Information and Resident History revealed the resident preferred a shower and the preferred time of day was 9:00 A.M. to 10:00 A.M. Review of the resident preferences plan of care, initiated on 08/29/22 revealed interventions including make sure she gets a shower between 9-10:00 A.M. as per their request Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the shower documentation from 09/13/22 through 10/05/22 revealed the resident received a shower on 09/20/22, 09/27/22, 10/04/22 and 10/05/22. Review of the undated document titled Shower Schedule (Hall Name) Night Shift revealed the schedule was based off resident preferences, do not change). The document reflected Resident #32 was to receive a shower three days a week on Monday, Wednesday and Friday on night shift (6:00 P.M. to 6:30 A.M.) On 10/03/22 at 12:07 P.M. interview with Resident #32 revealed she doesn't get showered as often as she would like and she would like to receive showers more often. A follow-up interview on 10/05/22 at 11:00 A.M. revealed the resident received showers on night shift which she does not like because then she goes to bed with wet hair and her hair was a mess the following morning. On 10/04/22 at 4:10 P.M. interview with State tested Nursing Assistant (STNA) #32 verified the resident was to be showered three times a week on night shift and the showers were documented in the facility electronic/computer system. The STNA revealed the facility did not utilize shower sheets or other paper documentation for showers. On 10/05/22 at 1:59 P.M. interview with the Director of Nursing (DON) verified the resident was not provided showers per her preference as she was scheduled on night shift and the resident's MDS information, which was asked on admission and her plan of care both indicated the resident wanted showered between 9-10:00 A.M. The DON also verified the resident had only received four showers in the last 30 days and she was scheduled to received showers three times a week. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. His current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note revealed for registered dietician to follow and address nutritional concerns as appropriate. Review of Resident #11's meal intakes on hemodialysis days (M-W-F) from 09/02/22 to 10/03/22 revealed the resident had zero intakes for breakfast on the 7th, 9th, 12th, 14th, 19th, 21st, 23rd, 26th, 28th, 30th of September and 10/03/22. Review of Resident #11's nutritional plan of care revealed the resident's goal was to maintain meal intakes of 66% or greater. Interventions included to honor food preferences and offer meal replacement for poor intakes or upon request. Review of Resident #11's current orders for 10/2022 revealed orders for hemodialysis days Monday, Wednesday, and Friday at 7:00 A.M. and a diet order was for a non-gastric irritating (no OJ, tomatoes or fried foods) regular texture diet with thin (regular) liquids. Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he only received two meals (lunch and dinner) on [CONDITION(S)] days. The resident revealed the [CONDITION(S)] center does not permit food in the center so he could not even take snack to eat, and the nursing home kitchen was not open early enough to make him a breakfast before he left for [CONDITION(S)]. The resident reported he would like something to eat besides cold cereal and peanut butter sandwiches, which was all the staff had access to in the morning before he left to offer him. The resident verified he was not offered any other choices of breakfast items to eat prior to go to [CONDITION(S)]. Interview on 10/04/22 at 2:32 P.M. and 3:09 P.M., with the Dietary Manager (DM) #4 and Resident #11 revealed the DM was not aware the resident was not eating breakfast on [CONDITION(S)] days. The direct care staff had never reported to her he was not eating breakfast on those days. The DM confirmed the kitchen staff do not come in early enough to make him a hot breakfast. The resident reported staff were getting him up and ready around 5:30 A.M. and he leaves between 6-6:30 A.M. for his 7:00 A.M., chair time. The DM confirmed residents were not permitted to eat at [CONDITION(S)] center and the [CONDITION(S)] center had called her reported to remind the resident not to bring food to the [CONDITION(S)] center. Interview on 10/04/22 at 3:02 P.M., with STNA #28 confirmed Resident #11 doesn't get a breakfast meal or eat anything in the mornings prior to going to [CONDITION(S)]. The STNA reported one of the reasons was the kitchen was not open until 6:00 A.M. and the second reason was they used to offer him a peanut butter sandwich in the morning, but he was declining them. The STNA reported the only breakfast items they have to offer him in the mornings were cold cereal and peanut butter sandwiches. Interview on 10/05/22 at 2:44 P.M., with Dietician #80 revealed she was not aware the resident was not eating breakfast on [CONDITION(S)] days, but stated she was not too worried because he had snacks in his room, however if a resident was not eating, she would inquire into why they were not eating.

Based on record review, facility policy and procedure review and interview the facility failed to ensure resident health concerns were timely reported to the physician. This affected one resident (#32) of five residents reviewed for range of motion. Findings include: Review of Resident #32's hospital history and physical, dated 08/22/22 revealed the resident had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for [CONDITION(S)] medication or [CONDITION(S)] laboratory monitoring. Review of the five day admission Minimum Data Set (MDS) 3.0 assessment, dated 09/03/22 revealed the resident was cognitively intact and required extensive assistance from one staff member with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review revealed the resident did not have [CONDITION(S)] disease coded on the MDS as a diagnosis. On 10/03/22 at 11:47 A.M. interview with Resident #32 revealed she had been feeling nervous, had been crying and unable to sleep. The resident shared she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated she had taken medication prior to COVID but then COVID affected getting her medications refilled and she had not taken the medication for some time. The resident also revealed she informed the nurse at the facility she needed checked as she thought her [CONDITION(S)] was out of whack and the reason she had been having issues. As the interview was occurring, Licensed Practical Nurse (LPN) #53 was walking in the hall and stopped to ask the resident what she needed. The resident informed the nurse she thought her [CONDITION(S)] was off and the nurse informed the resident she would call and update the resident's physician. Further review of the medical record as of 10/05/22 revealed no evidence LPN #53 notified the physician of the resident's concern. On 10/05/22 at 2:13 P.M. telephone interview with LPN #53 verified she did not notify Resident #32's physician regarding her concerns with her [CONDITION(S)] levels. The LPN stated she should have notified the physician on 10/03/22, when the resident reported to her the concerns she was having regarding her [CONDITION(S)]. On 10/05/22 at 3:03 P.M. interview with the Director of Nursing (DON) verified LPN #53 should have contacted the resident's physician about her concerns regarding her [CONDITION(S)]. The DON stated she spoke with the resident's medical care provider and she ordered lab studies to be completed for the resident. On 10/05/22 at 3:03 P.M. interview with Registered Nurse (RN) #57 verified the MDS assessment did not accurately reflect the resident's [CONDITION(S)] disease and verified the hospital documentation listed [CONDITION(S)] disease as part of the resident's medical history. Review of the undated Physician Notification of Changes in Resident Status Policy revealed specific signs, symptoms and laboratory values suggestive of acute illness needing immediate medical assessment should be reported to the attending physician by the staff as soon as possible after they were identified. All acute changes in resident status reported to the medical staff on an immediate basis would be assessed and documented in the medical record by the nursing staff. Specific signs/symptoms and lab values suggestive of sub-acute illness shall be reported to the attending physician but not on an immediate basis. All subacute changes in resident status reported to the physician on a non-immediate basis would be assessed and documented in the medical record. If a physician does not respond by the end of the shift, the information would be given to the oncoming shift who would be responsible for follow-up.

Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to prevent an incident of misappropriation of personal property involving Resident #11. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to implement their abuse/misappropriation policy and procedure to prevent an incident of misappropriation, to ensure the incident was thoroughly investigated and to ensure the incident was reported to the State agency. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

Based on record review, review of a facility investigation, facility policy and procedure review and interview the facility failed to report an allegation of misappropriation of personal property involving Resident #11 to the State agency as required. This affected one resident (#11) of five residents reviewed for misappropriation. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/12/22 revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of 15). Interview on 10/03/22 at 2:32 P.M., with Resident #11 revealed in April the resident's wallet came up missing out of his locked cabinet. The facility replaced the wallet and helped him obtain a new social security card. The resident stated he canceled his debit card himself, however the facility would not replace the $63.00 that was in his wallet. Review of the facility investigation revealed: A lost or missing article report form, dated 02/28/22 indicated Resident #11 reported to Social Service (SS) #43 his wallet containing $42.00 and social security card were missing. The resolution was to replace the wallet and order a new social security card. The report indicated the money would not be replaced due to facility policy. Review of a grievance/concern form, dated 02/28/22 revealed Resident #11 reported his wallet was missing. The writer and Resident #11 went through the resident's drawers and they were not able to find the wallet. The writer asked if maybe the resident's niece might have taken it to keep the wallet safe. The resident reported she (the niece) didn't have it. Action taken was to replace the wallet if not found and replacement social security card ordered. The author signed the resident was satisfied with the outcome. The form was not signed by the Director of Nursing (DON) or administrator in the spaces provided at the end of the form, nor was the form signed by the resident. The investigation also noted a review of a nursing note, dated 12/24/21 revealed the resident's niece picked up the resident's laptop, charger, wallet, money, phone, and glasses. Review of a signed consent, dated 12/24/21 from Resident #11's niece revealed she took the resident's laptop, charger, wallet, money (no amount noted), phone, and glasses. Review of SS #43's statement, dated 02/28/22 revealed Resident #11 had reported that his wallet and money were missing. The SS and resident looked through the locked drawer and could not find the wallet. The resident confirmed his niece did not have his wallet. SS #43 called the niece and she reported he had returned the resident's laptop and everything to him. Staff who worked on the resident's hall were interviewed and no one had seen the wallet aside from the nurse who gave it to his niece in December 2021. She notified the resident she would replace the wallet and help him get a new social security card. Review of State tested Nursing Assistant (STNA) #28's undated statement revealed he had never seen the resident's wallet nor was aware the wallet was missing. Review of STNA #81's statement, dated 03/01/22 revealed she had never seen Resident #11's wallet. Review of Licensed Practical Nurse (LPN) #59's statement, dated 02/28/22 revealed she was present when the resident's niece had signed out the resident's belongings on 12/24/21. Further review of the investigation revealed no evidence of any additional staff, family or resident interviews conducted. Review of the February 2022 schedule revealed on 02/27/22 and 02/28/22 nine additional STNAs who worked on 02/27/22, three housekeepers, one activities staff and four nurses. On 02/28/22 there were seven additional STNAs, five housekeepers, and five additional nurses. There was no evidence STNA #81 was on the schedule on 02/27/22 or 02/28/22 and LPN #59 only worked 02/28/22. Interview on 10/05/22 at 10:09 A.M., with Resident #11's niece revealed she had picked up some items for her uncle on 12/24/21, however returned all the items around the end of December. The niece reported the resident had two bank envelopes containing cash. One envelope had 13 one-dollar bills and the other one had $40 with $5 bills. The niece stated she had the resident count the money when she returned it to him. She did not open his wallet, so she did not know what items he had in it. The resident had kept his money and wallet locked in the dresser; however, the key was in his room when he was out to the hospital. Interview on 10/05/22 at 8:35 A.M. with SS #43 and the Director of Nursing (DON) revealed they had not reported the allegation of misappropriation to the State agency because they did not feel they could prove the resident's niece had returned the resident's wallet/money that she signed out two months prior when Resident #11 was in the hospital, even though when they called the niece on 02/28/22 she had reported she had already returned all his items. The DON reported no one had seen the wallet and she thought the family still had it. The SS confirmed she did ask the niece originally the date she had returned the items. The SS reported she had called the niece yesterday; however, it had been so long the niece could not remember the date when she returned the items. The facility was not aware of any credit/debit card the resident had in his wallet. The SS confirmed the resident had the wallet in a locked cabinet when it had come up missing. She did not know when the resident had last seen his wallet to determine when it had come up missing. Interview on 10/05/22 at 11:44 A.M., with the Director of Nursing (DON) revealed the investigation was not through or complete and the misappropriation of the wallet and belongings were not reported to the State agency, and should have been reported no matter who took the wallet. There was no evidence in the investigation when the resident last saw the wallet or when the niece returned the items taken in December while the resident was in the hospital. The DON was not sure why the wallet was replaced and not the money. Interview on 10/05/22 at 12:30 PM with Resident #11 and DON revealed the resident reported he had counted the money the day before the wallet had come up missing and he had $63 in his wallet. He only had one card which was debit card and he canceled it right away and no transactions were made on it. He kept his wallet locked in the cabinet but at that time he left the key on the bed rail. Review of the facility undated admission agreement revealed the facility could not guarantee that items would not be lost or stolen. The agreement revealed should an item become missing, please notify the nursing staff immediately so the nursing staff could notify administration. The facility would follow their policies for items reported missing or stolen. Our facility would make every effort to keep track of (resident) belongings. Review of the mistreatment, neglect, abuse, and misappropriation policy, dated 06/09/22 revealed the facility would not tolerate misappropriation of resident's funds or property by anyone. The facility shall report an incident or suspicion of misappropriation of property immediately. The Administrator or designee would report the incident to the State agency. An investigation shall be completed, whenever possible, within five days after the Administrator or DON have knowledge of the incident. The investigation should include interviews with the resident and all witnesses. Obtain written statements from the resident and witness. In the case of alleged or suspected misappropriation, a physical audit of funds or other property was performed. Collect, review, and retain all pertinent facility documentation which may have a bearing on a full and proper investigation (schedule, work assignment, policies, and procedures). If a third party (including family member) have stolen from a resident, the Administrator or designee should report the incident immediately to the State agency or refer the matter for appropriate professional interventions.

Based on observation, record review and interview the facility failed to ensure Resident #18, who was dependent on staff for activities of daily living (ADL) care received proper and adequate oral care. This affected one resident (#18) of one resident reviewed for activities of daily living (ADL). Findings include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's last dental note, dated 01/23/18 revealed the resident had lots of debris and inflammation. The note revealed the resident needed assistance with brushing teeth and gums. Patient was uncooperative; unable to clean teeth today and would try with next visit. Review of Resident #18's Minimum Data Set (MDS) 3.0 assessment, dated 07/26/22 revealed the resident had severe cognitive impairment, had no behaviors or rejection of care. The resident was assessed to be total dependent on one staff member for personal hygiene including brushing her teeth. The resident had obvious or likely cavity or broken natural teeth. Review of Resident #18's personal hygiene plan of care revealed staff were to brush the resident's teeth every morning and night and as needed. Further review of Resident #18's plan of care revealed the resident refused medication at times and spits them out. However, there was no evidence the resident refused oral care. Review of the nurse aide tracking documentation for personal hygiene, dated 09/03/22 to 10/03/22 revealed the resident was mostly dependent of staff for hygiene care. Observation on 10/03/22 at 3:16 P.M., revealed Resident #18 had plaque build-up noted on the teeth, The resident's teeth were also discolored with one tooth missing on the top. There was no evidence of oral hygiene products visible in the resident's room or bathroom. Observation of Resident #18 and interview on 10/06/22 at 2:27 PM with Licensed Practical Nurse (LPN) #51 and State tested Nursing Assistant (STNA) #28 confirmed the resident had no oral care supplies (toothbrushes, swabs, mouth wash, toothpaste) in the room. Both staff members confirmed the resident's teeth were in poor condition with plaque buildup. The STNA reported he thought one of the Hospice aides brought her own oral hygiene supplies to do mouth care but was not sure if the rest of the Hospice aides did. The Hospice aides visit three times a week per LPN #51. STNA #51 reported he only used mouth wash on a swab when he provided mouth care to Resident #18 even though she had her own natural teeth. STNA #28 reported the resident would often tell you no if you asked her any questions and then she would play possum, (acting like she is asleep). An additional observation on 10/11/22 at 10:11 PM with STNA #44 revealed the STNA reported she had not provided mouth care to the resident in the past but was told to use a mouth swab with mouth wash on it to clean the resident's teeth. The aide reported she should be using tooth paste in addition since the resident had her natural teeth. The STNA reported she would not just use mouth wash to clean her own natural teeth. The STNA #44 then removed an unopened box of tooth paste from the dresser and applied it to the swab. The STNA asked the resident if she could provide oral care and the resident responded no. The STNA did not encourage the resident to participate or help with her own oral care. Interview on 10/11/22 at 11:04 A.M., with LPN #51 revealed the resident refused to open her mouth for the dentist in 2018 and she had not been seen by the dentist since. The resident had consented to see the dentist and she should have been seen in 2021 and 2022. The dentist did not visit in 2020 due to COVID-19. The LPN reported she would make sure the resident was on the list to be seen at the next visit.

Based on observation, record review, and interview the facility failed to develop and implement comprehensive and individualized restorative nursing service plans to ensure interventions and treatments were provided to residents to prevent a decline in range of motion (ROM) or maintain current ROM function. This affected two residents (#1 and #11) of five residents reviewed for mobility. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's annual Minimum Date Set (MDS) 3.0 assessment, dated 09/20/22 revealed the resident had limited range of motion to one side of the upper extremity. Review of Resident #1's current orders, dated 10/2022 revealed an order (dated 02/04/22) to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed. The order indicated to keep wash cloth in place as tolerated throughout the day and at night. Review of Resident #1's risk for skin breakdown and risk for impaired functional range of motion care plans revealed the resident was to wear a rolled cloth to the right hand and if not able to tolerate, let therapy know and to gently perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Review of the nursing task list dated 09/11/22 to 10/11/22 revealed to gentle perform passive range of motion to the right hand and place rolled wash cloth after range of motion was performed, keep wash cloth in place as tolerated throughout the day and at night. Further review revealed on 10/11/22 staff documented at 2:25 P.M. the washcloth was in-place. Observation on 10/11/22 at 2:48 P.M., with Licensed Practical Nurse (LPN) #51 revealed the resident was resting in bed and no washcloth was noted in the right hand or bed. The resident would not let the LPN touch her hand and kept pulling it way. The hand was noted to be contracted. Interview on 10/11/22 at 2:51 P.M., with LPN #51 revealed she had spoken to the resident's aide, and she reported the resident had gotten ketchup on the washcloth at lunch and she removed it and forgot to replace it. Interview on 10/11/22 at 3:05 P.M., interview with the Director of Nursing (DON) revealed she had just helped the aide place a new washcloth in the right hand it was difficult, but they were able to slide the washcloth in her hand. The DON verified staff had documented at 2:25 P.M., the washcloth was in-place, however the observation at 2:51 P.M., revealed the washcloth was not in-place, and the staff reported to LPN #51 she had removed it after lunch and forgot to replace it. 2. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's quarterly MDS 3.0 assessment, dated 07/12/22 revealed the resident's cognition was intact. The assessment revealed the resident had behaviors or refusal of care and had had impairment to his bilateral lower extremities. Review of a therapy referral to restorative form, dated 05/25/22 revealed Resident #1 was referred for active range of motion (AROM) to the right and left upper and lower extremities, two sets and ten repetitions. The number of times per day was blank. Review of Resident #11's task documentation, dated 05/26/22 revealed AROM to bilateral upper and lower extremities. There was no indication on how many repetitions or sets or how many times a week to complete. Record review revealed the resident had a current limited mobility plan of care. The plan revealed the resident would receive AROM to the bilateral upper and lower extremities, two sets of ten repetitions for at least 15 minutes daily. Interview on 10/03/22 at 2:35 P.M., with Resident #11 revealed staff were not assisting him with range of motion exercises and he had limitations to his lower extremities. Interview on 10/04/22 at 3:02 P.M., with STNA #28 revealed floor staff were responsible for restorative therapy and ROM. STNA #28 reported Resident #11 would allow staff to do ROM with his upper extremities, however he would not allow you to touch his legs. The resident would scream out in pain even before you touched him. Interview on 10/05/22 at 12:30 P.M., with Resident #11 and the DON revealed he would like to have therapy, but was concerned his insurance would not cover it. The resident revealed he had been taking pain medication three times a day and had seen a doctor for steroid injections at one time. Interview on 10/05/22 at 2:51 P.M., with Registered Nurse (RN) #57 revealed she was new to the program and was not aware resident was not participating in the lower leg AROM program. The RN confirmed the program under the task section for the aides to document did not include the number of repetitions, sets, time, or frequency to complete each upper and lower extremity exercise. The RN reported under the task section, the upper extremity and lower extremities had been separated and should have included two sets of 10 reps for 15 minutes; six to seven times a week. The RN reported she would update therapy on the resident's refusal to perform AROM to the lower extremity and update the task order for the aide.

Based on observation, record review, review of [CONDITION(S)] dietary notes, facility policy and procedure review and interview the facility failed to ensure residents were assessed and timely identified related to continued significant weight loss. The facility also failed to ensure residents receiving hemodialysis had accurate diet and fluid restriction orders. This affected two residents (#11 and #21) of three residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's nutritional note, dated 07/21/22 revealed the resident was ordered a no OJ, tomatoes or fried foods diet. The resident was currently not on any supplements, had no significant weight changes, meal intakes were 76% to 100% and fluid intakes were good. The resident was alert, and able to feed self. Nutritional needs were 1832-2290 calories, protein 92-110 and fluids were 1832-2290. The nutritional summary indicated the resident tolerated diet as ordered with meal intakes averaging 95% and no chewing or swallowing difficulties noted. The resident's current weight was 290.4 pounds with a body mass index (BMI) of 40.5, indicating resident was morbidly obese. There were no significant weight changes triggering at present. The resident had no pressure wounds. The note indicated registered dietician to follow and address nutritional concerns as appropriate. Review of a [CONDITION(S)] dietary note, (requested by surveyor), dated 09/26/22 revealed to reinforce one liter fluid restriction, limit salt use, and encourage oral nutrition supplements in the facility with high protein food choices. Further review of the [CONDITION(S)] dietary note, dated 08/04/22 revealed the [CONDITION(S)] registered dietician noted to encourage resident to eat meats and or eggs with each meal three times daily. There were multiple documentation entries from 02/01/22 to present to work with the facility to stabilize fluid intake and encourage high protein diet. One note, on 05/27/22 revealed the registered dietician called the nursing home to encourage a fluid restriction for the resident due to him being a [CONDITION(S)] patient. Review of Resident #11's current orders for 10/2022 revealed the resident received hemodialysis every Monday, Wednesday, and Friday at 7:00 A.M. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the resident was on fluid restriction or a renal diet. Interview on 10/03/22 at 2:42 P.M., with Resident #11 revealed he was not aware of any fluid or diet restrictions at the facility. Interview on 10/06/22 at 10:47 AM with Registered Nurse (RN) #50 revealed Resident #11 was not on a fluid restriction or renal diet. Interview on 10/06/22 at 11:00 A.M., with Dietary Aide #8 revealed Resident #11 had been on a fluid restriction but it was discontinued a long time ago. Interview on 10/05/22 at 2:44 P.M., 10/06/22 11:50 A.M. and 10/11/22 at 10:25 A.M. with Dietician #80 revealed the resident's fluid restriction was not reordered upon his return from a hospital visit in December 2021. Dietician #80 revealed she was not aware of the [CONDITION(S)] dietician recommendation for diet and fluids until the surveyor had requested notes from the [CONDITION(S)] centers dietician during the survey. The resident was in and out of the hospital multiple times in the past year and his diet and fluid restriction orders were not reordered. The dietician reported she was able to write dietary orders, however the facility policies was she was not permitted to write orders. She had not talked to the [CONDITION(S)] dietician probably since spring regarding this resident. Dietician #80 revealed she was not aware the dietician from the [CONDITION(S)] center had called the facility in May 2022 to discuss the resident's fluid restrictions. Dietician #80 revealed she called and spoke to the [CONDITION(S)] dietician on 10/06/22 after reviewing the notes and verified orders for a 1500 cubic centimeter (cc) fluid restriction, however she did not verify the diet order for the resident. The dietician currently reported the resident's diet order was for GI issues and not his renal failure. 2. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident requires a therapeutic nutrition intervention plan of care dated 12/10/20 revealed interventions including honor food preferences, offer a meal replacement for poor intakes or upon request, offer a nourishing bedtime snack daily, provide diet as ordered and record intakes every meal and provide supplements as order- Mighty Shakes twice a day. Review of Resident #21's weights revealed: On 05/04/22 216 pounds On 06/10/22 216 pounds On 07/07/22 210 pounds On 08/05/22 202 pounds On 09/11/22 194 pounds a 7.8% weight loss (16 pounds) since 07/07/22. No additional weight monitoring was noted in the medical record. Review of the resident requires a pureed diet with nectar thick liquids plan of care, dated 07/28/22 revealed interventions including consult speech as needed and follow recommendations provided, observe for difficulty swallowing, holding food in mouth, prolonged swallowing time. repeated swallows ER bite, coughing, throat clearing, drooling, pocketing food in mouth and excessive chewing, provide diet texture as ordered. Review of the quarterly MDS 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and the resident was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months per the MDS assessment. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was receiving mighty shakes (supplement) two times a day from 07/29/22 through 09/16/22. Review of the resident's supplement intakes for September and October 2022 revealed the nurse documented with a check mark indicating the resident received his nutritional supplement but did not document the percentage consumed. Review of the nutrition progress note dated 09/15/22 revealed the physician was notified of the weight loss of 22.2 pounds (10.3 % in three months). Current weight 193.8 pounds with a body mass index of 25.6. Meal intakes average 68% yet ongoing weight loss was noted. Resident's diet texture was downgraded to puree with honey thickened liquids. Mighty shakes ordered twice a day. The registered dietician (RD #80) recommended to discontinue mighty shakes twice a day and provide magic cups three times a day. On 10/05/22 at 12:28 P.M. Resident #21 was observed seated in his wheelchair in the dining room. The resident was being assisted with his meal by a family member. On 10/05/22 at 5:25 P.M. Resident #21 was observed seated in his wheel chair in the dining room. The resident was feeding himself and was being provided verbal cues from staff in the dining room. The resident was observed to eat his magic cup during the meal and was provided the appropriate diet and fluid consistency. On 10/06/22 at 10:42 A.M. interview with RD #80 revealed the resident had experienced significant weight loss and recently had a change in his fluid consistency from nectar to honey thickened and his diet changed to puree texture in July 2022. The RD stated speech therapy was working with the resident and verified she had not observed the resident eating since she was not always in the facility during meal times. The RD stated she did not recommend changing the resident from monthly weights to weekly weights despite the resident's identified significant weight loss of 10.3 % or 22.2 pounds in three months. On 10/06/22 at 11:15 A.M. LPN #51 and State tested Nursing Assistant (STNA) #26 were observed to weigh Resident #21 while in his wheelchair. The resident and chair weighed 242.4 pounds and this was verified by LPN #51. At 11:20 A.M. LPN #51 weighed only the resident's wheelchair and it weighed 52.8 pounds. This indicated the resident now weighed 189.6 pounds, a 4.2 pound weight loss since 09/11/22. This was verified with LPN #51 at the time of the observation. On 10/06/22 at 11:40 A.M. a follow-up interview was completed with RD #80. The RD verified the resident's additional weight loss and felt all hope is not lost and the resident's weight loss could have been worse. The stated she would consider the resident nutritionally complex and would need to re-evaluate him. She indicated she used information such as observing the resident eat, weights and labs to determine if the facility was meeting the resident's nutritional needs. On 10/11/22 at 10:50 A.M. a follow-up interview was completed with RD #80 which revealed she spoke to someone (she was unable to recall the staff member) regarding the resident's weight fluctuations and felt this may be due to excess fluid but had no additional information to support her thought of excess fluid volume. The RD stated the resident was weighed over the weekend but the weight was not documented. Lastly, the RD stated more frequent weights may be upsetting to residents and some don't like seeing the scale and being weighed so she didn't want to upset the residents by weighing them more often than monthly. On 10/06/22 at 12:35 P.M. telephone interview with the Speech Therapist (ST) #75 revealed she wasn't seeing the resident any longer and discharged him about two weeks ago with recommendations for him including to be up at 90 degrees, go to the dining room for meals, close supervision while eating, feed only when alert, small bites and sips while eating and alternate liquids and solids. She stated she felt his [CONDITION(S)] disease may be progressing and this caused a lot of his nutritional issues and his participation varied greatly related to his fatigue level and how tired he was. If the resident was fatigued and needed assistance he could go to bed and have the head of the bed elevated 90 degrees. ST #75 revealed the resident does very well but how well he does depends on him and his day. The ST did not feel the resident had any additional therapy needs such as occupational therapy at the time of discharge from ST. On 10/06/22 at 6:00 P.M. interview with the DON verified the resident had experienced significant weight loss and diet changes as well as the addition of some nutritional interventions. The DON verified the resident's weight loss should have been identified timely and monitored more closely due to his complex issues such as dysphagia, diet changes and co-morbidities. The DON stated she planned to discuss the resident with the dietician and place the resident on weekly weights to ensure his needs were being met. A follow-up interview on 10/11/22 at 11:04 A.M. verified the resident's nutrition care plan was not updated to reflect the resident's supplement change or consistency of his liquids being changed from nectar thick to honey thick. The DON also verified there was no indication the resident was experiencing any fluid overload as he was not experiencing any shortness of breath, [CONDITION(S)] or adventitious lung sounds. Review of the Weight Policy, reviewed and revised 07/13/16 revealed residents would be weighed upon admission within 48 hours and then once a month or as ordered by the physician. Available information would be reviewed for possible reasons for weight loss. Physicians would be notified of any weight change of five percent or more in a month, seven and a half percent in three months and 10 % in six months and all necessary interventions would be implemented as ordered.

Based on record review and interview the facility failed to ensure parameters were noted when to administer analgesic verses narcotic pain medication. The facility also failed to ensure nonpharmacological intervention were attempted prior to administration of narcotics. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's orders, dated 09/01/22 to 10/06/22 revealed the resident was ordered Acetaminophen 325 milligrams (mg) two tablets every four hours as needed for pain and [MEDICATION(S)] 10 mg one tablet every six hours as needed for pain. Review of Resident #11's medication administration records (MAR) dated 09/2022 and 10/2022 revealed Acetaminophen was administered for a pain level of four to six as well as [MEDICATION(S)] being administered for pain rated a level of zero to nine. Review of Resident #11's progress notes dated 09/01/22 to 10/06/22 revealed resident received 35 doses of [MEDICATION(S)] without evidence a nonpharmacological interventions being considered or attempted first. Interview on 10/06/22 at 10:17 A.M. with the Director of Nursing (DON) confirmed there were no parameters as to when staff were to administer the Acetaminophen versus [MEDICATION(S)] for the same pain level. The DON also verified there were several times nonpharmacological interventions were not attempted prior to administering the as need narcotic medication. The DON reported nurses should try a nonpharmacological intervention prior to administering [MEDICATION(S)].

Based on record review, facility policy and procedure review and interview the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed [CONDITION(S)] medications. This affected one resident (#21) of five residents reviewed for unnecessary medications use. Findings include: Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses including depression, Alzheimer's Disease and [CONDITION(S)] disorder. The diagnosis of [CONDITION(S)] Disease was added to the resident's medical record in December of 2021. Review of the resident uses anti-anxiety medications related to anxiety disorder plan of care, dated 07/07/21 revealed interventions including administer medications per orders and observe for side effects and effectiveness. Review of the physician's orders revealed an order for [MEDICATION(S)] (anti-anxiety medication) 50 milligrams tablet one tablet by mouth twice a day for anxiety disorder (initiated 07/24/22) and one 50 mg tablet daily as needed for restlessness for 14 days only (dated 09/23/22) and discontinued on 10/07/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/15/22 revealed the resident had modified cognitive impairment and was dependent on two staff members for bed mobility, transfers, dressing and toilet use. The resident required supervision while eating and had not experienced a significant weight loss in the last three to six months. Review of the Medication Administration Record (MAR) for September 2022 revealed the resident received as needed [MEDICATION(S)] on 09/24/22 at 2:17 P.M., 09/25/22 at 3:43 P.M. and 09/27/22 at 10:00 P.M. All doses were marked as effective. Review of the nursing progress notes revealed the following: On 09/25/22 at 3:41 P.M. the resident continued to wander around the facility in his wheelchair looking for family, tried to transfer self and appeared anxious. As needed [MEDICATION(S)] given. On 09/25/22 at 4:06 P.M. the resident's fingernails were cleaned and trimmed. On 09/27/22 at 10:36 P.M. no adverse reactions from increase to [MEDICATION(S)]. Received one dose this shift for [CONDITION(S)]/agitation. Further review of the medical record revealed no evidence non-pharmacological interventions were attempted prior to administration of the [MEDICATION(S)] on 09/25/22 and 09/27/22. On 10/06/22 at 2:00 P.M. interview with the Director of Nursing verified non-pharmacological interventions were not attempted prior to the administration of the as needed [MEDICATION(S)]. The DON stated the interventions attempted should be documented in the medical record and the progress notes should contain documentation describing the resident's behaviors that warrant the use of the as needed medication. The DON verified the care plan did not inform the staff to attempt non-pharmacological interventions or the specific interventions to try for the resident prior to administering the as needed medication. Review of an untitled policy, dated 04/24/18 revealed when giving as needed medications the following steps would be completed including attempt non-pharmacological interventions prior to giving the medication and document in the progress notes what non-pharmacological interventions were attempted. Give as needed medication if non-pharmacological interventions were not effective.

Based on record review, infection control log review, McGeer's Criteria review, facility policy and procedure review and interview the facility failed to ensure antibiotic use was appropriate and/or met antibiotic stewardship criteria. This affected two residents (#3 and #21) of five residents reviewed for unnecessary medications and one resident (#40) of one resident reviewed for antibiotic stewardship. Findings include: 1. Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the June 2022 Infection Control Log revealed a urine culture was obtained due to increased behaviors and urgency on 06/17/22 and contained greater than 100,000 colony count of escherichia coli and this met McGeer's Criteria for treatment due to the colony count and increased urgency. The resident was treated with the antibiotic, [MEDICATION(S)] for a urinary tract infection. Review of the urine culture obtained on 06/17/22 and verified on 06/19/22 revealed the resident did have E coli in her urine, however [MEDICATION(S)] was not listed as a treatment option. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received the entire course of antibiotics. Review of the nursing progress note, dated 06/17/22 at 3:20 P.M. revealed the resident was transported to the emergency room due to [CONDITION(S)]. The resident returned to the facility at 9:01 P.M. with orders for [MEDICATION(S)] 500 mg twice a day for seven days to treat a urinary tract infection. Further review revealed on 06/20/22 at 9:17 P.M. revealed the urinalysis and culture was received and showed greater than 100,000 E. coli. The nurse practitioner was notified and ordered to continue [MEDICATION(S)] as ordered from the emergency room . On 10/11/22 at 3:55 P.M. interview with the Director of Nursing (DON) verified the resident met criteria for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified the facility utilized McGeer's Criteria for the definition of infections and antibiotic stewardship. 2. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2022 Infection Control Log revealed Resident #21 presented with a cough and hoarseness on 06/24/22 and a chest x-ray was obtained. The resident's chest x-ray was negative for acute cardiopulmonary disease but due to the resident having two symptoms, the resident met McGeer's criteria for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the nursing progress notes, from 06/24/22 through 06/28/22 revealed the resident had a non-productive cough but no other symptoms were documented. Review of the McGeer's Criteria revealed the resident must present with at least two symptoms to meet criteria for treatment. On 10/11/22 at 3:58 P.M. interview with the DON verified the medical record only indicated the resident had a non-productive cough with no other symptoms were documented. The DON verified the resident did not meet criteria for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #40's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 Infection Control Log revealed the resident had increased falls and a urinalysis was completed on 07/21/22. The urinalysis did not contain abnormalities to require a urine culture. The resident did not meet McGeer's Criteria for treatment due to not meeting criteria for a urine culture. However, the resident was ordered the antibiotic, [MEDICATION(S)] and received the entire course of treatment. Review of the nursing progress note, dated 07/21/22 at 6:41 P.M. revealed the resident was sent to the emergency room due to somnolence, increased falls and disequilibrium. The resident returned with orders for antibiotic, [MEDICATION(S)] 500 mg every six hours for [CONDITION(S)] for seven days. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes revealed the facility received the urinalysis results on 07/25/22 and reported the results to the physician with orders to continue [MEDICATION(S)] as ordered in the emergency room . On 10/11/22 at 4:00 P.M. interview with the DON verified the resident's urinalysis did not indicate the resident had a [CONDITION(S)] and therefore did not meet McGeer's Criteria for treatment. The DON verified the resident was treated with [MEDICATION(S)] without appropriate justification and the physician did not provide rationale as to why treatment should continue. Review of the Infection Prevention and Control: Antibiotic Stewardship Policy, dated 02/20/20 revealed the facility had developed and implemented written policies and procedures for the provision of infection prevention and control. The facility administration and medical director should ensure that current standards of practices based on recognized guidelines were incorporated in the residents' care policies and procedures. Nursing would obtain labs, cultures, chest x-rays etc as ordered and fax or call results to the physician. Nursing would follow orders as given by the physician, nursing would complete the criteria checklist as related to symptoms, educate nursing staff on what to monitor of criteria if not met and continue to inform the physician when criteria not met for antibiotic stewardship protocol.

Based on observation, review of Resident #1's medical record, death certificate, police report, hospital record, pre-admission screening and resident review (PASRR) and interviews with facility staff, family, Physician #160, Psychiatrist #165, Certified Nurse Practitioner #170, Emergency Medical Technician #175 and #180, and Area Agency on Agency (AAA) Passport Case Manager #185 the facility failed to meet the psychosocial needs of Resident #1, who was admitted to the facility on [DATE] following an inpatient psychiatric hospitalization for depression and suicidal ideation with a plan for his death, to prevent the resident's death by suicide. At the time of admission, PASRR recommendations included the need for a safety plan, mental health counseling and ongoing monitoring of the effectiveness of current [MEDICAL CONDITION] medications on target symptoms which were not completed for the resident. Resident #1 voiced concerns of increased depression and/or medication concerns on [DATE] and [DATE] with requests to contact the physician which were not completed by staff. On [DATE] at approximately 5:40 [NAME]M. Licensed Practical Nurse (LPN) #80 found Resident #1 lying in a pool of his blood, with a pocket knife in his right hand and a one inch cut to each antecubital area, without vital signs. The resident was subsequently pronounced dead upon arrival by Emergency Medical Service Technicians. The lack of comprehensive and individualized behavioral health care for Resident #1 resulted in Immediate Jeopardy. Actual Harm occurred when the resident was found to have committed suicide on [DATE]. In addition, concerns identified at a level that does not rise to Immediate Jeopardy included the facility failed to ensure Resident #30 and #49, who had PASRR recommendations for behavioral health care, [DIAGNOSES REDACTED]. This affected three residents (#1, #30 and #49) of four residents reviewed for behavioral healthcare needs. On [DATE] at 5:00 P.M. the Administrator, Director of Nursing (DON) Registered Nurse (RN) #130 and Licensed Practical Nurse (LPN) #75 were notified Immediate Jeopardy began on [DATE] when Resident #1 was admitted to the facility after an inpatient psychiatric hospitalization for depression and suicidal ideation. The pre-admission screening completed on [DATE], recommended mental health counseling services, monitoring [MEDICAL CONDITION] medications for targeted behaviors and a safety plan. On [DATE] at 12:59 [NAME]M. the resident reported he felt over medicated and didn't feel right taking all the medications he was prescribed and wanted to the physician to complete a medication review. On [DATE] at 2:26 P.M. Resident #1 reported he just feels sluggish and has a poor appetite. The resident reported to staff he had lived a good life and if it was time for him to go, he was ready to go. The note indicated he felt his system was slowing down and perhaps he would die soon. And on [DATE] at 8:36 P.M. Resident #1 requested his medical doctor be contacted due to feelings of depression. There was no evidence the resident's primary care physician, psychiatrist or CNP were notified related to any of these statements/requests made by the resident. On [DATE] at approximately 5:40 [NAME]M. Resident #1 was found on the floor of his bathroom with a knife in his hand with self-inflicted wounds to both antecubital veins. The resident was pronounced dead in the facility. The death certificate identified the immediate cause of Resident #1's death was hypovolemic shock caused by exsanguination (loss of blood to a degree to cause death) and self-inflicted wounds to both antecubital veins. The Immediate Jeopardy was removed on [DATE] after the facility implemented the following corrective action: · On [DATE] at 5:54 [NAME]M. 911 was called and Emergency Medical Service (EMS) arrived onsite to assess and assume care for Resident #1. The resident was subsequently pronounced dead at the facility from a suicide. · On [DATE] as part of a facility investigation statements were obtained from State tested Nursing Assistant (STNA) #100, #92 and #63 and from Licensed Practical Nurse (LPN) #80 and #78, staff who were working at the time of Resident #1's death. · On [DATE] RN #130 and the DON revised the facility suicide policy to include one on one supervision for residents assessed to be in imminent danger or suicidal until the resident could be transferred to the emergency room . · On [DATE] and [DATE] RN #130 and the DON provided education to all 54 employees of the facility on depression, suicide and the Dangerous and Prohibited Items policy. In addition, the 13 licensed nurses received additional education related to change in condition/notification, rights of medication administration and concise clinical documentation. · On [DATE] and [DATE] the DON, RN #130, RN #60 and LPN #73 completed mood assessments for the 35 current residents residing in the facility identified to be alert and oriented and interviewable. · On [DATE] at 2:30 P.M. the DON reviewed all current resident's progress notes for any change in condition to ensure the changes were documented and reported to the physician. · On [DATE] at 4:00 P.M. LPN #73 and Social Service Designee (SSD) #123 searched all resident rooms for dangerous weapons. · On [DATE] the Administrator updated the facility Admission Agreement and Rules policy to include a section titled Approval of Items Brought on Premises. Between [DATE] and [DATE] the new agreement and Rules policy was mailed to all resident families and was provided to all 35 of the facility alert and oriented residents. · On [DATE] RN #130 developed a new policy titled Resident Personal Item Inventory with a plan for personal property to be inventoried for all new admissions and for current residents if/when they receive new items in the facility. · On [DATE] RN #130 developed a new policy titled Patient Safety Plan which included the directive for all residents, identified to be at risk for suicide/depression to have a personalized written plan to serve as coping strategies and source of support. · On [DATE] and [DATE] the DON and RN # 130 provided education to 53 of 54 employees related to the new inventory sheet process and the patient safety plan policy. A plan to ensure LPN #80, who was on vacation at the time of the training received the training was implemented. · On [DATE] the DON and RN #60 reviewed the medical records for the 28 current residents who had a [DIAGNOSES REDACTED]. · On [DATE] the DON and LPN #75 reviewed all current residents Pre-Admission Screening and Resident Review (PASRR) forms to ensure any residents with PASRR recommendations had care plans to reflect the recommendations and to ensure the recommendations were being provided. The facility identified two residents, Resident #30 and Resident #36 who had recommendations and provided a plan to implement the recommendations for these residents. · On [DATE] LPN #75 and RN #130 contacted point click care support to make changes to electronic software allowing STNA staff to access resident care plan information, including behavioral health care needs/interventions from the electronic kiosk. The STNA staff were then educated on how to access the information. · On [DATE] the DON and LPN #73 identified two residents, Resident #36 and Resident #49 who had a history of [REDACTED]. RN #60 developed an additional plan of care for both residents related to suicidal ideation. · Beginning on [DATE] a plan for the DON/designee to audit five random residents comprehensive nursing notes and progress notes daily for one month and then three times per week for one month and then once a week for one month was implemented. · Beginning on [DATE] a plan was implemented for the DON to review all new admissions to ensure any resident with a [DIAGNOSES REDACTED]. · Beginning on [DATE] a plan was implemented for the DON/designee to review all new admissions PASRR forms to ensure any recommendations were implemented and care planned. · Beginning on [DATE] a plan was implemented for the DON to interview five random employees three times per week for one month and then randomly to ensure staff are aware of residents psychosocial/behavioral needs. · Beginning on [DATE] a plan was implemented for the DON/designee to review all residents admitted with a history of suicidal ideation to ensure they have a Patient Safety Plan in place. · Beginning on [DATE] a plan was implemented for the DON/designee to interview five random residents three times per week for one month and then one time per week for one month to ensure they feel their psychosocial needs are being met. · On [DATE] between 11:35 [NAME]M. and 4:26 P.M. interviews with STNA #94, Activity Director #121, RN #74, LPN #79 and Maintenance #118 revealed all staff interviewed acknowledged they had received staff education related to depression/suicide, personal inventory and notification of change. The staff interviewed were knowledgeable regarding the signs/symptoms of depression, reporting dangerous objects, keeping residents safe, inventory sheets and the facility suicide policy. · The facility scheduled a Quality Assessment and Performance Improvement (QAPI) meeting to be held on [DATE] to discuss the psychosocial and social service needs of the residents residing in the facility. The QAPI committee consisted of staff including the DON, RN #130, the Administrator, the medical director, RN #60, LPN #75, SSD #123 and LPN #73. · On [DATE] the DON provided education to SSD #123 related to the role of social service in meeting the psychosocial needs of residents, developing Patient Safety Plans and ensuring communication and documentation of social services was being completed. · On [DATE] at 9:00 [NAME]M. Consultant Licensed Social Worker #150 was scheduled onsite in the facility to meet with Resident #30 and Resident #49, the two residents identified with PASRR recommendations related to depression/psychosocial needs and to collaborate with the DON and SSD #123 related to implementing effective social services to meet the psychosocial needs of all facility residents. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing behavioral health interventions for Resident #30 and Resident #49, implementing new policies and procedures related to inventory documentation and the development of Resident Safety Plans and completing audits to monitor for correction actions. Findings include: 1. Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] following an inpatient psychiatric hospitalization with [DIAGNOSES REDACTED]. Advance directives at the time of admission revealed the resident was a full code. Prior to the hospitalization and Resident #1 resided in the community with Passport services. Review of the psychiatric hospitalization records revealed the resident was hospitalized from [DATE] through [DATE] due to severe recurrent depression and suicidal ideation. The hospital discharge summary, dated [DATE] revealed the resident presented to the hospital with a chief complaint of being increasingly depressed and despondent with suicidal ideation. The hospital records revealed the resident had previously been admitted to the behavioral health unit and returned home. He reported once he got home, he became overwhelmed with keeping up with his activities of daily living, cooking and cleaning and even remembering to take his medications. He reported he was episodically noncompliant with his medications and subsequently found himself getting deeper and deeper into depression with suicide being his only answer. His plan was to overdose on his pills. Instead, he contacted the behavioral health unit and was instructed to go to the emergency room for clearance. Upon clearance, he was admitted . The resident was restarted on his previous medications which were effective. The antidepressant medication, [MEDICATION NAME] was titrated from 15 milligrams (mg) to the targeted dose of 45 mg daily at bedtime, [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) was titrated to 10 mg twice a day and an [MEDICATION NAME] (used to treat mild to moderate dementia) was titrated to 13.3 mg daily. Most of his stay concentrated on placement for 24-hour supervision to help with cooking, cleaning and taking his medications and he agreed to a 30-day rehabilitation stay with the possibility of making this permanent or looking into placement at an assisted living. Review of the PASRR, dated [DATE] revealed the resident had been ruled out for further PASRR review due to primary neurocognitive disorder which was documented to be the focus of the resident ' s treatment needs. The review noted the resident had been admitted repeatedly over the past few months for various issues including [MEDICAL CONDITION], serious cognitive decline and repeated memory loss. The review concluded, if the resident was admitted to a Medicaid certified nursing facility, he would need the following services and/or supports: safety plan, ongoing evaluation of the effectiveness of current [MEDICAL CONDITION] medications on target symptoms and mental health counseling. Resident #1 was subsequently admitted to the facility on [DATE]. Review of the admission medication orders revealed the resident had orders for [MEDICATION NAME] and [MEDICATION NAME] (at the same doses from the hospital). Record review revealed an Area Agency on Agency (AAA) notification letter, dated [DATE] which provided the facility information on the resident's community services. The letter revealed the facility was notified Resident #1 was a Passport consumer and listed his case manager, AAA Passport Case Manager (CM) #185. The CM's contact number was provided and notification the CM would be contacting the facility regarding the current schedule of passport services, goals for returning home and progress with therapy. The letter also stated the facility was to contact the CM if there was a change in the resident's health status or death. Record review revealed the facility developed a PASRR plan of care (P[NAME]), dated [DATE]. The P[NAME] reflected the resident's PASRR evaluation was done on [DATE]. The plan of care goal was for the resident s [MEDICAL CONDITION] to be reduced and to develop independent care for the resident to be able to go to assisted living. Interventions listed on the P[NAME] included mental health counseling, ongoing evaluation of the effectiveness of current [MEDICAL CONDITION] medications on target symptoms and a safety plan. However, there was no additional information related to what a safety plan was or how staff were to implement it. Review of the Social Services Admission Eval 1.2, dated [DATE] revealed the resident had Passport services (Medicaid waiver program that helps Medicaid-eligible older residents get the long-term services and supports they need to stay in their homes or other community settings, rather than enter nursing homes, when appropriate) prior to admission to the facility. The resident had mental health or behavioral/emotional needs as he had a psychiatric hospital stay from [DATE] to [DATE]. Review of the nursing progress notes, dated [DATE] at 12:24 P.M. revealed Psychiatrist #165 was in to assess the resident and no new orders were given. Review of the psychiatry note, dated [DATE] revealed the resident was known to Psychiatrist #165 after the resident's second (hospital) admit for major [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident was alert and oriented with time gaps. Psychiatrist #165 documented the resident had no evidence of depression at the time of his assessment. Review of the nursing progress notes, dated [DATE] at 12:59 [NAME]M. revealed the resident refused his bedtime medication stating he felt over medicated and doesn't feel right taking all the medications he was ordered. The resident stated he was not depressed anymore and doesn't feel he needs the medications. The nursing progress note documented the resident stated he did not see Psychiatrist #165 when he made rounds on [DATE] so he was unable to ask him about it, but he would like a medication review. The medical record contained no evidence Psychiatrist #165, CNP #170 or Physician #160 were aware of the resident's request at that time. Review of the comprehensive nursing notes 1.1, dated [DATE] at 2:26 P.M. revealed the resident stated he felt sluggish and had a poor appetite, had lived a good life and if it's time for him to go, he was ready to go. Per the nursing progress note, the resident felt his system was slowing down and perhaps he would die soon but denied being suicidal. On [DATE] Resident #1 was moved from a semi-private room with a roommate to a private room per his request. Review of a social service department note, dated [DATE] (no time) revealed the facility held an admission care conference. The resident was present and the note documented the resident was sometimes tired. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #1 was admitted to the facility from a psychiatric hospital. The assessment revealed the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 13 and required limited assistance from one staff member for bed mobility, transfers, walking in his room or corridor, locomotion on and off the unit, dressing, toilet use and personal hygiene. The assessment revealed over the last two weeks the resident felt down, depressed or hopeless, had trouble falling or staying asleep, or sleeping too much two to six days, feeling tired or having little energy two to six days and had poor appetite or overeating two to six days. The resident denied thoughts he would be better off dead or of hurting himself in any way. Record review revealed the facility developed a plan of care, dated [DATE] for the use of antidepressant medication related to depression. Interventions included administer antidepressant medications as ordered by the physician. Observe/document side effects and effectiveness; observe document/report to medical doctor (MD) as needed ongoing signs or symptoms of depression unaltered by antidepressant medications such as sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative mood or comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety and constant reassurance. Review of the comprehensive nursing note 1.1, dated [DATE] at 8:36 P.M. revealed the resident stated he was depressed and requested his medical doctor (MD) be contacted due to feelings of depression. The nursing progress note revealed a fax was sent to the MD. Review of the comprehensive nursing note 1.1 dated [DATE] at 3:24 P.M. revealed a check box was marked that the resident was depressed. However, there was no additional documentation related to the symptoms the resident was having or why the resident was depressed. In addition, there was no follow up information related to the resident ' s request for the physician to be contacted or the fax that was documented as being completed in the [DATE] 8:36 P.M. note. Review of the comprehensive nursing note 1.1 dated [DATE] at 10:49 P.M. revealed a check box was marked that the resident was depressed, but did not indicate symptoms or why the resident was depressed. Review of Resident #1's medication administration records from [DATE] through [DATE] revealed the resident received the [MEDICATION NAME] and [MEDICATION NAME] as ordered. However, there was no documentation contained on the administration records or in the nursing progress notes related to what the resident's target symptoms were or how staff were completing ongoing evaluations of the effectiveness of the current [MEDICAL CONDITION] medications on the target symptoms. Review of a nursing progress note, documented as a late entry for [DATE] at 5:40 [NAME]M. revealed LPN #80 went to Resident #1's room to administer his morning medication. The note indicated the nurse attempted to administer the medication at 5:15 [NAME]M. but noted the resident was in the bathroom with the door closed. The nurse exited the room to give the resident privacy. LPN #80 went back to attempt to administer the medication when the resident was observed lying in his back on the bathroom floor. The nurse called for staff help and LPN #75 came to the room to assist with the resident. There was no additional documentation contained in this note related to any type of assessment or the care LPN #80 provided to the resident. The next nursing progress note entry, dated [DATE] at 5:45 [NAME]M. and completed by LPN #75 revealed (LPN #80) yelled for help from Resident #1's room and staff (the note did not identify which staff) responded to the call. Upon entering the resident's room, the resident was noted to be laying on his back with blood on the floor and a pocket knife noted in the resident's right hand. Pressure was applied to all noted wounds on his arms (location of wounds were not documented nor was there any description of the actual wound(s)). The resident did not have audible or palpable vital signs, cardiopulmonary resuscitation (CPR) was initiated and 911 was called. The DON, Administrator and Physician #165 were notified. At 6:00 [NAME]M. EMS arrived, took over the code and then stopped the code. The local police arrived, an investigation was completed and the pocket knife was taken for evidence. The police notified the family and at 7:00 [NAME]M. Physician #160 arrived at the facility and ordered to release the body to the morgue. At 7:30 [NAME]M. the resident 's body left the facility. Review of the EMS Run Report, dated [DATE] revealed EMS received a call at 5:52 [NAME]M. related to Resident #1 and arrived to the facility at 6:00 [NAME]M. The chief complaint was possible suicide attempt with bilateral self-inflicted lacerations to the antecubital (triangular area on the anterior view of the elbow) area. EMS was called to the facility for a resident (Resident #1) in [MEDICAL CONDITION]. Upon arrival, nursing staff stated the resident cut himself and bled out. Initial exam showed the resident laying in a puddle of blood with two one-inch cuts in the bilateral antecubital area. Per the report, the wounds were self-inflicted with a small pocket knife that was still in the resident's right hand. The resident was mottled, the jaw was rigored and the resident's skin was cold. No pulse was felt, no spontaneous respirations and blood was congealed around the resident. Nursing staff were doing CPR. EMS told the staff to stop due to his obvious irreversible condition. The local police were contacted as well as the coroner. The local police was unable to contact the immediate family for funeral preferences. The resident was transported to the morgue. Review of the Police Officer Report for Incident ,[DATE], dated [DATE] revealed upon arrival, Officer #200 was notified by EMS Resident #1 had committed suicide. The officer saw Resident #1 in his bathroom, lying face up just outside the shower with a pocket knife in his right hand. The resident had cut the inside of both elbows and appeared to be seated in the shower but eventually fell on to the floor. The resident's nurse, (LPN #80), stated she gave him his night time medications at 10:10 P.M. and when she returned at 5:45 [NAME]M. the resident was found unresponsive. EMS contacted the coroner and were instructed to transport the body to the morgue. Review of the certificate of death, dated [DATE] revealed Resident #1's immediate cause of death was hypovolemic shock due to exsanguination from self-inflicted wounds to both antecubital veins. During the onsite survey, a request to review the facility investigation of Resident #1's death revealed the DON completed an undated typed timeline which revealed on [DATE] at about 5:51 [NAME]M. she received a phone call from LPN #75 reporting Resident #1 was noted to have cut himself and was bleeding. The timeline documented the resident had apparently killed himself. LPN #75 reported she called 911 and the nurses (no names provided) were doing CPR as there were no vital signs. The DON instructed LPN #75 to go back to the room and assist and indicated she (the DON) would be in shortly. The DON notified administration. Upon the DON ' s arrival to the facility, EMS and the local police department were already in the facility and handling the situation and had already completed their investigation. The resident had a little pocket knife found in his right hand and had cut his arms with a total of four cuts with two on each arm. The local police took the knife for evidence. The timeline revealed the DON spoke with all staff present at the time and they wrote out their statements. Staff present (names not provided) on the ,[DATE] shift said they checked on the resident throughout the night and he did come out of his room and had no complaints. The timeline revealed, during an interview with LPN #80, she stated she went to the resident's room at approximately 5:15 [NAME]M. and the resident was in the bathroom with the door closed so she respected his privacy and returned about a half hour later and found him lying in the bathroom with the bathroom door open. Bleeding was noted. She stated she initially thought he fell until she saw the pocket knife in his right hand. She yelled for help and then other staff (names not provided) came running into the room. Pressure was applied to all wounds, CPR initiated and 911 called. CPR continued until EMS arrived and EMS took over and stopped CPR. The timeline revealed this incident involving Resident #1 was not reported to the State Agency. Review of LPN #80's written statement, dated [DATE] at 7:30 [NAME]M. revealed she went into Resident #1's room around 5:15 [NAME]M. and noted the resident was in the bathroom. The statement revealed she left in order to give the resident privacy. The statement indicated the nurse went back into the resident's room at 5:45 [NAME]M. to give him his medication and noted the resident was lying on the bathroom floor with blood all around him. The resident did not have a pulse and it was noted he was a full code (wanted CPR in the event his heart stopped, or he stopped breathing) and stated she started CPR with the assistance of LPN #75. Review of STNA #92 and #100 written statements, dated [DATE] revealed staff checked on the resident multiple times throughout the night and he did not act out of the ordinary. Neither statement provided any information as to the time these STNA's had last seen Resident #1 prior to the resident being found on the bathroom floor without vital signs. Review of LPN #78's written statement, dated [DATE] revealed she had seen Resident #1 yesterday evening taking his medications that were given to him by the nurse before bedtime. The statement indicated the resident was up walking and in no distress. There was no additional information contained on the written statement. On [DATE] at 5:37 [NAME]M. interview with LPN #78 revealed she had worked during the night shift and was on duty at the time Resident #1 was found unresponsive but was not his assigned nurse. During the interview, LPN #78 stated she heard LPN #80 call for help and responded to the call, but did not provide any type of care or assist in the care of Resident #1 on the morning of [DATE]. The LPN stated she took emergency equipment to the room, made copies, was aware LPN #75 had called 911 and watched for EMS to arrive. The LPN stated she had been told the resident had used a pocket knife to harm himself but did not see the knife. On [DATE] at 8:25 [NAME]M. telephone interview with STNA #100 revealed she was not the STNA assigned to Resident #1 during the night shift on [DATE] into [DATE] but did work with the STNA assigned to him, STNA #92. STNA #100 stated the STNA on night shift typically worked together and she stated she had last seen Resident #1 between 4:00 [NAME]M. and 4:15 [NAME]M. at which time he was resting quietly in his bed with his eyes closed. On [DATE] at 9:36 [NAME]M. telephone interview with Psychiatrist #165 revealed he had known Resident #1 for a couple of months and had been his psychiatrist in the hospital for two psychiatric admissions for depression and suicidal ideation. Further interview with the psychiatrist revealed when he saw the resident on [DATE] in the facility, the resident did not display signs of increased depression during his evaluation and he felt the resident had responded well to the medications. In regards to the safety plan identified in the PASRR, the psychiatrist revealed supervision levels in a safety plan varied depending on each case but he described Resident #1 as being lonely and stated he did not figure the resident needed direct supervision as he had in the hospital with every 15-minute checks. Further interview revealed his expectation would be to receive notification if the resident complained of increased depression. Psychiatrist #165 stated the facility could notify him, CNP #170 or Physician #160 of concerns with depression and he denied any notification from staff of Resident #1 having any medication concerns or complaints of depression while in the facility. On [DATE] at 9:49 [NAME]M. telephone interview with STNA #92 revealed she was assigned to care for Resident #1 during the night shift which began on [DATE] at 6:00 P.M. (through [DATE] at 6:00 [NAME]M). During the interview, STNA #92 revealed the resident was up most of the night and was watching TV at 3:00 [NAME]M. and 4:30 [NAME]M. STNA #92 stated she asked the resident if he needed anything at 4:30 [NAME]M. and he declined. Further interview with STNA #92 revealed the resident had depression and about a week before the incident (actual date not provided) he received his night time medication around 7:30 P.M. and at 9:30 P.M. he asked for more medication because he said the first dose hadn ' t worked. The STNA was unsure of who the nurse was that worked that night. STNA #92 denied knowledge of the resident having a knife in his room, but felt the facility should have paid more attention to the resident since he had a history of [REDACTED]. STNA #92 stated the resident did not have any interventions for a safety plan listed in his plan of care related to depression and stated it would have been helpful to be able to have those interventions for staff to review. On [DATE] at 10:23 [NAME]M. telephone interview with LPN #80 revealed she was the nurse assigned to Resident #1 on [DATE] when the incident had occurred. The LPN stated she had entered the resident's room at approximately 5:15 [NAME]M. to give him his prescribed [MEDICATION NAME] but the resident was in the bathroom. The LPN stated she knocked on the bathroom door, but the resident did not respond. LPN #80 denied this being unusual as she stated the resident was hard of hearing. LPN #80 left the room and planned to return after the resident was finished in the bathroom. At 5:45 [NAME]M. LPN #80 returned to Resident #1's room and the bathroom door was open. At this time, LPN #80 stated she found Resident #1 laying on the bathroom floor with a halo of blood around his head. LPN #80 went to yell for help and LPN #75 responded first followed by unidentified STNA staff. She stated as soon as th

Based on medical record review, staff interview, physician interview and review of a facility policy, the facility failed to thoroughly assess, notify the physician and seek medical attention timely for one resident (Resident #37) who experienced a significant change in condition. This resulted in Immediate Jeopardy when facility staff failed to provide emergent medical intervention for Resident #37 who began experiencing respiratory distress evidenced by audible gurgling lung sounds and coughing. Resident #37 was later found without a pulse and respirations, and was pronounced dead at the facility. This affected one of seven residents reviewed for a change in condition. The facility identified no other residents who expired at the facility, over the past three months, who were not receiving Hospice services. The facility census was 38. Harm occurred when Resident #37 experienced audible gurgling lung sounds and coughing and went into respiratory distress. Resident #37 was found without a pulse and respirations and was pronounced dead at the facility. On [DATE] at 2:39 P.M., the Administrator, Director of Nursing (DON) and facility owner were notified Immediate Jeopardy began on [DATE] at 4:47 P.M., when nursing staff were notified by family, of a change in condition for Resident #37 who had audible gurgling sounds. Licensed Practical Nurses (LPNs) #10 and #9 looked at the resident but failed to auscultate lung sounds, obtain a blood pressure, heart rate and respiratory rate and did not check a blood oxygen level even though that was ordered to be done every shift. The attending physician was notified, and a chest X-ray (CXR) was ordered and obtained on [DATE] at 5:20 P.M. On [DATE], at 10:25 P.M., LPN #11 received faxed results of the CXR indicating Resident #37 had right parahilar infiltrates that were indicative of pneumonia. LPN #11, who was assigned to Resident #37, immediately paged the attending physician with no return call. At 10:27 P.M., LPN #11 faxed the CXR results to the physician ' s office. On [DATE] at 3:34 A.M. and again at 5:05 A.M., LPN #11 paged the attending physician with no return call. On [DATE] at 6:30 A.M., LPN #11 reported to the oncoming nurse, LPN #10, she had been unable to reach the attending physician to notify him of the abnormal CXR results for Resident #37. LPN #11 faxed the CXR results again to the physician ' s office. LPN #10 attempted to contact the attending physician ' s office and received a message to try again later. LPN #10 was going to check on Resident #37 but proceeded to begin medication pass on another hall. On [DATE] at approximately 7:45 A.M., State tested Nurse Aide (STNA) #20 reported to LPN #10 that Resident #37 was not breathing and his body was cold to touch. LPN #10 immediately assessed Resident #37 and found the absence of pulse, respirations and blood pressure. Resident #37 was pronounced dead at the facility. Resident #37 had a physician ordered Do Not Resuscitate on file. Immediate jeopardy was removed on [DATE] at 9:15 A.M., when the facility implemented the following corrective action: · On [DATE] at 4:30 P.M., the DON posted a note at the nurses' station indicating the Medical Director (MD#40) and the DON must be contacted if the primary physician was unavailable or not returning calls, to get orders as needed. This note was located by the physician contact numbers. The posted note also instructed the nurses to send the resident to the emergency room without an order as a nursing measure to ensure immediate care. At 4:40 P.M., the note was observed posted at the nurse ' s station by the physician ' s phone numbers as indicated by the DON. · On [DATE] at 6:00 P.M., all RNs, including RN #30 and RN #31 and LPNs #9, #10, #11, #12, #13, #14, #15 attended a mandatory in-service given by the DON at the facility. The agenda included the following: the proper way to complete a full assessment including vital signs and auscultation of lungs, observation of skin color and character of respirations, appropriate interventions, physician notification, obtaining emergent care and transfer of the resident to the hospital without an order as a nursing measure if necessary, proper documentation, follow up notification of the attending of abnormal diagnostic findings and what to do if unable to reach the attending physician. · On [DATE] at 9:15 A.M., the DON completed faxing and mailing of letters to all 13 attending physicians who currently had residents under their care at the facility. The letters notified the physicians of an urgent issue related to difficulty for nurses to contact and receive a response from them, especially in emergency cases. The physicians were urged to cooperate by responding to calls as soon as possible and contact the DON with any questions or concerns. Additionally, both current Medical Directors were faxed and mailed similar letters of notification of difficulty contacting and receiving responses from attending physicians. The Medical Directors were urged to intervene and when appropriate provide orders in the event the attending physician could not be reached. · On [DATE] at 9:35 A.M., phone interview with MD #40 revealed he had been made aware of the issue with nurses having difficulty contacting and getting a response from some attending physicians. MD #40 explained it was his responsibility to address any concerns with attending physicians. He indicated he had been available in the past and would continue to do so as needed. The facility had current and accurate contact information for MD#40. MD #40 and/or his associate MD #41 were available 24 hours a day, seven days a week for any concerns. MD#40 indicated nurses could and should notify them in the event an attending physician could not be reached or did not respond. MD #40 indicated he felt the issue with Resident #37 was that the nurse did not follow protocol, as she did not attempt to contact either Medical Director. MD #40 added that he had been on call on [DATE] through [DATE] and had received several calls from his answering service; none however, had been from the facility. On his part, he would speak with Attending Physician #50 to reinforce the need to be available and respond to calls timely. · On [DATE] from 10:45 A.M. to 11:15 A.M., interview with LPNs #10, #14 and #15 and RN #30 and RN #31 revealed they attended the mandatory in-service on [DATE] at 6:00 P.M. All nurses were knowledgeable on how perform a full assessment for a resident experiencing a change in condition including obtaining a temperature, heart rate, respiratory rate, blood pressure, auscultation of the lungs and checking the blood oxygen level. The nurses indicated they would report all findings to the attending physician and notify them of any laboratory, X-ray or other findings as ordered by the physician. The nurses were all familiar with the location of contact information for the attending physicians, both Medical Directors and the DON. The nurses indicated the DON would be notified of the resident ' s status. If they are unable to reach the attending physician, the nurses indicated they would contact the Medical Director. The nurses indicated if necessary they would transfer the resident to the hospital without an order for [REDACTED]. · On [DATE] at 11:30 A.M., interview with LPN #11 confirmed she attended the mandatory in-service, received education and was knowledgeable on assessment of a resident with a change in condition and the protocol to ensure physician notification. · On [DATE] at 11:45 A.M., phone interview with Resident #37 ' s Attending Physician (AP) #50 revealed he was notified on [DATE], Resident #37 was having symptoms of respiratory distress and he ordered a CXR. As of 7:00 P.M. that day his associate was on call. AP #50 indicated the facility had all the contact numbers and there was no reason they should not have been able to get in touch with his associate on [DATE]. AP #50 had taken action to verify the facility had the correct contact information to reach him during and after office hours. · On [DATE] at 2:35 P.M., the DON initiated an audit for three randomly chosen residents (Residents #52, #49 and #17) for any significant change in condition, proper assessment and documentation, notification and response of attending physician and notification of the DON if unable to reach the attending physician. · On [DATE] at 9:00 A.M., the DON provided a list of verified contact numbers to be used during and after office hours for both Medical Directors and all current attending physicians. · The DON or her designee will randomly monitor three residents per week for the next 90 days and one resident per week thereafter until the issue is resolved. The residents will be reviewed to determine the following: 1. Did they have a significant change in condition? 2. If yes, was the resident properly assessed for the change in condition and properly documented? 3. Did the resident ' s Attending Physician need to be notified and was the nurse able to receive return communication in a timely manner? 4. If unable to contact the Attending Physician timely, did the nurse contact the DON and was the DON able to achieve a satisfactory resolution? Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan to ensure on-going compliance. Findings include: Review of the closed record for Resident #37 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] Resident #37 was sent to the hospital for evaluation of change in mental status and readmitted on [DATE] following treatment for [REDACTED]. Review of a physician ' s order, dated [DATE], revealed Resident #37 ' s code status was changed from full code to Do Not Resuscitate Comfort Care. There was a signed Do Not Resuscitate Comfort Care Protocol (DNRCC) form in place which indicated it was effective as of [DATE]. Review of physician ' s orders dated [DATE] indicated an order to check the blood oxygen saturation level every shift (6:00 A.M. to 8:00 P.M. and 8:00 P.M. to 6:00 A.M.) and order to administer [MEDICATION NAME]/[MEDICATION NAME] 0XXX,[DATE].5 milligrams via aerosol inhalation (a respiratory treatment) four times a day. Review of a physician ' s order dated [DATE] revealed continuous oxygen therapy was discontinued and Resident #37 was ordered oxygen at three liters per minute by nasal cannula as needed and may titrate to keep oxygen saturation level greater than 92%. Review of the Medication Administration Record [REDACTED]. There were no initialed blocks to indicate if Resident #37 had used oxygen. Further review of the MAR for May, 2016 revealed the blood oxygen saturation level was not recorded to indicate it was checked on [DATE], [DATE] or [DATE]. There was no evidence found the [MEDICATION NAME]/[MEDICATION NAME] 0XXX,[DATE].5 milligrams via aerosol inhalation which was due to be given on [DATE] at 1:00 A.M., had been given to Resident #37. Review of nurses notes revealed on [DATE] at 4:47 P.M., LPN #10 documented Resident #37 was experiencing gurgling sounds in his chest. Family members were present and stated their concern. AP #50 was notified and ordered a CXR which was completed at 5:20 P.M. On [DATE] at 10:25 P.M., LPN #11 documented the facility received a fax stating the CXR showed the resident had a right parahilar infiltrate, likely representing pneumonia. AP #50 was paged immediately to get an order, but no return call was received. On [DATE] at 10:27 P.M., LPN #11 documented the doctor never returned the page, so LPN #11 had AP #50 paged again and faxed the CXR results to the doctor ' s office. LPN #11 documented they were waiting for a return call. On [DATE] at 3:34 A.M., LPN #11 documented there was no return call received from AP #50 and he was paged again. On [DATE] at 5:05 A.M., LPN #11 documented AP #50 was paged again regarding Resident #37 ' s CXR results and the facility was awaiting a return call. On [DATE] at 6:30 A.M.,LPN #11 reported to the oncoming nurse, LPN #10, that she was unable to reach AP #50 and the CXR results were re-faxed to AP #50 ' s office again. On [DATE] at 7:54 A.M., RN #30 documented she was notified by LPN #10 Resident #37 was found unresponsive. Upon assessment, Resident #37 was found without any palpable pulses or breath sounds and was cold to the touch. AP #50 was paged and LPN #10 was to notify the family. On [DATE] at 10:38 A.M., RN #30, called the local hospital to have AP #50 paged to inform him of Resident #37 ' s passing. The switchboard operator stated that AP #51 was on call for AP #50 so AP #51 was paged. On [DATE] at 11:40 A.M., RN #30 documented AP #51 returned the page and was notified of Resident #37's death. On [DATE] at 12:08 P.M., a late entry for 7:45 A.M., LPN #10, documented she was passing medications to residents when STNA #20 informed her that Resident #37 was not responding and was not breathing. An assessment revealed no pulse, no blood pressure reading and no heart or lung sounds were noted. The resident ' s skin was cold. RN #30 was informed of the resident ' s change in status and verified assessment findings. The family members were notified that the resident had expired. On [DATE] at 1:15 P.M., interview with LPN #10 revealed on [DATE] Resident #37 ' s daughter and son-in-law were visiting and were concerned the resident was not himself. LPN #10 explained, she was newly hired and it was just her second day working with Resident #37. LPN #10 was not familiar with Resident #37 and asked LPN #9 to check the resident. LPN #9 told LPN #10 she agreed with the family that the resident did not seem himself. LPN #10 called the resident ' s physician (AP #50) and a CXR was ordered. LPN #10 thought she took vital signs but said she did not have the ability to log into the computer yet and none were documented. LPN #10 recalled Resident #37 had audible gurgling sounds and was coughing. LPN #10 did not apply oxygen because she did not think Resident #37 needed it. LPN #10 did not assess the resident ' s respiratory status; she did not auscultate for lung sounds with a stethoscope or check the blood oxygen level with a pulse oximeter. The CXR was completed at dinner time, since she remembered they got Resident #37 from the dining room to take the CXR. LPN #10 did not have the results of the CXR back prior to the end of the shift and leaving for the day. On [DATE] at 6:00 A.M., LPN #10 returned on the day shift and was again assigned to Resident #37. LPN #11 reported Resident #37 ' s CXR results had come back and showed pneumonia. LPN #10 tried to call AP #50 but had not been able to contact him. LPN #11 did not say anything about how Resident #37 was doing. LPN #10 proceeded to call AP #50 ' s office, but got a message to call later because all lines were busy. LPN #10 recalled it was the Monday, of the Memorial Day holiday. LPN #10 was going to check on Resident #37, but went to pass medications on the B unit first. Resident #37 was on the E unit. At about 7:45 A.M., one hour and 45 minutes after she started her shift, LPN #10 was on the E unit, just outside Resident #37 ' s room. STNA #20 came out of the resident ' s room and told LPN #10, she did not think the resident was breathing and his body felt very cold. LPN #10 went in the room to check Resident #37, which was the first time she had seen him since she started her shift, and found Resident #37 expired. LPN #10 told RN #30, who came to verify Resident #37 expired. LPN #10 explained to RN #30 she was not able to get in touch with Resident #37 ' s physician at the office number. RN #30 tried the same number and got the same message to call back later. RN #30 then called the hospital. As far as LPN #10 knew, RN #30 finally got in touch with AP #50 and notified him of the resident ' s death. LPN #10 explained the MD should be called according to policy if the AP was not available or did not respond. As far as she knew, there was no attempt made to call MD #40 with the CXR results for Resident #37. On [DATE] at 3:15 P.M., phone interview with LPN #9 revealed on [DATE], LPN#10 asked her to check Resident #37 secondary to family concerns that he was not himself. LPN #9 verified she was more familiar with Resident #37. LPN #9 did listen to Resident #37 ' s lungs. LPN #10 was not in the room at the time, but after checking on Resident #37, LPN #9 told LPN #10 she agreed with the family that the Resident was not himself. LPN #10 called AP #50. A CXR was ordered and obtained but results had not come back when they left. That was all she knew. On [DATE] at 9:10 A.M., phone interview with LPN #11 revealed she worked the night shift beginning on [DATE] at 6:00 P.M., to [DATE] at 7:00 A.M. LPN #11 verified she was assigned to Resident #37. LPN #11 verified she received the faxed CXR results that indicated the resident had pneumonia and paged AP #50 multiple times. Each time she called and told the answering service the physician had not called back, LPN #11 was told they would page him again. LPN #11 also faxed the CXR results to the office even though it was closed for the holiday weekend. LPN #11 stated she checked Resident #37 at 4:30 A.M. Resident #37 was awake and talking. LPN #11 listened to his lungs and heard wheezes but did not apply oxygen because she also checked the blood oxygen level and it was in the high 90 ' s. LPN #11 denied checking the resident ' s temperature, heart rate, respiratory rate or blood pressure. LPN #11 also said she attempted, just once, to contact MD #40 but did not receive a return call. LPN #11 verified she had not documented any assessment or attempt to page MD #40. LPN #11 had not documented the entries for attempted notification of AP #50 until directed by the DON on [DATE]. LPN #11 documented the late entries for [DATE] and [DATE] on [DATE]. On [DATE] at 11:30 A.M., follow up interview with LPN #11 revealed she attended the mandatory in-service, on [DATE] and received education. LPN #11 was knowledgeable to thorough resident assessment and the protocol to ensure physician notification. LPN #11 stated she would notify both MDs. LPN #11 added she tried to call both MDs multiple times, on [DATE] with CXR results for Resident #37. LPN #11 then recanted and stated she only called one of the MDs but could not remember which one she tried to call. Review of the facility policy and procedure titled Notification of Changes (revised [DATE]) revealed the facility will immediately notify the resident, family and attending physician of any significant change in medical status.

Based on observation, record review and interview the facility failed to ensure areas of impaired skin integrity were comprehensively assessed, interventions were ordered and implemented and treatments were completed as ordered resulting in the development of avoidable pressure ulcers. Harm resulted to Resident #20 when the resident developed facility acquired left hip trochanter, left buttock and left gluteal fold unstageable pressure ulcers (wound bed not visible due to covering of dead or nonviable tissue) and an avoidable facility acquired Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer to the right buttock. This affected one resident (Resident #20) of three resident's reviewed for quality of care and treatment. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most current annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #20 was moderately impaired for daily decision making and required extensive assistance of two for bed mobility and transfers. Review of the 06/29/16 Braden Scale for Predicting Pressure Sore Risk assessment revealed Resident #20 was assessed to be at low risk for pressure ulcers when assessed to have have no sensory impairment, rarely moist skin, was chairfast (ability to walk severely limited), had very limited mobility (makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently) and had probably inadequate nutrition (rarely eats a complete meal and generally eats only about half the food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement) and had a potential problem with friction and shear (moves feebly or requires minimum assistance). Review of the current physician's orders [REDACTED]. Record review revealed Resident #20 had an indwelling urinary catheter. Review of the facility provided literature from Facts and Comparisons 2016 indicated Chamosyn ointment was a protective barrier that prevents and helps heal skin irritations from urine, diarrhea, perspiration, wound or fistula damage/drainage, diaper rash, and feeding tube site leakage: temporarily relieves pain and itching due to minor burns, minor cuts, scrapes, insect bites, sunburn and minor skin irritations; dries oozing and weeping poison ivy, oak or [MEDICATION NAME]; relief of local discomfort, burning, and itching in the perianal area related to anorectal disorders and hemorrhoids; temporarily relief of pain; and may provide cooling sensation. Resident #20 received occupational therapy until 06/13/16 for abnormal posture. On 08/16/16 at 11:48 A.M. Resident #20 was in bed on his left side on an air mattress Select Air 7. There was no evidence of two pillows under his calves. On 08/16/16 at 12:18 P.M. Nurse Aide in Training (NAT) #2 took a lunch tray of strawberries, bologna, bread and butter, water, milk, juice and coffee into the room. On 08/16/16 at 12:34 P.M. Resident #20 refused lunch. NAT #2 took back the covers to reposition him. An undated dressing was observed on his right hip. There was a pillow behind his back, under his head and on the bed behind his calves. There were not two pillows under his calves as ordered. There was not a pillow between his knees. NAT #2 indicated she did not know he was to have two pillows under his calves. Review of 07/20/16 Weekly Skin Evaluation revealed no pressure areas and previously identified non pressure areas identified included a red excoriated scrotum and groin area and a red blanchable area to the left hip. A Skin Grid Non Pressure was initiated for excoriation and areas were identified as new skin conditions acquired 07/20/16 were a red excoriated groin, a red blanchable left trochanter hip and another unidentified area that was red and excoriated. A physician's orders [REDACTED]. Review of a 07/20/16 3:03 P.M. nurse's note indicated a new order to apply antifungal cream to scrotum and groin area twice a day and as needed. The resident's son and and pharmacy were made aware. Record review revealed there was not an order written [REDACTED]. There was no orders related to the new red area to the left hip. On 08/18/16 at 10:12 A.M. interview of the Regional Director of Nursing verified the 07/20/16 Skin Grid Non Pressure identified a red excoriated area with the absence of an area identified. Verification occurred there was not a treatment ordered for the red excoriated scrotum identified on the Weekly Skin Evaluation. Record review revealed there was not a follow up Weekly Skin Evaluation or Non Pressure Grid assessment in the computer system the week of 07/27/16. The back side of a treatment sheet indicated on 07/27/16 a red blanchable gluteal fold, right buttock and left hip were identified as well as groin and scrotum excoriation. A written notation by the Regional Director of Nursing indicated the computer system was not available. The notation indicated Chamosyn to right buttocks, fold and left hip. Will consult wound nurse practitioner if family agree. The back side of the treatment sheet revealed right buttocks and left hip were hand written in the treatment box where the Chamosyn to the coccyx twice a day treatment was located. Record review revealed there were no new physician orders [REDACTED]. There were orders for the excoriated scrotum first identified 07/20/16. There was no evidence the physician and family were notified of the additional red areas or inquires made for a wound nurse practitioner consult after the 07/27/16 skin assessment. Review of the treatment sheet revealed float heels with two pillows under calves was not completed on the 6:00 P.M.-6:00 A.M. shift 07/29/16, 07/30/16 and 07/31/16. The intervention to turn and position every two hours while in bed was completed on the 07/31/16 6:00 P.M.-6:00 A.M. shift. On 08/18/16 at 10:10 A.M. interview of the Regional Director of Nursing revealed she did not compare the areas noted on 07/27/16 to the assessment from 07/20/16 to identify if the skin had improved or declined. The Regional Director of Nursing verified there was no evidence of physician or family notification or additional orders to treat the skin impairments. The Regional Director of Nursing verified there was no evidence of a physician and/or family inquiry related to the consult of a wound nurse practitioner. Review of the 08/02/16 Skin Grid Non pressure revealed excoriation of the groin and scrotum. Review of the 08/02/16 Skin Grid Pressure revealed an area on the coccyx 0.3 centimeters (cm) by (x) 0.3 cm with a depth of 0.1 cm. The grid revealed stage was non applicable- moisture associated skin damage. A left trochanter hip ulcer measuring 3.0 cm x 1.0 cm x 0.1 cm identified as a Stage II pressure ulcer, a right buttock pressure ulcer measuring 1.0 cm x 1.0 cm x 0.1 cm identified as a Stage II, a left buttock pressure ulcer measuring 5.9 cm x 3.8 cm x 0.1 cm identified as an unstageable pressure ulcer (wound bed not visible due to covering of dead or nonviable tissue), an unstageable left gluteal fold pressure ulcer measuring 4.5 cm x 3.5 cm x 0.1 cm and a scrotum abrasion measuring 4.5 cm x 4.5 cm x 0.2 cm. There was no evidence of treatments ordered or applied to the left hip, right buttock, left buttock and left gluteal fold pressure ulcers identified on 08/02/16 until 08/03/16. Review of the Wound Management Service notes dated 08/03/16 identified a date of 07/29/16 as the date of onset for the unstageable left hip, gluteal fold and left distal buttocks pressure ulcers with 25-50% loose adherent slough, the right distal buttock Stage II pressure ulcer, coccyx moisture associated skin damage and the scrotal abrasion all with the above stated measurements. On 08/03/16 the wound nurse practitioner was consulted and orders were received to discontinue current treatment to wound areas. An air mattress and turn every two hours and check for incontinence was ordered. Clean all buttock, scrotal and left hip wounds with soap and water and then normal saline and gauze. Apply silver alginate and foam after using skin prep to the left hip, gluteal fold and left distal buttock unstageable wounds, change three times a week and as needed for loosening or drainage and check dressings for placement every shift. Apply Chamosyn ointment to scrotal excoriations and right buttock wound twice a day and as needed after incontinence episodes. There was no order written for the coccyx There was no evidence the physician was notified of the pressure ulcers until 08/03/16. A fax dated 08/03/16 notified the physician of the pressure ulcers, the family in agreement for the wound nurse practitioner consult and the air mattress order. On 08/04/16 the physician was faxed that the dietitian recommended a liquid protein supplement to promote wound healing and Pro-Stat 30 milliliters twice a day was ordered. Review of the August 2016 treatment sheet revealed the hand written right buttocks and left hip to the Chamosyn ointment treatment was not written on the August treatment sheet revealing only an order for [REDACTED]. There were no nurse notes from 08/02/16 or 08/03/16. There was no mention in the nurse notes between 07/20/16 and 08/04/16 of skin impairment. On 08/05/16 the weekly skin evaluation indicated no new skin issues. On 08/10/16 the Wound Management Service indicated the coccyx, right buttock and scrotum resolved. The gluteal fold deteriorated to 75-100% slough. The left hip and left buttock improved. There was a new suspected deep tissue injury to the right trochanter hip which measured 1.7 x 0.5 x 0. An order was added for the right hip to apply zinc oxide ointment three times a day and as needed while skin intact. Review of the August 2016 treatment sheet revealed the zinc to the right hip trochanter was not completed as ordered on [DATE] at 10:00 P.M., 08/13/16, 08/14/16 and 08/16/16 at 2:00 P.M. and 08/16/16 at 6:00 A.M. On 08/18/16 at 12:12 P.M. LPN #1 verified the zinc to the right hip was not signed off as ordered. The 08/12/16 Weekly Skin Evaluation revealed no new skin issues. The 08/17/16 Skin Grid Pressure grid revealed the right trochanter hip unstageable pressure ulcer was now identified as an intact blister measuring 5.0 cm x 4.0 cm x 0.1 cm. The right hip trochanter measured larger at 5.0 cm x 4.0 cm x 0.1 cm. The left buttock and gluteal fold showed improvement. On 08/17/16 an order was received add silver alginate to the right hip dressing and change three times a week and as needed. Discontinue zinc oxide to right hip wound and apply Chamosyn to the right buttock and coccyx twice a day and as needed for prevention. Observation on 08/18/16 at 2:45 P.M. revealed the pressure ulcer to left buttock was pink with clean edges. The left gluteal fold had white Calcium Alginate on the surface of the pressure ulcer. The ulcer was cleansed with normal saline and measured larger and deeper than the 08/17/16 measurement of 4.3 cm x 3.0 cm x 0.1 cm. The right hip dressing was not changed. On 08/18/16 at 2:50 P.M. LPN #1 indicated the left gluteal fold measurement was larger due to the nurse practitioner [MEDICATION NAME] the area on 08/17/16. On 08/18/16 at 11:28 A.M. Licensed Practical Nurse #1 (LPN) indicated she did the 07/20/16 skin assessments and went on vacation. LPN #1 indicated someone else was to take over wound care in her absence. LPN #1 indicated on 08/02/16 a State tested nurse assistant alerted her to the left gluteal fold area of Resident #20 after he was put to bed. LPN #1 revealed the 3.0 cm length measurement to the left hip pressure ulcer should have been documented 0.3 cm and the wound nurse practitioner on 08/03/16 identified the wound as unstageable not a Stage II pressure ulcer. LPN #1 indicated she used the the wound nurse practitioner measurements from 08/03/16 to complete the 08/02/16 Skin Grid Pressure Assessment and did not have measurements from when the pressure ulcers were identified on 08/02/16. LPN #1 verified there were no treatment's ordered on [DATE] and no evidence the pressure ulcers were treated when discovered on 08/02/16.

Based on observation, medical record review, review of personnel files and Fall/Accident Investigations, resident and staff interviews, review of the manufacturer ' s instructions for the use of the shower chair, review of the Med Watch FDA 3500 Report Form, review of the facility ' s policies related to Charting and Documentation, Accidents/Incidents, Investigating and Reporting, Transportation, Falls Protocol, and Fall Assessment, the facility failed to ensure appropriate and safe use of a shower chair, failed to ensure a resident had adequate supervision to prevent a fall, and failed to ensure safe transportation of a resident utilizing the facility ' s van. This resulted in Immediate Jeopardy for Resident #37 who was impaled on a shower chair and sustained severe lacerations requiring surgical intervention, Resident #42, who sustained a head laceration requiring closure during transport by the facility van, and Resident #51 who fell and experienced trauma to her head while unsupervised in the bathroom. This affected three of five residents reviewed for accidents and supervision (Residents #37, #42, and #51). On [DATE] at 11:20 A.M., Administrator #1, the Director of Nursing (DON) and Consultant Registered Nurse (CRN) #1 were notified Immediate Jeopardy began on [DATE] at approximately 9:30 A.M. when a shower chair came apart and impaled Resident #37 in the rectal and vaginal area. The shower chair was incorrectly used to move the resident approximately 14 feet from her bathroom to the recliner chair in her room. Immediate Jeopardy continued on [DATE] at 7:00 A.M. when Resident #51, who required limited assistance of one staff for transfer and mobility, was alone in the bathroom and fell face down. Resident #51 sustained a goose egg injury to her right temporal area, developed a hematoma (localized swelling filled with blood) and was transported to the hospital. State-tested Nurse Aide (STNA) #3 was in the resident ' s room, was aware the resident was accessing the bathroom alone, however STNA #3 ' s back was turned away from the resident and heard the resident fall in the bathroom. Resident #51 was transferred to the hospital where she expired at 4:30 P.M. that day. Immediate Jeopardy remained on [DATE] (time not identified), when Resident #42 returned to the facility from an outpatient treatment at a local hospital (blood transfusion) via facility van by Transporter #20 with a laceration to his head requiring three staples to close the wound. There was no evidence transport staff were educated to safely transport residents until [DATE]. The facility did not ensure transport personnel were appropriately trained prior to transporting residents. The facility also did not ensure the van was safe for resident use after the incident until [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the shower chair used for Resident #37 was removed from service. · On [DATE], all six (6) shower chairs (two bariatric, two regular and two reclining shower chairs) were inspected for safety by the DON and Maintenance Man (MM) #9. · On [DATE] at 1:00 P.M. and 2:00 P.M. nine dietary staff (DS #24, #500, #501, #502, #503, #504, #506, #507 and CDM #21) 12 STNA ' s (#2, #3 #518, #600, #605, #610, #615, #620, #625, #630, # 635, #908) one Nurse Aide in Training (NAT) #1, six Licensed Practical Nurses (LPNs) (#6, #25, #28, #30, #517, #518) five Registered Nurses (RNs) (#7, #8, #50, #516, #519) five housekeeping staff (#508, #509, #511, #910, #911) and Transporter #20 were inserviced by the DON regarding shower chair preventative maintenance The training included checking the chair wheels to ensure they locked, checking the seats to ensure stability, checking for any cracks in the piping, following the manufacturer ' s guidelines and visibly checking the shower chairs to ensure it is safe for use. · On [DATE] at 8:45 A.M. the facility's DON in-serviced Maintenance Man #9, Activities Staff #27 and Transporter #20 in regard to securing wheelchairs in the transportation van. · On [DATE], the facility contracted with a Risk Management Solutions Consultant to assist management with corrective procedures. The consultant nurse RNC #1 was present onsite [DATE], [DATE] and was to return the week of [DATE]. On [DATE] at 2:00 P.M., an in-service was completed by the DON and RNC #1 on resident supervision, limited assistance, extensive assistance, total dependence, Resident Rights and plan of care, report to STNAs from the supervising licensed nurse at the onset of the shift regarding the condition of the residents on their assignments. The inservice also included nursing review of all residents ' Activities Daily Living (ADL) and status update needs on admission/readmission and with any decline or improvement and resident needs documented on all direct care workers assignment. Twenty-three STNAs (#518, #901, #2, #645, #650, #655, #610, #605, #11, #600, #10, #670, #23, #625, #630, #675, #680, #3, #685, #635, #800 and #909 and NAT #1), five LPNs (#6, #25, #26, #28 and #518) Administrator #1, six RNs (#7, #8, #50, #516, #519 and #701) three housekeepers (#507, #508, #701), one CDM (#21), one dietitian (#515), two laundry staff (#510 and #511) , MM #9, two activity staff (#22 and #27) and three office staff (#512, #513 and #514) were inserviced. One staff member on leave, STNA #615, will be inserviced prior to working her next scheduled shift. On [DATE], Monitoring/Audit Tools were initiated by the DON to ensure compliance in regard to New Equipment Checklist, Resident Care Audit Sheets, New Equipment Preventative Maintenance, Transportation Audit Sheets, Wheelchair and Rider Securement Procedures and Checklist. Twenty-three STNA ' s (#518, #901, #2, #645, #650, #655, #610, #605, #11, #600, #10, #670, #23, #625, #630, #675, #680, #3, #685, #635, #800 and #909 and NAT #1), five LPN ' s (#25, #26, #518, #6, #28), the Administrator, six RN ' s (#7, #8, #702, #516, #50, #519, three housekeepers (#507, #508, #701), one certified dietary manager #21, one dietitian #515, two laundry staff (#510 and #511) , MM#9, two activity staff (#22 and #27) and three office staff (#512, #513 and #514) were In-serviced on the audit tools. One staff member on leave, STNA #615, will be in-serviced prior to working her next scheduled shift. · On [DATE] from 9:55 A.M through 10:15 A.M., interview with RN #7, RN #8, STNAs #10, #23 and #24, CDM #21, Activity Staff #22, and LPN #25 revealed staff were knowledgeable in regard to education provided on [DATE]. · On [DATE] at 5:30 P.M., the facility DON, in-serviced three transport drivers regarding pre-trip inspection, Transportation Policy, Off-site Incident and Accident Policy and the Off-site Incident and Accident Policy. · On [DATE] at 12:25 P.M. interview with LPN #26 revealed lack of knowledge related to the STNA plan of care sheets and the persons responsible for ensuring the STNA plan of care sheets were accurate and updated as discussed an in-service held on [DATE]. · On [DATE] from 8:30 A.M. to 9:00 A.M. interview with LPN #6 and MM #9 revealed knowledge of the newly implemented policies and procedures. · On [DATE] at 6:00 P.M., the DON held an inservice for four LPNs (#6, #25, #28 and #904), five RNs (#7, #50, #516, #519, #905) and eight STNAs (#2 #11, #518, #630, #635, #650, #655, #903) and one NAT (NAT #1) regarding the facility Incident and Accident Policy, STNA care plan, shower chair and preventative maintenance. · On [DATE] at 7:30 A.M., the DON inserviced two LPNs (#26, and #518,), five RNs (#7, #8, #519, #719, and #905), two nurse aide in training (NAT) (#670 #906) and 12 STNAs (#2, #3, #10, #23, #518, #600, #605, #610, #625, #630, #635, #670) regarding the same. · On [DATE] at 8:45 A.M. LPN #26 verbalized during interview the understanding of the STNA plan of care sheets and the nurses ' responsibility to update the sheets. · On [DATE] from 8:48 A.M. to 9:30 A.M. interview with the three facility identified transport staff (MM #9, Transporter #20 and Activities #27) identified knowledge of the transporter ' s role and responsibilities. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as not all staff have been trained and not all interventions have been in place to audit/review to ensure compliance. Findings include: 1. Review of Resident #37 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) Assessment 3.0 dated [DATE], identified the resident was assessed as cognitively intact and required extensive assistance of two staff members with bed mobility, transfers and toilet use. The resident required extensive assistance of one staff member with personal hygiene. Review of the Fall Risk assessment dated [DATE], revealed the resident scored above 10 indicating she was at a high fall risk. Review of the Plan of Care initiated [DATE], revealed the resident had an activity of daily living (ADL) self-care performance deficit related to dementia, limited range of motion (ROM), fatigue, musculoskeletal impairment, activity intolerance, limited mobility, pain, shortness of breath and impaired balance with interventions to include the resident was total dependence on staff for dressing and repositioning and turning in bed. Review of the resident ' s Fall Accident/Incident Investigation dated [DATE] revealed NAT #1 and STNA #2 showered Resident #37. During the shower, NAT #1 and STNA #2 stood up Resident #37 to cleanse her bottom due to the resident being incontinent. She then sat back down on the shower seat. After the shower, NAT #1 and STNA #2 transported the resident in the shower chair approximately 14 feet from the bathroom to the resident ' s recliner chair located by her bed. NAT #1 and STNA #2 attempted to stand the resident up from the shower chair but could not and they noticed that her leg was stuck in the opening of the front of the chair. Once the resident was out of the shower chair a large cut was observed near her rectum. Gauze and pressure were applied to the area. Review of the Nurses ' Progress Notes dated [DATE] at 9:30 A.M. revealed the resident was on the shower chair and had received a shower. When the staff members attempted to move the resident, the shower chair came apart and the resident's leg went through the gap and part of the frame of the chair was lodged near the resident ' s rectum. The resident was laid down on the floor and examined. There was an abrasion to the right groin and two skin tears at the rectum that were visible. The bleeding was controlled until the resident was transported to the hospital. The note identified Resident #37 was admitted to the hospital on [DATE] at 5:00 P.M. Review of the Hospital History and Physical completed by Physician #5 dated [DATE] revealed there was a large perianal tear that extended from the vaginal introitus (entrance that goes into a hollow canal or hollow organ) to the rectum. There was a blood clot in the vagina that was unable to be removed secondary to patient discomfort. Physician #5 was also unable to perform a rectal exam secondary to discomfort. Impression was the resident had a perineal/rectal tear status [REDACTED].#5 planned for examination under anesthesia and repair of the lacerations. On [DATE] at 2:50 P.M., Resident #37 was readmitted to the facility with a [DIAGNOSES REDACTED]. The skin assessment revealed a peri-anal hematoma and external sutures to the perineum. Review of the nursing home documentation, there were internal sutures as well. There was a small amount of brown blood draining from the rectum and gauze was applied for the drainage. On [DATE] at 7:30 P.M., according to the nursing records, the resident was oozing very large amounts of stool through the rectal wounds and vagina. Physician #4 was notified and ordered the resident sent to the emergency room (ER). On [DATE] at 1:30 A.M. the resident was admitted to the intensive care unit with a fistula (an abnormal connection between two hollow spaces) and critical blood count. A colostomy was performed on Resident #37 during the hospitalization . On [DATE] at 6:00 P.M., Resident #37 was readmitted again to the facility. Resident #37 was alert and oriented to person, place and time. According to nursing documentation, an upper abdomen colostomy was observed with a six inch round protruding stoma per nursing documentation. The resident had a fistula just above the rectum that measured 1.5 centimeters (cm) long and 1.0 cm wide with a depth of 7.0 cm and oozed brown material. The vagina also oozed brown material. On [DATE], no time listed, the resident returned from an appointment with Physician #5. Physician #5 ordered to change the colostomy every four days and as needed. Additional orders included to pack the perirectal wound with Aquacel rope (used to pack wounds that are infected or are at risk for infection) and leave access on top of the wound daily. Review of Med Watch FDA Form 3500A (a form used per the facility policy to notify the FDA of faulty equipment) dated [DATE] revealed the resident was showered using the shower chair in question. The resident ' s right leg slipped down into the front opening. The report identified the seat of the shower chair slid to the left and the black clips did not hold. The bar where the clip was to hold the seat in place was exposed. The resident slid down onto the bar and was impaled in the rectum causing extensive tearing. The resident was sent to the ER and the resident had surgery to repair the injury. On [DATE] at 11:30 A.M., interview with the DON revealed she stated she sent a copy of the FDA form and she retained a copy. Review of NAT #1 ' s and STNA #2 ' s incident statement dated [DATE] at 9:40 A.M. revealed the resident called out she was incontinent and STNA #2 and NAT #1 got her up to a shower chair. The resident was incontinent of bowel and during the shower both aides were present. The resident was cleaned up and was being transported back to her recliner when her right leg slid into the opening of the seat of the shower chair. The seat of the shower chair moved to the left. The resident ' s bottom caught on the small bar under the seat causing two tears near the rectum. The resident was moved to the floor for comfort. The resident was transported to the ER. The shower chair was immediately checked by maintenance. Observation of the Resident #37 on [DATE] at 10:23 A.M., 12:10 P.M., on [DATE] at 8:40 A.M., 9:50 A.M., and 2:30 P.M. and on [DATE] at 8:25 A.M., revealed the resident was in bed leaning to her left side with the head of her bed slightly elevated. On [DATE] at 10:23 A.M., interview with Resident #37 stated she fell through the shower chair and she told the staff many times she needed repositioned but they told her she was alright and did not reposition her. Resident #37 stated she got her leg caught in the shower chair. On [DATE] at 10:25 A.M., interview with LPN #6 revealed the shower chair cushion moved while Resident #37 was using the chair and the bar under the cushion impaled her rectal area and the resident had to have surgery. On [DATE] at 10:28 A.M. interview with the DON revealed the shower chair had a four to five inch gap in front of the shower chair which was where the resident ' s leg was caught and the metal bar impaled the resident ' s rectum. The DON stated the shower chair was immediately removed from service after the incident and staff was in-serviced on preventative shower chair maintenance. Observation of the shower chair at the time of the interview revealed a three to four inch opening on the front of the chair with a blue seat. The blue seat also had an opening which was smaller than the opening between the metal bars. The blue seat was a pliable material that looked like a toilet seat. Only two black clips were present on the apparatus to hold the seat in place. Review of the Chair Owner ' s Manual not dated, revealed the chair was for stationary use and should not be used to transport residents. There was no documentation on how to position a resident on the shower chair in the owner ' s manual. On [DATE] at 10:40 A.M. observation of the facility shower chairs currently in use with the DON revealed there were two traditional shower chairs, two bariatric shower chairs and two reclining shower chairs. The DON verified at that time, no additional shower chairs like the one used for Resident #37 was present for use in the facility. On [DATE] at 11:24 A.M. interview with RN #7 revealed she was the nurse working when the incident occurred. RN #7 stated one of the STNAs, who she could not identify, informed her they needed her now because they had an emergency. RN #7 stated the aides tried to stand Resident #37 up from the shower chair and they noticed the resident wasn ' t standing. The aides looked down and saw the cushion moving and the resident ' s right leg was stuck in the gap in the front of the chair. At that point they got the nurse. RN #7 stated she went into the resident ' s room and knew it was worse than what had been described to her. The right bar that the resident should have been seated on was now over her lower right abdomen and right hip area. The resident was leaning to the right side in the chair. RN #7 stated the resident was quiet so they had no idea she was injured. The cushion was flapping around behind her so they took it off. RN #7 requested additional assistance from RN #8. RN #7, RN #8, STNA #2 and NAT #1 placed Resident #37 on her abdomen on a bath blanket on the floor to maneuver the chair off of the resident. The staff discovered two tears around the resident ' s rectum; one toward the top and one on the side of her rectum. According to RN #7, six staff (RN #7, RN #8, DON, LPN #200, NAT #1 and STNA #2) lifted Resident #37 onto the bed using the bath blanket. RN #7 identified there were tears at the resident ' s rectum that were bleeding a small amount. Physician #29 and the resident ' s family were notified and the resident was transferred to the hospital. On [DATE] at 11:58 A.M., interview with NAT #1 revealed she and STNA #2 showered Resident #37 on [DATE]. They used the shower chair with the blue seat. Once out of the shower, the two staff dried the resident off and wheeled her to the recliner chair in her room from the bathroom in her room. The recliner was on the other side of the resident ' s bed. The two staff tried to stand Resident #37, but her leg was caught in the opening of the shower chair. Further interview revealed NAT #1 did not know the seat came up. Resident #37 ' s leg was lodged in the gap in the front of the chair. NAT #1 stated the resident did not say anything about pain until they tried to move her and then she said her leg was stuck and it was hurting. NAT #1 denied the resident identified she was sliding or asked to be pulled up in the chair. NAT #1 was unable to recall how the staff was able to maneuver the resident from the chair. On [DATE] at 12:10 P.M., observation of Resident #37 ' s room revealed the resident ' s bed was between the bath/shower room and the resident ' s recliner. The distance was approximately 14 feet. On [DATE] at 12:20 P.M., observation of the shower chair revealed one black clip on each bar in the front of the chair were attached to the shower chair seat. No fastener was observed on the back of the seat. This finding was verified with the DON at that time. On [DATE] at 1:00 P.M. interview with the DON verified the bathroom was about 14 feet from the recliner and the staff used the shower chair to transport the resident from the shower to her recliner chair on [DATE]. The DON verified the Shower Chair ' s Owner ' s Manual directed to not use the chair to transport. The DON verified staff was not educated regarding the use of the shower chair when it was put into use in [DATE]. On [DATE] at 9:40 A.M., interview with the Administrator revealed the chair was not a sturdy chair in regard to the seat of the shower chair not being secure. The Administrator placed his fist in the gap of the seat cushion/seat and rotated his wrist causing the back of the seat to lift from the chair. He also stated light pressure applied to the seat caused the seat to move. The Administrator stated the chair was not built well and has stored the chair in his office to prevent staff from using the chair. He verified the seat was not secured in any way at the back of the chair. On [DATE] at 9:50 A.M., MM #9, the DON and the surveyor measured the distance of 14 feet from the resident ' s bathroom doorway to her recliner. The DON verified this was the same set up of the resident ' s room as on the day of the incident. On [DATE] at 12:19 P.M., interview with STNA #2 revealed she assisted NAT #1 with Resident #37 ' s shower on [DATE]. The two staff placed the resident on the shower chair and showered her. She was incontinent of stool so they stood her up to clean her buttocks. When the resident was cleaned, the staff sat her back onto the wheeled shower chair with the blue seat, which was the new chair. The staff transported the resident from her bathroom to her recliner chair in her room using the wheeled shower chair. When they attempted to stand the resident, they discovered she was unable to stand because her right leg was caught in the gap in the front of the chair. The two staff stayed with the resident, holding her in the chair to prevent her from falling further into the opening of the center of the seat, rang the call light and began yelling for the nurse. RN #7 came in and they determined she needed laid on the floor to help remove her from the chair. STNA #2 stated the right bar was now at the resident's right lower abdomen/hip area. The resident was placed on a bath blanket on her right side on the floor. The chair was removed. The resident did not complain. STNA #2 stated the left bar of the chair had feces on it and ' we knew she was injured from the chair. We placed her in bed so the nurse could check her ' . On [DATE] at 1:10 P.M, interview with RN #8 revealed she assisted with Resident #37 on [DATE]. The resident was on the floor and the chair was removed when RN #8 entered the room. She was informed of the abrasion at the top of the resident ' s rectum with a tear on either side. The resident was lying on her abdomen on the floor. Staff assisted her to bed and RN #8 placed a 4x4 gauze over the area that was bleeding. Further interview revealed the resident's rectum was impaled by the shower chair. When she returned from her hospital stay, the tears were sutured at the rectum and she also had sutures inside of her vagina. RN #8 identified the resident was currently receiving packing in the fistula to the side of her rectum. On [DATE] at 2:20 P.M., RN #8 was observed completing Resident #37 ' s treatment. The observation revealed a dime sized beefy red area above her rectum. RN #8 shared the fistula was seven centimeters (cm) into the area near the rectum and described the location as 11 o'clock in regard to the rectum. The area was packed with Aquacel rope. On [DATE] at 9:50 A.M., interview with the DON verified the Shower Chair Owner ' s Manual directed to not transport the resident in the shower chair and the shower chair was to remain stationary. Further interview verified NAT #1 and STNA #2 used the shower chair to transport Resident #37 from the shower in her room to the recliner in her room and the distance was measured to be approximately 14 feet. On [DATE] at 2:45 P.M. interview with Medical Assistant #10 from Physician #5 ' s office revealed the resident was impaled in the rectal and vaginal area per the physician's notes and the area impaled required surgical repair. The injuries were extensive and the laceration was of the perineum including the muscle. On [DATE] at 10:59 A.M. interview with NAT #1 revealed the resident leans to the side and would not be able to recover to a seated position without intervention from staff. Further interview revealed she was unsure how and who selected the shower chair that was used [DATE]. NAT #1 stated the resident should have been in a reclining shower chair due to her poor balance when seated. On [DATE] at 11:49 A.M. interview with the DON revealed the resident required repositioning in bed that morning due to leaning to the left side. 2. Review of Resident #51 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment (MDS) 3.0 dated [DATE], revealed the resident did not have intact cognition and was limited assistance of one staff member with transfers and bed mobility. Review of the Fall Risk assessment dated [DATE] revealed the resident was identified as a high risk for falls. Review of a facility investigation dated [DATE] at 5:45 P.M. identified Resident #51 was moving her wheelchair across the room by herself, lost her balance and fell to the floor on her left side. No injuries were noted. A bed alarm was implemented at that time. Review of the Fall Accident/Incident Investigation dated [DATE] revealed at 7:00 A.M., Resident #51 was found by STNA #3 lying face down in the shower area of her bathroom. STNA #3 reported the resident requested to go to the bathroom and told the STNA I can do it myself. STNA #3 was present in the room when Resident #51 fell but did not assist the resident in the transfer to the bathroom. Resident #51 was assessed by LPN #30 as having an abrasion to her right lower back and a goose-egg sized knot to her right temple. The resident complained of pain from her back and her head and was medicated with an ' as needed ' pain medication Tylenol 650 milligrams (mg). Review of the medical record reflected the physician was notified of the event at 7:15 A.M and ordered the resident transferred to the hospital for evaluation. Review of the Nurses ' Progress Notes dated [DATE] at 7:30 A.M., revealed the alert and oriented resident was transferred to the hospital and was responding to stimuli upon transfer. The hospital staff notified the facility the resident expired at 4:30 P.M. on [DATE]. Review of the Hospital record dated [DATE] revealed the resident had computerized tomography (CT) scan of her head with contrast and it did not reveal any brain bleeding. The report identified the resident had a probable embolic stroke. Review of the resident ' s death certificate dated [DATE] revealed cause of death was cerebral vascular accident, [DIAGNOSES REDACTED]and flutter, hypertension and [DIAGNOSES REDACTED]. On [DATE] at 10:00 A.M., the DON verified there was no evidence any investigation was completed with regard to lack of assistance and supervision provided to Resident #51 nor was a Self-Reported Incident (SRI) completed and submitted to the State Agency. The DON verified no interventions were implemented to prevent a similar incident from occurring in the future. The DON stated STNA #3 was educated on proper ways to handle a situation when a cognitively impaired resident does not want staff assistance with safety concerns. The DON also verified residents identified as a fall risk should not be left unsupervised when ambulating or requiring staff assistance. On [DATE] at 12:11 P.M. interview with STNA #3 revealed Resident #51 put her call light on and the STNA helped her sit on the edge of the bed. The resident insisted she could walk to the bathroom and told the STNA to get her clothes. The STNA stated she went to get the resident's clothes from her closet and the resident was seated on the edge of her bed. While the STNA was getting the clothes, she stated she heard the resident getting up and going into the bathroom and then heard the resident fall. The STNA stated she found the resident partially in the shower and partially in the bathroom. The STNA stated she notified the nurse who was in the hallway. On [DATE], review of STNA #3 ' s statement revealed STNA #3 was assigned to provide care for Resident #51 on [DATE]. STNA #3 answered the call light and helped the resident to the side of the bed. Resident #51 was wet and the bed alarm had been unplugged by the resident. STNA #3 stood the resident up and the resident stated I can do it myself. The resident told STNA #3 to get her some dry clothes. STNA #3 was getting clothing for Resident #51 when she heard the resident fall in the bathroom. STNA #3 found Resident #51 lying face down halfway into the shower stall. STNA #3 notified the nurse. The resident was awake at that time. Review of the facility ' s Fall Risk assessment dated [DATE] revealed all residents were assessed for fall risk upon admission, quarterly and annually. If the resident was identified as a fall risk his/her environment would be assessed for hazards that may increase the resident ' s chance of falling or causing injury. The care plan was to be updated with the plan that was being used to prevent falls. On [DATE] at 8:45 A.M., interviews with STNA #10 and STNA #11 revealed residents identified as a high risk for falls were not to be ambulating unassisted or unsupervised. Review of the facility ' s Fall Protocol dated [DATE] revealed residents with a history of frequent falls or have a high risk of falling would be identified in an effort to prevent falls. 3. Review of Resident #42 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. Review of the Admission Minimum Data Set Assessment (MDS) 3.0 dated [DATE] revealed the resident was cognitively intact and required limited assistance of two with bed mobility and transfers. The resident required extensive assistance of one staff member with dressing and toilet use. Review of the fall risk assessment dated [DATE] revealed Resident #42 was a high fall risk with a score greater than 10. Review of an Incident Report dated [DATE], no time indicated, revealed Resident #42 was being transported to the hospital via the facility ' s van for an outpatient procedure, when the wheelchair tipped backwards and the resident hit his head. The resident sustained [REDACTED]. There was no evidence on the incident report the cause of the incident was investigated. On [DATE] at 2:30 P.M. interview with Resident #42 revealed he hit his head during transport to the hospital. The resident stated his wheelchair tipped back and he landed on the van floor hitting his head. The resident stated a physician repaired his injury while he remained in the facility van. On [DATE] at 3:31 P.M., interview with Transporter #20 revealed she was driving the facility van up a steep hill to the hospital. Transporter #20 stated she had secured Resident #42 in the van however, the wheelchair tipped and the resident struck his head on the van lift. Transporter #20 called the DON and was instructed to transport the resident to the hospital. Transporter #20 stated she was trained as to how to transport residents. Review of Maintenance Man (MM) #9 and Transporter #20 employee files revealed no evidence these employees had received any education regarding transporting residents until after the incident of [DATE]. On [DATE] at 3:45 P.M. observation of the facility van revealed the tethering straps were secured to the floor and a lap/shoulder belt was present. At the time of the observation, interview with Administrator #15 revealed the va