Every finding on record at Virginia Beach Healthcare and Rehab Center

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to protect the residents right to be free from abuse and neglect by facility staff for one resident (R4) in a survey sample of five Residents. This deficient practice resulted in the identification of Immediate Jeopardy (IJ), which constituted substandard quality of care. Following the verification of removal of the IJ, the scope and severity was lowered to a level three isolated. The findings included: For R4 the facility staff turned call light off from nurses' station, refused to come into the room, neglected to attend to resident needs and left resident in an unsafe position in the bed, which resulted in psychosocial harm for R4.R4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, due to gunshot wound to neck, epilepsy, neuromuscular disfunction of bladder, presence of suprapubic catheter, autonomic dysreflexia and PTSD (post-traumatic stress disorder). R4's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/20/26 coded R4 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15, indicating no cognitive impairment. R4 was also coded as being totally dependent on staff for all aspects of care due to her quadriplegia. She can utilize a motorized wheelchair with mouth control (Also known as Sip and Puff Wheelchair- using mouth to control wheelchair with puff or sip of air). On 5/6/26 at approximately 3:00 p.m. R4 was escorted to the conference room where she requested to speak to the survey team. R4 stated that she had been in the facility for roughly two months and had been experiencing problems on the night shift. R4 stated that on the night shift she is ignored, her call bell is turned off before anyone comes into her room, she stated the staff stand outside of her room and talk about her loudly enough for her to hear. She stated she has been called Extra and that staff have stated they won't take care of her or need two people to go into her room. R4 stated that on 4/27/26, very early in the morning, before day shift arrived, it got so bad she called the non-emergency police number to get an officer to come and get her some help. She stated that the police responded to the building and came to investigate why she was calling for help from the facility. R4 proceeded to pull up a picture from 4/27/26 and stated that she made the day shift certified nursing assistant (CNA) take a picture of how she was found before moving her. The picture showed R4 with legs hanging over the side of the bed and torso on the bed. R4 stated this is how they left me in the bed. R4 proceeded to show the survey team three videos she had of staff turning off the call light without attending to resident needs, The video showed R4 recording herself hitting the call light for assistance, she could not turn around to see the call light box but you can clearly see in the video the box over the bed lit up red when the call light was pressed by R4. After approximately 15 minutes the light on the box went off and you could hear the R4 say The ringing has stopped, they turned the light off from the nurses station.In the second video nursing staff can be seen coming into the room turning off the call light telling R4 that someone will be in to take care of her, yet the video continued to show no one coming in for another 15-20 minutes. When staff arrived, she told R4 that she will not come in the room alone, she refused to provide care and then left. R4 engaged the light again and the staff member came in turned off the light and refusesd to provide care. The resident can be heard asking If you don't want to take care of me who will? I still need care during the night. The last video shows R4 phoning the police to get some assistance. The police arrive and make staff leave the room because they are being argumentative and rude to R4. The police took a report and gave the resident a report number. R4 stated that she informed the Director of Nursing (DON) and the Unit Manager on the morning of 4/27/26 after she had called the police. R4 is a former victim of domestic violence who is unable to tend to any of her own basic needs and must rely on her care givers for all aspects of care. R4 stated I am now afraid to have them shut my door; they won't hear me if I scream. R4 stated I have PTSD and this is causing me a lot of fear and anxiety. R4 stated that she felt she could not trust the people that were supposed to look out for her. R4 was asked if she has counseling or psychiatry services and she stated that she would love to have some consistent therapy. R4 stated that she saw someone one time when she first arrived but not since then. This suggests that the facility staff were made aware of the abuse / neglect alleged by R4 on 4/27/26.A review of the clinical record revealed the admission Trauma Informed Screening was not completed until 5/6/26 at 4:44 p.m. (this document should be completed on or as soon after the admission as it is part of the admission Assessment Tool.) Further review of the clinical record revealed that there were no progress notes from psychiatric services.On the afternoon of 5/6/26 R4 showed the videos to Employee C, the Corporate Nurse. On 5/7/26 at approximately 9:00 a.m. an interview was conducted with CNA who wished to remain anonymous, the CNA confirmed that she did take the picture of the R4 hanging out of the bed but she stated I tried to put her in bed first but she insisted I take the picture so that she would have proof of how she had been treated.On 5/7/26 at approximately 12:00 PM an interview was conducted with the DON who stated that she was not aware of the alleged abuse and neglect of R4. The DON was asked if she was aware that the police were called and why on 4/27/26 and she stated that she was aware. The DON was asked if she was aware of who called the police she stated that she was aware. The DON admitted she was aware that an allegation of neglect was made by R4 on 4/27/26.A review of the Policy for Abuse Neglect and Misappropriation read as follows: Policy 701 - Effective 10/17/23. There is zero tolerance for mistreatment, abuse. neglect, misappropriation of property or any crime against a patient of the Health and Rehabilitation Center.3. All employees are responsible for immediately ( but not later than 2 hours if the allegation involves abuse or results in serious bodily injury, not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury) reporting to the Administrator, or in their absence the Director of Nursing or their direct supervisor any and all suspected or witnessed incidents of abuse, neglect, theft, exploitation, and or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient .According to the facility Policy titled, 703- Reporting Requirements Effective Date 2/5/23, it read in part, .1 Immediately upon notification of any alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours if the allegation involves abuse or results in serious bodily injury, not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily harm . 2 The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include but not be limited to, collecting the evidence, interviewing alleged victims, and witnesses, and involving other appropriate agents or authorities to assist in the process and determination.On 5/6/26 at 6:00 p.m., after consulting with the state agency supervisory team, immediate jeopardy was identified to have began 4/27/26. The facility was unable to provide an acceptable removal plan and R4 was assigned a 1:1 CNA to provide care overnight. The facility submitted the Immediacy Removal plan on the morning of 5/7/26, which was accepted. The removal plan read, 1. Immediate Corrective Actions: The facility immediately took the following actions to remove the Immediacy:Staff Education: All staff will be educated on facility abuse policies prior to next shift in addition to education on answering call lights and providing required services, promptly.Medical Oversight: The attending physician and Medical Director were notified of the deficiencies.Resident Safety: Resident #4 was offered a room change and declined. Resident #4 was interviewed to determine preferred staff that will deliver her care.Resident will be offered Psychiatric evaluation and treatmentFacility reportable incident has been submitted to all appropriate State agencies to include OLC , regional ombudsman and office of Adult protective services .Interviews related to abuse and neglect will be conducted on all cognitively intact residents with BIMS scores greater than 12.Skin assessments will be completed on all cognitively impaired residents with BIMS scores less than 13.Staff members involved in the investigation will be suspended until the investigation is completed.Resident will be provided 1:1 monitoring.Plan Completion will be on 5/7/2026 at 1:00 PM.The Survey Team verified education by interviewing staff and questioning the staff about the education they received. Staff were able to answer questions and converse appropriately about the topic of abuse and neglect. The Survey Team went to the resident's room and found that she did have a 1:1 sitter throughout the night. The survey team verified that the facility did indeed offer the R4 a room change and psychological support services which were scheduled for that day. R4 was interviewed and stated that the facility did offer and she did give names of her preferred staff for care. Skin assessments reviewed and residents were interviewed and no further incidents of abuse and neglect were reported.All involved staff were marked as suspended pending investigation.After verification of the plan of immediate jeopardy removal and consultation with state agency supervisory staff, the immediate jeopardy was removed on 5/7/26 as of 1:00 p.m. at which time the facility administration was notified. Following the removal of the immediate jeopardy status, this deficiency was cited at level 3, isolated (harm).

Based on interview, clinical record review and facility documentation, the facility staff failed to implement their abuse/neglect policy and take measures to protect a resident during an allegation of abuse/neglect, failed to report the allegation and failed to conduct a thorough investigation for one resident (Resident #4-R4) in a survey sample of five residents. This failure resulted in R4 sustaining psychosocial harm and the identification of immediate jeopardy (IJ) and resulted in substandard quality of care. The findings included:For R4 the facility staff failed to implement their abuse policy and take measures to protect the resident from alleged perpertrators, failed to investigate an incident of abuse and neglect, and failed to report the allegation of abuse and neglect, which resulted in psychosocial harm leaving R4 feeling anxious, and fearful of having her needs met, fearful of not being heard in the event of a medical emergency and refusing to allow staff to close the door at night.R4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to quadriplegia, due to gunshot wound to neck, epilepsy, neuromuscular disfunction of bladder, presence of suprapubic catheter, autonomic dysreflexia and PTSD (post-traumatic stress disorder). R4's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/20/26 coded R4 as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15, indicating no cognitive impairment. R4 was also coded as being totally dependent on staff for all aspects of care due to her quadriplegia. She can utilize a motorized wheelchair with mouth control (Also known as Sip and Puff Wheelchair- using mouth to control wheelchair with puff or sip of air). On 5/6/26 at approximately 3:00 p.m. an interview was conducted with R4. R4 stated that she had been in the facility for roughly two months and had been experiencing problems on the night shift. R4 stated that on the night shift she is ignored and neglected, her call bell is turned off before anyone comes into her room, she stated the staff stand outside of her room and talk about her loudly enough for her to hear. She stated she has been called Extra and that staff have stated they won't take care of her or need two people to go into her room. R4 stated that on 4/27/26, very early in the morning, before day shift arrived, it got so bad she called the non-emergency police number to get an officer to come and get her some help. She stated that the police responded to the building and came to investigate why she was calling for help from the facility. During the interview R4 showed the survey team a picture on her phone from 4/27/26 and stated that she made the day shift CNA take a picture of how she was found before moving her. The picture showed R4 with legs hanging over the side of the bed and torso on the bed. R4 stated this is how they left me in the bed R4 proceeded to show the survey team three videos she had of staff neglecting to provide for her care needs and turning off the call light. The video showed R4 recording herself hitting the call light for assistance, she could not turn around to see the call light box but you can clearly see in the video the box over the bed lit up red when the call light was pressed by R4. After approximately 15 minutes the light on the box went off and you could hear the R4 say The ringing has stopped, they turned the light off from the nurses station.In the second video nursing staff can be seen coming into the room turning off the call light telling R4 that someone will be in to take care of her, yet the video continued to show no one coming in for another 15-20 minutes. When staff arrived, they told R4 that they will not come in the room alone, she refused to provide care and then left. R4 engaged the light again and the staff member came in turned off the light and refused to provide care. The resident could be heard asking If you don't want to take care of me who will? I still need care during the night. The last video shown to the survey team was R4 phoning the police to get some assistance. The police arrived and asked staff leave the room because they were being argumentative and rude to R4. The police took a report and gave the resident a report number. R4 stated that she informed the Director of Nursing (DON) and the Unit Manager on the morning of 4/27/26 after she had called the police. On 5/7/26 at approximately 12:00 PM an interview was conducted with the Director of Nursing (DON) who stated that she was not aware of the alleged abuse and neglect of R4. The DON was asked if she was aware that the police were called and asked why on 4/27/26. The DON confirmed she was aware. The DON admitted she was aware that an allegation of neglect was made by R4 on 4/27/26.The facility failed to have evidence that they implemented any measures to protect the resident from alleged perpetrators, failed to report the allegation to regulatory agencies, and failed to investigate the allegation of neglect. Resident #4 continued to have the same care givers assigned to her that neglected her and out of fear she refused to allow the staff to close her door and reported being fearful, which constituted psychosocial harm.A review of the Policy for Abuse Neglect and Misappropriation read as follows: Policy 701 - Effective 10/17/23. There is zero tolerance for mistreatment, abuse. neglect, misappropriation of property or any crime against a patient of the Health and Rehabilitation Center.3. All employees are responsible for immediately (but not later than 2 hours if the allegation involves abuse or results in serious bodily injury, not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury) reporting to the Administrator, or in their absence the Director of Nursing or their direct supervisor any and all suspected or witnessed incidents of abuse, neglect, theft, exploitation, and or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient .According to the facility Policy titled, 703- Reporting Requirements Effective Date 2/5/23, it read in part, .1 Immediately upon notification of any alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours if the allegation involves abuse or results in serious bodily injury, not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily harm . 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include but not be limited to, collecting the evidence, interviewing alleged victims, and witnesses, and involving other appropriate agents or authorities to assist in the process and determination.Immediate Jeopardy was identified and the facility notified on 5/6/26 at 6:00 p.m. after consulting with the state agency supervisory staff. After the facility was unable to provide an acceptable removal plan R4 was assigned a one to one certified nursing assistant overnight. On the morning of 5/7/26 an acceptable removal plan was received. The plan read, Immediate Corrective Actions. The facility immediately took the following actions to remove the Immediacy: Staff Education: All staff will be educated prior to next shift on abuse policy and procedures to include mandated reporting.Resident Safety:Resident #4 was offered a room change and declined. Resident #4 was interviewed to determine preferred staff that will deliver her care.Resident #4 will be provided with 1:1 monitoringResident will be offered psychiatric evaluation and treatment Facility reportable incident has been submitted to all appropriate state agencies to include OLC, regional ombudsman office, state office adult protective services.Begin thorough investigation process.Interviews related to abuse and neglect will be completed on all cognitively intact residents with BIMS greater than 12.Skin Assessments will be completed on cognitively impaired residents with BIMS less than 13.Plan Completion will be on 5/7/2026 at 1:00 PM.On 5/7/26, after verification of the plan of immediate jeopardy removal and consultation with state agency supervisory staff, the immediate jeopardy was determined to have been removed at 1:00 pm on 5/7/26. Following the removal of immediate jeopardy status, the deficiency was cited at level 3, isolated (harm).

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents on four of four units had snacks available to them.The findings included: On 5/5/26 during initial tour on unit 1 CNA B was asked if there were snacks available to residents. CNA B opened the pantry refrigerator and pulled out a plastic bag containing 6 small individual cups of applesauce. CNA B was asked if the applesauce was the only snack that was available for the entire unit and she stated that they were. On 5/5/26 at approximately 11:15 am a tour of unit 2 was conducted CNA C was asked if snacks were available and she stated that they were not available. On 5/5/26 at approximately 11:25 am a tour of unit 3 was conducted and LPN B was asked if snacks were available to residents and she stated that they had a few containers of applesauce but if they wanted anything more substantial like a sandwich they would have to see if the kitchen would accommodate them. She stated that usually they could get something if a diabetic needed it. On 5/5/26 at approximately 11:40 am a tour of unit 4 was conducted and LPN C was asked if there were snacks available and she stated that there were no snacks available in general but if they needed something for diabetic residents they could go to the kitchen and get it. LPN C was asked what they would do in an off shift like nights she stated they would have to check all the units. She stated that they always have applesauce available for med pass. On 5/5/26 at 1:00 pm an interview was conducted with the dietary manager who stated that they do send sandwiches to the unit in the evening after dinner for the diabetics with orders. The dietary manager stated that they do not send cookies, crackers or fruit to the units for all residents; snacks are only sent for diabetics. On 5/5/26 at approximately 3:00 pm an interview was conducted with the Administrator who explained the facility would be taking over food service and the contracted company was no longer going to be in control of the dietary services. On 5/5/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record reveiew and facility documentation, the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for one resident, (Resident #5-R5) in a survey sample of five residents. The findings included:For R5 the facility staff failed to ensure proper bathing, and grooming to prevent body odor and maintain good personal hygeine.R5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified severe protein-calorie malnutrition, hip pain (right), myalgia, stiff man syndrome, abnormal coagulation profile, and hypertension. The most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/24/26 R5 was coded as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15, indicating no cognitive impairment. R5 was also coded as requiring physical assistance from staff for all aspects of ADL care.On 5/6/26 at 9:00 a.m. surveyor was standing outside of R5 room and could smell a [NAME] scent of body odor. R5 was observed in a flat lying in bed with a sheet over his body, his feet were exposed. R5's feet were observed to be extremely dry with peeling dry/dead skin and long thick, discolored and mycotic toenails. The closer this surveyor got to the resident the stronger the odor became. R5 was resting in bed with his eyes closed. On 5/6/26 at approximately 2:00 p.m. an interview was conducted with R5 who stated that he did not like to get into the shower because it hurt to transfer in the lift and get on the shower stretcher. R5 stated that the certified nursing assistants (CNA's) give him a bed bath a couple of times a month. R5 stated that he did not get up out of the bed because of the transfer via the mechanical lift was painful due to his condition of Stiff Man Syndrome.On 5/7/26 at approximately 8:45 am an interview was conducted with certified nursing assistant #2 (CNA 2) who stated that R5 always refuses to shower. When asked if he allows a bed bath daily CNA 2 stated that the resident will allow a bed bath some times but not daily. On 5/7/26 at approximately 9:15 a.m. an interview was conducted with a licensed practical nurse (LPN 3) who stated that R5 was Care planned for refusal of showers. When asked what that meant, LPN 3 stated he refuses showers so its on his care plan that he refuses. LPN 3 stated that they have interventions on the care plan but they don't work. A review of the care plan revealed the following entry:FOCUS: R5 [name redacted] has behaviors *Refusing medications/ weights/ showers and bed baths at times- education has been provided and provider notified of refusals Created on: 08/09/2025 Revision on: 02/23/2026GOAL: the residents' behaviors will not cause them or other residents' distress thru the review periodCreated on: 08/09/2025 Target Date: 02/13/2026INTERVENTION: administer medications as ordered Created on: 08/18/2025assure the residents are safe if they become distressed Created on: 08/09/2025psych services referral as needed Created on: 08/09/2025redirect resident to subjects that matter to them when behaviors occur Created on: 08/09/2025. On 5/7/26 at approximately 10:00 a.m an interview was conducted with the DON who stated that the care plan directs the care of the resident. The DON stated that the care plan interventions should be periodically reviewed and revised if they are not effective, and new intrventions should be put in place. On 5/7/26 the Admistrator was made aware of the concerns and no further information was provided.

Based on observation, interview and clinical record review the facility staff failed to ensure residents received proper treatment and care to maintain good foot health for one resident in a survey sample of five residents, (Resident #5- R5).The findings included:For R5 the facility staff failed to ensure proper foot care to include exfoliation of dry / dead skin and care of mycotic toenails.R5 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified severe protein-calorie malnutrition, hip pain (right), myalgia, stiff man syndrome, abnormal coagulation profile, and hypertension. The most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/24/26 R5 was coded as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15, indicating no cognitive impairment. R5 was also coded as requiring physical assistance from staff for all aspects of ADL care.On 5/6/26 at 9:00 a.m. R5 was observed in a flat lying in bed with a sheet over his body, his feet were exposed. R5's feet were observed to be extremely dry with peeling dry/dead skin and long thick, discolored and mycotic toenails. R5 was resting in bed with his eyes closed.On 5/6/26 at approximately 3:00 p.m. an interview was conducted with R5 who stated that he does not walk due to his condition of stiff man syndrome. R5 says it hurts to move and transfer. R5 was asked if he had seen the podiatrist for foot care, and he stated that he had but it's been a long time. R5 said no one puts lotion on his skin and no one has tried to cut his toenails since the podiatrist visited a long time ago. When asked if he would like to see the podiatrist R5 said, Yes I would like that a lot.On 5/6/26 at 4:00 p.m. an interview was conducted with a licensed practical nurse (LPN B) who stated, I cannot put R5 on the list for podiatry until I have an order from the doctor. LPN B further stated she would get the order when the doctor or nurse practitioner made rounds.On 5/7/26 the Administrator was made aware of the concerns and no further information was provided.

Based on clinical record review, facility document review, and staff interview, facility staff failed to develop a comprehensive plan of care for Hemorrhoids with internal treatment with a medication for one Resident (Resident #1-R1) in a survey sample of five Residents.The findings included.Resident #1 [R1] was initially admitted to the facility on [DATE] and discharged on 4-12-26. R1's diagnoses included Breast Cancer current, osteoporosis with femur fracture and surgical repair current, Beta Thalassemia, chronic kidney disease stage 4 severe, Irritable Bowel Syndrome, Atrial fibrillation, Arteriosclerotic Cardiovascular disease, Chronic heart failure, high blood pressure, Rheumatoid Arthritis, Thrombocytopenia, PTSD, panic disorder, and depression.R1's most recent and only admission minimum data set [MDS] assessment with an ARD [assessment reference date] of 4-12-26 revealed that the Resident was her own responsible party and was cognitively independent.Review of the clinical record revealed physician's orders and Medication Administration Records [MARs] for all of R1's current medications and treatments. The records revealed the following order. Hydrocortisone external cream 2.5% Hydrocortisone (topical) insert 1 application rectally 2 times per day for hemorrhoids. Ordered by the physician on 4-10-26 at 4:25 PM, the corticosteroid was administered twice on 4-11-26. The Resident was discharged and expired on 4-12-26. It is unknown what the amount of insert 1 application rectally means, as no dosage nor quantity is reflected in the order. This reveals that a different amounts could have been administered each time as no standard dose measurement is directed in the order.References for this medication were reviewed to include National Institutes of Health [NIH] which indicated that this medication is to be applied in a thin layer externally and never taken internally.The nursing care plan was reviewed and revealed no care plan having been derived for the internal treatment of hemorrhoids which would require specific nursing knowledge of rectal insertion that carries a danger of perforating the bowel to an untrained staff member.Nursing and physician progress notes, and hospital records which indicated that on 4-12-26 at 5:23 AM R1's vital signs were Blood pressure 108/80, pulse 89, respirations 18, tympanic temperature 97.3, and pulse oximetry 97% on room air. During shift change, at approximately 7:05 AM, a Code Blue and Cardiopulmonary Resuscitation [CPR] was initiated using 30 compressions to 2 ventilations by nursing as the Resident was found unresponsive without a palpable pulse. An emergency rescue squad was called to respond and transport the Resident to the local hospital emergency room. The family was notified immediately of the incident and given information as to where the Resident had been sent for treatment.The Resident later expired in the hospital.On 5-7-26 at 11:00 AM the Administrator, and Director of Nursing were made aware of the findings. They stated they had nothing further to provide.

Based on Clinical record review, facility document review, and staff interview, the facility staff failed to clarify a physician's order which was written without a specific dosage, and with a contraindicated route for a significant medication, for one Resident (Resident #1/R1) in a survey sample of five Residents.The findings included.Resident #1 [R1] was initially admitted to the facility on [DATE] and discharged on 4-12-26. R1's diagnoses included Breast Cancer current, osteoporosis with femur fracture and surgical repair current, Beta Thalassemia, chronic kidney disease stage 4 severe, Irritable Bowel Syndrome, Atrial fibrillation, Arteriosclerotic Cardiovascular disease, Chronic heart failure, high blood pressure, Rheumatoid Arthritis, Thrombocytopenia, PTSD, panic disorder, and depression.R1's most recent and only admission minimum data set [MDS] assessment with an ARD [assessment reference date] of 4-12-26 revealed that the Resident was her own responsible party and was cognitively independent.Review of the clinical record revealed physician's orders and Medication Administration Records [MARs] for all of R1's current medications and treatments. The records revealed the following order. Hydrocortisone external cream 2.5% Hydrocortisone (topical) insert 1 application rectally 2 times per day for hemorrhoids. Ordered by the physician on 4-10-26 at 4:25 PM, the corticosteroid was administered twice on 4-11-26. The Resident was discharged and expired on 4-12-26. It is unknown what the amount of insert 1 application rectally means, as no dosage nor quantity is reflected in the order. This reveals that a different amounts could have been administered each time as no standard dose measurement is directed in the order.References for this medication were reviewed to include National Institutes of Health [NIH] which indicated that this medication is to be applied in a thin layer externally and never taken internally.The nursing care plan was reviewed and revealed no care plan having been derived for the internal treatment of hemorrhoids which would require specific nursing knowledge of rectal insertion that carries a danger of perforating the bowel to an untrained staff member.nursing and physician progress notes, and hospital records which indicated that on 4-12-26 at 5:23 AM R1's vital signs were Blood pressure 108/80, pulse 89, respirations 18, tympanic temperature 97.3, and pulse oximetry 97% on room air. During shift change, at approximately 7:05 AM, a Code Blue and Cardiopulmonary Resuscitation [CPR] was initiated using 30 compressions to 2 ventilations by nursing as the Resident was found unresponsive without a palpable pulse. An emergency rescue squad was called to respond and transport the Resident to the local hospital emergency room. The family was notified immediately of the incident and given information as to where the Resident had been sent for treatment.The Resident later expired in the hospital.The DON was asked what nursing reference for care the facility used, and she stated [NAME], Mosby, and [NAME]/[NAME].[NAME] professional nursing standards. Guidance was given from [NAME], Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentationOn 5-7-26 at 11:00 AM the Administrator, and Director of Nursing [DON] were made aware of the findings. They stated they had nothing further to provide.

Based on observation, staff interview, and review of facility documents, the facility staff failed to assure that a medication cart was not kept locked or under direct observation of authorized staff in an area where residents could access it. The findings included: During an observation tour of unit 1 on 12/22/25 at 11:35 AM, medication cart A was found unlocked outside of the nursing station, with no authorized staff within eyesight. At 11:37 AM the Unit 1 Manager approached the State Surveyor and stated, May I help you?'. The Unit 1 Manager further stated that she did not know where the Nurse that is assigned to medication cart A is currently located. On 12/22/25 at 11:38 AM Licensed Practical Nurse (LPN) #1 entered the building through the outside entrance door and approached the State Surveyor. LPN #1 stated that she is the nurse assigned to medication cart A and she was outside making a phone call. On 12/22/25 at 1:15 PM an interview was conducted with the Unit 1 Manager. The Unit 1 Manager stated that LPN #1 should not have been outside of the building while medication cart A was unlocked and not under direct observation of authorized staff. On 12/22/25 at 1:20 PM an interview was conducted with LPN #1. LPN #1 stated that she knows it was wrong being outside of the building while medication cart A was not locked or under observation of authorized staff. LPN #1 further stated it was a mistake. The facility's Storage of Medications policy with an effective date of 09-2018 read: 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. On 12/22/25 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and Regional Director of Clinical Services. They had no further comments and voiced no concerns regarding the above allegation.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to prevent the elopements for two (2) residents out of 24 residents. Resident #217 and Resident # 223, in the survey sample. The findings included: 1.Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., The facility staff failed to report the elopement within the required time frame of 2 hours to the State Survey Agency. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Suicidal Ideations and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #217 cognitive abilities for daily decision making moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as being independent with eating, oral hygiene, requires supervision or touch assistance when walking 150 feet. The Care Plan dated 12/30/24 read that Resident #217 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment. The facility synopsis of events dated 1/21/25 read that Resident #217 was observed by staff in the parking lot. Returned to the building, no injuries noted. Resident #217 elopement was not reported until 1/22/25. The fax confirmation to the State Reporting Agency was dated 1/22/25 at 4:06 PM.,which was a total of 16 hours and 3 minutes after the elopement occurred. According to the Health Status note and the Final Synopsis listed above. Resident #217's elopement wasn't reported to the State Agency and Adult Protective services until 16 hours and 3 minutes later. On 1/22/25 an interview was conducted with Resident #217 at approximately 4:10 PM., concerning his elopement. Resident #217 said that he left the building to check on his home. On 1/23/25 at approximately 4:30 PM., an interview was conducted with the DON concerning the above elopement. The DON said that the incident should have been reported within 2 hours, but it was reported later. 2. Resident #223. The facility staff failed to report his elopement to the State Survey Agency after resident eloped from the facility. Resident #223 was originally admitted to the facility 10/18/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #223 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up assistance with eating and oral hygiene. Dependent with toileting hygiene and requires substantial maximal assistance with bathing/showering. The Care Plan dated 12/30/24 read that Resident #223 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment. A review of Resident #223's incident report completed on 12/29/24 at 2:00 PM., read that Resident #223's family observed resident sitting in his wheelchair in the parking lot. Resident said that he was going for a walk. No injuries were observed by staff. A Facility Synopsis of the event was not completed. On 1/23/25 at approximately 6:30 PM., an interview was conducted with the DON. The DON said that the family informed the staff that the resident was in the parking lot. The DON also mentioned that a report (Facility Synopsis) was not completed but an elopement incident report was completed. The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the state agency, but no later than 2 hours after the allegation is made. On 1/23/25 at approximately 7:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Regional Nurse Consultant (RNC) said that the staff was re-educated on resident elopements and investigating.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide the necessary supervision to prevent an elopement for two (2) out of 24 residents. Resident #217 and Resident # 223, in the survey sample. The findings included: 1. Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., in the snow to the facility parking lot where employees and visitors parked their vehicles. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; suicidal Ideations and unspecified dementia, unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #217 cognitive abilities for daily decision making moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as being independent with eating, oral hygiene, requires supervision or touch assistance when walking 150 feet. The Care Plan dated 12/30/24 read that Resident #217 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment. The December 2024 Physician Order Summary (POS) read: Check function of wander bracelet weekly every day shift every Monday for monitor placement. Active 12/29/2024. Check Wander Prevention Patient Band every shift. every shift Verbal Active 12/29/2024. A Health status noted dated 1/21/2025 at 11:03 PM., read that Resident #217 was found outside walking around the facility. Wander Guard did sound off and was alerted to the whole facility the Wander Guard was found on resident; door alarm did sound off and was alerted to the facility. No injuries found. A Health status noted dated 1/21/25 at 12:08 AM., read that the Medical Doctor (MD) was notified. Vital signs taken. Temperature=97.9, Pulse=83, Blood Pressure =143/80, Respirations = 18, Oxygen = O2 sat's 96% on Room Air (RA). No noted distress, injuries, discomfort or complaints of pain, skin is intact. The final synopsis of events dated 1/21/25 read that Resident #217 was observed by staff in the parking lot. Returned to the building, no injuries noted. Resident #217 elopement was not reported until 1/22/25. The fax confirmation to the state reporting agency was dated 1/22/25 at 4:06 PM. According to the Health Status note and the Final Synopsis listed above. Resident #217's elopement wasn't reported to the State Agency and Adult Protective services until 16 hours and 3 minutes later. On 1/22/25 an interview was conducted with Resident #217 at approximately 4:10 PM., concerning his elopement. Resident #217 said that he left the building to check on his home. On 1/23/25 at approximately 11:00 AM., the Director of Nursing (DON) was given a list of three residents to check wander guard placement and function. Resident #217, Resident #218 and Resident #224. On 1/23/25 at approximately 11:55 AM., the wander guards on the above three residents were observed and tested for function by Licensed Practical Nurse (LPN) # 4. No issues were found. On 1/23/25 at approximately 4:30 PM., an interview was conducted with the DON concerning the above elopement. The DON said that the incident should have been reported within 2 hours, but it was reported later. Elopement Scoring: 0 - 7 =Low Risk 8 - 9 =At Risk for elopement/exit seeking 10 - above =High Risk for elopement/exit seeking The elopement Risk Tool assessment dated [DATE] at 8:38 PM., was reviewed. Resident #217 was assessed as scoring an 8 on the assessment which indicated that resident was at risk for elopement/exit seeking. On 01/23/25 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Regional Consultant said that whenever a resident leaves the building without the staff knowing is considered an elopement. 2.Resident #223. The facility staff failed to keep him from eloping from the facility. Resident #223 was originally admitted to the facility 10/18/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; depression, unspecified. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #223 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up assistance with eating and oral hygiene. Dependent with toileting hygiene and requires substantial maximal assistance with bathing/showering. The Care Plan dated 12/30/24 read that Resident #223 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment. Elopement Scoring: 0 - 7 =Low Risk 8 - 9 =At Risk for elopement/exit seeking 10 - above =High Risk for elopement/exit seeking The elopement Risk Tool assessment dated [DATE] at 7:14 PM., was reviewed. Resident #223 was assessed as scoring 9 on the assessment which indicated that resident was at risk for elopement/exit seeking. The December Physician Order Summary (POS) read: Check function of wander bracelet weekly every day shift every Saturday. Active 12/30/2024. Check Wander Prevention Patient Band every shift. every shift. Active 12/30/2024. A review of Resident #223's incident report completed on 12/29/24 at 2:00 PM., read that Resident #223's family observed resident sitting in his wheelchair in the parking lot. Resident said that he was going for a walk. No injuries were observed by staff. An interview was conducted on 1/22/25 at approximately 1:15 PM., with Resident #223. Resident #223 complained that the facility wouldn't let him leave at his own will by placing an ankle bracelet on his left ankle against his wishes. Resident #223 also said that he left Against Medical Advice (AMA) because he no longer wanted to stay at the facility. An interview was conducted on 1/22/25 at approximately 4:35 PM., with Registered Nurse (RN) #2. RN #2 said that the facility staff tried to talk him out of leaving the facility. RN #2 also mentioned that the resident wore a wander guard because he was exit seeking. He never mentioned that staff wasn't treating him right. RN #2 also said that she removed his wander guard from his ankle on his day of discharge. On 1/23/25 at approximately 6:30 PM., an interview was conducted with the Director of Nursing (DON). The DON said that the family informed the staff that the resident was in the parking lot. The DON also mentioned that a report (Facility Synopsis) was not completed but an elopement incident report was completed. The facility's policy, Elopement/Exit Seeking Behaviors dated 1/29/24 read: The Elopement Risk Tool Assessment will be used to evaluate a patient's risk of elopement/exit seeking behaviors. Procedure: Upon admission to the center, each patient will be assessed for elopement/exit seeking history and or behaviors using the elopement Risk Tool Assessment. If a patient is determined to be at risk, a wander guard will be placed for intervention. An order will be obtained from the provider, the Responsible Party will be notified. If the resident begins demonstrating unsafe exit seeking behaviors after the initial admission, the Elopement Risk Tool Assessment will be utilized. What is Nursing Home Elopement In nursing homes and other long-term care facilities, an elopement is a form of unsupervised wandering that leads to the resident leaving the facility. Elopement risk refers to the potential danger when a patient, often deemed too ill or impaired to make sound decisions, leaves a healthcare facility unauthorized, posing immediate threats to their health or safety. This endangers the resident immediately and can result in serious injury, or even death, depending on circumstances such as the location of the facility, the time of year, how long it takes staff to recognize the resident is missing, and how long it takes to find the resident. https://www.bbga.com/practice-areas/nursing-home-abuse/nursing-home-elopement/ On 1/23/25 at approximately 7:30 p.m., the above findings were shared with the Administrator, DON and Corporate Consultant. The Regional Nurse Consultant (RNC) said that the staff was re-educated on resident elopements and investigating.

2. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to this, she did not receive the scheduled two (2) doses of Gabapentin on 8/17/24 and 8/18/24 and 1 scheduled dose of Tylenol on 8/18/24. Resident #47 voiced that due to not taking these medications, her pain level was a 9 out of 10, with 10 being the worst pain possible. Resident #47 further voiced that she experienced severe pain in her neck, head, and shaking of her hands. The Care Plan with a revision date of 2/16/23 read that Resident #47 has a history of chronic pain related to cerebrovascular accident (CVA). The goal was the resident will not have discomfort related to side effects of analgesia. The intervention for Resident #47 was to administer analgesia per order. Give before treatments or care as needed. The Physician's Order Summary (POS) for August 2024 read: Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for Pain with a start date of 12/15/2021 and Tylenol (Acetaminophen) 8 Hour Oral Tablet Extended Release 650 MG Give 1 tablet by mouth every 8 hours for Chronic Pain with a start date of 9/27/2023. A review of the Medication Administration Record (MAR) revealed that Resident #47 missed 2 doses of Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day on the following dates: 8/17/24-8/18/24 and missed 1 dose of Tylenol (Acetaminophen) 8 Hour Oral Tablet Extended Release 650 MG Give 1 tablet by mouth every 8 hours on the following date: 8/18/24. Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome. https://medlineplus.gov/druginfo/meds/a694007.htm Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. https://medlineplus.gov/druginfo/meds/a681004.html On 10/7/24 at 12:50 PM an interview was conducted with the two Regional Nurse Consultants. The Regional Nurse Consultants stated that the medications were available for Resident #47, and they could not explain why the resident was not administered these medications on 8/17/24 and 8/18/24. The two Regional Nurse Consultants also stated that no pain assessments were completed for Resident #47 on 8/17/24 and 8/18/24 regarding the missed doses of Gabapentin and the Tylenol. On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above resident issue. Based on observation, resident, family and staff interview, clinical record review, and review of facility documents, the facility staff failed to administer analgesics to treat and manage pain which constituted harm for 2 of 55 residents (Resident #473 and Resident #325), in the survey sample. The findings included: 1. The facility's staff failed to manage Resident #473 pain, which resulted in two emergency room visits to achieve relief and constituted harm. Resident #473 was initially admitted to the facility on [DATE] and discharged home on 8/24/22. The resident's diagnoses at the time of his admission were lumbar spinal stenosis with lower back pain radiating to his feet, lumbar spinal fusion, and chronic musculoskeletal injuries from a motor vehicle accident. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/8/22, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #473's cognitive abilities for daily decision-making were intact. In section GG0130 (Self-Care) the resident was coded as independent with eating, oral care, upper body dressing, rolling left and right, sitting to lying, lying to sitting on the side of bed, and toilet transfer, requiring supervision or touching assistance with climbing four steps, and the ability to go up and down a curb, partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, walking 10 feet, setup or clean-up assistance sit to stand, and chair/bed-to-chair transfer. The resident's care plan, dated 8/06/22, included a problem with Pain. The goal read that the resident would have no/decreased complaints of pain through the next review, 8/24/22. The interventions included medicating as ordered, positioning the resident for comfort, and notifying the physician/practitioner of pain not relieved with medication or of new complaints of pain. On 10/9/24 at 11:25 AM, an interview was conducted with Family Member (FM) #1. FM #1 stated while her brother was a resident at the facility, he was transferred to the hospital because the facility's staff did not have the ordered pain medication Percocet Tablet 5-325 MG available for administration. FM #1 stated she brought twenty-seven Percocet Tablet 5-325 MG to the facility for staff administration to ensure Resident #473 would not be in pain. An interview was conducted with the resident on 10/11/24 at 11:07 AM. The resident stated that most days, while a resident at the facility, he experienced excruciating pain. Pain so severe he did not want to move, walk, exercise, or eat. The resident stated the staff failed to inform him that it was his responsibility to request the pain medication, and when he learned that was the system, he followed it. The resident stated that most of the time, there was a long delay in administration after he requested the medication. Resident #473 had multiple Percocet orders during his stay. They were: 8/05/22 - 8/16/22 2128 Percocet Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for pain and 8/05/22 - 8/16/22 1634 Percocet Tablet 5-325 MG, Give 2 tablet by mouth every 4 hours as needed for mild pain (1-3). 8/16/22 1227 Percocet Tablet 5-325 MG, give 2 tablets by mouth STAT for Pain. Pull from Omnicell. 8/16/22 - 8/22/22 1242 Percocet Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for mild to moderate pain (1-5) and 8/16/2022 - 8/22/22 Percocet Tablet 5-325 MG, Give 2 tablets by mouth every 4 hours as needed for severe pain (6-10) 8/22/2022 1034 -8/25/2022 Tylenol Tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for pain or fever 8/23/22 - 8/25/2022 1155 Percocet Tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for severe pain (1-5) and 8/23/22 - 8/25/2022 Percocet Tablet 5-325 MG, Give 2 tablet by mouth every 4 hours as needed for severe pain (6-10) The resident stated he could not remember what occurred on 8/14/22 while he was a resident at (name of the facility), but he knew he had an enormous tolerance to pain, and if the pain was severe enough for him to request an ER visit, he was suffering unbearable pain. A review of the nurse's note dated 8/14/22 at 14:46 revealed the resident complained of lower back pain that radiated to his feet. The on-call practitioner was notified and recommended that the resident wait until tomorrow to be assessed, but if he could not wait, the nurse would transfer the resident to the local ER. The nurse's note further stated near the end of the shift, the resident requested to go to ER because he was experiencing the worst pain he had ever suffered. A review of the Medication Administration Record (MAR) revealed that when the resident was transferred to the ER on [DATE], he had not been administered the Percocet Tablet 5-325 MG since 8/12/24 at 14:44. The ER's After Visit Summary dated 8/14/22 revealed that the resident arrived at the ER at 15:24, and his chief complaint was breakthrough pain to the lower back with tingling in his legs more constant and more severe over the last 3 days. The resident was treated with a Hydromorphone (Dilaudid) injection of 0.5 mg Intravenous (IV) Push at 16:35. and Dexamethasone (Decadron) 10 mg IV injection at 16:39. On 8/14/22 at 18:31, the resident was prepared to return to the long-term care facility with orders for Percocet 5-325 MG Tablets by mouth as ordered, and Prednisone 10 mg by mouth as ordered. A nurse's note dated 8/16/22 at 01:40 read the resident requested to be sent to the ER for uncontrolled back pain. The nurse offered to administer his as-needed pain medication, but the resident had no more Percocet. The pharmacy authorized the removal of one Percocet from the Omnicell, but the resident refused to take the one Percocet and stated he wanted two Percocet tablets or to go to the ER. The Resident was transferred to the ER. The nurse failed to document an assessment of the resident's pain. A review of the Medication Administration Record (MAR) revealed that when the resident was transferred to the ER on [DATE], he had not been administered the Percocet Tablet 5-325 MG since 8/14/22 at 23:50. The ER's After Visit Summary dated 8/16/22 revealed that the resident arrived at the ER at 01:50, and his chief complaint was bilateral lower extremity pain and low back pain since approximately 20:00 8/15/22. The pain was suspected to be related to his recent surgery and known spinal seroma and spinal stenosis. The resident rated the pain as 7 out of 10 and described it as pounding pain to the posterior aspect of his calves and radiating to bilateral hips. The summary revealed EMS administered two Percocet Tablets 5-325 MG to the resident before his arrival to the ER and during their assessment of his pain, the resident stated 7/10. The summary also revealed that Family Member #1 told the ER staff that she called the facility to arrange to obtain the Resident's Percocet Tablets 5-325 prescription at an outside pharmacy because the Resident requested not to return to the facility from the ER until it was confirmed the Percocet Tablets 5-325 would be available for administration. The resident described his experience to the ER staff regarding his pain on 8/14/22. He reaffirmed that he had suffered the worst pain he had ever endured and that his goal in coming to the ER on that day (8/16/22) was to get help before the unbearable pain returned. The ER nurse contacted the long-term care facility, and the facility stated that the resident's Percocet tablets would arrive at the facility during the AM and the Prednisone ordered on 8/14/22 would be started at 09:00 on 8/16/22. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify and treat an avoidable pressure ulcer resulting in harm for one Resident (Resident #73) in a survey sample of 55 Residents. The findings included: Resident #73, with contracted fingers of the left hand, experienced a pressure sore injury from his fingernails pressing into his palm. The pressure sore became infected resulting in cellulitis, which led to the identification of the pressure sore injury in the facility. The pressure sore and resulting infection caused the Resident to be sent out to the hospital for treatment with IV (intravenous) antibiotics for 10 days. The facility staff were unaware of the wound prior to the infection, and had not been applying the Residents hand splint (palm guard) to prevent the wound. Further the Resident was suffering from significant weight loss and malnutrition, increasing debility, and inability to heal. Resident #73 was originally admitted to the facility on [DATE], was hospitalized on [DATE] for a pressure sore injury with infection and cellulitis, and returned 10 days later on 6-1-24. Diagnoses included; acute infection/cellulitis of upper left limb, stroke with left hemiplegia, dementia, contractures of left side limbs, dysphagia, epilepsy, hypertension, hypernatremia, and vitamin D deficiency. Resident #73's most recent Minimum Data Set assessment was a Significant change assessment with an assessment reference date of 7-29-24. Resident #73 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He required extensive to total assistance with eating, bathing and personal hygiene. He was coded to have impaired Range of Motion on both upper extremities, and one lower extremity. He was coded with no behaviors, no swallowing difficulty, and had a mechanically altered regular pureed diet. Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, honey thick liquids consistency. On 10-4-24 at approximately 12:00 PM, during continued tour of the facility, Resident #73 was observed eating lunch and being fed by a Certified Nursing Assistant (CNA). The Resident's hands were both contracted. He was not observed to be wearing a palm guard nor any other type of equipment in the upper extremities. The CNA was interviewed and stated Yes he eats really well, and usually finishes 100% of his meals. She was asked why the servings were so small, she stated yeah it doesn't look like enough, but it's pureed so that's what he gets. When asked why the items listed on the tray ticket were missing, she stated They must have missed the other stuff in the kitchen. The Resident had just begun eating from 3 scoops of pureed food each scoop was approximately 2 inches long by 2 inches wide scoop circles (resembling a scoop of ice cream) and approximately 1 inch high. one scoop was gray and semi solid, one scoop was light tan/white and had a grainy pudding consistency, and the third scoop was a white smooth pudding consistency. There was also a clear plastic container with a lid containing approximately 90 milliliters of green liquefied gelatin which smelled like lime, and a cup with approximately 120 milliliters of thickened brown liquid described by the CNA as thickened tea. The Resident consumed all of the meal. The tray ticket menu and preparation instructions for quantity was reviewed and revealed it should have contained; Pureed turkey meatloaf 6 ounces with brown gravy 2 ounces, Pureed buttered diced carrots 8 ounces, Mashed potatoes with gravy 1 cup, Pureed dinner roll with 1 margarine, Fortified pudding 8 ounces, Pureed soft peanut butter cookie 8 ounces, Hot coffee or hot tea, honey thick 16 ounces. In American apothecary measurements and standardized metric medication measurements, 30 milliliters are equal to one ounce. One cup is equal to 8 fluid ounces. The 3 Pureed food servings on Resident #73's meal tray would have totaled approximately 3 ounces each, the gelatin was approximately 3 ounces, and thickened tea would have been approximately 4 ounces. There was half of the pureed meatloaf ordered, no gravy, no carrots, less than half of the potatoes, no gravy, no fortified pudding, no pureed cookie, and half of the thickened tea. The gelatin did not appear on the tray ticket. The meal did not contain all of the menu items nor was it quantity sufficient. Resident #73 was addressed in greeting and did not respond. The CNA stated he's not verbal. 2 hand splints were noted on a chair in the room against the wall at the foot of the bed. The CNA was asked are those splints for this Resident or his room mate. The CNA replied I'm not sure I will check and get back to you. The CNA was asked if the Resident lashed out or refused care, and she stated no, he doesn't ever do any of that, he can't. The CNA was unaware of the splint use and did not apply them as a result. On 10-4-24 at 1:30 PM, Kitchen staff were interviewed and told about the small quantity of food on Resident #73's tray, and the fact that all of the items were not on the tray and they responded that they were out of the pudding, and they didn't get magic cup in because it was too expensive so they substituted the Jello. They also stated that someone had made a mistake and left items off. When asked to see what the pureed cookie looked like, they stated all of the food was gone and they had none left. On 10-7-24 at approximately 12:00 PM Resident #73 was again observed during the lunch meal being fed to him by a staff member. The tray portions were unchanged and insufficient as before, the Resident ate 100%, and no house fortified pudding was on the tray. Resident #73's clinical record was reviewed. Weight documents all completed by mechanical Hoyer lift revealed the following; 5-01-24 - 118.0 pounds prior to the pressure sore injury and cellulitis. 5-20-24 - A nursing note documented Hoyer lift scale not working. 5-22-24 - The Resident went to the hospital with cellulitis after pressure sore injury. 6-10-24 - 125.2 pounds after hospitalization for cellulitis, after gaining 7 pounds in 10 days while hospitalized . 6-24-24 - 108.5 pounds 8-09-24 - 109.0 pounds 9-11-24 - 107.6 pounds 10-8-24 - 97.0 pounds taken during survey with 2 CNA's & surveyor. On 10-8-24 Two CNA's on 3 PM-11 PM shift weighed the Resident at the request of the surveyor by way of the Hoyer mechanical lift correctly zeroing out the scale prior to lift. The Resident did not seem to mind the jostling and placing on the sling nor lifting in the sling and had no facial nor physical response to the experience. The Resident's weight was found to be 97.0 pounds. The CNA's were asked if he refused care or splinting and both stated no, he never fights me over anything. Malnutrition Universal Screening (MUST) Tools were reviewed and revealed an assessment on 6-6-24 upon readmission after the 6-1-24 hospital discharge which documented low risk for malnutrition. The same (MUST) assessment was completed again on 7-24-24 and documented high Risk for malnutrition, weight of 108.5 which had been obtained a month earlier on 6-24-24. The 7-24-24 (MUST) assessment occurred after another full month of continued significant weight loss greater than 10% in less than 2 months. The downward trend continued through 9-11-24 which was the last facility obtained weight documented in the clinical record until the time of survey. On 10-8-24 when surveyors obtained a weight, no weight had been taken by facility staff for another month. The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. RD notes were reviewed and revealed continued weight loss until hospitalization , with no change in recommendations. While the Resident was hospitalized for the Pressure sore injury and cellulitis a 7 pound weight gain was experienced. Then after the readmission to the facility the weight loss began again, and continued through survey without any change to recommendations, with the exception of the 5 following items; 1. 7-25-24 Discontinuance of the vitamin C. 2. The Resident never received the magic cups. 3. 9-26-24 pro-stat liquid (protein for healing) for 3 days then discontinued 9-29-24. 4. 9-18-24 the Vitamin C restarted 2 months after discontinuance. 5. 10-4-24 the house fortified pudding was added, instead of the magic cup, which was observed as not received. The weekly weights which were recommended by the RD were never obtained. The Resident did not receive meals in the quantity/caloric intake that was ordered, nor was the ordered diet followed. Review of Physician's orders revealed only the following order for the left hand contracture and pressure wound injury with cellulitis; 1. Devices were ordered by the physician on 6-1-24 and again on 9-26-24. That device was Bean bag splints to left upper and left lower extremities as tolerated. No order for, nor directions for, use of palm guards was found in the clinical record. Physician and Nursing progress notes were reviewed for information on the Resident's contractures, left palm pressure wound, and splint usage. That review revealed that From 5-1-24 through 5-19-24 the Resident had no skin wounds. On 5-20-24 at 2:20 PM, the Physicians Assistant (PA) documented Patient seen today for nursing reports of wound to the left palm. Left hand is contracted. Drainage, erythema and swelling noted. Patient says ouch when I touch his hand. Comments; one centimeter wound to the left palm with surrounding erythema and swelling that extends into his middle finger. Hand is warm to touch. Hand is contracted so range of motion is limited. Pain states ouch when I move his hand. Assessment and plan; Cellulitis secondary to wound of the left hand. Wound appears to have been caused by (finger) nail of contracted hand being dug into his palm. Palm guard present at bedside but it is unclear how often it is actually being placed on the patient's hand. Swelling and erythema extends into middle finger and dorsal aspect of the hand. Wound cleaned with DWC (Dakin's wound Cleanser) and bandaged. Palm guard placed. Plan: Wound care - Left hand palm cleanse with wound cleanser, pat dry with gauze, then apply antibiotic ointment to wound bed, cover with dry dressing daily and as needed. Apply palm guard, only remove when eating. Start Keflex 500 mg 4 times per day for 7 days. Monitor closely, if wound worsens consider labs and additional antibiotics emergency room visit if warranted. The Keflex order was changed later that same day to a renal dose of 500 mg twice per day instead of 4 times. The Keflex antibiotic ordered on 5-20-24 at 2:20 PM was not obtained and administered until the afternoon of 5-21-24, which was 24 hours after the cellulitis was identified. It is notable to mention that the Keflex (Cefalexin 500 mg) 15 doses, was available for administration immediately in the facility, in the Omnicell stat box. The purpose of the Omnicell stat box is for staff to have on hand, and available, at all times, needed medications while waiting for the pharmacy to deliver the order, so as not to delay treatment. That was not done. On 5-20-24 at 9:33 PM the Resident was again seen by the same PA, with no changes made. On 5-21-24 at 1:38 AM nursing states notification received that the Resident will be starting the antibiotic treatment by mouth. On 5-21-24 at 10:17 AM the PA documents seeing the Resident again for the cellulitis, stating the cellulitis resulted from the Resident's fingernail digging into his chronically contracted hand and it seemed that his palm guard had not been consistently applied daily, she had been made aware of the wound on 5-20-24, and was still waiting on the pharmacy to deliver the antibiotic to begin treatment. On 5-22-24 at 8:47 AM the PA again assessed the Resident documenting worsening cellulitis. Further documenting only 3 doses of the oral antibiotic Keflex had been administered, and the hand continued to become more swollen and extended throughout the entire hand and into the wrist. Cellulitis progressing rapidly and has not responded to oral antibiotics, given the swift advancement of erythema and swelling she was sending the Resident to the hospital for evaluation and possible IV (intravenous) antibiotics. There was concern by the PA that the tendon may have become infected, as a wound in the palm of the hand tissue which is shallow in depth, could reach underlying structures easily. On 5-22-24 at 4:43 PM nursing notes indicate the order was received to send the Resident out to the hospital non-emergently, and at 5:08, that the Resident was sent non-emergently after 24 hours without antibiotics after the order, and 2 days after the infected pressure wound with symptoms was identified. The Resident remained in the hospital for 10 days before returning with orders to continue Amoxicillin oral antibiotics twice per day for the cellulitis for 7 more days after receiving IV Zosyn, and IV Vancomycin in the hospital. The Resident's care plan was reviewed and interventions revealed a focus for refusing to wear splint to (bilateral upper extremities/bilateral lower extremities - Bean Bag.) Cellulitis resolved 7-6-24. There was never a care plan devised for the palm guards. Progress notes review revealed no refusals for splint nor bean bag placement, and no other aberrant behaviors nor refusals were documented for this Resident. The Resident's Kardex which is used by CNA's to guide specific care for each resident need was reviewed and revealed bean bag splints as tolerated with no other instruction on use, nor location of use, and no mention of the palm guards. Staff were unaware of the palm guard need. Facility policies and procedures were reviewed. The policy titled Skin assessments stated that skin assessments would be conducted by nursing weekly and daily with ADL care. Resident #73 experienced an avoidable pressure sore injury which was not identified until a cellulitis infection was present. The Resident was at risk for skin breakdown after a stroke and immobility with contractures, and was experiencing continued significant weight loss. The contracted left palm required palm guards to be implemented to protect the skin from wounds, however, they were not being used consistently. The pressure sore injury was identified only after it became infected requiring hospitalization . The pressure sore injury risk should have been identified during ADL care of the contracted hand prior to the actual wound opening and forming, which led to infection and hospitalization . The wound healed with care. On 10-9-24 at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified that the survey team was considering a harm level deficiency. The facility staff was given the opportunity to provide any further information or explanation. They stated they had no further information.

Based on observation, interview, and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The findings included: For the facility staff failed to ensure that the facility was free from damp mildew smell, wet ceiling tiles, unsanitary shower rooms, and ice machines were kept clean and sanitary and document preventative maintenance and cleaning schedules. On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew. The Administrator was coming down the hall and asked to view the area when asked if he thought it was safe and sanitary for Residents to consume ice made in that environment, he stated that it was not. The date on the ice machine filter was illegible. There was no documentation of cleaning schedule or inspection. On 10/11/24 the maintenance person was asked about the cleaning schedule for the ice machines and he stated we wipe them down once a month, then quarterly we empty it and sanitize it and every 6 months we change the filters. He was then asked to provide the policy for ice machine cleaning. The ice machine in the kitchen area had a filter change date of 6/7/24 however the ice machine cleaning log had not been filled in (all sheets were blank). The following excerpt from the ice machine policy read: Policy: All ice machines will be inspected regularly as scheduled and preventative maintenance will be performed t6 verify p-[NAME] and safe operation. Procedure: Monthly 1. Shut ice machines down for preventive maintenance service 2. Check water valves and connectors 3. Check for slime, sediment, build up, rust or corrosion clean/repair as needed 4. Clean according to manufacturer instructions using nickel safe cleaner. Observations made on 10/11/24 at 2:40 p.m. Unit 1 - Women's shower room-wet washcloth left in bathroom on floor, floor needs mopping, stains visible on floor, black substance in shower area in grout lines and near floor of shower. Unit 1 Men's shower room - trash had not been emptied, shower room smelled of urine, floor dirty, shower stall has black substance in corners and at base of the shower. Unit 2 - Women's shower room - bariatric shower seat in the stall had a soaking wet sheet on it stained with brownish yellow stains, the toilet paper holder is broken, shower curtains have black substance on the bottom edge, opened toothpaste and deodorant sitting on the shelf no name on it. Floor needs to be cleaned. Unit 2 Men's shower room - rust stains behind toilet, dirty pajama bottoms and socks on the floor, strong urine odor in shower room, shower curtains have black stain, and the shower stall floors have black in the grout and the corners. Unit 3 Women shower room -Rust on shower chair, chipped broken tiles at corner of wall, toilet paper holder is broken. Unit 3 Men's shower - Oxygen concentrator in shower room no name or room number on it, light in toilet area is not working, toilet paper holder was broken, and black and rust colored stains in the shower area. Unit 4 Women's shower room - Dirty wash cloth on chair, shower area dirty especially at base where wall and floor meet, black/brown substance, and floor needs swept and mopped. Unit 4 Men's shower room - used incontinence brief in trash, floor needs swept and mopped, paper trash on floor, shower area dirty black substance in corners and in grout, On 10/11/24 during the end of day meeting the administrator was made aware of the concerns and no further information was provided,

Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases, infections, Legionnaires', and other potentially transmissible waterborne pathogens, on 4 of 4 Resident living units and communal spaces. The findings included; The facility staff failed to ensure that the facility was free from dampness, and mold. Surveyors observed wet mold on floors, walls, ceiling tiles, ceiling insulation and pipes, shower grout, base boards, and shower curtains, and Resident rooms. Unsanitary areas also included shower rooms, laundry facilities, the main kitchen, insects on 4 of 4 units, ice machines were not kept clean and sanitary, and staff further failed to complete, and document preventative maintenance, water/water damage testing, and cleaning schedules. On 10-9-24 observation of the Resident hydration ice machine in the closet across from the dining room revealed standing water on the floor, a 1/2 inch thick, 3 foot by 3 foot rubber hole punched mat, with live cock roaches (5-6 of them) crawling around it, and under it. The ice machine drainage pipe was dripping directly onto the floor, and not into a drain. Under the ice machine was an approximately 4 inches wide, by 4 inches long, by 1/2 inch high, irregularly shaped circular, black slimy mold growing substance. The mold had a gelatinous, semi solid, humped shape, with encircled stringy, anemone like tentacle out growths. The out growths had the appearance of a fringe with a yellow colored cast around the outer edges. The mold was partially on the wet floor and partially on the 5-7 pieces of wet paper trash under the ice machine, and behind it. The entire area smelled of dampness, dirt, and mold. The Administrator was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for Residents to consume ice made in that environment, he stated that it was not. The date on the ice machine filter was illegible. There was no documentation of a cleaning schedule, nor inspection of the area. On 10-9-24 the Maintenance Director was asked about the cleaning schedule for the ice machines and he stated we wipe them down once a month, then quarterly we empty it and sanitize it, then every 6 months we change the filters. He was then asked to provide the policy for ice room and machine cleaning. The ice machine in the kitchen area had a filter change date of 6-7-24, however, the ice machine cleaning log had not been filled in (all sheets were blank). The following excerpt from the ice machine policy read: Policy: All ice machines will be inspected regularly as scheduled and preventative maintenance will be performed to verify proper and safe operation. Procedure: Monthly 1. Shut ice machines down for preventive maintenance service. 2. Check water valves and connectors. 3. Check for slime, sediment, build up, rust or corrosion clean/repair as needed. 4. Clean according to manufacturer instructions using nickel safe cleaner. The Centers for (CDC) Disease Control was stated as the facility standard for infection control practices and procedures for the facility. The CDC states in teaching that mold growing in buildings, regardless of type indicates there is a problem with water or moisture that should be immediately addressed. The CDC standards on mold review revealed the following: Exposure to damp and moldy environments may cause a variety of health effects. For some people, mold can cause a stuffy nose, sore throat, coughing or wheezing, burning eyes, or skin rash. People with asthma or who are allergic to mold may have severe reactions. Immune-compromised people and people with chronic lung disease may get infections in their lungs from mold. For people who are sensitive to molds, exposure to molds can lead to symptoms such as stuffy nose, wheezing, and red or itchy eyes, or skin. Severe reactions, such as fever or shortness of breath, may occur among workers (or those living in an environment) exposed to large amounts of molds in a setting. In 2004 the Institute of Medicine (IOM) found there was sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people; with asthma symptoms in people with asthma; and with hypersensitivity pneumonitis in individuals susceptible to that immune-mediated condition. In 2009, the World Health Organization issued additional guidance, the WHO Guidelines for Indoor Air Quality: Dampness and Mold. Other recent studies have suggested a potential link of early mold exposure to development of asthma in some children, particularly among children who may be genetically susceptible to asthma development, and that selected interventions that improve housing conditions can reduce morbidity from asthma and respiratory allergies. The National Institute of Occupational Safety and Health (NIOSH) recommendations follow: The health of those who live, attend school, or work in damp buildings has been a growing concern through the years due to a broad range of reported building-related symptoms and illnesses. Research has found that people who spend time in damp buildings are more likely to report health problems such as these: o Respiratory symptoms (such as in nose, throat, lungs) o Development or worsening of asthma o Hypersensitivity pneumonitis (a rare lung disease caused by an immune system response to repeated inhalation of sensitizing substances such as bacteria, fungi, and organic dusts.) o Respiratory infections o Allergic rhinitis (often called hay fever) o Bronchitis o Eczema Exposures in damp buildings are complex. They vary from building to building, and in different places within a building. Mildew versus mold identification is not typically difficult. Mildew will appear as a white/gray, or tan powdery appearance which is superficial to the surface it is on, making cleaning and eradication easier than mold . Mold is imbedded in a surface and is much more difficult to eradicate, and in some instances impossible, thus the surface must be replaced entirely. Moisture allows indoor mold to multiply more easily on building materials or other surfaces, and people inside buildings may be exposed to microbes and their structural components, such as spores, biologically released chemicals, and fungal fragments. Mold may also produce substances that can cause or worsen health problems, and these substances vary depending on the mold species and on conditions related to the indoor environment. Moisture can also attract cockroaches, rodents, and dust mites. Moisture-damaged building materials can release volatile organic compounds that can cause health problems. Researchers have not found exactly how much exposure to dampness-related substances it takes to cause health problems. Research studies report that finding and correcting sources of dampness is a more effective way to prevent health problems. Therefore, NIOSH developed a tool to help assess areas of dampness in buildings and to help prioritize remediation of problems areas. Legionnaires' and other potentially transmissible waterborne pathogens. Resident symptoms were noted and complained of by 8 Residents on all 4 Resident living units. The complaints ranged from intractable headaches, to sore throats, asthma, shortness of breath, nausea, diarrhea, body aches, and head pressure with nasal congestion. Residents #424, 38, 151, 68, 20, and #127 all complained of these symptoms to 4 different surveyors independently of one another, and without knowing others had complained as well. On 10-7-24 at approximately 3:00 p.m. an interview was conducted with Resident #153 who stated that he had Mold and Mildew in his ceiling, and they keep just painting over it. He pointed out a spot on the ceiling that appeared freshly painted, however there were black spots bleeding through the painted area. Resident #153 stated that the ceiling leaks and then it dries and then when he complains of the black spots They just paint over it, that is not fixing the problem. On 10-7-24 at approximately 3:30 PM an interview was conducted with Resident #424. The surveyor was talking to two nurses at the nursing station and Resident #424 came up the hall yelling someone has got to do something about my room! I am trying to get over pneumonia and I can not get better with that mold in my room. It's keeping me sick. A second surveyor joined and the three went to the Resident's room to inspect it. The ceiling tiles had been recently replaced and the room still smelled of fresh paint, however, black mold dots appeared through the paint behind the door all the way from the ceiling to the floor in varying stages of emergence. Some still under the new paint and some clearly visible on top of it. There were also 2 ceiling tiles which showed the mold coming through them as well. The surveyors continued back to the nursing station to find the Maintenance Director standing in the hallway under an open area in the ceiling where ceiling tiles had been removed. The area above was clearly wet and leaking, and he stated it was from condensation caused by the air conditioning lines, and the insulation around the pipes were soaking wet and slimy. The entire building was experiencing this water leakage with buckets and trash cans in the hallways noted to be under the continuously dripping leaks. Staff members stated this had been an ongoing issue for many months, and it's worse when it rains. Staff complained that they had symptoms too, and it was true what the Residents were saying. During the interview he explained he had just found 22 Blowers in the ceiling which would have kept air circulation above the ceiling moving, so that this would not happen. He went on to say he had been unaware of the blowers existence until he saw one today while changing out a ceiling tile. He stated they had not been operating and he was working on getting them operating. He was asked why the wet insulation was left in the ceiling which would continue to leak until it was removed. He stated that it needed to be removed, and he was working on it, however, if he could get the blowers working that would solved the problem. During the above interview at 4:30 PM the Maintenance Director came to the conference room and stated that he had the one blower working and it was an easy fix, so he was going to get them all working. He was asked if testing had been done in the ceiling and insulation to determine what was growing up there, as mold was already apparent throughout the building, and those blowers would then spread (aerosolize) it into the air. He stated no testing had been done and they were not required to test unless Residents had symptoms. He was informed that he was now aware that residents did have symptoms, and conditions were present for multiple pathogenic organisms to grow. He was asked for the Legionnaires' policy at that time. A review of the Legionnaires' policy revealed that the Infection Preventionist and the Maintenance Director would work together to identify those areas where there was a potential risk for contaminates associated with the development of Legionnella. Those areas include Standing/non-circulating water, scale and sediment build-up, and the presence of biofilm, also known as slime. The policy goes on to say Conduct daily, weekly, monthly, and as needed rounds to inspect and monitor the environment .in order to identify whether conditions are present that could lead to the spread of Legionnella. If conditions are present they need to contact a professional water treatment service in order to obtain samples and send to the lab for analysis. The policy goes on to describe areas in the facility where Legionnella could grow which included the cooling system. The facility staff was aware of the standing water in the leaking ceiling, and the slime on the insulation and should have known that this was an identified area of risk. Further, the policy did not state testing must only be completed after symptoms in the population. That would be counterproductive. Infection control policies are required by regulation to be implemented in order to guide the prevention of the spread of infection and communicable disease. Communal Resident shower room observations on all 4 units were made on 10-9-24 at 2:40 p.m. and were as follows: Unit 1 - Women's shower room- A wet washcloth left in bathroom on floor, floor needed mopping, stains were visible on the floor, black substances in shower area in grout lines and near the floor of shower. Unit 1 Men's shower room - The trash had not been emptied, the shower room smelled of urine, the floor was dirty, shower stalls had black substance in corners and at base of the shower. Unit 2 - Women's shower room - Bariatric shower seat in the stall which had a soaking wet sheet on it stained with brownish yellow stains, the toilet paper holder was broken, shower curtains had black substance on the bottom edge, opened toothpaste and deodorant sitting on the shelf with no name on it, the floor needed to be cleaned. Unit 2 Men's shower room - Rust stains behind a toilet, dirty pajama bottoms and socks were on the floor, strong urine odor was present in the shower room, shower curtains had black stains, and the shower stall floors had black in the grout and the corners. Unit 3 Women's shower room -Rust on a shower chair, chipped broken tiles at the corner of a wall, toilet paper holder was broken. Unit 3 Men's shower room - Oxygen concentrator was in the shower room with no name or room number on it, the light in toilet area was not working, the toilet paper holder was broken, and black and rust colored stains were in the shower area. Unit 4 Women's shower room - A dirty wash cloth was on a chair, the shower area was dirty, especially at the base where wall and floor meet encrusted in a black/brown substance, and the floor needed to be swept and mopped. Unit 4 Men's shower room - A used incontinence brief was in the trash, the floor needed to be swept and mopped, paper trash was on the floor, the shower area was dirty, with a black substance in the corners and in the grout. Pest Control Review: During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, in the kitchen, and in the common areas. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility. Laundry and linen review: Residents on 4 of 4 units complained of lack of linens and personal clothing taking too long to come back from laundry, and wearing clothing for 2-3 days straight. On 10-10-24 at 2:00 PM, an interview was conducted with the director of housekeeping who was asked why there was a shortage of linens, and the laundry was not getting done in a timely manner. She stated that they are doing the best they could with 1 washing machine. When asked if that is all the facility has for 180 beds, she stated that the other 2 washers were broken. She stated that the laundry staff are working 7 days a week with the one washer, and they must try and keep up with all the linens and facility laundry as well as Resident personal clothing. Facility maintenance records indicated that on 9-30-24 Washer 1 & 2 down and waiting on replacement for #1. As of the close of survey on 10-11-24 the washing machines had still not been repaired nor replaced. Kitchen Review: On 10-4-24 at 12:45 PM during the active lunch service, the dining room and kitchen inspection was continued. 14 hospital beds were stacked haphazardly on the right side of the dining room close to the kitchen door. 3 of those beds were new, and 11 were old, used, and dirty, commingled with the new beds. The old used dirty beds were encrusted with hair, dust, brown greasy substances, what looked like food debris and cracker crumbs, rust, mold, chipped wood particles, and the head boards and foot boards were separating and broken. Residents were in the dining room eating lunch and being fed at tables in close proximity to the beds. Two CNAs were in the dining room assisting Residents at the time and both stated those beds have been in here for months. They are using this as a storage room and it's dangerous, they are nasty, and someone could fall. Two dead cock roaches were noted in the kitchen's dry food storage area and one in the kitchen near the 3-compartment sink. The floor in the dry storage area had paper trash and food debris on the floor. The floor was visibly stained, and the dishwasher was found to be inoperable. On 10-8-24 an interview was conducted with Other Employed #5 who stated that he wasn't exactly sure how long the dishwasher had been down. He was asked to research and provide a timeline. The kitchen staff were noted to be using Styrofoam take out containers for food service during the lunch and dinner meals. When questioned Other Employee #9 stated the dishwasher has been broken for weeks maybe months now. He stated, we have a new one it's just not hooked up yet. Food temps on 4 of 4 Resident living units was investigated, temperatures were taken, and found to be between 80 - 100 degrees Fahrenheit. On all 4 units the Residents complained of continued lukewarm, or cold food. Many Residents stated that since they started using Styrofoam boxes the food is cold. A review of the work orders and emails from the Maintenance Director to the facility corporate office revealed the dishwasher had been inoperable since 8-9-24. Review of those emails and communications follow below: 8-6-24 - dishwasher was purchased (evidenced by email from corporate purchasing office to maintenance). 9-24-24 - dishwasher arrived at facility (as evidenced by email between maintenance and supplier). 10-10-24 -during the survey, the dishwasher installed and running as of breakfast meal. On 10-11-24 at the end of day debriefing the facility Administrator, Director of Nursing and other corporate staff were made aware of the concerns. They stated they had no further information to provide prior to survey exit.

Based on staff interview and facility documentation review, the facility staff failed to devise a facility-specific facility assessment The Findings included: On 10/9/2024 at 4:00 p.m., the facility Administrator was informed of the plan to review the Facility Assessment with the Administrator on 10/10/2024. A copy of the Facility Assessment was given to the surveyor. On 10/10/2024 upon arrival at the facility, the survey team was informed that the Administrator was no longer working at the facility as of the evening of 10/9/2024. The Regional [NAME] President of Operations was serving as the Acting Administrator. On 10/10/2024 at 11:15 a.m.,review of the facility assessment was conducted with the Regional Director of Operations (Acting Administrator). Review revealed the assessment was not tailored to the facility. The facility assessment was 22 pages in length. The assessment utilized a template but did not answer the questions as they related to the facility. Examples of non-compliance included: The facility assessment was dated 9/3/2024. There was no documentation that the assessment was reviewed by the Quality Assurance Process Improvement (QAPI) Committee. The date for review by the QAA/QAPI committee was blank. On page 18/22, 3.10, the answer was written about monthly meetings, daily rounds and an open door policy for staff, residents and families to speak with the Administrator. There was no mention of a compliance hot line, grievance process, Resident Council, Family Council or QAPI. Under # 3.11 List of contracts was written All contracts are kept in the Administrator's office and/or Medical Records office. There was no description of the facility's process for overseeing the services and how the services would meet the needs of the residents. Per the Regional consultant, Medical Records actually keeps them in the Medical Records office. The Regional Consultant stated the facility assessment did not list the contracts, memoranda of understanding or agreements with third parties. On page 19/22 -3.12-List health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The only answer written was :The facility EHR (electronic health record) is PointClickCare. The assessment did not address how the facility would securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. There were concerns identified during the survey regarding residents not receiving access to their medical records upon request and copies were not obtained within required time frames. The Acting Administrator stated, We have a back up of the EHR (Electronic Health Record.) We have systems in place but they are not in this assessment. The facility assessment did not include an evaluation of the physical environment necessary to meet the needs of the residents. It did not address how the facility needed to be equipped and maintained to protect and promote the health and safety of residents. There was only one working washing machine in the facility at the time of survey. According to interviews conducted with the Housekeeping staff, the other washing machines had been inoperable for at least two months prior to survey. During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings that throughout the facility assessment, there were only generalizations but no tailoring of the assessment to the facility. The Acting Administrator stated the facility assessment needed more details added to it to make sure it reflected the facility. No further information was provided prior to survey exit.

Based on observation, staff interview, facility documentation review, the facility staff failed to ensure the facility was administered effectively to maintain the highest practicable well being of each resident. The findings included: The facility had a multi-system failure to include deficient practices including environmental services, sanitary and a safe building and dining, infection control practices, medication storage and administration, and resident abuse. These issues affected the quality of life of the residents in the facility. During the survey, investigations revealed the facility had issues involving multiple systems. There were issues involving environmental services to include inadequate laundry services with only one working washing machine for several months. Residents were complaining of not having adequate linens for their beds, not being able to get clean gowns , not getting their personal clothing washed and returned in timely manner. Staff members were observed while performing duties and providing care. Some staff members were overheard apologizing to other staff members for using the last gowns during incontinence care rounds. Staff members were interviewed by surveyors who stated there had been issues with the laundry for months. Inspection of the kitchen revealed unsanitary conditions including rodent activity, roaches and an unsanitary ice machine. Resident expressed concerns about the food from the Dietary department. There were issues with resident to resident abuse where the facility staff did not protect other residents from the perpetrator. Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 10/8/2024-10/11/2024. The Maintenance logs, Pest control logs were reviewed by the survey team. Review of the Resident Council minutes and Grievance logs revealed the facility's administration was aware of issues/concerns voiced by residents and families. The issues continued for several months without resolution. On 10/9/2024 at approximately 4:20 p.m., an interview was conducted with the Administrator who stated he was aware that the washing machines were not working. He stated he had been employed at the facility for 4 weeks and recognized there were issues with the washing machines. The Administrator stated he had ordered parts but received the wrong parts for one washing machine. He stated he was aware of the impact on the amount of linen for the residents. During the end of day debriefing on 10/9/2024, the Facility Administrator, the Regional [NAME] President of Operations, Administrator in Training, two Regional Nurse Consultants (Corporate-1 and Corporate-2) and Director of Nursing were informed of the findings of the multi-system failures that were identified by the survey team. On 10/10/2024 upon arrival at the facility, the survey team was informed that the Administrator was no longer working at the facility as of the evening of 10/9/2024. The Regional [NAME] President of Operations was serving as the Acting Administrator. During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings. The Acting Administrator stated he would address the issues identified by the survey team. No further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to serve food that is palatable, attractive, and an appetizing temperature for Residents on 4/4 units. The findings included: The facility staff was utilizing Styrofoam take out containers to serve food due to an inoperable dishwasher from August 9, 2024 - October 10, 2024. The Residents of all units complained about food being cold due to it sitting on the carts in the hall before being served. On 10/7/24 during the kitchen inspection it was noted that all food temps were within safe and acceptable ranges. food was plated in the Styrofoam containers and placed on the cart to send to the various units. Once arriving on the units the food was distributed by the CNA's. The time the carts sat on the floor before trays were delivered ranged from 10-20 minutes. Residents on 4/4 units complained of Lukewarm or Cold food. Many Residents stated that since they are using Styrofoam the food is cold. A review of the work orders and emails from maintenance to corporate revealed the dishwasher has been down since 8/9/24. Residents complained the portions were small and the food was not good. The following are excerpts from the Resident council indicating that the repeated food concerns have gone unaddressed by the Administration. 4/24/24 - Oatmeal watery, some residents getting trays not enough food not getting coffee o every meal not getting food that is on the ticket, not getting alternative requested. 5/29/24 Bring back dinner in dining room, would like hot tea instead of coffee, who do you tell you want alternative meal? 6/26/24 - Diets not being followed, tickets not matching trays, want more vegetables and fruits, condiments and decaf coffee, Chicken is hard over cooked difficult to eat, French fries/potatoes are not cooked all the way, food is cold. 7/23/24 - residents' would like bigger breakfast portions, more fresh fruit, diets not being followed / trays not matching ticket, decaf coffee, English muffin/bread not being toasted. 8/28/24 - portions small for all meals food cold no flavor more seasoning more variety. 9/24/24 - Small potions during breakfast / dinner meals, want more fruit, only getting a half a sandwich for snack, more variety of meals. On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on four of four units and some common areas, which resulted in Substandard Quality of Life. The findings included: 1. Upon entering the facility on 10/4/24 at approximately 10:20 AM, water was observed leaking from the ceiling in the lobby. During the initial tour of Unit one at approximately 11:15 AM, the corridor was with much debris, many dark spots and a bed near the rear exit door. room [ROOM NUMBER]'s floors were soiled, the trash can was without a liner and a used glove was observed on the floor. room [ROOM NUMBER] was with strong odors, straw papers, sugar packages and other debris was also observed on the floor. In room [ROOM NUMBER] pungent odors was in the room and the toilet was observed to be clogged. In room [ROOM NUMBER] soiled linen was observed beneath the sink and many black splatter marks were on the floor. In room [ROOM NUMBER] the privacy curtain for the A bed was fifty percent covered with a dark brown substance. On 10/7/24 at 2:00 PM a Resident Group meeting was held with the President, [NAME] President, four resident who attends the group meeting regularly and one who does not attend the regularly. It was a consensus of all attending the meeting that their home was not sanitary, comfortable, and homelike. A review of six months of the Resident Group minutes revealed that the residents voiced the following concerns multiple times regarding the call bells are not answered and often they are just turned off, their rooms/floors not getting cleaned, trash is not removed from the rooms on the weekends, toilet paper is not replenished, ceiling tiles over resident beds are frequently wet and sometimes their personal belongings become wet because of the wet tiles. Residents in the group meeting also stated roaches and water bugs were seen frequently in their rooms especially when the lights are turned off. Resident representative from units 1, 2 and 3 stated that the roaches are also seen climbing the walls and they fly onto the TV screens. One resident stated when she opened the Styrofoam box to consume her lunch on 10/8/24, a roach was observed crawling on the food and she shut the top and did not eat because of the abhorrence. The consensus of all of the resident were they are tired of it and their desire is for action to be taken immediately. An interview was conducted with Resident #6 on 10/9/24 at approximately 12:25 PM. Resident #6 stated often there are constant strong urine odors on unit 1, the trash can in her room is without liners and waste is seen falling onto the floor. Resident #6 further stated the bathrooms are not cleaned and the floors are not mopped daily. Resident #6 pointed to the dark areas on the floor in her room and in the corridor outside of her room. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information. 40026 2. The facility staff failed to provide a sanitary ice machine, adequate pest control, palatable meals, and timely laundry and linens to meet the needs of the Residents. On 10/7/24 during the kitchen inspection there were 2 dead roaches noted in the dry storage area and one in the kitchen near the 3-compartment sink, and the floor in the dry storage had paper trash and some food debris as well as needing to be mopped, there were visible stains on the floor. On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew. During the entire survey there were fruit flies as well as large flies noted on all units and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building on a monthly basis however the pests continue to be visible. On 10/7/24 at approximately 3:00 p.m. an interview was conducted with Resident #153 who stated that he had Mold and Mildew in his ceiling, and they keep just painting over it. He pointed out a spot on the ceiling that appeared freshly painted, however there were black spots bleeding through the painted area. Resident #153 that the ceiling leaks and then it dries and then when he complains of the black spots They just paint over it, that is not fixing the problem. Food temps on all units ranged between 80-100 degrees, Residents on 4/4 units complained of Lukewarm or Cold food. Many Residents stated that since they started using Styrofoam the food is cold. A review of the work orders and emails from maintenance to corporate revealed the dishwasher has been inoperable since 8/9/24. Residents on 4/4 units complained of lack of linens and personal clothing taking too long to come back from laundry, On 10/10/24 at 3:00 pm, an interview was conducted with the director of housekeeping who was asked why there was a shortage of linens, and the laundry was not getting done in a timely manner. She stated that they are doing the best they can with 1 washing machine. When asked if that is all the facility has for 180 beds, she stated that the other 2 washers are broken. She stated that they are working 7 days a week with the one washer they have to try and keep up with all the linens and facility laundry as well as Resident personal clothing. On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 40711 3. Unit 1B During the initial tour on 10/01/24 at approximately 4:30 PM., on unit 1 B across from the laundry room in the hallway were 3 large trash bags on the floor, filled with clothing. A rolling laundry cart was also observed in the hallway with approximately 16 items hanging from it. The items observed hanging were shirts, pants and 1 coat. On 10/01/24 an interview was conducted on 10/01/24 at approximately 4:45 PM., with the House Keeping /Laundry aide (Other Staff Member/OSM) #11 concerning the above issue. OSM #11 said that they didn't have enough room inside the laundry room, so they were keeping additional laundry items on the hall. Unit 2B, room [ROOM NUMBER] On 10/08/24 at approximately 10:28 AM., an observation of room [ROOM NUMBER] on unit 2B was conducted. Ceiling tiles in the left corner of room appeared wet looking with brown stains. The roommate, Resident #3 said they changed the tiles on yesterday and it's staining already. Unit 1A, room [ROOM NUMBER]A On 10/07/24 at approximately 3:28 PM., an observation was made of room [ROOM NUMBER]A on unit 1A. Cobb webs were observed on the wall near the resident's bed, [NAME] stains were observed on 2 ceiling tiles, the curtains hanging at the window also had a brown substance on them. The resident appeared irritated and angry due to his room being nasty and filthy. Resident #371 also said that he's afraid to touch things due to the filth. He also said that They need to burn this place down. On 10/07/24 at approximately 3:35 PM., Registered Nurse (RN) #3 entered the resident's room. RN #3 reassured the resident concerning his room condition. On 10/07/24 at approximately 3:41 PM. The maintenance tech (Other Staff Members/OSM) #13, entered the resident's room with a ladder and started removing and replacing 2 ceiling tiles that had a black substance on them. OSM #13 said that the discoloration is coming from condensation of the chiller pipes from heating and air unit. On 10/11/2024 at approximately 6:00 p.m., the above findings were shared with the Acting Administrator in Training, Director of Nursing and the Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 49917 Surveyor: [NAME], [NAME] 4. Unit 3: a. In room [ROOM NUMBER] small, flat black spots with a powdery texture was observed behind the bedroom door extending toward the bed. Resident #424 was observed in bed and an interview was conducted with her on 10/8/24 at 12:45 PM. The resident stated the black spots have been on the wall for a while. Resident #424 also stated she believes the black spots are the reason she is not feeling well and cannot get well. The resident's admission Minimum Data Set Assessment (MDS) dated [DATE] coded the resident Brief Interview for Mental Status (BIMS) score as 15 out of 15. This indicated her daily decision-making ability was intact. On 10/8/24 at 4:00 PM two maintenance personnel were observed cleaning the wall that was covered in small, flat black spots with a powdery texture in room [ROOM NUMBER]. b. On 10/4/24 at 12:18PM a live cockroach was observed outside of room [ROOM NUMBER] in the hallway on Unit 3. The Director of Nursing (DON) and Maintenance Director were notified. The Maintenance Director was observed catching the pest in a Styrofoam cup and disposing the pest.

Based on information obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action and/or a rationale for not taking action to the Resident Group grievances. The findings included: On 10/7/24 at 2:00 PM a Resident Group meeting was held with the President, [NAME] President, four resident who attends the group meeting regularly and one who does not attend the regularly. It was a consensus of all attending the meeting that their grievances are not acted upon even when they had been voiced multiple times. The groups stated they had never received communication from the administrative staff regarding any of their grievances. The group's President stated that the Activity's Director (AD) assists with the meeting and she ensures the departments are aware of their grievances but she has her assistant act as a liaison between the residents and the staff. A review of six months of the Resident Group minutes revealed that the residents voiced the following concerns multiple times; medication are not administration as ordered, linen are not changed as needed, unprofessional of nursing staff, a desire for a variety of foods for meals, meal portions are too small, resident shopping trips are desired, rooms/floors not getting cleaned, trash not removed from the rooms on the weekends, toilet paper not replenished, call bells not answered or just turned off, water bugs in rooms, ceiling tiles over resident beds wet as well as their personal belongings, showers not given, dinner in the dining room wanted, personal laundry not returned but receiving others persons laundry, and episodes of having only 1-2 Certified Nursing Assistants on the unit. An interview was conducted with the AD on 10/10/24 at approximately 12: 48 PM. The AD stated she does present the group grievances to the department heads during the morning meetings but she has never received feedback to their grievances to report back to the group. The AD also stated she was not aware a response, action and/or a rationale if applicable were requirements. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20 and #521, ) in a survey sample size of 55 residents. The findings included: The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain. Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on 11-14-19. Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture. Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on 7-18-23. Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma. Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing. On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey. While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now. On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order; On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented. On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20. On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair. On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521. On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room. (Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior. On 9-23-24 a psychiatric consultation was ordered. It was never obtained. On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time. On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back. Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day. During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below: 1. Nine days after admission on 9-13-24 for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident. 2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change. 3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present. A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 10 were provided by the Administrator, and 9 of the 10 followed the standardized format and documentation was provided for notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24. The tenth alleged FRI involving Resident #68, and Resident #521 was incomplete and contained 7 documents. The documents included four statements from staff alleging abuse to Resident #68. One of the staff statements alleged repeated abuse allegations documented from 9-17-24 through 9-20-24 and for over a week. Also included was a fifth documented statement from the Resident alleging verbal and physical abuse. The sixth document was a written synopsis by the Administrator which was not signed, and only described the initial abuse allegation for Resident #68. It did not include Resident #20's abuse by Resident #521, the room changes, nor the incident with the unknown neighbor after being installed in the third room. The seventh document was a response from APS stating that the report to them did not meet validity criteria required to initiate an APS investigation. The Administrator's synopsis stated that Resident #68 was asked what was triggering Resident #521's behavior, which implies that the victim is the causative factor, or that the victim is able to psychologically assess her room mate who only spoke Spanish, and Resident #68 only spoke English. The synopsis also stated that Resident #521 would be moved to a room with someone more compatible. The Administrator's synopsis goes on to describe Resident #521 as having a BIMS score of 3 points out of a possible 15 points indicating severe dementia, which was incorrect. The Resident's BIMS score was 12. The state agency VDH/OLC did not receive the fax sent by the Administrator and review of the fax number revealed it to be in error. All of the documents were completed on 9-20-24, the initial day of assault reporting on Resident #68, and #521. There was no report, investigation, nor protections for Resident #20 after her multiple assaults on 9-21-24, nor for the unknown Resident on 9-22-24 after a third room was inhabited by Resident #521 in less than 48 hours. The Administrator was interviewed on 10-8-24, and was asked why the document from 9-20-24 was not completed as the other FRI's were, his response was that he had only been here 4 weeks, and I am not required by law to use the FRI document, and I have all of the investigation, and here it is, this is the initial and 5 day follow up all in one. The synopsis was simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up, and it was not signed. Included in the packet were 3 copies of a fax cover sheet To: VDH/APS/[NAME] From: (first name & last name first letter only) the Administrator, documenting that the fax contained 2 pages. The fax was sent on 9-20-24, at 2:24 PM, 2:26 PM, 2:27 PM respectively. The Administrator stated he wrote the synopsis, and sent the fax, and that in error he didn't sign it. This indicates the only 2 sheets allegedly sent were the fax cover sheet and the synopsis which was not signed, and did not state it was an initial FRI, nor a 5 day follow up. At that time the Administrator was informed that the investigation was incomplete as no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. The other 2 Resident's who were later involved were not protected from abuse and added to the initial investigation, and a 5 day follow up as required by law would have captured them as well. The Administrator was made aware that no second FRI and investigation was ever conducted after further abuse from Resident #521 on Resident #20, and the unknown Resident. Residents were not protected from a known abuser. Further they had not implemented their policies on abuse. The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections. Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521. Resident #521 was then placed with Resident #20 who was not protected and was abused. Resident #521 was moved again and went to a third unknown Resident's room to abuse. The allegations were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing. No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them. On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.

Based on observation, resident interview, staff interviews, clinical record view and facility documentation review, the facility staff failed to ensure 1 of 3 residents (Resident #2) in the survey sample was provided adequate supervision during incontinence care to prevent an accident hazard that resulted in a fall with fractures which constitutes harm of past non-compliance. The findings included: Resident #2 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) an annual assessment with an Assessment Reference Date (ARD) of 11/19/19 coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #2 total dependence of two with toilet use, personal hygiene and bathing, total dependence of one with dressing, extensive assistance of two with bed mobility for Activities of Daily Living (ADL) care. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both sides for upper and lower extremity. The MDS prior to Resident #2's right femur and left tibia fracture was a quarterly assessment with an ARD date of 05/07/19 coded Resident #2 total dependence of two with transfer and toilet use, extensive assistance of two with bed mobility, extensive assistance of one with dressing and hygiene. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both sides for upper and lower extremity. The review of Resident #2's comprehensive care plan with a revision date of 08/12/19 documented Resident #2 has ADL self-care performances deficit related to (r/t) disease progress ([MEDICAL CONDITION]). Some of the intervention/approaches to manage goal included two assist with ADL. Resident #2's care plan also included at risk for falls r/t deconditioning. Some of the intervention/approaches to manage goal included two assist with transfer, anticipate, and meet the resident's needs. An interview was conducted with Resident #2 on 02/11/20 at approximately 2:30 p.m. Resident #2 stated the Certified Nursing Assistant (CNA) #1 Was giving me a bath or changing me, I can't remember which, but she turned me over in bed; I tried to hold on but I couldn't, I fell on the floor. Resident #2 stated, When I fell out of the bed, my legs bent under me; I was on the floor sitting on my knees (like in a praying position). Resident #2 was asked, Who assisted (CNA #1) with your ADL care the day you fell out of the bed she replied, No one, the CNA was by herself. Resident #2 said now they always use two people when providing my care. A phone call was placed to CNA #1 on 02/11/20 at approximately 2:48 p.m. CNA #1 was assigned to Resident #2 on 08/05/19 (the day of her fall) a message was left, however the CNA never called back. On 02/11/20 at approximately 3:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 was assigned to Resident #2 on 08/05/19; day of her fall. The LPN said she heard CNA #1 yelling for help. The LPN said she ran into Resident #2's room, observed resident on the floor; yelling out in pain. The LPN said she asked CNA #1 what happen, the CNA replied, I was providing care to Resident #2, I rolled her over the wrong way and the next thing I know, she was on the floor. The nurse said she completed an assessment and thought it was best to send Resident #2 to the hospital because she was having a pain level of 10/10 to her right leg. The LPN said the right leg looked out of place. She said Resident #2's right leg/knee was red and swollen but would not allow nurse to touch her right leg. The LPN was asked, If a person is a two person assist with bed mobility and toilet use, how many staff member should have been providing care to Resident #2, she replied, Two staff members. The LPN was asked, What is the purpose for using two people with bed mobility and ADL care she replied, To ensure the safety of the resident; so when the resident is repositioned/turned in bed; they don't fall out of bed. An interview was conducted with Registered Nurse (RN) #1 on 02/12/20 at approximately 12:00 p.m. RN #1 said she provided education to the CNA's related to bed mobility and providing ADL care in bed. She said an action plan was written to make sure to make all residents received the correct number of staff members while providing ADL care in bed. The RN said spot checks were made while staff were providing ADL to make sure the required staff was present with bed mobility and ADL care. Review of the clinical nurse's notes (SBAR) evidenced an entry dated 08/04/19 documented the following: -Situation: Resident #2 had a witness fall. -Background: History of fall. -Assessment: Resident #2 complained of (c/o) pain level 10/10 to her right knee. Resident #2's right knee was swollen, red and tender. -Recommendations: Frequent Monitoring. Review of Post fall assessment dated [DATE] documented the following: -Information: Resident #2 had a fall on 08/04/19, while receiving ADL care from Certified Nursing Assistant (CNA) #1. Resident #2 fell off the bed. -Action following fall: Vital Signs (VS) obtained, neuro checks started, 4 staff members assisted getting Resident #2 off the floor. Review of clinical note with an entry note written by CNA #1 on 08/04/19 revealed the following documentation, While providing incontinent care, I went to turn Resident #2 on her right side; her right leg slid off the side of the bed. I was trying to pull her back but her left leg slid off also. I gently assisted Resident #2 to the floor. Resident #2 screamed; her right leg was under her left, I screamed for help. An interview was conducted with the Director of Nursing (DON) on 02/12/19 at approximately 12:15 p.m. She said once we (nurse consultant and myself) reviewed the incident report of Resident #2, we realized a significant injury had occurred. The DON said immediate action was taken to ensure the safety of Resident #2 and all the other resident's in the facility. The DON stated, I wanted to make sure the staff were using the correct number of staff members while providing ADL care to all residents while they when in bed. The DON stated, CNA #1 said she did not realize Resident #2 required two people with ADL care and bed mobility. The DON said the MDS department went through every resident's MDS (under section G), so we would know exactly who required one or two assist from staff. She said the unit managers did spot checks while staff were providing ADL care to ensure the correct number of staff were present. The DON present the following Corrective Action Plan for Resident #2's fall on 08/04/19. Corrective Action Plan: documented the following: Problem - Fall with injury during care. 1. Staff member involved educated and corrected in the corrective action process. Revised care plan for resident involved. 2. Review current residents MDS section G for bed mobility to determine staff assistance needed. 3. Revise care plan as needed to reflect those residents needing two person assist with bed mobility and place two person assist sign in patient room. 4. Educate nursing staff on: ensuring they are utilizing appropriate staff support for bed mobility and two persons assist sign above the bed. 5. Random weekly observations to ensure sign is in place, staff rendering bed mobility have appropriate staff support and care plan is accurate. 6. MDS to notify nursing management of new admission residents, and significant change residents that are coded as two persons assist with bed mobility weekly at quarterly meeting. 7. P[NAME] with an effective date of 08/30/19 but nursing continued with audits until 12/27/19 to ensure staff continued to follow. 8. Results of audits will be brought to Quality Assurance (QA) meeting for review. Review of Employee Correction Action implement to CNA #1 on 08/06/19 included the following: -Verbal Counseling Confirmation. -Describe specific facts: Failed to ensure patient was properly position in bed prior when turning to side to perform ADL care resulting in a fall. -Describe the impact the infraction had on the patient: Patient sustained a fall with injury as a result for not positioning properly and not ensuring for a second person to assist. -Employee comments: I realize that if it says two people that meant two people to turn as well as lift. On 02/12/20, a series of observations were made between 9:20 a.m. to 10:00 a.m., on random resident rooms to observe adequate staff providing ADL care. On 02/12/20 at approximately 11:00 a.m., the education for the Corrective Action Plan r/t Resident #2's fall with major injury was reviewed. The QA meeting held on 10/25/19 contained documentation related to reported fall with injury and any action plans that were completed during the quarter. Review of Resident #2's clinical nurse's note evidenced an entry dated 08/05/19 at 11:28 a.m. The nurse documented the following: Summary of witness fall: During ADL care, resident was noted to be sliding off the bed into a standing position, resident stated that her legs started to give out and resident was lowered to the floor by staff. Resident #1 c/o right knee pain; resident was sent to the emergency room (ER). Resident was admitted related to fractures. Review of (name) local hospital discharge summary for Resident #2 documented the following on 08/12/19: -admitted on [DATE] and discharged on [DATE]. -Problem managed during hospitalization : admitted to (name of hospital) after fall at nursing home resulting in mildly displaced supracondylar femur fracture and left ankle - displaced distal tibial metaphyseal fracture. Discharge hospital orders for Resident #2 on 08/12/19: -Weight bearing: (non weight bearing) to bilateral lower extremity. -Given conambulator status, closed injuries, mild displacement - would recommend closed management. -Left lower extremity into well-padded posterior splint or both with padding, watching for skin breakdown. -Right lower extremity in knee immobilizer in extension. A briefing was held with the Administrator, Director of Nursing and Nurse Consultant on 02/12/20 at approximately 12:30 p.m. The facility did not present any further information about the findings. Definitions: -Fracture is a break, usually in a bone. If the broken bone punctures the skin, it is called an open or compound fracture. Fractures commonly happen because of car accidents, falls, or sports injuries (medlineplus.gov). -Muscle weakness is reduced strength in one or more muscles (https://medlineplus.gov/ency/article/ 5.htm). Compliant deficiency; past non-compliance.

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure 2 of 29 residents in the survey sample were free from a significant medication error, Resident #29 and #5. 1. The facility staff administered 100 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered by the physician to Resident #29. The resident was subsequently admitted to the hospital for two days for close supervision and monitoring. Following the administration of the [MEDICATION NAME] the resident became nauseated and was administered 12.5 mg of [MEDICATION NAME] (for nausea) which she is allergic to. 2. The facility staff failed to administer the physician ordered [MEDICATION NAME] 50 mg from 5/18/13 through 7/30/13 for the treatment of [REDACTED]. The findings include: 1. A Facility Reported Incident (FRI) was received in the State Agency office on 9/19/12 indicating Resident #29 had received an incorrect dose of [MEDICATION NAME], which exceeded the amount prescribed. The resident was subsequently transferred to the emergency room and was admitted for further care and monitoring. Resident #29 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was listed as allergic to [MEDICATION NAME] (an antiemetic for nausea) in the clinical record and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] is listed as causing GI (gastrointestinal) distress for Resident #29 in the hospital physicians admission history and physical dated 9/21/12. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 6/11/13 assessed the resident as scoring a 15 of 15 on the BIMS (Brief Interview for Mental Status). The resident required extensive assistance of two staff for bed mobility and transfers. The resident was assessed as receiving a scheduled pain medication regimen in the last 5 days, and antidepressants in the last 7 days. The facilities final investigation report dated 9/26/12 evidenced that on 9/18/12 the resident had been "over-medicated". On 9/18/12 Resident #29 was receiving her routine 9 am medications, when licensed practical nurse(LPN) #10 administered 100 mg of extended release [MEDICATION NAME] (narcotic pain reliever) instead of the physician ordered 15 mg. This medication error was identified during the 3 P.M., change of shift when counting the narcotics. The physician, the director of nursing (DON) and supervisor where all notified at this time. The resident was immediately assessed and found to be lethargic and easily aroused with verbal stimuli. The physician in the building assessed the resident and an order for [REDACTED]. The resident also presented with nausea and orders were received to administer [MEDICATION NAME] to relieve it. Due to the unavailability of the [MEDICATION NAME] the order was changed to 12.5 mg of [MEDICATION NAME] by mouth. The resident was sent the emergency room , received additional [MEDICATION NAME] and was admitted for close monitoring for two days. As a result of the medication error LPN#10 was suspended, later terminated and reported to the board of health professionals. Further review of the employee file for LPN#10 evidenced there had been 3 other recent incidences involving medication errors. The hospital discharge summary dated 9/20/12 evidenced the patient active hospital list as: *Accidental medication overdose of [MEDICATION NAME] The resident was admitted to the hospital and neurochecks were observed every 2 hours. Diagnostic blood work was conducted. The physician documented after a "reasonable time for washout of the long acting [MEDICATION NAME] has passed she will return to the SNF (skilled nursing facility)". On 8/1/13 at 3:25 P.M., the resident was interviewed and asked about the aforementioned incident. She stated, "I remember every second of that day...15 mg was all I was supposed to be getting and somehow I was given 100 mg...I started feeling bad...I didn't eat lunch...I was sick to my stomach...I felt like I couldn't move anything...I sat here on the edge of my bed...I turned on my call bell and the CNA (certified nurse aide) came in and I said, I am so sick give me a bucket...the longer I sat the worse I felt...they took me to the hospital...I don't remember them taking me there...my sister was there...I could remember them doing stuff to me but I was out of it...for 2 days...It was scary...I felt like I was dying...it effects me still now mentally...just talking about it...like I want to breakdown and cry...that was a terrible thing to have happen to me..." The resident was asked about her allergy to [MEDICATION NAME]. She stated, "I throw up, it makes me nauseated and I feel like my throat is closing up". I threw up after the [MEDICATION NAME] was given to me...my throat felt like it was closing up...I wasn't aware I was given [MEDICATION NAME] was scary...just like you can't breath...after I said I can't breath-some one thought about the oxygen...thank goodness it didn't leave me a vegetable..." Review of the nurses notes late entry dated 9/19/12 for 9/18/12 reads: "At approximately 8:15 pm Nurse supervisor reported 02 sats (saturation) of 64-66% O2 4l/nc (nasal cannula)...on call advised to send to ER for eval d/t O2 sats...Upon findings of noting allergy to [MEDICATION NAME] resident was assessed, noted to have no known reaction...sister reported the reaction resident has to this medication was increased vomiting, resident was noted to have no episodes of vomiting from time of administration at approximately 5:30pm-8:15pm." 2. The facility staff failed to administer the physician ordered [MEDICATION NAME] 50 mg from 5/18/13 through 7/30/13 for the treatment of [REDACTED]. Resident #5 is a [AGE] year old originally admitted to the facility on [DATE] with a readmission date of [DATE]. The resident's [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a process in which neurons in the cerebellum - the area of the brain that controls coordination and balance - deteriorate and die. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 6/11/13 assessed the resident as scoring a 15 of 15 on the BIMS (Brief Interview for Mental Status). The resident required limited assistance of 1 staff for bed mobility, transfers and dressing, and extensive assistance with toileting, personal hygiene and bathing. Resident #5 required supervision with set-up assistance for eating. Review of the clinical record evidenced a neurologist consult dated 4/30/13. The request for the consultation was listed as heaches and ataxia. The report findings were; profound gait/ sensory ataxia. Under [DIAGNOSES REDACTED]. Occipital Neuralgia. Under recommendations was listed; 1. GON (greater occipital nerve) block today 2. Stop [MEDICATION NAME] 3. Increase [MEDICATION NAME] to 50 mg BID (twice a day). The previous dose of [MEDICATION NAME] was 50 mg once a day. The Specialized Long-term Care Nursing Handbook 2008, pg 95 list [MEDICATION NAME] as a beta-blocker. According to Johns Hopkins Medicine at www.hopkinsmedicine.org the treatment for [REDACTED]. Beta-blockers may reduce the prominence of some cerebellar tremors. Ataxia symptoms include: Gait/posture abnormalities, fine motor incoordination such as difficulty with handwriting, cutting food, opening jars, buttoning clothes, sewing, typing, speech and swallowing difficulties;visual abnormalities;increased fatigue;cognitive and mood problems;personality and mood disorders, such as increased irritability, anxiety, and depression On 5/4/13 the resident was admitted to the hospital for a change in condition with [DIAGNOSES REDACTED]. The resident remained in the hospital from 5/4/13 and discharged back to the facility on [DATE]. The hospital discharge paperwork included a Discharge Summary and Discharge Instructions. The discharge summarized the hospital course and included medications to be taken; it did not list the [MEDICATION NAME]. The discharge instructions listed to start taking the [MEDICATION NAME] 50 mg twice a day as previously ordered by the neurologist. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7/31/13 at 12:55 P.M., the resident was interviewed. She had just returned from a neurologist appointment. When asked how the appointment went she stated, "I have tremors, they have me on meds for that...the tremors have gotten worse...the neurologist told me,"Your more nervous". "I have trouble feeding myself because I shake so much...I prefer to eat in my room because I don't want to embarrass my self in front of others so I don't eat in the dining room". On 7/31/13 at 3:20 P.M., the unit 2 manager was interviewed. The medication error for the [MEDICATION NAME] discovered by this surveyor during chart review was shared. After review and consultation with the nurse practitioner (NP) the unit manager returned to the surveyor and stated, "The [MEDICATION NAME] will be started today". He indicated the NP had reviewed the list of medications on the hospital discharge summary and did not look at the list of medications to be started on the hospital discharge instructions. As a result, the [MEDICATION NAME] medication order was missed and the medication was not administered from 5/18/13 through 7/31/13. On 8/1/13 at 11:50 P.M., the neurologist was interviewed over the phone. She was asked if she was aware Resident #5 had not been receiving the [MEDICATION NAME] as ordered from 5/18/13 through 7/31/13. She said she was not aware, and stated, "I basically write the scripts, it's the facilities responsibility to administer the medication as ordered." When asked if she had noted a change in the resident's tremors during the follow up appointment on 7/31/13 she stated, "I didn't have a chance to examine her (Resident #5)...I did a quick procedure (the GON)...we may have seen some improvement if she would have taken the [MEDICATION NAME] as ordered..." On 8/2/13 at approximately 3:30 P.M., the above findings was shared with the administrator, the director of nursing, the corporate nurse and the assistant director of nursing services.

Based on observation, clinical record review, staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to ensure each resident received the necessary care and services to attain and maintain the highest physical and mental well being for 9 of 41 residents in the survey sample, Resident's, #28, #37, #29, #8, #24, #33, #9, #19 and #1. The findings include: 1. The facility staff failed to ensure the result of a hemoglobin and hematocrit level was received and a physician ordered transfusion was administered for Resident # 28. 2. Facility staff failed to assess, monitor, and report weight gain for Resident #37 which resulted in hospitalization for [MEDICAL CONDITION] exacerbation. 3. Facility staff failed to immediately administer a physician ordered antibiotic contributing to the expiration of Resident #29, according to the attending physician. 4. The facility staff failed to provide Resident #8 with a physician ordered psychiatric consult. 5. In the course of a complaint investigation it was found the facility staff failed to ensure PRN (as needed) [MEDICATION NAME] (narcotic pain medication) was available for administration to manage Resident #24's chronic lower back pain. 6. The facility staff failed to ensure appropriate care was provided for Resident #33 immediately following a fall with suspected right hip injury. 7. The facility staff failed to obtain physician ordered lab for Resident #9. 8. Resident #19 had an old closed [MEDICAL CONDITION] site the facility staff failed to assess and identify for treatment. 9. Resident #1 had an physician ordered status of NPO (nothing by mouth) which had not been followed. The findings include: 1. The facility staff failed to ensure the result of a hemoglobin and hematocrit level was received and a physician ordered transfusion was administered for Resident # 28. Three days later, the resident arrested in the facility, was transferred to the Emergency Department of an acute care facility where she expired. Resident # 28 was an [AGE] year old admitted to the facility on [DATE], following a fall while ambulating in a department store. The fall resulted in a complex, comminuted [MEDICAL CONDITION] femoral neck with right inferior and superior pubic rami fractures. The resident was admitted to the facility for skilled nursing care following the surgical repair of the hip. Other [DIAGNOSES REDACTED]. According to a progress note on [DATE] at 12:16 pm the plan on admission was to discharge Resident # 28 home with daughter following the admission for skilled care. According to the initial MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of [DATE], Resident # 28 was coded as 3 of 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as usually able to understand others and be understood. Resident # 28 was coded as requiring the extensive assistance of a least 2 staff in bed mobility and transfers. On [DATE] at 10:24 pm a Progress Note entry read " Called in by PT (Physical Therapy) c/o (complaining of) resident not looking right. Resident assist unable to arouse. No pulse note. Code called at 5:10 pm. CPR (Cardio-pulmonary Resuscitation) started at 5:12 p (a line was drawn through the time indicating its omission) (1) 911 called by another nurse. CPR cont (continued) until 911 was present and took over. Family notified. NP (Nurse Practitioner) present at time of CPR. Resident was transported to (Name of Acute Care Facility/ ER) via 911 via stretcher " . Review of the History of Present Illness in ER dated [DATE] revealed Resident # 28 was placed on a monitor and found to be in asystole, was intubated and an attempt at resuscitation was initiated. The resident was pronounced dead at 6:00 pm. Review of Resident # 28 ' s Clinical Record revealed a Physician order [REDACTED]. Resident # 28 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On ,[DATE] a Nurse Fax Communication Form indicated the resident ' s PT was 37 seconds and the INR was 3.1. The Physician wrote an order to decrease the [MEDICATION NAME] to 4.5 mg po q PM. On [DATE] a Nurse Fax Communication Form indicated the resident ' s PT was 75 seconds and the INR was 6.3. An order by the Nurse Practitioner on [DATE] read " Vitamin K 10 mg po 1 now " . Review of Complete Blood Count orders revealed: ,[DATE]/ 12 Hemoglobin 8.4 (low)(normal 11.7 - 16.1) Hematocrit 24.5 (low)(normal 35.1 - 48.3) WBC (white blood cells) 13.1 (high)(normal 4 - 11) Review of a physician note on [DATE] revealed, item # 2 under the heading Assessment and Plan: " [MEDICAL CONDITION] - Worsening, will begin workup by checking Iron Stores and Hemocult (Guiac- test for blood in stools) Stools x 3. [DATE] Hemoglobin 7.9 (low) Hematocrit 24.3 (low) WBC 13.6 (high) Review of a physician note on [DATE] included , item # 1 under the heading Assessment and Plan : " [MEDICAL CONDITION] - Seems to be from [MEDICAL CONDITION] ...I will check a CBC with diff in the am. If H&H is < ,[DATE], she is to be set up for an outpatient transfusion. I will reorder guiac stools x 3. " Review of the MAR indicated [REDACTED] for Guiac on [DATE] was positive. Review of the Clinical Record revealed that on [DATE], the Physician wrote an order that read : " Guiac stools x 3; CBC with diff in am. If H&H is < than ,[DATE], set up for outpatient transfusion " . [DATE] Hemoglobin 7.1 (low) Hematocrit 23.8 (low) WBC 15.4 (high) The results showed a rapid decline in the resident's hemoglobin and hematocrit in one day. The lab report indicated the [DATE] sample was collected at 12:26 pm. The report indicated it was faxed to the facility on [DATE] at 3:56 pm, shortly before Resident # 28 arrested at around 5:10 pm . Review of Resident # 28 ' s Progress Notes and the 24 Hour Report from [DATE] through [DATE] does not include any documentation of a problem obtaining the lab results. There was no documentation regarding the order for the transfusion based on the lab results, as ordered. There was no documentation that the resident received the transfusion, as ordered. Review of a document provided by the facility entitled Laboratory Tracking, dated [DATE], read, under the Policy Statement: " a licensed nurse will monitor and track all physician ordered laboratory tests; ensure that lab tests are drawn as ordered; and, communicate results to the physician in a timely manner. On [DATE] at 5:15 pm the Director of Nursing (DON) stated she heard the Code called for Resident # 28 on [DATE] in the late pm. On [DATE] at 9:05 am, LPN # 12 stated she was Resident # 28 ' s nurse on the day she expired. She stated the resident coded after she had left for the day. When asked, the LPN stated she had heard there was a problem with the resident ' s Hemoglobin and Hematocrit. She stated the nurse would have been expected to have gotten the results verbally and asked for a faxed copy to be sent. She stated the nurse would have been expected to have proceeded with the transfer order once she received the results. On [DATE] at 10:05 am the Unit Secretary (US) stated she use to " help out " the nurses with lab tracking. The US said usually the lab would fax the results to the unit and she would give the results to the nurse. She stated she would review the log to see if the lab reports had been received and if the report had not been faxed yet she would check the system to see if the results were listed. She said if the results were not in the system she would sometimes call the lab for the nurse and ask for the results to be faxed. In review of the lab and related transfusion order the US stated she did not recall any discussion of the results. She stated she recalled the nurse stating she had put the lab in the resident ' s record. She stated she would have been the one to set up the blood transfusion and she was not made aware of the need to set up a transfusion for Resident # 28. On [DATE] at 10:25 am, LPN (Licensed Practical Nurse) # 7 stated, in explaining the lab tracking process, the ,[DATE] staff were responsible for printing out forms for lab tech ' s to draw the am specimens and the ,[DATE] staff were responsible for printing off the lab results and following up on related orders and physician notification. The LPN stated, when asked, if there was an associated order based on lab results, the nurse would carry out the order but would also call the MD just to let him know the results. The LPN stated that sometimes the lab results were not ready by the time ,[DATE] staff finished their shift, and then the missing lab results would be reported to the ,[DATE] shift during the shift report and would be added to the 24 hour report. In reviewing Resident # 28 ' s order for lab and transfusion for [DATE], the LPN stated, based on the fact the specimen was collected at 12:26 pm on [DATE], she believed the report would have needed to be followed up by the ,[DATE] staff. The LPN stated when asked, she could have called and gotten a verbal report from the lab and then asked the lab to fax a copy to the facility. The LPN, who worked on the afternoon of [DATE], stated she did not remember anyone speaking to her about the results or the need for a transfusion. On the afternoon of [DATE] the DON stated she was unaware of any problem with the H&H lab results and the transfusion order dated [DATE], until after the resident had coded. She stated she began an investigation at that point. A statement by the Unit Secretary (US), generated as a result of the above investigation, indicated the lab H&H results were not ready on the afternoon of [DATE]. According to the statement at the time of the investigation, the results were not received on [DATE]. On [DATE] the US made several phone calls to the lab. She called again on [DATE]. There was no indication in her statement, nor during the interview, that she discussed the issue with the nurses, or that the nurses called to obtain the result. There were no statements provided by the 4 individual nurses who worked the evening shift on [DATE] through the day shift on [DATE], about why the results were not obtained either over the phone or by fax prior to Resident # 28 ' s arrest on the ,[DATE] shift [DATE]. Facility staff failed to obtain the lab result for the ensuing 3 days. The resident never received the transfusion as ordered since the lab values were below the parameters set in the physician's orders [REDACTED]. 3. Facility staff failed to immediately administer a physician ordered antibiotic to Resident #29. Resident #29 was a [AGE] year admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Abdominal Bleeding, [MEDICAL CONDITIONS], Dementia, Parotitis, Hypertension, Osteo[DIAGNOSES REDACTED], [MEDICAL CONDITION], Cerebral [DIAGNOSES REDACTED], Orthostatic [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Resident #29's most recent MDS (minimum data set) was a quarterly with a reference date of [DATE]. Resident #29 was assessed as being severely impaired for making every day life decisions. Resident #29 was assessed as being totally dependent on one staff for bed mobility, eating, bathing and personal hygiene. Resident #29 was coded as being bedfast all or most of the time. Resident #29 expired in the local hospital after being transferred from the emergency roiagnom on [DATE]. On [DATE] at 11:45 AM, Resident #29's clinical record was reviewed. Review of the Nursing Plan of Care with updates to [DATE] on the clinical record evidenced interventions included: Give medications as ordered by the attending physician. Review of the nursing notes on the clinical record evidenced the following: "[DATE] at (@) 12:48 AM: Resident presented with a low grade temperature (Temp) of 100.1 degrees, appears lethargic, bilateral wheezing noted in lung fields on auscultation, As needed Tylenol 20 ML given, Resident continues scheduled [MEDICATION NAME] via face mask, oral care given. Attending physician notified via communication book, will continue to monitor." "[DATE] @ 3:05 PM: Med Nurse notified this nurse at this time of resident being febrile (102.6), As needed Tylenol was given, temp at this time 101.6. Phone attending physician, left detailed voice mail for attending physician to call nursing station. Wheezing noted on expiration per Med Nurse with scheduled albuteral neb treatment (Tx) given. Will endorse follow up with evening desk nurse if no call within 10 minutes (Min) from attending physician. Vital Signs (VS) - Temp - 101.6, Pulse (P) - 78, Respirations (R) - 24, Blood Pressure (B/S) - ,[DATE]." "[DATE] @ 4:19 PM: New order: Immediately (STAT) blood culture x2, Stat CBC with Diff, Stat Urine (UA) CNS, STAT chest x-ray, [MEDICATION NAME] 859 MG x1, RP notified." "[DATE] @ 12:01 AM: Due to increase congestion got a verbal for suctioning PRN and oxygen (O2) @ 2 liters via Nasal Canula, Resident VS - B/P - ,[DATE], P-121, R - 24, Temp - 103.3. Nurse Practitioner notified, given order to give as needed Tylenol, resident suction x2: thick green mucus was obtained, Attending physician came in to check resident, order resident to be sent to emergency room at 12:50 via transport team on stretcher. RP notified." "[DATE] @ 12:01 AM: 7:00 AM, called placed to emergency room for status report by Unit Nurse, advised resident admitted with [DIAGNOSES REDACTED]." Resident #29 expired in the local hospital after being transferred from the emergency roiagnom on [DATE]. Review of the local hospital Discharge Summary date [DATE] evidenced: Resident brought in unresponsive state, noted to have UTI and Pneumonia, started aggressive on IV Antibiotics, in acute [MEDICAL CONDITION], heavily dependent on [MEDICAL CONDITION] (helps users breathe more easily) with 100% oxygen, Placed on Comfort Care after family consulted, expired [DATE] @ 7:12 PM. Review of the attending physician "Acute Visit" note dated [DATE] evidenced the following: "Assessment/Plan: Respiratory Distress 2 degree to Pneumonia, at 3:15 I gave orders for STAT blood cultures x2, STAT CBC with Diff, STAT U/A and C&S and a STAT X-ray, I told staff once completed resident was to immediately receive Levoquin 750 MG so the resident would have coverage for today. They were told we did not have to wait for the X-ray as the appearance would not be affected by the antibiotic. When I was called to see the patient it was close to midnight and I was informed the resident had not received he Levoquin despite this being ordered approximately 9 hours ago. The evening supervisor and the night supervisor have both been notified of this and the resident is being sent out 911 to the hospital." Review of the clinical record evidenced the following: ? Urinalysis collected: [DATE] at 3:50 PM ? X-ray completed: 4:52 PM ? Laboratory tests collected: [DATE] at 5:15 PM Review of the STAT Emergency Drug Box on four of four nursing units evidenced Levoquin was stocked in 250 MG tables (8 tablets in box). During an interview with Licensed Practical Nurse (LPN #6), on [DATE] at 11:57 AM, whom took the verbal orders from the attending physician on [DATE] @ 4:19 PM, when asked why the ordered Levoquin was not given STAT after the STAT Labs and U/A was obtained, she stated the resident was a tube feed, so she ordered a liquid from the pharmacy. When asked since Levoquin was not on the "Do Not Crush" list on her medication cart and could be crushed to give via the peg tube, she stated she did not check the STAT Emergency Drug Box. When advised the liquid Levoquin arrived to the unit on [DATE] at 9:02 PM, after the STAT labs and U/A had been obtained and the medication still was not given, and she did not complete her shift until 11:00 PM, she stated the nurses coming on could have given the medication to the resident, as well. On [DATE] at 10:19 AM during a telephone call with the attending physician, he stated that he wanted the Levoquin to be given STAT after the labs and U/A so intervention could be started right away and she would have coverage. The attending physician stated he was quite concerned his order was not followed because the resident had a lot of medical issues and the Levoquin would have been a immediate starting intervention. The attending physician stated he feels not starting the antibiotic as ordered contributed to the expiration of Resident #29. During an interview with the Director of Nursing and Corporate Nurses on [DATE] at 3:22 PM, when asked if they had read the attending physician's "Acute Visit" note written on [DATE], they all stated "yes". When asked if any follow up actions had been taken as the attending physician had indicated he told the evening and the night supervisors of his concern and the Director of nursing stated "Not at this Time". 4. The facility staff failed to provide Resident #8 with a physician ordered psychiatric consult. Resident #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated: Resident #8 was assessed as being independent for cognitive ability. Resident #8 was coded as having feelings of feeling down, depressed, or hopeless. Resident #8 required extensive assistance with two plus staff for all activities of daily living (ADL's). A review of the Nursing Plan of Care with updated to [DATE] evidenced the following: ? Under Depression: Evaluation needed for psych (psychiatric) consult A review of the attending physician ordered dated [DATE] evidenced: ? Psych consult per family request A review of the nursing notes up to [DATE] on Resident #8's clinical record did not indicate the ordered psych consult on [DATE] was completed. A review of the consultations on Resident #8's clinical record did not evidence a Psych Consult was completed for the order written [DATE]. A review of the nursing unit documentation did not evidenced the order was faxed to the office of the attending psych physician to complete the consult ordered [DATE] as indicated by protocol advised the Unit #4 Nursing Unit Manager. During an interview on [DATE] at 4:00 PM with the Administrative Staff the aforementioned was presented. The administrator or Director of Nursing did not present a physician ordered psych consult prior to the survey ending on [DATE]. 5. In the course of a complaint investigation it was found the facility staff failed to ensure PRN (as needed) [MEDICATION NAME] (narcotic pain medication) was available for administration to manage Resident #24's chronic lower back pain. Resident #24 a [AGE] year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of [DATE] assessed the resident as having intact cognition. Resident #24 required supervision with bed mobility, transfers, ambulation and locomotion on and off the unit with the use of a motorized wheel chair. Resident #24 required extensive assistance of 1 staff for dressing, personal hygiene and dependent with bathing. The resident was assessed as requiring PRN pain medication for "almost constant pain". The resident indicated his worst pain over the past 5 days on a zero to ten scale was a 3. Review of the comprehensive plan of care dated [DATE] with a current review date of [DATE] evidenced the resident was identified as having chronic pain. The measurable goal set was the resident would express relief within ,[DATE] minutes of intervention. One of the interventions listed to achieve the goal was to administer medications and monitor effects. The physician order [REDACTED]. 1. Tylenol 325 mg (milligrams) 2 tabs by mouth every 4 hours as needed for pain or elevated temperature. 2. [MEDICATION NAME] 4 mg by mouth every 3 hours as needed (PRN) for pain. On [DATE] at 9:37 A.M., Resident #24 was interviewed. He stated on 3 occasions in the last 2 months the facility had run out of his pain medication ([MEDICATION NAME]). He indicated the pain was in his lower back and legs as a result of surgical intervention for the removal of melanomas. He raised his shirt and showed the inspector a large scar on his right lower flank area. He stated he takes his pain medication ([MEDICATION NAME]) 4 times a day at 6:30 AM, 9:30 AM, 1:00 PM and 6:00 PM, and if needed more often he will ask for it. He described his pain as, "a tight muscle that goes from my lower back to my buttocks...feels like 2 elastic bands pulling, the pain is sharp and pulsating...the longer I sit in my wheelchair it will start hurting more", the resident rated his pain at this time a 6 out of 10. Just then, the nurse entered the room and administered a PRN [MEDICATION NAME] per the resident's request. Resident #24 stated the 1st two times the medication was not available, "I grimaced and bared it from morning to 10 PM...I stayed in bed those two days...this last time I got fed up with it..." He stated he went to speak with the ADON (assistant director of nurses)...who,"pitched a dickens with whoever he called...they had to get orders faxed back and forth in order to get me pain medication...at 1 PM he tried to get me a shot...by 5 PM I finally got a shot...it helped". He described his pain at that time was "above a 10". He stated, "I can't function without my pain medicine...after the shot 15 minutes later I was back in my chair...I was in bed by 8 PM...I had been in pain all day". A review of the clinical record evidenced the following for [DATE]: (1). Three hand written prescriptions by the nurse practitioner dated [DATE] for: 1. [MEDICATION NAME] 4 mg tab PO (by mouth) every 3 hours PRN (as needed ) for pain #120 tabs 2. [MEDICATION NAME] 4 mg/ml give 2 mg (0.5 ml) IM x 1 Now 3. [MEDICATION NAME] ,[DATE] mg 2 tabs PO (by mouth) Now (2). A Request for Removal of Controlled Substance Medication form dated [DATE] was noted in the clinical record. The approval for removal was faxed back to the facility at 3:55 P.M. for [MEDICATION NAME] 4 mg/ml IM. (3). The [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] (4). A narcotic control sheet for [MEDICATION NAME] 4 mg tabs evidenced a packet of 30 tabs was delivered to the facility on [DATE]. The last tab in the packet was administered at 6:00 AM on [DATE]. (5). Shipment details received by the pharmacy evidenced 30 tabs of [MEDICATION NAME] 4 mg were delivered to the facility on [DATE] at 3:29 PM. On [DATE] at 3:50 P.M., the licensed practical nurse who was assigned to care for Resident #24 on [DATE] was interviewed. She stated, "When I came into work it wasn't there ([MEDICATION NAME])...he refused the [MEDICATION NAME] ([MEDICATION NAME])...we had to give him an injection...we needed a hard script and had to wait for the (name of nurse practitioner). When asked why the resident had refused the [MEDICATION NAME] she stated she did not ask him why. She stated the resident's pain (lower back) was an 8 out of 10 on the pain scale at that time. The unit manager stated she was aware of this incident, stating," One of the staff overheard him complaining his pain med was not available...I spoke with the staff...they are informed of reordering pain medication...one of the night nurses is new...she gave his last one ([MEDICATION NAME]) and she needed to have reordered it...it is important to order it when it is on the last column (referring to the package). The unit manager stated she was not aware of any other incidences where Resident #24's pain medication was not available for administration. MAR's and narcotic control sheets from [DATE] through [DATE] were reviewed. There were no other incidences of the [MEDICATION NAME] not being available for administration for Resident #24's chronic back pain except for [DATE]. 6. The facility staff failed to ensure appropriate care was provided for Resident #33 immediately following a fall with suspected right hip injury. Resident #33 an [AGE] year old was originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of [DATE] assessed the resident as having severely impaired cognition. Resident #33 required extensive assistance of 2 staff for bed mobility, 1 staff assistance with transfers, and supervision with ambulation between locations in her room and in the corridor on the unit. The resident was able to stabilize without human assistance when moving from seated to standing position, walking, turning around, and surface-to-surface transfer. The resident was not steady when moving on and off the toilet. Mobility devices included a wheelchair. Resident #33 was incontinent of bowel and bladder. The resident was not identified as having a fall since admission or prior assessment. Review of the comprehensive plan of care dated [DATE] identified the resident had a potential for fall secondary to delusional disorder, impaired insight and safety awareness. The goal was the resident will not sustain any injury related to fall over the next review date. Interventions to achieve the goal was to keep the bed in lowest position, keep call bell in place, keep environment free of obstacles, nonskid socks and or shoes when ambulating. Under evaluation dated [DATE] evidenced the resident had an actual fall on [DATE] without injury. The resident was attempting to ambulate to the bathroom, and indicated the resident ambulates on her own daily. A second entry dated [DATE] evidenced the resident had an actual fall on [DATE]. The resident fell off the right side of the bed. The resident was identified as having a urinary tract infection and being treated with antibiotics. A third entry dated [DATE] evidenced the resident fell ambulating to the bathroom and obtained a right [MEDICAL CONDITION]. Review of the nurses notes for [DATE] documented by the assistant director of nurses (ADON) at 8:35 A.M., read the following: "Entered resident's room after hearing resident scream. Found on the floor supine (on her back). "resident immediately stated "help, my leg hurts so bad" Resident then attempted to sit up but screamed in pain. Right leg appears to be slight {sic} rotated externally, although this is hard to assess due {sic}her positioning and guarding of the extremity. Leg length discrepancy could not be assess re: pain. Resident assisted to chair from floor by nurse and two CNA's (certified nurse aides) Pain is evident. Resident continues to guard her right leg. Decision made by ADON to refer to ED (emergency department) for further evaluation. The resident was sent to the emergency room and admitted with a traumatic [MEDICAL CONDITION] hip. The resident had surgical repair of the [MEDICAL CONDITION] on [DATE] and was discharged back to the facility for aftercare on [DATE]. On [DATE] at 12:30 P.M., and interview was conducted with CNA #1 caring for Resident #33 on [DATE]. She was asked to recall the fall. She stated, "I remember, we were short that day, that's why I got assigned her...It was a Saturday and I had just finished with A bed (roommate of Resident #33), and left the room for a minute to get some linen. I heard her fall and yell...I entered the room and she was yelling, "My hip broke...my hip broke..." "I hollered for help and stayed in the room with her...(name of ADON) entered the room and asked what happened...I said she fell on her back...he touched her knee area...she kept hollering her hip was broke..she pointed down there (to her pelvis) and the ADON told her (the resident),"I don't got nothing to do with that"...he then picked her up under her arms, then I grabbed under the other (arm)...(LPN#3) then entered the room and put a chair behind the resident...the resident was placed in the chair until 911 came." The CNA stated she believed the resident was on her way to the bathroom. When asked about the ADON picking the resident up and standing her on her feet she stated, "That wasn't right, it was very wrong, he should have left her there (on the floor)...I was mad but he was the supervisor...(name of LPN#3) said he was wrong...he should not have picked her up...it could have caused more damage..." On [DATE] at 10:41 A.M., LPN#3 was interviewed. She stated, "I did not assess or see the fall...I was passing meds...when I entered the room (ADON) was there and the patient was standing up...I was surprised to see her standing...(ADON) kept saying, "stand up, stand up"...you could see the right foot was internally rotated...this indicated an injury or dislocation...I was directed to call 911...when I went back into the room she (Resident #33) was in the chair...she kept saying "I feel like I broke it...she was grimacing...moaning and guarding her hip". LPN#3 stated when assessing a resident for injury after a fall, " if injury is determined leave the resident there, do not move her until the paramedics arrive". Review of the ADON written statement dated [DATE] following an investigation in response to the fall reads: "I entered the room the resident had obviously fallen, noted that her (R) leg was malpositioned, and that the resident was in excruciating pain. I determined that her pain might be reduced if the resident's weight was taken off the leg. In my professional opinion, alleviating some of the resident's pain was more critical at that point in time than concern for further injury". On [DATE] at 11:19 A.M., nurse practitioner #1 was interviewed. The actions of the ADON standing up the resident after a fall with suspected hip injury was reviewed. She stated," I would not have done that...I would never stand some one up if they were complaining of hip pain or sit them in a 90 degree angle...this could displace the fracture even more or cause further trauma". Review of the facilities titled Falls Management Program #1201 effective date [DATE] reads under fall occurrence: 1. Do not move or reposition the resident until a licensed nurse has completed a physical and mental assessment. A licensed nurse will: * Assess, intervene,and promptly provide the necessary interventions for any resident experiencing a fall. During the survey the director of nurses and corporate nurse were informed of the above findings. On [DATE] the survey team was notified of the termination of the ADON effective [DATE]. 7. The facility staff failed to obtain physician ordered lab for Resident #9. Resident #9 a [AGE] year old was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a significant change with an assessment reference date of [DATE] assessed the resident as having moderately impaired cognition. Resident #9 required extensive assistance of 1 staff for bed mobility, walking in the room, dressing and personal hygiene, and assistance of 2 staff for transfers and dependent on staff for baths. On [DATE] in response to a nursing fax communication form informing the physician the resident was receiving [MEDICATION NAME] 40 mg (milligrams) twice a day for [MEDICAL CONDITION], not on a Potassium Chloride supplement, and a BMP had not been obtained s

2. Resident #115 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #115 was admitted to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was readmitted to the nursing facility on [DATE] at 8:25 pm. The most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident with a score of 9 (Moderately impaired cognitive status) on the Brief Interview for mental Status (BIMS). The resident was assessed with [REDACTED]. He had minimal difficulty in hearing ability. The most recent care plan dated [DATE] identified [DIAGNOSES REDACTED]. The goals were the resident would remain free from injury related to [MEDICAL CONDITION] activity and would not experience complications related to infection. Some of the approaches to accomplish these goals included lab tests as ordered by the physician, observe and record signs and symptoms of [MEDICAL CONDITION] disorder, monitor for changes in mental status and vital signs as needed. The care plan dated [DATE] also identified potential for falls, 5 actual falls with the most recent un-witnessed fall on [DATE]. According to facility's nurse's notes dated [DATE], Resident #115 was found by Licensed Practical Nurse (LPN) #5 sitting on the floor mat beside his bed at 4:45 pm. Documented monitoring after the fall failed to evidence the neurological status/assessment and monitoring of the resident that would have included frequent vital signs, functional status, level of consciousness, speech, response to verbal and physical stimuli and other assessments to include [MEDICAL CONDITION] activity, vomiting and headache. LPN #5 documented the resident vomited at 10:50 pm. LPN #5 was interviewed via telephone on [DATE] at 2:35 pm. She stated she found the resident on the floor on [DATE] as documented in the nurse's notes and the fall was considered as un-witnessed and she informed the physician. She stated it was the first time she had the resident in a while and he was different because he was somewhat aggressive and more confused. She stated the Certified Nursing Assistants (C.N.A.) placed him in the chair during the shift. She said the resident was placed back in bed after he vomited at 10:50 pm. She stated she passed on to the ,[DATE] shift about the resident's fall and vomiting episode. She said, "I forgot to do the full neurological assessment on (Resident #115's name)." According to facility's nurse's notes dated [DATE], for the ,[DATE] shift Resident #115 was found by Licensed Practical Nurse (LPN) #4 as not at his normal, unable to take his medication because he was unable to open his mouth. Respirations unstable, oxygen saturation was 71 percent (%)(,[DATE]% =normal; www. medhelp.org), extremities cold to touch. MD gave orders to send resident to Emergency Department (ED). LPN #4 was interviewed via telephone on [DATE] at 2:50 pm. She stated she had worked that previous weekend prior to the ,[DATE] shift on [DATE] and felt the resident's mental status was "definitely not like him". She said, she parked her medication cart by his room because he was her first resident at which time she saw two C.N.A.'s try to place him in his wheelchair with him slumped over. She stated she could not arouse the resident, he looked extremely sick and his Oxygen (O2) saturation level was around 70. She said she started O2 and immediately called the physician. During the interview with LPN #4, she said 911 was called and the resident was transferred to the ED around 9:30 am. She stated she was never told during report from the ,[DATE] shift nurse that Resident #115 had fallen on the ,[DATE] shift or that he had vomited on that same shift. She said the ,[DATE] nurse told her "the resident slept". She stated she found out about the fall just before the resident left with the emergency rescue. LPN #4 said, "I felt he should have long been out of here based on how bad he was. The full neurological assessment would have given tons of information to include level of consciousness changes and frequent vital signs." The LPN stated the resident was somewhat combative over the previous weekend and a U/A C&S was obtained pending culture results to determine treatment. Resident #115 arrived at the local ED [DATE] at 10:00 am, neurological evaluation revealed he was unresponsive, unable to follow commands or answer any questions. A UTI was confirmed from the sample obtained from the nursing facility, and a [MEDICATION NAME] level obtained resulted in a critical toxic level of 45 (normal =,[DATE] mcg/ml). The level was repeated and remained toxic at 42. The resident was admitted to the hospital based on the aforementioned assessment with associated [DIAGNOSES REDACTED]. Intravenous fluids were started, antibiotic for UTI and close monitoring of toxic [MEDICATION NAME] level and resume at a lower dose once levels were low enough verses switching to another medication. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at approximately 11:45 am. The ADON stated when he came on for the ,[DATE] shift on [DATE], he found out from the ,[DATE] shift RN supervisor that Resident #115 had fallen on the ,[DATE] shift. He stated he went to check the post fall information in the computer which was completed, but found out neurological assessment/monitoring had not been conducted by either the ,[DATE] shift LPN (#5) or the ,[DATE] LPN (#1). He said neurological assessments are to be conducted on all residents with un-witnessed falls as a component of a full nursing assessment. He stated LPN #1 told him the resident appeared dazed and confused on her shift, but he could not understand why there was no documentation of her assessment of the resident. He said he specifically asked LPN #1 about neurological assessment and monitoring, to which she responded the fall did not occur on her shift; so she felt she did not have to do any, and she was tired of cleaning up other people's messes. The ADON stated he told LPN #1, "You still bare responsibility to start an assessment on your shift regardless of whether the neurological assessments were not done on the ,[DATE] shift." During the above interview with the ADON, he stated he instructed LPN #1 to document nurse's notes prior to leaving her assigned shift. The ADON stated after review of the LPN's note, he discovered she was deceptive in her note and gave the impression she had called the physician on her shift about the decline in the resident's condition; when it fact it was the ,[DATE] shift LPN #5 that had initially made the call to the physician on [DATE] at 6:00 pm. He stated he did not know what she had done for the resident on her shift. On [DATE] at 12:45 pm, an interview was conducted with Registered Nurse (RN) Interim Unit III Manager. She stated it was her first or second day and she did not know Resident #115's baseline, but LPN #4 knew him well and stated he was barely responsive and weak. She said, "Based on resident having the vomiting; it was a primary concern following an un-witnessed fall. Coming in on the shift and not having that neuro information was serious. He needed to have gone out to the hospital. The way he looked that morning ([DATE]); I would have sent him out the previous shift and called the physician later." An interview was conducted with LPN #7 on [DATE] at 1:35 pm. The LPN stated when she came on for the ,[DATE] shift, LPN #1 initiated an altercation with verbal threat towards her over C.N.A. assignment issues. She said, "After the altercation with me I was made aware of the condition of Resident #115 and thought maybe that was the reason for LPN #1's outburst." She stated she went in with the assigned ,[DATE] LPN#4 and the resident "looked bad and his O2 sats were critical". She said the resident was usually pleasant and could give his first and last name. During the above interview with LPN #7 she stated Resident #115 had a [MEDICAL CONDITION] the previous week and when she found out he had a fallen, she wondered if had been as a result of a [MEDICAL CONDITION]. She stated there were no neuro assessments on ,[DATE] or ,[DATE]. She said, "I was praying nothing happened to him; that's how bad he looked. Neuro assessments require that you evaluate the resident every 15 minutes for 1 hour, every 30 minutes for 2 hours and every hour for 4 hours. You can start them at any time, if you see the need. There's lots of information you obtain by doing them, and you can see vital sign changes. You have to assess and closely monitor for three straight shifts after a fall. I don't think his condition was sudden at 7:00 am, considering the way he looked that morning." On [DATE] at approximately 11:20 am, an interview was conducted with the Director of Nursing and the Regional Nurse Consultant (RNC). The DON stated nurses are to give a report about the resident to the oncoming shift. She said LPN #5 told her and the ADON she had informed LPN #1 about the fall, as well as the vomiting. The DON stated the nursing supervisor had worked a double from ,[DATE] on [DATE] into the next shift from ,[DATE] am on [DATE] and was aware of the fall. She stated it was the responsibility of the assigned nurse to inform the supervisor of any changes in resident conditions or incidents. She said the nursing supervisor would expect a call if any resident was doing poorly and she was not informed of any more than a fall regarding Resident #115. Resident #115 had returned from the hospital on [DATE] at 8:25 pm. On [DATE] at 10:00 am, 1:00 pm and 4:00 pm; he was observed in bed and appeared to be asleep. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions (11) of the nurse's failure to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] LPN #1 was suspended pending investigation of her failure to assess Resident #115 after a fall. The LPN was terminated on [DATE] for threatening another staff member. On [DATE] at approximately 3:45 pm, an interview was conducted with the DON, ADON and two Regional Nurse Consultants (RNC). They said a facility to hospital transfer form was not located, even the carbon copy. The ADON stated LPN #4 told him she may have sent both copies with the resident to the hospital. The DON stated it was her expectation that both LPN #1 and LPN #5 should have completed full nursing assessments to include the neuro assessments especially with a change in mental status. She stated, "If I was the ,[DATE] on-coming nurse (referring to LPN#1); I would have been right in there with an immediate assessment and consistent follow-up." The ADON stated the assessment of the resident should have taken place early in the ,[DATE] shift. During the above interview the RNC's stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility would be reporting LPN#1 to the board of health professionals. COMPLAINT DEFICIENCY Based on staff interview, clinical record review, facility documented review and complaint investigation the facility staff failed to assess and monitor 2 of 19 residents in the survey sample (Residents #117 and #115). 1. The nurse failed to assess and obtain vital signs for Resident #117 after the CNA notified her that she could not obtain the resident's blood pressure. Subsequently, the resident's condition deteriorated and she expired. 2. Resident #115 had a fall, after which he experienced vomiting and a change in mental status that was not thoroughly assessed and monitored. The resident became and unresponsive and was hospitalized for [REDACTED]. The findings include: Resident #117 was a [AGE] year old who was originally admitted to the facility on [DATE] for skilled services following hospitalization for complaints of chest pain. [DIAGNOSES REDACTED]. Resident #117 had been living alone independently at home prior to the hospitalization . The resident utilized a front wheel walker for independent ambulation. Discharge plans were for the resident to transition to long term care at the facility. Following a fall at the facility on [DATE] Resident #117 was admitted to the hospital with [REDACTED]. The resident was discharged back to the facility on [DATE] for skilled services. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] assessed the resident as having impaired short-term memory, intact long-term memory and moderately impaired cognitive skills for daily decision-making. The 14 day scheduled assessment dated [DATE] assessed the resident as requiring extensive assistance of 2 staff for bed mobility, dependent on staff for transfers and bathing, and extensive assistance with toileting, dressing and personal hygiene. The resident had an unsteady gait and history of fallen in the past 30 days. Review of the physician orders [REDACTED]. A full code status means if a resident goes into respiratory or [MEDICAL CONDITION] every possible measure available will be used to resuscitate them. On [DATE] the resident was examined by the nurse practitioner (NP) due to abnormal labs. The NP documented the resident was "lying in bed with nursing staff at bedside giving her a bath. She (the resident) states she is cold and thirsty". Physical exam revealed the resident was alert and answers appropriately. Respirations were clear to auscultation, cardiovascular system with RRR (regular rate and rhythm) abdomen was soft with active bowel sounds, and extremities cool to touch, no [MEDICAL CONDITION], pulses 2+. The resident was diagnosed with [REDACTED]. The plan was to repeat the basic metabolic panel (BMP). The 11 PM-7 AM licensed practical nurse (LPN#1) responsible for the care of Resident #117 on [DATE] documented the following, "Received pt (patient) asleep in bed. At 12:30 am, the CNA (certified nurse aide) informed me that she could not get a blood pressure on the patient. CNA was informed to obtain the other vitals and that the nurse would get a blood pressure shortly. At 2:30 am, the lab technician entered the patient's room and came to the nurses' station to inform the nurse that the patient did not look good. The nurse then entered the patient's room to find the patient molding (mottling) on the lower extremities, faint pulse, cyanosis of the fingernails, respirations present Q (every) ,[DATE] minutes, and the patient had a blank stare. The nurse entered the hallway and yelled for the supervisor (name) who came to assess the patient. (Supervisor's name) assessed the patient while the nurse continued palpating for a pulse and 3 CNA's entered the room to ask how they could be of assistance. At 2:33 am, oxygen was administered as well as CPR. The nurse was instructed by the supervisor to get all paperwork together and a nurse, from another unit, was asked to call 911. Rescue arrived at 2:40 am and took over CPR. An IV was inserted to the left arm, an oral airway inserted, and defibrillator attached. CPR and rescue attempts continued until 3:10 am. Emergency personnel announced the patient expired at that time." The RN supervisor documented, "When the resident was discovered she had mottling up her legs to the knees and her hand (s) were blue and cold as well...She had a peaceful relaxed posture indicating that she died in her sleep..." Review of the clinical record failed to evidence vital signs or a nursing assessment was obtained between 12:30 AM and 2:30 A.M. on [DATE]. On [DATE] at 9:44 A.M., LPN#1 was interviewed on the phone. The nurse was asked if she assessed the resident after being informed by the CNA that she was unable to obtain the resident's blood pressure, she stated, "it was so long ago, I can't remember everything". The nurse was asked if she documented all the events for that night with Resident #117 she stated, "I believe I did...I documented everything...whatever I documented I stand behind". The LPN is no longer employed by the facility. A telephone message was left in an attempt to interview the RN supervisor on [DATE], with no return call. The supervisor is no longer employed by the facility. Two attempts were made to contact the CNA who notified the nurse of the resident's blood pressure, with no return call. The CNA is no longer employed by the facility. On [DATE] at 4:42 P.M., the resident's attending physician (medical director) was interviewed. The resident's status was discussed. The physician indicated the resident was in stable condition and her death was not anticipated. He stated the resident may have had a [MEDICAL CONDITIONS], and could not determine cause of death. He reviewed LPN #1's nursing notes, and stated he would have expected the nurse to have immediately assessed the resident. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions of the nurse neglecting to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] the nurse was terminated for threatening another staff member. 1. On [DATE] the nurse failed to use reasonable nursing judgement in assessment of a resident with a fall, failed to initiate neuro assessments, failed to notify the physician and supervisor of a resident change in condition, and documentation was deliberately deceptive. The resident subsequently required emergency room services and was admitted to the hospital. 2. On [DATE] refused to accept full assignment as directed by the nursing supervisor. 3. On [DATE] failed to follow physician orders [REDACTED]. 4. On [DATE] failed to write treatment orders and initiate treatment for [REDACTED]. 5. On [DATE], [DATE]and [DATE] the nurse left medication at a residents bedside. 6 On [DATE] failed to provide appropriate care and services for the management of IV infusion. 7. On [DATE] medication error. 8. On [DATE] failed to properly identify, treat and document a pressure ulcer. 9. On [DATE] failed to contact the physician to obtain medication orders. Review of the facilities policy and procedure named Significant Change of Condition dated [DATE] reads: 1. The resident's change of condition shall be reported to a licensed nurse. 2. A licensed nurse shall assess the resident for signs and symptoms of physical or mental change in condition. 3. This assessment shall be reported to primary physician or designated alternate. 8. Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. On [DATE] at 10:57 A.M., the above findings was shared with the administrator, the director of nurses (DON), and the 2 regional nurse consultants (RNC). The DON and the 2 RNC's indicated they would have expected the nurse to have immediately assessed the resident. It was confirmed there was no documentation or evidence in the clinical record to support the nurse had obtained the resident's blood pressure or assessed the resident after she was notified by the CNA. The RNC's stated they would have expected the DON (who is no longer employed at the facility) to have began an investigation of this "unusual occurrence". They would have expected to have been notified immediately so they could review the clinical record and initiate an immediate action plan to include education. The RNC stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility will be reporting LPN#1 to the board of health professionals.

2. Resident #115 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #115 was admitted to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was readmitted to the nursing facility on [DATE] at 8:25 pm. The most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident with a score of 9 (Moderately impaired cognitive status) on the Brief Interview for mental Status (BIMS). The resident was assessed with [REDACTED]. He had minimal difficulty in hearing ability. The most recent care plan dated [DATE] identified [DIAGNOSES REDACTED]. The goals were the resident would remain free from injury related to [MEDICAL CONDITION] activity and would not experience complications related to infection. Some of the approaches to accomplish these goals included lab tests as ordered by the physician, observe and record signs and symptoms of [MEDICAL CONDITION] disorder, monitor for changes in mental status and vital signs as needed. The care plan dated [DATE] also identified potential for falls, 5 actual falls with the most recent un-witnessed fall on [DATE]. According to facility's nurse's notes dated [DATE], Resident #115 was found by Licensed Practical Nurse (LPN) #5 sitting on the floor mat beside his bed at 4:45 pm. Documented monitoring after the fall failed to evidence the neurological status/assessment and monitoring of the resident that would have included frequent vital signs, functional status, level of consciousness, speech, response to verbal and physical stimuli and other assessments to include [MEDICAL CONDITION] activity, vomiting and headache. LPN #5 documented the resident vomited at 10:50 pm. LPN #5 was interviewed via telephone on [DATE] at 2:35 pm. She stated she found the resident on the floor on [DATE] as documented in the nurse's notes and the fall was considered as un-witnessed and she informed the physician. She stated it was the first time she had the resident in a while and he was different because he was somewhat aggressive and more confused. She stated the Certified Nursing Assistants (C.N.A.) placed him in the chair during the shift. She said the resident was placed back in bed after he vomited at 10:50 pm. She stated she passed on to the ,[DATE] shift about the resident's fall and vomiting episode. She said, "I forgot to do the full neurological assessment on (Resident #115's name)." According to facility's nurse's notes dated [DATE], for the ,[DATE] shift Resident #115 was found by Licensed Practical Nurse (LPN) #4 as not at his normal, unable to take his medication because he was unable to open his mouth. Respirations unstable, oxygen saturation was 71 percent (%)(,[DATE]% =normal; www. medhelp.org), extremities cold to touch. MD gave orders to send resident to Emergency Department (ED). LPN #4 was interviewed via telephone on [DATE] at 2:50 pm. She stated she had worked that previous weekend prior to the ,[DATE] shift on [DATE] and felt the resident's mental status was "definitely not like him". She said, she parked her medication cart by his room because he was her first resident at which time she saw two C.N.A.'s try to place him in his wheelchair with him slumped over. She stated she could not arouse the resident, he looked extremely sick and his Oxygen (O2) saturation level was around 70. She said she started O2 and immediately called the physician. During the interview with LPN #4, she said 911 was called and the resident was transferred to the ED around 9:30 am. She stated she was never told during report from the ,[DATE] shift nurse that Resident #115 had fallen on the ,[DATE] shift or that he had vomited on that same shift. She said the ,[DATE] nurse told her "the resident slept". She stated she found out about the fall just before the resident left with the emergency rescue. LPN #4 said, "I felt he should have long been out of here based on how bad he was. The full neurological assessment would have given tons of information to include level of consciousness changes and frequent vital signs." The LPN stated the resident was somewhat combative over the previous weekend and a U/A C&S was obtained pending culture results to determine treatment. Resident #115 arrived at the local ED [DATE] at 10:00 am, neurological evaluation revealed he was unresponsive, unable to follow commands or answer any questions. A UTI was confirmed from the sample obtained from the nursing facility, and a [MEDICATION NAME] level obtained resulted in a critical toxic level of 45 (normal =,[DATE] mcg/ml). The level was repeated and remained toxic at 42. The resident was admitted to the hospital based on the aforementioned assessment with associated [DIAGNOSES REDACTED]. Intravenous fluids were started, antibiotic for UTI and close monitoring of toxic [MEDICATION NAME] level and resume at a lower dose once levels were low enough verses switching to another medication. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at approximately 11:45 am. The ADON stated when he came on for the ,[DATE] shift on [DATE], he found out from the ,[DATE] shift RN supervisor that Resident #115 had fallen on the ,[DATE] shift. He stated he went to check the post fall information in the computer which was completed, but found out neurological assessment/monitoring had not been conducted by either the ,[DATE] shift LPN (#5) or the ,[DATE] LPN (#1). He said neurological assessments are to be conducted on all residents with un-witnessed falls as a component of a full nursing assessment. He stated LPN #1 told him the resident appeared dazed and confused on her shift, but he could not understand why there was no documentation of her assessment of the resident. He said he specifically asked LPN #1 about neurological assessment and monitoring, to which she responded the fall did not occur on her shift; so she felt she did not have to do any, and she was tired of cleaning up other people's messes. The ADON stated he told LPN #1, "You still bare responsibility to start an assessment on your shift regardless of whether the neurological assessments were not done on the ,[DATE] shift." During the above interview with the ADON, he stated he instructed LPN #1 to document nurse's notes prior to leaving her assigned shift. The ADON stated after review of the LPN's note, he discovered she was deceptive in her note and gave the impression she had called the physician on her shift about the decline in the resident's condition; when it fact it was the ,[DATE] shift LPN #5 that had initially made the call to the physician on [DATE] at 6:00 pm. He stated he did not know what she had done for the resident on her shift. On [DATE] at 12:45 pm, an interview was conducted with Registered Nurse (RN) Interim Unit III Manager. She stated it was her first or second day and she did not know Resident #115's baseline, but LPN #4 knew him well and stated he was barely responsive and weak. She said, "Based on resident having the vomiting; it was a primary concern following an un-witnessed fall. Coming in on the shift and not having that neuro information was serious. He needed to have gone out to the hospital. The way he looked that morning ([DATE]); I would have sent him out the previous shift and called the physician later." An interview was conducted with LPN #7 on [DATE] at 1:35 pm. The LPN stated when she came on for the ,[DATE] shift, LPN #1 initiated an altercation with verbal threat towards her over C.N.A. assignment issues. She said, "After the altercation with me I was made aware of the condition of Resident #115 and thought maybe that was the reason for LPN #1's outburst." She stated she went in with the assigned ,[DATE] LPN#4 and the resident "looked bad and his O2 sats were critical". She said the resident was usually pleasant and could give his first and last name. During the above interview with LPN #7 she stated Resident #115 had a [MEDICAL CONDITION] the previous week and when she found out he had a fallen, she wondered if had been as a result of a [MEDICAL CONDITION]. She stated there were no neuro assessments on ,[DATE] or ,[DATE]. She said, "I was praying nothing happened to him; that's how bad he looked. Neuro assessments require that you evaluate the resident every 15 minutes for 1 hour, every 30 minutes for 2 hours and every hour for 4 hours. You can start them at any time, if you see the need. There's lots of information you obtain by doing them, and you can see vital sign changes. You have to assess and closely monitor for three straight shifts after a fall. I don't think his condition was sudden at 7:00 am, considering the way he looked that morning." On [DATE] at approximately 11:20 am, an interview was conducted with the Director of Nursing and the Regional Nurse Consultant (RNC). The DON stated nurses are to give a report about the resident to the oncoming shift. She said LPN #5 told her and the ADON she had informed LPN #1 about the fall, as well as the vomiting. The DON stated the nursing supervisor had worked a double from ,[DATE] on [DATE] into the next shift from ,[DATE] am on [DATE] and was aware of the fall. She stated it was the responsibility of the assigned nurse to inform the supervisor of any changes in resident conditions or incidents. She said the nursing supervisor would expect a call if any resident was doing poorly and she was not informed of any more than a fall regarding Resident #115. Resident #115 had returned from the hospital on [DATE] at 8:25 pm. On [DATE] at 10:00 am, 1:00 pm and 4:00 pm; he was observed in bed and appeared to be asleep. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions (11) of the nurse's failure to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] LPN #1 was suspended pending investigation of her failure to assess Resident #115 after a fall. The LPN was terminated on [DATE] for threatening another staff member. On [DATE] at approximately 3:45 pm, an interview was conducted with the DON, ADON and two Regional Nurse Consultants (RNC). They said a facility to hospital transfer form was not located, even the carbon copy. The ADON stated LPN #4 told him she may have sent both copies with the resident to the hospital. The DON stated it was her expectation that both LPN #1 and LPN #5 should have completed full nursing assessments to include the neuro assessments especially with a change in mental status. She stated, "If I was the ,[DATE] on-coming nurse (referring to LPN#1); I would have been right in there with an immediate assessment and consistent follow-up." The ADON stated the assessment of the resident should have taken place early in the ,[DATE] shift. During the above interview the RNC's stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility would be reporting LPN#1 to the board of health professionals. COMPLAINT DEFICIENCY Based on staff interview, clinical record review, facility documented review and complaint investigation the facility staff failed to assess and monitor 2 of 19 residents in the survey sample (Residents #117 and #115). 1. The nurse failed to assess and obtain vital signs for Resident #117 after the CNA notified her that she could not obtain the resident's blood pressure. Subsequently, the resident's condition deteriorated and she expired. 2. Resident #115 had a fall, after which he experienced vomiting and a change in mental status that was not thoroughly assessed and monitored. The resident became and unresponsive and was hospitalized for [REDACTED]. The findings include: Resident #117 was a [AGE] year old who was originally admitted to the facility on [DATE] for skilled services following hospitalization for complaints of chest pain. [DIAGNOSES REDACTED]. Resident #117 had been living alone independently at home prior to the hospitalization . The resident utilized a front wheel walker for independent ambulation. Discharge plans were for the resident to transition to long term care at the facility. Following a fall at the facility on [DATE] Resident #117 was admitted to the hospital with [REDACTED]. The resident was discharged back to the facility on [DATE] for skilled services. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] assessed the resident as having impaired short-term memory, intact long-term memory and moderately impaired cognitive skills for daily decision-making. The 14 day scheduled assessment dated [DATE] assessed the resident as requiring extensive assistance of 2 staff for bed mobility, dependent on staff for transfers and bathing, and extensive assistance with toileting, dressing and personal hygiene. The resident had an unsteady gait and history of fallen in the past 30 days. Review of the physician orders [REDACTED]. A full code status means if a resident goes into respiratory or [MEDICAL CONDITION] every possible measure available will be used to resuscitate them. On [DATE] the resident was examined by the nurse practitioner (NP) due to abnormal labs. The NP documented the resident was "lying in bed with nursing staff at bedside giving her a bath. She (the resident) states she is cold and thirsty". Physical exam revealed the resident was alert and answers appropriately. Respirations were clear to auscultation, cardiovascular system with RRR (regular rate and rhythm) abdomen was soft with active bowel sounds, and extremities cool to touch, no [MEDICAL CONDITION], pulses 2+. The resident was diagnosed with [REDACTED]. The plan was to repeat the basic metabolic panel (BMP). The 11 PM-7 AM licensed practical nurse (LPN#1) responsible for the care of Resident #117 on [DATE] documented the following, "Received pt (patient) asleep in bed. At 12:30 am, the CNA (certified nurse aide) informed me that she could not get a blood pressure on the patient. CNA was informed to obtain the other vitals and that the nurse would get a blood pressure shortly. At 2:30 am, the lab technician entered the patient's room and came to the nurses' station to inform the nurse that the patient did not look good. The nurse then entered the patient's room to find the patient molding (mottling) on the lower extremities, faint pulse, cyanosis of the fingernails, respirations present Q (every) ,[DATE] minutes, and the patient had a blank stare. The nurse entered the hallway and yelled for the supervisor (name) who came to assess the patient. (Supervisor's name) assessed the patient while the nurse continued palpating for a pulse and 3 CNA's entered the room to ask how they could be of assistance. At 2:33 am, oxygen was administered as well as CPR. The nurse was instructed by the supervisor to get all paperwork together and a nurse, from another unit, was asked to call 911. Rescue arrived at 2:40 am and took over CPR. An IV was inserted to the left arm, an oral airway inserted, and defibrillator attached. CPR and rescue attempts continued until 3:10 am. Emergency personnel announced the patient expired at that time." The RN supervisor documented, "When the resident was discovered she had mottling up her legs to the knees and her hand (s) were blue and cold as well...She had a peaceful relaxed posture indicating that she died in her sleep..." Review of the clinical record failed to evidence vital signs or a nursing assessment was obtained between 12:30 AM and 2:30 A.M. on [DATE]. On [DATE] at 9:44 A.M., LPN#1 was interviewed on the phone. The nurse was asked if she assessed the resident after being informed by the CNA that she was unable to obtain the resident's blood pressure, she stated, "it was so long ago, I can't remember everything". The nurse was asked if she documented all the events for that night with Resident #117 she stated, "I believe I did...I documented everything...whatever I documented I stand behind". The LPN is no longer employed by the facility. A telephone message was left in an attempt to interview the RN supervisor on [DATE], with no return call. The supervisor is no longer employed by the facility. Two attempts were made to contact the CNA who notified the nurse of the resident's blood pressure, with no return call. The CNA is no longer employed by the facility. On [DATE] at 4:42 P.M., the resident's attending physician (medical director) was interviewed. The resident's status was discussed. The physician indicated the resident was in stable condition and her death was not anticipated. He stated the resident may have had a [MEDICAL CONDITIONS], and could not determine cause of death. He reviewed LPN #1's nursing notes, and stated he would have expected the nurse to have immediately assessed the resident. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions of the nurse neglecting to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] the nurse was terminated for threatening another staff member. 1. On [DATE] the nurse failed to use reasonable nursing judgement in assessment of a resident with a fall, failed to initiate neuro assessments, failed to notify the physician and supervisor of a resident change in condition, and documentation was deliberately deceptive. The resident subsequently required emergency room services and was admitted to the hospital. 2. On [DATE] refused to accept full assignment as directed by the nursing supervisor. 3. On [DATE] failed to follow physician orders [REDACTED]. 4. On [DATE] failed to write treatment orders and initiate treatment for [REDACTED]. 5. On [DATE], [DATE]and [DATE] the nurse left medication at a residents bedside. 6 On [DATE] failed to provide appropriate care and services for the management of IV infusion. 7. On [DATE] medication error. 8. On [DATE] failed to properly identify, treat and document a pressure ulcer. 9. On [DATE] failed to contact the physician to obtain medication orders. Review of the facilities policy and procedure named Significant Change of Condition dated [DATE] reads: 1. The resident's change of condition shall be reported to a licensed nurse. 2. A licensed nurse shall assess the resident for signs and symptoms of physical or mental change in condition. 3. This assessment shall be reported to primary physician or designated alternate. 8. Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. On [DATE] at 10:57 A.M., the above findings was shared with the administrator, the director of nurses (DON), and the 2 regional nurse consultants (RNC). The DON and the 2 RNC's indicated they would have expected the nurse to have immediately assessed the resident. It was confirmed there was no documentation or evidence in the clinical record to support the nurse had obtained the resident's blood pressure or assessed the resident after she was notified by the CNA. The RNC's stated they would have expected the DON (who is no longer employed at the facility) to have began an investigation of this "unusual occurrence". They would have expected to have been notified immediately so they could review the clinical record and initiate an immediate action plan to include education. The RNC stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility will be reporting LPN#1 to the board of health professionals. COMPLAINT DEFICIENCY

2. Resident #115 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #115 was admitted to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was readmitted to the nursing facility on [DATE] at 8:25 pm. The most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident with a score of 9 (Moderately impaired cognitive status) on the Brief Interview for mental Status (BIMS). The resident was assessed with [REDACTED]. He had minimal difficulty in hearing ability. The most recent care plan dated [DATE] identified [DIAGNOSES REDACTED]. The goals were the resident would remain free from injury related to [MEDICAL CONDITION] activity and would not experience complications related to infection. Some of the approaches to accomplish these goals included lab tests as ordered by the physician, observe and record signs and symptoms of [MEDICAL CONDITION] disorder, monitor for changes in mental status and vital signs as needed. The care plan dated [DATE] also identified potential for falls, 5 actual falls with the most recent un-witnessed fall on [DATE]. According to facility's nurse's notes dated [DATE], Resident #115 was found by Licensed Practical Nurse (LPN) #5 sitting on the floor mat beside his bed at 4:45 pm. Documented monitoring after the fall failed to evidence the neurological status/assessment and monitoring of the resident that would have included frequent vital signs, functional status, level of consciousness, speech, response to verbal and physical stimuli and other assessments to include [MEDICAL CONDITION] activity, vomiting and headache. LPN #5 documented the resident vomited at 10:50 pm. LPN #5 was interviewed via telephone on [DATE] at 2:35 pm. She stated she found the resident on the floor on [DATE] as documented in the nurse's notes and the fall was considered as un-witnessed and she informed the physician. She stated it was the first time she had the resident in a while and he was different because he was somewhat aggressive and more confused. She stated the Certified Nursing Assistants (C.N.A.) placed him in the chair during the shift. She said the resident was placed back in bed after he vomited at 10:50 pm. She stated she passed on to the ,[DATE] shift about the resident's fall and vomiting episode. She said, "I forgot to do the full neurological assessment on (Resident #115's name)." According to facility's nurse's notes dated [DATE], for the ,[DATE] shift Resident #115 was found by Licensed Practical Nurse (LPN) #4 as not at his normal, unable to take his medication because he was unable to open his mouth. Respirations unstable, oxygen saturation was 71 percent (%)(,[DATE]% =normal; www. medhelp.org), extremities cold to touch. MD gave orders to send resident to Emergency Department (ED). LPN #4 was interviewed via telephone on [DATE] at 2:50 pm. She stated she had worked that previous weekend prior to the ,[DATE] shift on [DATE] and felt the resident's mental status was "definitely not like him". She said, she parked her medication cart by his room because he was her first resident at which time she saw two C.N.A.'s try to place him in his wheelchair with him slumped over. She stated she could not arouse the resident, he looked extremely sick and his Oxygen (O2) saturation level was around 70. She said she started O2 and immediately called the physician. During the interview with LPN #4, she said 911 was called and the resident was transferred to the ED around 9:30 am. She stated she was never told during report from the ,[DATE] shift nurse that Resident #115 had fallen on the ,[DATE] shift or that he had vomited on that same shift. She said the ,[DATE] nurse told her "the resident slept". She stated she found out about the fall just before the resident left with the emergency rescue. LPN #4 said, "I felt he should have long been out of here based on how bad he was. The full neurological assessment would have given tons of information to include level of consciousness changes and frequent vital signs." The LPN stated the resident was somewhat combative over the previous weekend and a U/A C&S was obtained pending culture results to determine treatment. Resident #115 arrived at the local ED [DATE] at 10:00 am, neurological evaluation revealed he was unresponsive, unable to follow commands or answer any questions. A UTI was confirmed from the sample obtained from the nursing facility, and a [MEDICATION NAME] level obtained resulted in a critical toxic level of 45 (normal =,[DATE] mcg/ml). The level was repeated and remained toxic at 42. The resident was admitted to the hospital based on the aforementioned assessment with associated [DIAGNOSES REDACTED]. Intravenous fluids were started, antibiotic for UTI and close monitoring of toxic [MEDICATION NAME] level and resume at a lower dose once levels were low enough verses switching to another medication. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at approximately 11:45 am. The ADON stated when he came on for the ,[DATE] shift on [DATE], he found out from the ,[DATE] shift RN supervisor that Resident #115 had fallen on the ,[DATE] shift. He stated he went to check the post fall information in the computer which was completed, but found out neurological assessment/monitoring had not been conducted by either the ,[DATE] shift LPN (#5) or the ,[DATE] LPN (#1). He said neurological assessments are to be conducted on all residents with un-witnessed falls as a component of a full nursing assessment. He stated LPN #1 told him the resident appeared dazed and confused on her shift, but he could not understand why there was no documentation of her assessment of the resident. He said he specifically asked LPN #1 about neurological assessment and monitoring, to which she responded the fall did not occur on her shift; so she felt she did not have to do any, and she was tired of cleaning up other people's messes. The ADON stated he told LPN #1, "You still bare responsibility to start an assessment on your shift regardless of whether the neurological assessments were not done on the ,[DATE] shift." During the above interview with the ADON, he stated he instructed LPN #1 to document nurse's notes prior to leaving her assigned shift. The ADON stated after review of the LPN's note, he discovered she was deceptive in her note and gave the impression she had called the physician on her shift about the decline in the resident's condition; when it fact it was the ,[DATE] shift LPN #5 that had initially made the call to the physician on [DATE] at 6:00 pm. He stated he did not know what she had done for the resident on her shift. On [DATE] at 12:45 pm, an interview was conducted with Registered Nurse (RN) Interim Unit III Manager. She stated it was her first or second day and she did not know Resident #115's baseline, but LPN #4 knew him well and stated he was barely responsive and weak. She said, "Based on resident having the vomiting; it was a primary concern following an un-witnessed fall. Coming in on the shift and not having that neuro information was serious. He needed to have gone out to the hospital. The way he looked that morning ([DATE]); I would have sent him out the previous shift and called the physician later." An interview was conducted with LPN #7 on [DATE] at 1:35 pm. The LPN stated when she came on for the ,[DATE] shift, LPN #1 initiated an altercation with verbal threat towards her over C.N.A. assignment issues. She said, "After the altercation with me I was made aware of the condition of Resident #115 and thought maybe that was the reason for LPN #1's outburst." She stated she went in with the assigned ,[DATE] LPN#4 and the resident "looked bad and his O2 sats were critical". She said the resident was usually pleasant and could give his first and last name. During the above interview with LPN #7 she stated Resident #115 had a [MEDICAL CONDITION] the previous week and when she found out he had a fallen, she wondered if had been as a result of a [MEDICAL CONDITION]. She stated there were no neuro assessments on ,[DATE] or ,[DATE]. She said, "I was praying nothing happened to him; that's how bad he looked. Neuro assessments require that you evaluate the resident every 15 minutes for 1 hour, every 30 minutes for 2 hours and every hour for 4 hours. You can start them at any time, if you see the need. There's lots of information you obtain by doing them, and you can see vital sign changes. You have to assess and closely monitor for three straight shifts after a fall. I don't think his condition was sudden at 7:00 am, considering the way he looked that morning." On [DATE] at approximately 11:20 am, an interview was conducted with the Director of Nursing and the Regional Nurse Consultant (RNC). The DON stated nurses are to give a report about the resident to the oncoming shift. She said LPN #5 told her and the ADON she had informed LPN #1 about the fall, as well as the vomiting. The DON stated the nursing supervisor had worked a double from ,[DATE] on [DATE] into the next shift from ,[DATE] am on [DATE] and was aware of the fall. She stated it was the responsibility of the assigned nurse to inform the supervisor of any changes in resident conditions or incidents. She said the nursing supervisor would expect a call if any resident was doing poorly and she was not informed of any more than a fall regarding Resident #115. Resident #115 had returned from the hospital on [DATE] at 8:25 pm. On [DATE] at 10:00 am, 1:00 pm and 4:00 pm; he was observed in bed and appeared to be asleep. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions (11) of the nurse's failure to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] LPN #1 was suspended pending investigation of her failure to assess Resident #115 after a fall. The LPN was terminated on [DATE] for threatening another staff member. On [DATE] at approximately 3:45 pm, an interview was conducted with the DON, ADON and two Regional Nurse Consultants (RNC). They said a facility to hospital transfer form was not located, even the carbon copy. The ADON stated LPN #4 told him she may have sent both copies with the resident to the hospital. The DON stated it was her expectation that both LPN #1 and LPN #5 should have completed full nursing assessments to include the neuro assessments especially with a change in mental status. She stated, "If I was the ,[DATE] on-coming nurse (referring to LPN#1); I would have been right in there with an immediate assessment and consistent follow-up." The ADON stated the assessment of the resident should have taken place early in the ,[DATE] shift. During the above interview the RNC's stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility would be reporting LPN#1 to the board of health professionals. Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the necessary care and services were provided to attain and maintain the highest physical well-being for 2 of 19 (Residents #117 and #115) residents in the survey sample. 1. The nurse failed to assess and obtain vital signs for Resident #117 after the CNA notified her that she could not obtain the resident's blood pressure. Subsequently, the resident's condition deteriorated and she expired. 2. The facility staff failed to monitor and assess for a reported changes in Resident #115's physical and mental status. The findings included: 1. Resident #117 was a [AGE] year old who was originally admitted to the facility on [DATE] for skilled services following hospitalization for complaints of chest pain. [DIAGNOSES REDACTED]. Resident #117 had been living alone independently at home prior to the hospitalization . The resident utilized a front wheel walker for independent ambulation. Discharge plans were for the resident to transition to long term care at the facility. Following a fall at the facility on [DATE] Resident #117 was admitted to the hospital with [REDACTED]. The resident was discharged back to the facility on [DATE] for skilled services. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] assessed the resident as having impaired short-term memory, intact long-term memory and moderately impaired cognitive skills for daily decision-making. The 14 day scheduled assessment dated [DATE] assessed the resident as requiring extensive assistance of 2 staff for bed mobility, dependent on staff for transfers and bathing, and extensive assistance with toileting, dressing and personal hygiene. The resident had an unsteady gait and history of fallen in the past 30 days. Review of the physician orders [REDACTED]. A full code status means if a resident goes into respiratory or [MEDICAL CONDITION] every possible measure available will be used to resuscitate them. On [DATE] the resident was examined by the nurse practitioner (NP) due to abnormal labs. The NP documented the resident was "lying in bed with nursing staff at bedside giving her a bath. She (the resident) states she is cold and thirsty". Physical exam revealed the resident was alert and answers appropriately. Respirations were clear to auscultation, cardiovascular system with RRR (regular rate and rhythm) abdomen was soft with active bowel sounds, and extremities cool to touch, no [MEDICAL CONDITION], pulses 2+. The resident was diagnosed with [REDACTED]. The plan was to repeat the basic metabolic panel (BMP). The 11 PM-7 AM licensed practical nurse (LPN#1) responsible for the care of Resident #117 on [DATE] documented the following, "Received pt (patient) asleep in bed. At 12:30 am, the CNA (certified nurse aide) informed me that she could not get a blood pressure on the patient. CNA was informed to obtain the other vitals and that the nurse would get a blood pressure shortly. At 2:30 am, the lab technician entered the patient's room and came to the nurses' station to inform the nurse that the patient did not look good. The nurse then entered the patient's room to find the patient molding (mottling) on the lower extremities, faint pulse, cyanosis of the fingernails, respirations present Q (every) ,[DATE] minutes, and the patient had a blank stare. The nurse entered the hallway and yelled for the supervisor (name) who came to assess the patient. (Supervisor's name) assessed the patient while the nurse continued palpating for a pulse and 3 CNA's entered the room to ask how they could be of assistance. At 2:33 am, oxygen was administered as well as CPR. The nurse was instructed by the supervisor to get all paperwork together and a nurse, from another unit, was asked to call 911. Rescue arrived at 2:40 am and took over CPR. An IV was inserted to the left arm, an oral airway inserted, and defibrillator attached. CPR and rescue attempts continued until 3:10 am. Emergency personnel announced the patient expired at that time." The RN supervisor documented, "When the resident was discovered she had mottling up her legs to the knees and her hand (s) were blue and cold as well...She had a peaceful relaxed posture indicating that she died in her sleep..." Review of the clinical record failed to evidence vital signs or a nursing assessment was obtained between 12:30 AM and 2:30 A.M. on [DATE]. On [DATE] at 9:44 A.M., LPN#1 was interviewed on the phone. The nurse was asked if she assessed the resident after being informed by the CNA that she was unable to obtain the resident's blood pressure, she stated, "it was so long ago, I can't remember everything". The nurse was asked if she documented all the events for that night with Resident #117 she stated, "I believe I did...I documented everything...whatever I documented I stand behind". The LPN is no longer employed by the facility. A telephone message was left in an attempt to interview the RN supervisor on [DATE], with no return call. The supervisor is no longer employed by the facility. Two attempts were made to contact the CNA who notified the nurse of the resident's blood pressure, with no return call. The CNA is no longer employed by the facility. On [DATE] at 4:42 P.M., the resident's attending physician (medical director) was interviewed. The resident's status was discussed. The physician indicated the resident was in stable condition and her death was not anticipated. He stated the resident may have had a [MEDICAL CONDITIONS], and could not determine cause of death. He reviewed LPN #1's nursing notes, and stated he would have expected the nurse to have immediately assessed the resident. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions of the nurse neglecting to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] the nurse was terminated for threatening another staff member. 1. On [DATE] the nurse failed to use reasonable nursing judgement in assessment of a resident with a fall, failed to initiate neuro assessments, failed to notify the physician and supervisor of a resident change in condition, and documentation was deliberately deceptive. The resident subsequently required emergency room services and was admitted to the hospital. 2. On [DATE] refused to accept full assignment as directed by the nursing supervisor. 3. On [DATE] failed to follow physician orders [REDACTED]. 4. On [DATE] failed to write treatment orders and initiate treatment for [REDACTED]. 5. On [DATE], [DATE]and [DATE] the nurse left medication at a residents bedside. 6 On [DATE] failed to provide appropriate care and services for the management of IV infusion. 7. On [DATE] medication error. 8. On [DATE] failed to properly identify, treat and document a pressure ulcer. 9. On [DATE] failed to contact the physician to obtain medication orders. Review of the facilities policy and procedure named Significant Change of Condition dated [DATE] reads: 1. The resident's change of condition shall be reported to a licensed nurse. 2. A licensed nurse shall assess the resident for signs and symptoms of physical or mental change in condition. 3. This assessment shall be reported to primary physician or designated alternate. 8. Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. On [DATE] at 10:57 A.M., the above findings was shared with the administrator, the director of nurses (DON), and the 2 regional nurse consultants (RNC). The DON and the 2 RNC's indicated they would have expected the nurse to have immediately assessed the resident. It was confirmed there was no documentation or evidence in the clinical record to support the nurse had obtained the resident's blood pressure or assessed the resident after she was notified by the CNA. The RNC's stated they would have expected the DON (who is no longer employed at the facility) to have began an investigation of this "unusual occurrence". They would have expected to have been notified immediately so they could review the clinical record and initiate an immediate action plan to include education. The RNC stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility will be reporting LPN#1 to the board of health professionals.

Based on observation, resident interview, staff interview, clinical record review, facility document review and during the course of a complaint investigation it was determined the facility staff failed to ensure assistive devices and supervision was provided to prevent accidents for 7 of 39 residents (Resident's #35, #2, #11, #30, #13, #22 and #26) in the survey sample, and failed to ensure the resident's environment was free of hazards. On 9/06/11 at 2:30 P.M., substandard quality of care was identified in the area of accidents. 1. The facility staff failed to ensure Resident #35 was placed on a wide enough support surface (mattress) to prevent injury, and failed to ensure 2 staff were assisting with bed mobility instead of 1. The resident was rolled off the bed, fell to the floor and sustained a fracture of the left lower leg. 2. The facility staff failed to provide for the safe use of a commode chair for Resident # 2. On 4/18/11 Resident # 2 fell off the commode chair and sustained a fractured nose and a laceration. 3. The facility staff failed to provide supervision while transferring Resident #11 from the wheelchair to the shower chair, resulting in a fall with fracture. 4. The facility staff failed to provide care to prevent a fall which resulted in a hip fracture for Resident #30. 5a. The facility staff failed to ensure Resident #13 was wearing hipsters (the product brochure stated "...Hipsters feature impact absorbing, soft foam pads over the critical fracture area to help reduce the risk of injuries from a fall, such as hip fractures...") on 2/23/11 when she fell and fractured her hip. 5b. The facility staff failed to ensure Resident #13's pommel cushion was positioned properly to ensure the resident was not sliding forward in her wheelchair, and to decrease the risk of the resident standing and falling. 6. The facility staff failed to ensure the unit 3 exit door alarm sounded when Resident #22's opened the door and exited the facility. 7. Facility staff failed to prevent an elopement of Resident #26 and follow physician's orders [REDACTED]. 8. Facility staff failed to maintain a safe environment stationing functioning hydrocollator in the restroom creating burning and tripping hazard. The findings include: 1. Resident #35's clinical record was reviewed as part of an expanded sample. The facility staff failed to ensure the resident was placed on a wide enough support surface (mattress) to prevent injury, and failed to ensure 2 staff were assisting with bed mobility instead of 1. During ADL care on 12/14/10 the resident was asked to reposition from her side to her back and fell off the bed, subsequently fracturing her left tibia/ fibula (according to the emergency room note dated 12/14/10). Investigation of the fall with fracture evidenced the following: Resident #35 a [AGE] year old was originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) at the time of the accident was a quarterly with an assessment reference date of 9/28/10. The MDS indicated the resident had short-term memory impairment and intact long-term memory, with modified independent daily decision making skills. Resident #35 was coded as needing extensive assistance of 2 staff for bed mobility, dressing and toileting, and completely dependent with transfers, personal hygiene and bathing. The resident was 52 inches tall and weighed 238 pounds. The care plan identified the resident was unable to complete ADL care independently related to muscle weakness, and history of pelvic fracture and degenerative joint disease. One approach was to provide/assist with bed mobility ( the care plan did not identify how many staff where required to assist the resident with bed mobility.) On 12/14/10 at 1:29 P.M., the licensed practical nurse documented she was called into the residents room at approximately 11:15 A.M. The resident was found laying on her right side between the window and bed, facing the door. "The resident's left leg was crossed over the right leg making it difficult to see the source of her bleeding. When trying to reposition her leg the resident yelled out, also c/o (complained) of R (right) rib pain. The left lower leg was noted to have a large skin tear with a possible puncture to it. Pressure was applied and held until wrapped by paramedics. The resident denied hitting her head however the staff member states she went head first when rolling out the bed." The fall investigation report written by the DON (director of nurses) was reviewed. The report indicated the resident was receiving ADL care and "when asked to roll back over onto her back, apparently the resident was using her right leg to gain momentum to roll over, had gained too much momentum and rolled out of the bed landing on her right side." The DON indicated in her report the resident had resided in the facility since 4/20/05 and has been a 1 person assist with ADL care. "No unsafe nursing practices were identified as a factor in this fall with fracture." The investigation included a handwritten description of the event by the certified nurse aide involved (CNA #1) dated 12/14/10. The CNA wrote she was providing AM care to the resident at 10:40 A.M. The resident was asked to roll on her left side so she could finish her peri-care, once finished the resident was asked to roll on her back. "As I was supporting her to come back she swung her right leg back over and fell off the bed with her head going first...as she was falling she also hit her left leg on the TV table which might have caused the puncture on her leg". Review of the facilities incident and accident report of the fall dated 12/14/10 indicated while the resident was being bathed she was asked to roll over. "She (the resident) swung her leg the wrong way and fell on to the floor". On 9/07/11 at 2:50 P.M., CNA #1 was interviewed. She stated Resident #35 was part of her permanent assignment. On the morning of 12/14/10 she was providing AM care for the resident. She stated after completing peri-care the resident was asked to roll on to her back, the resident then swung her right leg over and "flipped over and fell off" the bed. The CNA was asked about the resident's bed mobility and transfer requirements at the time of the fall, she stated the resident was a Hoyer lift and a 1 person assist with bed mobility. She stated,"I was never told she needed 2 people for bed mobility...if she wasn't feeling well I would get another staff to assist." The CNA stated the resident is now a 2 person assist with bed mobility and the resident is also now in a "bigger" bed. The CNA stated she had identified and reported to a charge nurse that the resident's bed was too small for her and she needed a wider bed prior to the fall. On 9/07/11 at 4:00 P.M., the administrator was interviewed. He stated after the fall the resident's bed was placed in the hallway. While inspecting the bed he noted the resident required a wider surface. He stated, "I asked the question why was she on a surface like that?...She needed a wider bed...it might have prevented the fall". The administrator stated when the resident returned to the facility she was placed on a wider surface mattress (a low air loss mattress). The resident was then switched to a bariatric bed, and has since been placed on a regular support surface. An extender kit was applied to extend the surface to 42" wide. The standard facility bed (support surface) measures 36" x 80". The administrator stated following Resident #35's fall he had directed the DON to make sure no other resident's in the facility were on a support surface that was not an appropriate size for them. He indicated the DON would have involved the central supply clerk /CNA to complete this task. He spoke with the central supply clerk earlier today. She stated she was not asked by the DON to assess any support surfaces following Resident #35's fall from the bed. The administrator was not able to provide any information of the outcome of the DON findings. The administrator could not confirm if there were other resident's at risk for falls due to being on a support surface that was not appropriate for them, nor was he able to confirm that the task was initiated or completed. The DON at the time of the accident is no longer an employee and was not available for interview. 2. The facility staff failed to provide for the safe use of a commode chair for Resident # 2. A total of 6 falls were recorded from 10/5/10 through 4/18/11 either while on or being transferred on or off the commode chair. On 4/18/11 Resident # 2 fell off the commode chair and sustained a fractured nose and a laceration. Resident # 2 was a [AGE] year old resident originally admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. According to Resident #2's most recent quarterly MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 8/10 11, the resident was coded as receiving a 4 on the BIMS (Brief Interview for Mental Status). The resident was coded as making self understood and usually having the ability to understand others. The resident was coded as having impaired vision. Resident # 2 was coded as requiring extensive assistance with the support of at least 2 staff members in the areas of bed mobility, transfers, and toilet use. The resident was coded as a 2 ("Not steady, only able to stabilize with the help of human assistance) in moving from seated to standing position, moving on and off toilet, and accomplishing surface to surface transfers (" transfer between bed and chair or wheelchair"). Review of Resident # 2's Progress Notes revealed an entry on 4/18/11 at 12:57 pm which read: "Resident experienced a fall this am at 9:35 am. Resident was sitting on potty (commode) chair and was attempting to adjust herself in seat and fell . RP (Responsible Party) and (Name of Physician) was notified. Resident will be sent to ER (emergency room ) for further evaluation". A second entry on 4/18/11 at 1:12 pm (related to the previous fall)read "Pt (Patient) found laying on left side next to bed. Pt bleeding from laceration above left eyebrow, laceration inbetween eyebrows and (bleeding) from both nostrils. Pt asked if in pain in any other area besides head. Pt stated "no", placed pressure on bridge of nose and head tilted back-effective to stop bleeding. Pt lifted to bed with assistance x 3. Attempted to take pts BP (Blood Pressure) unable to read machine CO5 (?). Pts nurse notified. EMT arrived.". The Post Fall Assessment stated under the heading Immediate Action Taken to Prevent Further Falls "Resident encouraged to ask for assistance while toileting if she needs to be readjusted on the bedside commode". The current Unit Manager (UM) , RN (Registered Nurse) # 3 stated on 9/7/11 at 11:40 am that CNA (Certified Nursing Assistant) # 2 and # 6 transferred Resident # 2 to the commode chair and CNA # 2 stayed in the room with the resident. The UM stated when the resident fell over, the CNA was unable to reach her before she hit the floor. On 9/7/11 at 11:40 am, CNA # 2 stated she and CNA # 6 transferred Resident # 2 to the commode chair. After CNA # 6 left the room, Resident # 2 started "jumping around on the chair, and when she leaned forward she fell and the chair fell with her". The CNA stated she was standing at the foot of the bed and was unable to reach her". On 9/8/11 at 3:00 pm when asked if the commode chair collapsed or was faulty, CNA #2 stated "no". When asked why she thought the resident fell , the CNA stated the resident was moving around and she just tipped over. The CNA stated Resident #2's feet did not reach the floor, that "her feet always dangled". Review of Resident#2's Clinical Record and Post fall Assessments revealed a history of 5 falls in transferring Resident # 2 on or off the commode chair, prior to the 4/18/11 fall starting on 10/6/10. Three of the falls resulted skin tears. Fall #1: According to an entry in the Progress Notes, on 10/6/10 at 12:03 am, Resident # 2 sustained a fall. Review of the Post Fall assessment dated [DATE] indicated, the fall took place on 10/5/10 at 8:00 pm. The Assessment stated "patient was being assisted from the bedside commode to her wheelchair. patient started to slip and fall was broken and she was eased to floor. patient scraped right leg on wheelchair." Under the heading: Immediate Action Taken To Prevent Further Falls , the report read " ...CNA (Certified Nursing Assistant) advised to request for assistance when rendering care to the patient. Resident # 2 remained a 1 person assist following this fall. Fall #2: Review of Resident 2's Progress Notes revealed an entry dated 10/6/10 at 8:35 pm that read "patient was getting off her bedside commode and with the cna assisting her, she was slipping to the floor and the cna assisted her to the floor. pt glazed her rt (right) leg on the w/c (wheelchair) and sustained a skin tear. Review of the 10/6/10 Post Fall Assessment indicated the fall on 10/6/11 at 3:30 pm, resulted in a skin tear. Under the heading: Immediate Action Taken To Prevent Further Falls the report read " ...CNA advised to request for assistance when rendering care to the patient. Resident # 2 remained a 1 person assist following this fall. Review of a Physical Therapy screen conducted on 10/8/10 following the above 2 falls revealed the following: "Pt has freq (frequently) been a dependent transfer since 10/09. Pt spoke with Unit 3 Manager regarding using Hoyer for safe transfers". Review of Nursing Notes and Care Plan reveal both documents remained silent on the use of a Hoyer Lift until June of 2011, after the fall where Resident # 2 sustained the fractured nose and laceration. Fall # 3: Review of Resident 2's Progress Notes revealed an entry dated 12/20/10 at 11:12 pm indicating the granddaughter had reported Resident # 2 had had a fall earlier that evening. Review of the Post Fall assessment dated [DATE], indicated Resident # 2 sustained a fall at 2:45 pm on 12/20/10. The Assessment, read under the heading: Immediate Action Taken To Prevent Further Falls " ...CNA advised to request for assistance when rendering care to the patient. Resident is (or was supposed to be) a 2 person assist". Review of the most recent MDS Assessment prior to the fall, with an ARD date of 12/15/10, revealed Resident #2 was coded as totally dependent, however, continued to be coded as a 1 person assist in the area of bed mobility, transfers and toilet use. Resident # 2 had sustained 3 falls where the Post Fall Assessment had recommended a 2 person assist which had not been implemented. Review of Resident # 2's Care Plan revealed a revision on 12/22/10, following the 3rd fall, under the heading; Evaluation "Two person assist". At that time the Care Plan documented only the fall on 10/5/10. Fall # 4: Review of Resident # 2's Progress Notes indicated the resident had another fall on 12/23/10 and had to be lowered to the floor "during transition from the wheelchair to the bedside commode". The Nurses Note was silent regarding whether a two person assist was used. The Post Fall Assessment listed "2 person" under the heading: List assistive devices in use at the time of the fall. Fall # 5: Review of Resident # 2's Progress Notes revealed an entry on 1/2/11 at 6:11 pm "resident assisted to floor on 7-3 shift...". The Post Fall Assessment was not available. The Incident Report stated the transfer was a two person transfer, however on 1/4/11 at 10:56 Resident #2's Nurses Notes continued to describe Resident #2 as " ... a one assist transfer". According to Progress Notes on 1/5/11 at 2:11 pm, Resident # 2 was evaluated by Occupational Therapy (OT) related to falls. Short Term goals included "transfer on and off commode chair with a gait belt assist and staff training in gait belt transfers". The OT note was silent on whether the Commode Chair was appropriate for the resident including the resident's balance or the requirement of the "2 person" transfer. The OT evaluation was silent on the PT evaluation conducted on 10/8/10 which had recommended transfer by Hoyer Lift. Review of Resident # 2's Care Plan revealed an entry dated 4/22/11, after the fall from the bedside commode with fracture on 4/18/11, that read: "rehab to screen for safe use of BSC (Commode Chair) prn (whenever necessary) with change in status". Another intervention read "Keep bedside commode next to bed. Do not leave resident unattended during toileting. Staff to be within arms reach". Review of Resident # 2's Nurses Notes revealed an entry on 6/7/11 at 4:46 pm that read "Called RP (Responsible Party) at 1:50 pm to give update on patient based on therapy screen ( not related to the 10/10 screen). This nurse explained that based on therapy recommendations (Resident # 2) should be a Hoyer transfer. Stated I don't want her using that machine, that means she won't be moving at all..." In an interview with the Manager of Rehab Department, conducted on 9/8/11 at 2:30 pm, she stated that since April, 2011 they do a screen of residents for the use of the Commode Chair, if they are not currently on the case load. She stated the department began doing screens post Resident # 2's fall. When asked she stated the assessment included : 1. Transferring capability: She stated they usually want the resident to be a 1 person assist. She stated a resident that was (coded as) a 2 person assist would not generally be appropriate for the commode chair. 2. Sitting Balance: The Manager stated that sitting balance and the ability to keep feet flat on floor were important. She states if feet could not be flat on floor you would want someone with the resident while they were on the commode. She stated that if the resident was a 2 person assist, a staff member should be within arms length if the resident was not being lifted by the mechanical lift. The Rehab Manager provided evidence, in the form of sign in sheets for staff education conducted on 4/25/11 and 5/3/11 on "Fall Assessment and Prevention". When asked, the Manager stated she included the need to assess for whether the resident was a one or two person assist and whether the resident had good balance and was positioned to have both feet on the floor". She stated, that in general, a commode chair would not be appropriate for a 2 person assist. She also stated the resident should be able to put both feet flat on the floor while sitting on the commode chair. In an interview with the Occupational Therapy Assistant on 9/8/11 at 3:15 pm, she stated she would not use a potty chair for a resident who was a two person assist. When asked, she stated she would want the resident to have the capability to place both feet on floor to maintain balance while sitting on the commode chair. Regional Nurse Consultant stated she had observed a safe transfer of Resident # 2 on and off the commode chair on 4/21/11. She stated the resident had shoes on and both feet were on the floor at the time . She stated the resident was transferred with two CNAs and the use of a gait belt. The Nurse Consultant and Unit Manager stated that they did not recall if the resident's feet touched the floor at other times. Unit Manager provided this surveyor with a copy of assessment of the use of two person assist initiated in May after a discussion between APS and the resident's RP, when the Unit Manager stated she realized the CNAs were not always providing a two person assist at that time and so she implemented a new monitoring tool. Based on: 1. the failure to assure implementation of a 2 person assist in transferring Resident # 2, to and from a commode chair after numerous falls and recognition in May, 2011 the 2 person assist was not always implemented and ; 2. Failure to respond to a PT assessment that questioned the appropriateness of the use of a commode chair until after a fall with a fracture on 4/18/11, the facility staff failed to provide a safe use of a commode chair including transfer on and off of the chair. 3. Clinical record review revealed, Resident #11 was a [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set assessment, dated 4/6/11 indicated she was severely impaired cognitively. Required extensive assistance with bed mobility and transfer. Resident #11 was coded as not steady, only to stabilize with human assistance. Resident #11 was coded as not steady, only able to stabilize with human assistance during transfer between bed, chair or wheelchair. Resident #11 was coded as not steady, only able to to stabilize with human assistance when moving from seated to standing position. Resident #11, required extensive assistance from staff for all activities of daily living (ADL's). She was 66" tall and weighed 119 pounds. Resident #11 was coded as a two plus person physical assist for transfer. Review of the clinical record evidenced a nursing note dated 5/26/11 that stated Resident #11 in bed with call bell in reach, no pain or distress noted, Resident had an assisted fall in shower room by Certified Nursing Assistant (CNA), this shift, Resident denies any pain or discomfort, vital signs normal. A nurse's note dated 5/29/11 at 2:14 PM evidenced that resident refused to get out of bed, bed maintained at low position, call bell in reach, tolerated medications and breathing treatments, complain of discomfort on her right upper arm (bruised), will continue to monitor A nurse's note dated 5/30/11 at 3:46 PM, evidenced that resident complains of pain in right arm, agitated refused to let CNA touch the arm when trying to assist with ADL's. Medicated with Vicodin as ordered for pain and ativan for agitation. MD aware, awaiting for response x-ray request, will continue to monitor for pain and discomfort. A nurse's note dated 5/31/11 at 12:34 AM, evidenced MD informed of the bruise and swell of right arm, MD ordered Xray and result came with "nondisplaced fracture on the humerus, MD informed with the result and ordered to send resident to emergency room for further evaluation. A nurse's note dated 5/31/11 evidenced resident returned from emergency room at 4:00 AM with sling to right arm. [DIAGNOSES REDACTED]. Resident's RP phoned facility at 6:45 PM and expressed concerns about the fracture. A follow up investigation by the facility started on 5/30/11 evidenced that on /26/11, Resident #11 had an assisted fall in shower room by the Certified Nursing Assistant (CNA). The report evidenced the Licensed Practical Nurse writing the Incident/Accident Report and the CNA reporting the assisted fall, failed to include in the report Resident #11's right arm hit the shower grab bar and/or the shower wall during the assisted fall. The involved CNA did not use a 2 person assist for transfer from the wheel chair to the shower chair in the shower room as indicated The Licensed Practical Nurse and involved CNA were not available for interview in person and/or by telephone during the survey period. On 9/8/11 at 2:14 PM, when the aforementioned was discussed the Director of Nursing (DON) and Assistant Director of Nursing (ADON), she stated the CNA should have followed what was in place for the resident and transferred with a 2 plus person assist. 4. During the facility tour and follow up observations from 8/30/11 through 9/9/11, it was evidenced in the joint physical therapy (PT) and occupational therapy (OT), activities room a Hydrocollator (uses hot water to keep heating pads ready for immediate use), supplied by electrical power was stored right beside the commode in the only restroom in the OT/PT joint activities room. The electrical power cord was running beside and behind the commode from the right side alone the left side and plugged into the wall. This presented a tripping and burning hazard as the metal body of the Hydrocollator was hot and warm to touch, the top of the Hydrocollator was not secured and could be easily open exposing the hot water and submereed heat packs. On 9/9/11 at 9:22 AM, during an interview the Certified Physical Therapy Aide (CPTA), she stated the restroom was used by both residents and staff, and they closed the door for privacy. She stated that there was a hand held call bell to use if the residents had a problem. She stated if the residents were to lock the door and they needed to get in as soon as possible to provide assistance, there was a door key taped to the outer door. During a continued interview with the PT/OT Director, she stated that the Hydrocollator stayed plugged in to the wall electrical power 24 hours a day, the staff added water daily as needed, and the daily temperature was taken daily. She stated the average temperature was between 168 degrees and 170 degrees at anytime. A review of the daily temperature log checks confirmed the temperatures. The PT/OT Director stated she could see how the location of the Hydrocollator could pose a tripping and burning hazard, after this discussion and she would move the machine to a resident free/accessible location. 5. Facility staff failed to provide care to prevent a fall which resulted in a hip fracture for Resident #30. Resident #30 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] evidenced Resident #30 was coded as having short-term and long-term memory problems and as moderately impaired in cognitive skills for daily decision making. The resident was coded as needing extensive assistance for bed mobility and ADLs (Activities of Daily Living) with one person assist. Review of the resident care plan dated 12/13/10 evidenced, "Potential for fall" with approaches/interventions that included low bed with mats, keep wheels on bed locked, sensor pad, and bed against wall. A nursing note dated 3/28/11 evidenced, "CNA pushed call light for assistance at 0245 (2:45AM), upon entering resident's room observed (resident name) lying on floor near bed on her right side with bed up in high position, moaning with discomfort. Asked CNA, what happened? She stated, "I was trying to change her and turn her over when she just rolled right out of bed and then onto the floor away from me." CNA is aware pt (patient) is a fall risk...Deep laceration noted to right side of eye with bleeding noted...Pt c/o (complained of) pain to right shoulder and c/o pain to right hip with ROM (range of motion). Redness over entire right side noted. No immiedate (sic) swelling or bruising noted...Supervisor notified and also assessed resident. 911 phoned for transport to ER (emergency room ) at 0250 (2:50AM) by supervisor...Pt remains alert and continues to moan and state, "Im (sic) hurting." Report phoned to ER nurse (name)". Review of Resident #30's hospital clinical recorded dated 3/28/11 evidenced an intertrochanteric fracture of right femur (hip fracture) that required O.R.I.F. (Open Reduction Internal Fixation which is a method of surgically repairing a fractured bone that involves either the use of plates and/or screws) and an intramedullary (IM) nailing (a rod inserted into the bone marrow canal in the center of the long bones) to stabilize the bone. During an interview with the Director of Nursing (DON) and Corporate Nurse #3 on 9/7/11 at 2:30PM, the corporate nurse was asked to provide evidence of an investigation of Resident #30's fall on 3/28/11. The DON provided a signed statement from the previous DON that evidenced, "...Resident had a fall on 3/28/11 that occurred during ADL care being provided by the CNA (name). According to the CNA, after she had adjusted her brief, she positioned (resident name) in the center of the bed in a supine position and as she pulled on the fitted sheet n (sic) the right side of the bed to straighten it out, the resident subsequently rolled out of the bed to the left. Return demonstration was provided to include myself, (name) Supervisor, and (name) (CNA). (Resident name) did have her bed against the wall, but the CNA did pull it out to change the sheets..." The DON also provided a hand written statement dated 3/28/11 from the Certified Nursing Assistant (CNA) who was providing care for Resident #30 when she fell from the bed. The CNA documented, "Around 2:40 a.m. I was changing (resident name) and her bed. I started changing the bed on the side of the wall first. I then started on the other side facing the floor. I started to get clean linen under (resident name) with my right hand and with the left hand I had placed on her hip area. After the linen was under her I pulled her towards me with it when she rolled off the bed. She was position in middle portion of bed when I pulled the sheet to me. I went on the side of bed that (resident name) fell I asked her if she was hurting anywhere and said yes. I called nurse station for the nurse to come down for a fall.." The CNA has resigned and was not available for interview. During an interview on 9/8/11 at 3:35PM, LPN #9 stated when the resident fell early in the morning in March, the CNA had turned on the call light and asked for help. She said when she entered the room the bed was in the high position and pulled away from the wall. She also said the resident was on the floor on the opposite side of the bed away from the CNA and was crying and moaning. LPN #9 said she would not have expected the bed to be pulled away from the wall since the resident was a small person and she had seen other CNAs provide care and change sheets from one side of the bed. 6a. The facility staff failed to ensure Resident #13 was wearing hipsters on 2/23/11 when she fell and fractured her hip (the product brochure stated "...Hipsters feature impact absorbing, soft foam pads over the critical fracture area to help reduce the risk of injuries from a fall, such as hip fractures..."). Clinical record review revealed, Resident #13 was a [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 30 day Minimum Data Set assessment (assessment prior to the fall), dated 1/19/11 stated she scored 5 out of a possible 15 on the Brief Interview for Mental Status. She needed limited staff assistance for bed mobility, transfers, walking, locomotion and eating. She needed extensive staff assistance for dressing and personal hygiene. She was totally dependent on staff assistance for bathing. She used a walker and a wheelchair. She was not steady, but able to stabilize without human assistance when moving from a seated to a standing position, walking with an assistive device if needed, turning around and facing the opposite direction while walking and transferring from surface to surface. She had 2 falls without injury since her admission or the prior assessment. Her care plan, dated 2/11/11 identified actual falls with the potential for others as a problem. The goal was the resident will not sustain any injury related to a fall thru the next review. There were several interventions including wearing hipsters, a low bed, and a bed and chair alarm. Her physician's orders [REDACTED].

Based on observation, staff interview and clinical record review the facility staff failed to ensure 1 of 19 residents in the survey sample was free from accidents (Resident #114). The facility staff failed to ensure the assitive device (hand mitten) was used as ordered to reduce the risk of Resident #114 pulling out a PICC line. The findings include: Resident #114 is a [AGE] year old originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #114's current MDS (Minimum Data Set) a quarterly with an assessment reference date of 10/11/11 assessed the resident as having impaired short-term memory, intact long-term memory and moderate independent daily decision making skills. Resident #114 required extensive assistance of 1 staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene, and was completely dependent on staff for bathing. Review of the clinical record evidenced the resident was found to have an abscess to the left buttock. The phsician ordered a culture and sensitivity (C&S) of the abscess on 10/12/11. The final report of the C&S received on 10/15/11 indicated the wound was infected with MRSA. As a result of this report the physician ordered the resident be placed on contact precautions, to insert a mid-line and ordered Vancomycin (an IV antibiotic) to be dosed by pharmacy. Midline catheters are peripheral venous access devices between 3 to 10 inches in length (8 to 25 cm).Midlines are usually placed in an upper arm vein such as the brachial or cephalic and the tip ends below the level of the axillary line. Midline catheters are longer than peripheral IV catheters which are generally 1 to 3 inches long and shorter than peripherally inserted central catheters (PICC) which extend into the vena cava. On 10/16/11 at 12:45 P.M., a single lumen midline was inserted to Resident #114's left brachial vein by the vascular access nurse. On 10/20/11 at 2:03 P.M., the licensed practical nurse documented the midline was "observed in the resident's hand". An x-ray was ordered to ensure the full length of the midline tubing was removed intact, and another order to replace the midline was obtained. On 10/20/11 at 7:00 P.M., a second midline was inserted to the resident's right brachial vein. A 2x2 gauze dressing was placed over the insertion site and covered with a transparent occlusive dressing dated 10/20/11. On 10/27/11 at 4:37 P.M., the LPN documented she entered the resident's room and found the midline laying next to the resident on the bedside table. Orders were obtained to insert a PICC line. Review of the physician clarification orders dated 10/27/11 read,"Wear mitt on (R) (right) hand secondary to resident pulling midline out X2." Representative party (RP) notification and verbal consent for the use of the mitten was noted in the record. On 10/28/11 at 9:22 A.M., the resident was observed in bed. A single mitten was observed above the resident's head on the bed. A new PICC line was observed to the resident's left arm. The dressing was dated 10/27/11. The integrity of the dressing was compromised, the edges of the transparent dressing was observed to have been peeled back. At 10:00 A.M., the single mitten was again observed off the resident's hand near the head of the bed. The surveyor left the resident's room and interviewed the travel pool CNA (certified nurse aide #1) caring for the resident. She stated she fed the resident her breakfast this morning and did not recall the resident having a mitten on. She indicated she was not told Resident #114 required a mitten. She stated all safety devices to be used by residents are listed in the CNA book located at the nurses station. The unit 2 B hall resident safety device list was reviewed; it did not include the use of mitts for Resident #114. Following this conversation, LPN #2 was interviewed at approximately 10:10 A.M. She stated the resident was to have the mitten on at all times to prevent her from removing the PICC line. When asked if she had assessed the resident's PICC line dressing or mitten this morning she stated she had not been in the residents room today. The observation of the mitten currently being off the resident was shared. She stated she would immediately take care of this.

Based on observations, staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to implement an effective Plan of Action for identified quality deficiencies related to fall prevention originally identified by the Quality Assurance Committee on October 22, 2010. Incidents of harm were identified during the survey for five residents and the findings constituted Substandard Quality of Care. Findings included: On 9/7/11 at 2:30 pm during a meeting with the Administrator, the Regional Nurse Consultants, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) the facility was made aware that the survey team had identified a significant issue with falls that resulted in harm and the facility was considered to be in substandard quality of care. On 9/8/11 at 9:15 am the survey team met with the facility Leadership Team including the Administrator, the Regional Nurse Consultants, the Director of Nursing (DON) , and the Assistant Director of Nursing (ADON) to review the document the facility referred to as a Plan of Correction which they began implementing in late June of 2011. The Regional Nursing Consultant, stated when asked, the Action Plan was put into place partially because of a problem the facility had identified with falls in 12/2010 and partially because it represented a new corporate fall program. The Plan included the following 8 steps: 1. Action Plan: The Action Plan was presented by the Regional Nursing Consultant and included a Fall Assessment form. The Consultant stated the Fall Assessment form was to be completed on all residents currently in the facility. 2. Master Fall Risk Log: The Log was to capture each resident's risk areas and was to be reviewed every shift by Nursing and CNAs. 3. Communication: The Corporate "Common Conditions of Aging" booklet was to be reviewed with resident / Responsible Parties 4. Care Plan /IDT: The Care Plan was to incorporate all interventions and was to be reviewed at the start of each shift. A CNA task List was to be kept up to date so the CNAs would know the tasks and devices for each resident assigned. 5. Falls were to be reviewed and tracked 6. Fall Management Committee to study falls 7. Restraints were to include policy revision and device assessment 8. Education of Resident, Responsible Parties and Staff were to be educated The Action Plan did not include any auditing of the implementation of fall interventions. A meeting was conducted on 9/9/11 by this surveyor at 9:45 am with the facility Administrator, the Regional Nurse Consultants, the Director of Nursing (DON) and the Corporate Vice president of Operations, to discuss the Quality Assurance Program and to review the Action Plan related to the Fall problem identified originally in 12/2010. A second surveyor was also in attendance. The Administrator confirmed that a "corrective action" was discussed with the previous DON in 12/2010 related to the increasing number of falls identified in October by the Quality Assurance Committee. The Administrator provided the surveyor with evidence of a "corrective action" dated 12/23/10 that stated in part, "...The falls per patient day have been steadily rising from late August (2010) until December, 2010. The concern for falls and the resulting fractures were identified at the 3rd quarter Quality Assurance Meeting on October 27th, 2010. During the time frame of 11/22/10 to 12/21/10 four residents incurred fractures requiring hospitalization and surgery. Incomplete and ineffective fall prevention measures contributed directly to the resident fractures". The Administrator provided the surveyors with a copy of a document entitled "Fall Prevention Action Plan" that reportedly was put in place by the DON at that time. The Action Plan called for review of all falls. The plan was silent on review or monitoring of fall prevention interventions. The Administrator stated the number of falls continued to increase and the DON resigned in 4/2011. The Administrator confirmed that no other action plan was put into effect until the new Corporate Fall Program implementation began in late 6/2011 with a completion date of 8/15/11. When asked the facility staff was unable to provide the surveyors with how they monitored the implementation of interventions for each patient to prevent falls as part of the 6/2011 Action Plan. The basis of monitoring the problem, originally identified in 10/2010, included the monitoring and tracking of falls after they occurred. The participants were unable to provide an example of any tracking or auditing of interventions to prevent falls. Review of the above findings demonstrated falls per patient day were increasing as early as 8/2010 with concern for falls and the resulting fractures identified at the 3rd quarter Quality Assurance Meeting on October 27th, 2010 with no resolution by the date of the survey. Please refer to F323 for specific information on individuals with falls.

Based on observation, clinical record review, review of the Plan of Correction (POC) for the survey ending 9/9/2011 and the identification of deficient practices in two repeat areas F Tags 309 and 328 it was determined the facility administration failed to meet compliance with the above federal requirements. The survey sample consisted of 19 residents with two resident #114 and #115 in uncorrected deficient areas. Four new areas of deficient practice were also identified involving residents #s 101, 102, 109, 114 and 117. The findings included: Facility administration failed to correct quality deficiencies identified in the standard survey. 1. Resident #115 did not have care and services provided for a reported change of condition (F309) when he became lethargic and vomited following a fall. 2. The facility staff failed to implement nursing care (F328) for the management of a midline and peripherally inserted central catheter (PICC) for Resident # 114. 3. The facility staff failed to ensure the assitive device (F323) of a hand mitten was used as ordered to reduce the risk of Resident #114 pulling out a PICC line. Additionally, during the survey four new areas of deficient practice were identified. One citation under the area of Resident Behavior and Facility Practice (F224) was cited at the harm level for Resident #117. Under the area of Quality of Care (F309) Resident #101 was cited with the potential for harm.

4. The facility staff failed to administer Resident #3's sliding scale insulin (the amount of insulin administered is based on the blood sugar level) as the physician ordered on 2 of 5 occasions in [DATE]. Clinical record review revealed, Resident #3 was an [AGE] year old female re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Her 14 day Minimum Data Set assessment, dated [DATE] stated her score on the Brief Interview for Mental Status was 11 out of a possible 15. She ate independently. She walked in her room with limited assistance. She needed extensive staff assistance for all other activities of daily living. She received insulin injections on 5 of the last 7 days. She received [MEDICAL TREATMENT] services in the last 14 days. Her physician's orders, dated [DATE] stated her blood sugar (BS) should be checked before meals and at bedtime. The orders said she should receive "[MEDICATION NAME] (insulin) sliding scale". There were no blood sugar parameters written on the physician's order sheet. Another order said "Humalog (insulin) 100 units/ml, inject ,[DATE] units...take as needed (BS-,[DATE])" (the insulin dose was determined by this formula). There was a line through the Humalog order. A handwritten entry stated the order was discontinued on [DATE]. On [DATE] at 12:00 noon, when asked what the blood sugar parameters were, Corporate Consulting Nurse (CCN) #3 stated the [MEDICATION NAME] sliding scale insulin order was a "standing order". She said the nurses should follow the insulin dosing noted on the [DATE] when the physician's order said to administer the [MEDICATION NAME] sliding scale insulin. Review of the [DATE] Medication Administration Record (MAR) revealed the resident's blood sugar were checked at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. In [DATE], the resident received [MEDICATION NAME]according to the following sliding scale: -,[DATE] give 2 units. -,[DATE] give 4 units. -,[DATE] give 6 units. -,[DATE] give 8 units. -,[DATE] give 10 units. -for blood sugar greater than 400 call the physician. The resident's blood sugar and insulin dose (if needed) was not recorded on the MAR or in the nurse's notes on the following days: -on [DATE] at 9:00 PM -on [DATE] at 4:30 PM -on [DATE] at 9:00 PM -on [DATE] at 6:30 AM and 9:00 PM -on [DATE] at 6:30 AM On [DATE] at 12:00 noon, CCN #3 noted the nurses administered the insulin according to the standing order in [DATE]. She said she did not know why the nurses did not record some blood sugars and [MEDICATION NAME] sliding scale insulin (if needed). The printed physician's orders, dated [DATE] stated the resident should receive "Humalog (insulin) 100 units/ml, inject ,[DATE] units...take as needed (BS-,[DATE])". There was a line through the Humalog and a hand written note, which said "[MEDICATION NAME]". As noted above, this physician's order was discontinued on [DATE]. The [DATE] MAR stated the resident's blood sugar should be checked at 6:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. The MAR said she should receive "[MEDICATION NAME]BS-,[DATE]". The resident received the following insulin doses when her blood sugar was greater than 150: -on [DATE] at 4:30 PM, 2 units for a blood sugar of 156 -on [DATE] at 9:00 PM, 2 units for a blood sugar of 168 -on [DATE] at 9:00 PM, the blood sugar and insulin dose (if needed) was not recorded -on [DATE] at 11:30 AM, 5 units for a blood sugar of 245 -on [DATE] at 11:30 AM, 6 units for a blood sugar of 267 -on [DATE] at 9:00 PM, 2 units for a blood sugar of 265 The insulin doses on [DATE] at 4:30 PM and 9:00 PM, and on [DATE] at 11:30 AM were administered according to the standing physician's [MEDICATION NAME] insulin. The insulin doses on [DATE] at 11:30 AM and on [DATE] at 9:00 PM, were not administered according to the standing physician's order for [MEDICATION NAME] sliding scale insulin. On [DATE] at 12:00 noon, CCN #3 said the standing physician's order for [MEDICATION NAME] sliding scale insulin was the current order. She noted the nurses were not following the current physician's order. She stated there must have been a transcription error during the end of the month recapitulation. 5. The facility staff failed to assess the effectiveness of a new pain medication for Resident #32. Clinical record review revealed, Resident #32 was a [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. She expired on [DATE]. Her quarterly Minimum Data Set assessment with an assessment reference date of [DATE] stated she had short and long term memory problems and made poor decisions. She exhibited sad, pained, worried facial expressions up to 5 days a week. She needed extensive staff assistance for bed mobility, dressing and eating. She was totally dependent on staff assistance for all other activities of daily living. She had excruciating pain less than 1 time a day in the 7 days prior to the assessment. On [DATE] a complaint was received by the State Agency. The complaint alleged the nursing staff did not administer his mother's pain medication upon his request when his mother had expressed being in pain. The physician's orders, dated [DATE] stated the resident should receive 650 mg of Tylenol every 4 hours as needed for mild pain and 5 mg of [MEDICATION NAME] sulfate every 3 hours as needed for pain. A nurse's note, dated [DATE] at 1:55 PM stated the resident complained of pain and Tylenol was administered with positive effects. The Medication Administration Record (MAR) stated [MEDICATION NAME] sulfate was administered at 7:30 PM on [DATE]. There was no nurse's note or explanation on the back of the MAR to indicate the medication was effective. The narcotic sheet was reviewed. There was no entry on the sheet for [MEDICATION NAME] sulfate administration on [DATE] at 7:30 PM. There was an entry on the sheet, which stated [MEDICATION NAME] was administered on [DATE] at 8:00 PM. The nurse's initials on the MAR were the same as the signature on the narcotic sheet. A nurse's note, dated [DATE] at 6:42 AM stated the resident complained of pain and the as needed [MEDICATION NAME] was administered with good effect. There was no physician's order for [MEDICATION NAME]. The [MEDICATION NAME] administration was not documented on the MAR. The narcotic sheet stated [MEDICATION NAME] sulfate was administered on [DATE] at 7:00 PM. There was no entry on the MAR indicating the medication was administered. There was no nurse's note or explanation on the back of the MAR to indicate the medication was effective. There were no nurse's notes from [DATE] at 6:42 AM to [DATE] at 3:20 PM. There were no other entries on the MAR or narcotic sheet for the administration of pain medication. A physician's progress note, dated [DATE] stated "...lying in bed. non verbal nsg (nursing) staff & daughter states pt (patient) grimaces with pain when turned and repositioned. The nurse practitioner's assessment and plan was "... acute pain - will order [MEDICATION NAME] (a patch with pain medication, which is absorbed through the skin over a 72 hour period)..." The nurse practitioner wrote an order for [REDACTED]. The order stated to apply the patch to the chest wall every 72 hours. The order stated to apply the first patch on [DATE]. The MAR stated the [MEDICATION NAME] was applied on [DATE] on the 3 to 11 shift. The narcotic sheet stated the patch was applied on [DATE] at 7:00 PM. There was no nurse's note or explanation on the back of the MAR to indicate the medication was effective. A nurse's note, dated [DATE] at 3:20 PM stated Resident #32 expired that morning at 10:04 AM. A facility policy and procedure, dated [DATE] and titled Pain Management stated "Policy: Resident will be assessed for acute pain and chronic pain by licensed nurse a plan of care will be established. Procedure:...2. Initiate a pain assessment any time thereafter should a resident experience pain that is not usual for the patient. 3. Administration of pian medication and effectiveness utilizing the pain scale will be monitored on the MAR...." On [DATE] at 4:35 PM, Corporate Consulting Nurse (CCN) #3 stated the reason (i.e. back pain, headache etc.) pain medication was administered should be recorded on the back of the MAR. She noted a nurse's note should be written for new on-set pain. She said the effectiveness of the [MEDICATION NAME] should have been documented. On [DATE] at 10:05 AM, CCN #4 stated the resident's record was reviewed. She noted no documentation of a pain assessment was found in the resident's nurse's notes or the MAR. 6. The facility staff failed to obtain all tests in a fasting lipid panel (FLP) for Resident #18 as the physician ordered. Clinical record review revealed, Resident #18 was an [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set assessment, dated [DATE] stated she had long and short term memory problems and rarely made decisions. She needed extensive staff assistance for bed mobility and eating. She was totally dependent on staff assistance for all other activities of daily living. On [DATE] the pharmacist wrote "...Please reevaluate continued [MEDICATION NAME] use with noted dermatology condition and consider stopping [MEDICATION NAME] at this time__and monitor FLP in one month..." On [DATE] the physician stated he was seeing the resident due to the pharmacy recommendation to re-evaluate the use of [MEDICATION NAME]. The note said to check the fasting lipid panel in the morning. The note said there were no other changes. A physician's order to obtain a fasting lipid panel in the morning was written on [DATE]. The test results, dated [DATE] stated the resident's cholesterol was 126 (normal ,[DATE]) and high density lipoproteins (HDL) were 49 (normal ,[DATE]). There was a handwritten note on the test results, which said "Where are LDL (low density lipoprotein) and triglycerides". The note was dated [DATE] and signed by the physician's assistant. There were no other FLP test results in the clinical record from [DATE] to [DATE]. On [DATE] the pharmacist wrote Resident #18 "...has orders for labs to be drawn, but at the time of this review they were not available in the resident record. The missing lab values include: FLP and only cholesterol and HDL noted, LDL? Triglycerides?..." The complete FLP was obtained on [DATE]. The results were as follows: cholesterol 113 (normal ,[DATE]), triglycerides 106 (normal ,[DATE]), HDL 45 (normal ,[DATE]) and LDL (,[DATE]). [DATE] at 8:45 AM, the Corporate Consulting Nurse (CCN) #3 stated she would look into what tests should be included in a fasting lipid panel. On [DATE] at 12:00 noon, CCN #3 provided a reference guide, dated ,[DATE] from the laboratory provider. The guide did not list a test for fasting lipid panel. There was a complete lipid panel, which said the test included cholesterol, HDL and triglycerides. The guide said if the triglycerides were greater than 400, a direct LDL would be performed. As noted above, the physician's assistant asked for the LDL and triglycerides on [DATE]. Based on resident interview, staff interview, a complaint investigation, facility document review, and clinical record review, facility staff failed to provide the care and services to attain or maintain the highest practicable physical well-being for 7 of 39 residents in the survey sample (Resident #16, #17, #4, #3, #32, #18, and #14). 1. The facility staff failed to recheck blood sugars outside of ordered parameters and notify the physician within an hour after rechecking for Resident #16. 2. The facility staff failed to administer and provide treatment to Resident #17 after a fall with injuries as ordered by the attending physician 3. The facility staff failed to administer physician's ordered antibiotic therapy for Resident #4. 4. The facility staff failed to administer Resident #3's sliding scale insulin (the amount of insulin administered is based on the blood sugar level) as the physician ordered on 2 of 5 occasions in [DATE]. 5. The facility staff failed to assess the effectiveness of a new pain medication for Resident #32. 6. The facility staff failed to obtain all tests in a fasting lipid panel (FLP) for Resident #18 as the physician ordered. 7. The facility failed to apply Vascura Hose (Compression stockings which help maximize blood flow and reduce [MEDICAL CONDITION]) as ordered by the physician for Resident #14 and failed to follow the physician order to transfer Resident #14 out of the wheelchair every 2 hours. The findings include: 1. The facility staff failed to recheck blood sugars outside of ordered parameters and notify the physician within an hour after rechecking for Resident #16. Resident #16 was a [AGE] year old admitted to the facility on [DATE] and an readmitted s of [DATE], and [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] evidenced Resident #16 was coded as being cognitively intact. Resident #16 had no behavioral problems. Resident #16 was assessed needing limited total assistance with activities of daily living (ADL's). There was no notification to the attending physician per order to recheck blood sugars outside of ordered parameters and notify the physician within an hour after rechecking A review of the clinical record evidenced Resident #16 had the following physician orders dated [DATE] at the time of admission and recertified last on [DATE]: ? Sliding scale blood sugars with insulin coverage ? Blood sugars greater than 400, sliding scale insulin, recheck and notify the physician within an hour after rechecking A Review of Resident #16's Care Plan with updates through [DATE] evidenced interventions for diabetes that included: Resident #16 at risk for hyper (high) and hypoglycemic (low) (Blood Plasma Sugar) episodes secondary to diabetes, Blood sugar will be within normal limits by next review, medications and labs as ordered. Report abnormal results promptly. A review of the Medication Administration Record (MAR) for July and [DATE] documented the following Blood Sugar results: Date Time Accuchecks Results ,[DATE] 11:30 AM 413 ,[DATE] 11:30 AM 451 ,[DATE] 09:00 PM 452 ,[DATE] 04:30 PM 418 ,[DATE] 11:30 AM 407 ,[DATE] 09:00 PM 432 A review of Resident #16's clinical record evidenced no documentation a recheck of the blood sugar was completed after the administration of the sliding scale insulin and the attending physician was notified within a hour after rechecking. A review of the clinical record evidenced Resident #16 required sliding scale insulin coverage daily and consistently after blood sugar checks as verified by the Medication Administration Record (MAR). A review of the laboratory results ordered by the attending physician to monitor Resident #16's diabetes and glucose (sugar) levels evidenced the following: Hemoglobin A1C lab results (monitors body blood glucose/sugar levels over a 3 month period) ? [DATE] - 8.7 (High) - Ranges: 4XXX,[DATE].9 (Normal) ? [DATE] - 8.4 (High) - Ranges: 4XXX,[DATE].9 (Normal) Fasting Glucose results (monitors most recent blood sugar levels after fasting) ? [DATE] - 207 (High) - Ranges: ,[DATE] (Normal) ? [DATE] - 229 (High) - Ranges: ,[DATE] (Normal) ? [DATE] - 248 (High) - Ranges: ,[DATE] (Normal) On [DATE] at 10:15 AM, Resident #16 was observed lying in bed, appearing to be sleep. On [DATE] at 1:30 PM, Resident #16 attended the Resident Counsel Group meeting, noted to be verbal with resident interview completed. When asked during an interview on [DATE] at 9:15 A.M., the Unit Manager Licensed Practical Nurse (LPN #4), for Nursing Unit #2, she was not able to provide any documentation the attending physician per order after the administration of sliding scale insulin rechecked blood sugars outside of ordered parameters and notified the physician within an hour after rechecking on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 2:30 PM during an interview with the Director of Nursing (DON), and Assistant Director of nursing (ADON), the DON stated we were made aware of this problem and have no additional information to provide at this time." No documentation was presented regarding the blood sugars by the facility prior to the survey end on 9//,[DATE] at 2:00 P.M. 2. The facility staff failed to administer and provide treatment to Resident #17 after a fall with injuries as ordered by the attending physician Resident #17 was a [AGE] year old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE] evidenced Resident #17 was coded as being modified impaired cognitively. Resident #17 had no behavioral problems Resident #1 was assessed needing limited extensive assistance with activities of daily living (ADL's). Review of Resident #17's clinical record evidenced a nursing note dated [DATE] at 12:16 AM, that stated resident fell this shift ([DATE] at 6:50 PM), skin tear on top of right hand. Lump on left occipital area of head, attending physician and responsible party (RP) notified, cleaned skin tear with dry dressing. Vital signs normal. Neuro checks were done, oriented to self, speech clear, no pain or distress. Will continue to monitor. Review of the physician order sheet on Resident #17's clinical record evidenced the following physician order: ? [DATE] at 11:00 PM - Apply cold compress to the bump on the left occipital area (q)every shift x 24 hours, then change to warm compress. A review of the Treatment Administration Record evidenced the nursing staff noted the order and slotted the TAR for the treatment to be administered as ordered. Review of the TAR evidenced there was no documentation the treatments had been completed from [DATE] through [DATE]. Review of the nursing notes from [DATE] through [DATE] evidenced there was no nursing staff notation in the notes the treatments had been administered. When asked during an interview on [DATE] at 9:29 AM, the Unit Manager Licensed Practical Nurse (LPN #4), for Nursing Unit #2, she was not able to provide any documentation the physician ordered treatments had been administered as ordered. On [DATE] at 10:07 AM, the Unit Manager Licensed Practical Nurse (LPN #4), for Nursing Unit #2, advised the nurse noted the order and copied it to the TAR never initiated the order or advised anyone about it during shift change. On [DATE] at 2:30 PM during an interview with the Director of Nursing (DON), and Assistant Director of nursing (ADON), the DON stated we were made aware of this problem and have no additional information to provide at this time." No evidence was presented regarding the treatments for Resident #17 by the facility prior to the survey end on 9//,[DATE] at 2:00 P.M. 7. The facility failed to apply Vascura Hose (Compression stockings which help maximize blood flow and reduce [MEDICAL CONDITION]) as ordered by the physician for Resident #14 and failed to follow the physician order to transfer Resident #14 out of the wheelchair every 2 hours. Resident #14 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS), dated [DATE] evidenced Resident #14 was able to answer 5 of 6 questions on the Brief Interview for Mental Status. The resident was coded as needing extensive assistance for ADLs (Activities of Daily Living). A. The Physician's Order Form dated [DATE] evidenced an order for [REDACTED]. Resident #14 was observed in her room seated in her wheelchair without Vascura hose in place on [DATE] at 10:00AM, 11:30AM, 12:15PM, 1:30PM, and 2:00PM. The resident was observed again without Vascura hose on [DATE] at 8:45AM, 10:35AM, 2:00PM and 4:00PM. On [DATE] at 1:00PM the observations were shared with the Director of Nursing (DON). She stated staff should make sure the resident's Vascura hose are in place as ordered by the physician. B. Review of Resident #14 Care Plan dated [DATE] evidenced a problem of " Redness: Redness to R(right) & L(left) buttocks N.O. (new order) for [MEDICATION NAME] oint. (ointment) to be applied every shift" and "Impaired skin integrity admitted with Risk for further skin breakdown related to incontinence and impaired mobility..." with approaches that include pressure reduction surface to bed/chair at all times, specialty soft care cushion, low air loss mattress, and treatment per MD orders. Review of Resident #14 clinical record evidenced history of a Stage III pressure ulcer on the coccyx that was present when the resident was admitted . The resident's Wound Sheets and Weekly Skin Check Sheets evidenced a healing Stage III with a pin point opening. During an observation of a skin check for the resident on [DATE] at 3:25PM with LPN (Licensed Practical Nurse) #8, a pin point opening was noted on the coccyx and a red rash on the buttocks and upper back was identified as psoriasis by the nurse. The Physician's Order Form dated [DATE] evidenced, "Resident may be up in wheelchair for no more than 2 hours at a time". Resident #14 was observed seated in her wheelchair in her room on [DATE] at 10:00AM, 11:30AM, 12:15PM and 1:30PM. At 2:00PM, the resident was observed in bed sleeping. She was observed on [DATE] seated in her wheelchair at 8:45AM and at 10:35AM. On [DATE] at 11:45AM the resident was observed seated in her wheelchair in her room. During an interview on [DATE] at 11:50AM, CNA (Certified Nursing Assistant) #8 stated the resident had been moved from her bed to the wheelchair at about 8:15AM and would return to bed after lunch at about 1:45PM to 2:00PM. She also stated the resident's daily routine was to transfer from bed to the wheelchair after breakfast and to return to bed after lunch. On [DATE] at 1:00PM the observations were shared with the DON. She stated the resident should be transferred from the wheel chair to the bed every 2 hours as ordered by the physician to prevent skin breakdown and irritation related to her healing pressure area and psoriasis. COMPLAINT DEFICIENCY 3. Facility staff failed to administer physician's ordered antibiotic therapy for Resident #4. Resident #4 was a [AGE] year-old admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Resident #4 most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of [DATE] coded Resident #4 as being cognitively intact regarding her mental status. The facility staff coded Resident #4 as needing extensive assistance and one person physical assist for personal hygiene. A review was conducted on [DATE] of Resident #4 facility documentation and clinical records. Resident #4 ' s clinical records revealed a physician ' s order dated [DATE] for " [MEDICATION NAME] 100 Milligrams intravenous loading dose, then 50 Milligrams intravenous every 12 hours for 7 days and contact isolation precautions " for an Extend Spectrum Beta Lactamase infection (antibiotic-busting enzyme many different kinds of bacteria can produce). The facility scheduled resident ' s medication administration times for 9:00 A.M. and 9:00 P.M. daily. Furthered review of Resident #4 ' s Medication Administration Record (MAR) revealed the facility staff failed to administer physician ' s ordered antibiotic on the following dates: Dates Times -[DATE] 9:00 A.M. -[DATE] 9:00 P.M. -[DATE] 9:00 A.M. -[DATE] 9:00 P.M. -[DATE] 9:00 A.M. -[DATE] 9:00 P.M. -[DATE] 9:00 A.M. An interview was conducted on [DATE] at 10:00 A.M. with the facility Unit Manger (UM) regarding the findings. UM stated the facility had contacted an outside agency to start Resident #4 ' s peripheral intravenous (IV) site and the agency failed to response in a timely manner which delayed the resident receiving the medication. Surveyor found no evidences the facility staff had contacted Resident #4 ' s physician regarding the failure to administer the resident ' s antibiotic. In addition, the facility staff could not provide the surveyor with any documentation indicating exactly when the outside agency was contacted by the facility to resident ' s (IV) site. The facility administrator and clinical team were made aware of the stated findings at the end-of-day brief on [DATE] and no additional information was provided to the surveyor.

2. Resident #115 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #115 was admitted to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident was readmitted to the nursing facility on [DATE] at 8:25 pm. The most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident with a score of 9 (Moderately impaired cognitive status) on the Brief Interview for mental Status (BIMS). The resident was assessed with [REDACTED]. He had minimal difficulty in hearing ability. The most recent care plan dated [DATE] identified [DIAGNOSES REDACTED]. The goals were the resident would remain free from injury related to [MEDICAL CONDITION] activity and would not experience complications related to infection. Some of the approaches to accomplish these goals included lab tests as ordered by the physician, observe and record signs and symptoms of [MEDICAL CONDITION] disorder, monitor for changes in mental status and vital signs as needed. The care plan dated [DATE] also identified potential for falls, 5 actual falls with the most recent un-witnessed fall on [DATE]. According to facility's nurse's notes dated [DATE], Resident #115 was found by Licensed Practical Nurse (LPN) #5 sitting on the floor mat beside his bed at 4:45 pm. Documented monitoring after the fall failed to evidence the neurological status/assessment and monitoring of the resident that would have included frequent vital signs, functional status, level of consciousness, speech, response to verbal and physical stimuli and other assessments to include [MEDICAL CONDITION] activity, vomiting and headache. LPN #5 documented the resident vomited at 10:50 pm. LPN #5 was interviewed via telephone on [DATE] at 2:35 pm. She stated she found the resident on the floor on [DATE] as documented in the nurse's notes and the fall was considered as un-witnessed and she informed the physician. She stated it was the first time she had the resident in a while and he was different because he was somewhat aggressive and more confused. She stated the Certified Nursing Assistants (C.N.A.) placed him in the chair during the shift. She said the resident was placed back in bed after he vomited at 10:50 pm. She stated she passed on to the ,[DATE] shift about the resident's fall and vomiting episode. She said, "I forgot to do the full neurological assessment on (Resident #115's name)." According to facility's nurse's notes dated [DATE], for the ,[DATE] shift Resident #115 was found by Licensed Practical Nurse (LPN) #4 as not at his normal, unable to take his medication because he was unable to open his mouth. Respirations unstable, oxygen saturation was 71 percent (%)(,[DATE]% =normal; www. medhelp.org), extremities cold to touch. MD gave orders to send resident to Emergency Department (ED). LPN #4 was interviewed via telephone on [DATE] at 2:50 pm. She stated she had worked that previous weekend prior to the ,[DATE] shift on [DATE] and felt the resident's mental status was "definitely not like him". She said, she parked her medication cart by his room because he was her first resident at which time she saw two C.N.A.'s try to place him in his wheelchair with him slumped over. She stated she could not arouse the resident, he looked extremely sick and his Oxygen (O2) saturation level was around 70. She said she started O2 and immediately called the physician. During the interview with LPN #4, she said 911 was called and the resident was transferred to the ED around 9:30 am. She stated she was never told during report from the ,[DATE] shift nurse that Resident #115 had fallen on the ,[DATE] shift or that he had vomited on that same shift. She said the ,[DATE] nurse told her "the resident slept". She stated she found out about the fall just before the resident left with the emergency rescue. LPN #4 said, "I felt he should have long been out of here based on how bad he was. The full neurological assessment would have given tons of information to include level of consciousness changes and frequent vital signs." The LPN stated the resident was somewhat combative over the previous weekend and a U/A C&S was obtained pending culture results to determine treatment. Resident #115 arrived at the local ED [DATE] at 10:00 am, neurological evaluation revealed he was unresponsive, unable to follow commands or answer any questions. A UTI was confirmed from the sample obtained from the nursing facility, and a [MEDICATION NAME] level obtained resulted in a critical toxic level of 45 (normal =,[DATE] mcg/ml). The level was repeated and remained toxic at 42. The resident was admitted to the hospital based on the aforementioned assessment with associated [DIAGNOSES REDACTED]. Intravenous fluids were started, antibiotic for UTI and close monitoring of toxic [MEDICATION NAME] level and resume at a lower dose once levels were low enough verses switching to another medication. The Assistant Director of Nursing (ADON) was interviewed on [DATE] at approximately 11:45 am. The ADON stated when he came on for the ,[DATE] shift on [DATE], he found out from the ,[DATE] shift RN supervisor that Resident #115 had fallen on the ,[DATE] shift. He stated he went to check the post fall information in the computer which was completed, but found out neurological assessment/monitoring had not been conducted by either the ,[DATE] shift LPN (#5) or the ,[DATE] LPN (#1). He said neurological assessments are to be conducted on all residents with un-witnessed falls as a component of a full nursing assessment. He stated LPN #1 told him the resident appeared dazed and confused on her shift, but he could not understand why there was no documentation of her assessment of the resident. He said he specifically asked LPN #1 about neurological assessment and monitoring, to which she responded the fall did not occur on her shift; so she felt she did not have to do any, and she was tired of cleaning up other people's messes. The ADON stated he told LPN #1, "You still bare responsibility to start an assessment on your shift regardless of whether the neurological assessments were not done on the ,[DATE] shift." During the above interview with the ADON, he stated he instructed LPN #1 to document nurse's notes prior to leaving her assigned shift. The ADON stated after review of the LPN's note, he discovered she was deceptive in her note and gave the impression she had called the physician on her shift about the decline in the resident's condition; when it fact it was the ,[DATE] shift LPN #5 that had initially made the call to the physician on [DATE] at 6:00 pm. He stated he did not know what she had done for the resident on her shift. On [DATE] at 12:45 pm, an interview was conducted with Registered Nurse (RN) Interim Unit III Manager. She stated it was her first or second day and she did not know Resident #115's baseline, but LPN #4 knew him well and stated he was barely responsive and weak. She said, "Based on resident having the vomiting; it was a primary concern following an un-witnessed fall. Coming in on the shift and not having that neuro information was serious. He needed to have gone out to the hospital. The way he looked that morning ([DATE]); I would have sent him out the previous shift and called the physician later." An interview was conducted with LPN #7 on [DATE] at 1:35 pm. The LPN stated when she came on for the ,[DATE] shift, LPN #1 initiated an altercation with verbal threat towards her over C.N.A. assignment issues. She said, "After the altercation with me I was made aware of the condition of Resident #115 and thought maybe that was the reason for LPN #1's outburst." She stated she went in with the assigned ,[DATE] LPN#4 and the resident "looked bad and his O2 sats were critical". She said the resident was usually pleasant and could give his first and last name. During the above interview with LPN #7 she stated Resident #115 had a [MEDICAL CONDITION] the previous week and when she found out he had a fallen, she wondered if had been as a result of a [MEDICAL CONDITION]. She stated there were no neuro assessments on ,[DATE] or ,[DATE]. She said, "I was praying nothing happened to him; that's how bad he looked. Neuro assessments require that you evaluate the resident every 15 minutes for 1 hour, every 30 minutes for 2 hours and every hour for 4 hours. You can start them at any time, if you see the need. There's lots of information you obtain by doing them, and you can see vital sign changes. You have to assess and closely monitor for three straight shifts after a fall. I don't think his condition was sudden at 7:00 am, considering the way he looked that morning." On [DATE] at approximately 11:20 am, an interview was conducted with the Director of Nursing and the Regional Nurse Consultant (RNC). The DON stated nurses are to give a report about the resident to the oncoming shift. She said LPN #5 told her and the ADON she had informed LPN #1 about the fall, as well as the vomiting. The DON stated the nursing supervisor had worked a double from ,[DATE] on [DATE] into the next shift from ,[DATE] am on [DATE] and was aware of the fall. She stated it was the responsibility of the assigned nurse to inform the supervisor of any changes in resident conditions or incidents. She said the nursing supervisor would expect a call if any resident was doing poorly and she was not informed of any more than a fall regarding Resident #115. Resident #115 had returned from the hospital on [DATE] at 8:25 pm. On [DATE] at 10:00 am, 1:00 pm and 4:00 pm; he was observed in bed and appeared to be asleep. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions (11) of the nurse's failure to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] LPN #1 was suspended pending investigation of her failure to assess Resident #115 after a fall. The LPN was terminated on [DATE] for threatening another staff member. On [DATE] at approximately 3:45 pm, an interview was conducted with the DON, ADON and two Regional Nurse Consultants (RNC). They said a facility to hospital transfer form was not located, even the carbon copy. The ADON stated LPN #4 told him she may have sent both copies with the resident to the hospital. The DON stated it was her expectation that both LPN #1 and LPN #5 should have completed full nursing assessments to include the neuro assessments especially with a change in mental status. She stated, "If I was the ,[DATE] on-coming nurse (referring to LPN#1); I would have been right in there with an immediate assessment and consistent follow-up." The ADON stated the assessment of the resident should have taken place early in the ,[DATE] shift. During the above interview the RNC's stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility would be reporting LPN#1 to the board of health professionals. Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the necessary care and services were provided to attain and maintain the highest physical well-being for 2 of 19 (Residents #117 and #115) residents in the survey sample. 1. The nurse failed to assess and obtain vital signs for Resident #117 after the CNA notified her that she could not obtain the resident's blood pressure. Subsequently, the resident's condition deteriorated and she expired. 2. The facility staff failed to monitor and assess for a reported changes in Resident #115's physical and mental status. The findings included: 1. Resident #117 was a [AGE] year old who was originally admitted to the facility on [DATE] for skilled services following hospitalization for complaints of chest pain. [DIAGNOSES REDACTED]. Resident #117 had been living alone independently at home prior to the hospitalization . The resident utilized a front wheel walker for independent ambulation. Discharge plans were for the resident to transition to long term care at the facility. Following a fall at the facility on [DATE] Resident #117 was admitted to the hospital with [REDACTED]. The resident was discharged back to the facility on [DATE] for skilled services. The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] assessed the resident as having impaired short-term memory, intact long-term memory and moderately impaired cognitive skills for daily decision-making. The 14 day scheduled assessment dated [DATE] assessed the resident as requiring extensive assistance of 2 staff for bed mobility, dependent on staff for transfers and bathing, and extensive assistance with toileting, dressing and personal hygiene. The resident had an unsteady gait and history of fallen in the past 30 days. Review of the physician orders [REDACTED]. A full code status means if a resident goes into respiratory or [MEDICAL CONDITION] every possible measure available will be used to resuscitate them. On [DATE] the resident was examined by the nurse practitioner (NP) due to abnormal labs. The NP documented the resident was "lying in bed with nursing staff at bedside giving her a bath. She (the resident) states she is cold and thirsty". Physical exam revealed the resident was alert and answers appropriately. Respirations were clear to auscultation, cardiovascular system with RRR (regular rate and rhythm) abdomen was soft with active bowel sounds, and extremities cool to touch, no [MEDICAL CONDITION], pulses 2+. The resident was diagnosed with [REDACTED]. The plan was to repeat the basic metabolic panel (BMP). The 11 PM-7 AM licensed practical nurse (LPN#1) responsible for the care of Resident #117 on [DATE] documented the following, "Received pt (patient) asleep in bed. At 12:30 am, the CNA (certified nurse aide) informed me that she could not get a blood pressure on the patient. CNA was informed to obtain the other vitals and that the nurse would get a blood pressure shortly. At 2:30 am, the lab technician entered the patient's room and came to the nurses' station to inform the nurse that the patient did not look good. The nurse then entered the patient's room to find the patient molding (mottling) on the lower extremities, faint pulse, cyanosis of the fingernails, respirations present Q (every) ,[DATE] minutes, and the patient had a blank stare. The nurse entered the hallway and yelled for the supervisor (name) who came to assess the patient. (Supervisor's name) assessed the patient while the nurse continued palpating for a pulse and 3 CNA's entered the room to ask how they could be of assistance. At 2:33 am, oxygen was administered as well as CPR. The nurse was instructed by the supervisor to get all paperwork together and a nurse, from another unit, was asked to call 911. Rescue arrived at 2:40 am and took over CPR. An IV was inserted to the left arm, an oral airway inserted, and defibrillator attached. CPR and rescue attempts continued until 3:10 am. Emergency personnel announced the patient expired at that time." The RN supervisor documented, "When the resident was discovered she had mottling up her legs to the knees and her hand (s) were blue and cold as well...She had a peaceful relaxed posture indicating that she died in her sleep..." Review of the clinical record failed to evidence vital signs or a nursing assessment was obtained between 12:30 AM and 2:30 A.M. on [DATE]. On [DATE] at 9:44 A.M., LPN#1 was interviewed on the phone. The nurse was asked if she assessed the resident after being informed by the CNA that she was unable to obtain the resident's blood pressure, she stated, "it was so long ago, I can't remember everything". The nurse was asked if she documented all the events for that night with Resident #117 she stated, "I believe I did...I documented everything...whatever I documented I stand behind". The LPN is no longer employed by the facility. A telephone message was left in an attempt to interview the RN supervisor on [DATE], with no return call. The supervisor is no longer employed by the facility. Two attempts were made to contact the CNA who notified the nurse of the resident's blood pressure, with no return call. The CNA is no longer employed by the facility. On [DATE] at 4:42 P.M., the resident's attending physician (medical director) was interviewed. The resident's status was discussed. The physician indicated the resident was in stable condition and her death was not anticipated. He stated the resident may have had a [MEDICAL CONDITIONS], and could not determine cause of death. He reviewed LPN #1's nursing notes, and stated he would have expected the nurse to have immediately assessed the resident. LPN#1's employee file was reviewed. It evidenced a pattern of multiple corrective actions of the nurse neglecting to assess, monitor, treat and perform general nursing care in accordance with the facilities nursing policies and procedures, and standard professional practice. On [DATE] the nurse was terminated for threatening another staff member. 1. On [DATE] the nurse failed to use reasonable nursing judgement in assessment of a resident with a fall, failed to initiate neuro assessments, failed to notify the physician and supervisor of a resident change in condition, and documentation was deliberately deceptive. The resident subsequently required emergency room services and was admitted to the hospital. 2. On [DATE] refused to accept full assignment as directed by the nursing supervisor. 3. On [DATE] failed to follow physician orders [REDACTED]. 4. On [DATE] failed to write treatment orders and initiate treatment for [REDACTED]. 5. On [DATE], [DATE]and [DATE] the nurse left medication at a residents bedside. 6 On [DATE] failed to provide appropriate care and services for the management of IV infusion. 7. On [DATE] medication error. 8. On [DATE] failed to properly identify, treat and document a pressure ulcer. 9. On [DATE] failed to contact the physician to obtain medication orders. Review of the facilities policy and procedure named Significant Change of Condition dated [DATE] reads: 1. The resident's change of condition shall be reported to a licensed nurse. 2. A licensed nurse shall assess the resident for signs and symptoms of physical or mental change in condition. 3. This assessment shall be reported to primary physician or designated alternate. 8. Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a resident should be transferred to an acute care setting. On [DATE] at 10:57 A.M., the above findings was shared with the administrator, the director of nurses (DON), and the 2 regional nurse consultants (RNC). The DON and the 2 RNC's indicated they would have expected the nurse to have immediately assessed the resident. It was confirmed there was no documentation or evidence in the clinical record to support the nurse had obtained the resident's blood pressure or assessed the resident after she was notified by the CNA. The RNC's stated they would have expected the DON (who is no longer employed at the facility) to have began an investigation of this "unusual occurrence". They would have expected to have been notified immediately so they could review the clinical record and initiate an immediate action plan to include education. The RNC stated they were not aware of the multiple corrective actions in LPN #1's employee file. RNC#1 stated the nurse should have been terminated "a long time ago". She indicated the facility will be reporting LPN#1 to the board of health professionals.