Every finding on record at Waterford Nursing and Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed keep residents' medical information confidential on four (second-floor medication cart #1 and cart # 2, third-floor medication cart #1 and cart #2) out of eight medication carts; at one (first floor nursing station) out of four nursing stations and failed to provide privacy for one (Resident #116) out of three sampled residents during medication administration. Observations of unattended open computer screens on the second-floor medication cart # 2 and third-floor medication cart #1; unsecured paperwork left at the first-floor nursing station, on the second-floor medication cart #1 and on the third-floor medication cart #1 and cart #2 with resident's information visible. There were 206 residents residing in the facility at the time of the survey. The findings included.1) Observation on 03/02/2026 at 9:20 AM on the facility's second floor revealed unattended medication cart # 2's computer screen was open with residents' information visible. (photo evidence).On 03/02/2026 at 9:22 AM Staff A, Registered Nurse (RN) was asked about the facility's protocol for protecting resident's information on computers screens and stated, We are supposed to close the computer screens to protect resident information.2) On 03/02/2026 at 9:48 AM an observation was made of a demographic sheet left visible and unattended at the first floor Nursing Station. The first floor RN supervisor was made aware of the identified concern. (photo evidence).3) On 03/02/2026 at 11:40 AM unattended paperwork with residents' information visible was observed on the second-floor medication cart #1.(photo evidence).On 03/02/2026 at 11:42 AM Staff B, Licensed Practical Nurse (LPN) was made aware of identified concern and stated, The paperwork should be turned over.4) Observation on 03/03/2026 at 9:23 AM revealed the third-floor medication cart #1 was left unattended with the computer screen open and residents' information visible. (photo evidence).On 03/03/2026 at 9:30 AM Staff C, RN revealed the computers screen is to be closed. I was helping a family member and left the computer open.5)On 03/03/2026 at 9:32 AM Staff D, RN was observed administering medications to Resident #116 in the room with the door open.Record review of Resident #116 clinical records revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included: Cerebral Infarction.Record review of Quarterly Minimum Data Set (MDS) reference dated 12/22/2025 indicated Resident #116 is cognitively intact and required set up clean up assistance for eating.Record review of a care plan initiated on 07/16/2024 and revised on 09/22/2025 noted Resident #116 had a self-care deficit with interventions that included: Allow resident to perform task at own pace.On 03/03/2026 at 10:24 AM the third floor RN Supervisor revealed nursing staff are to close computer screens to protect residents' information and nurses are to close the door and pull the curtain when administering medications to residents in their room to provide privacy.On 03/03/2026 at 12:42 PM the Director of Nursing (DON) stated, Nurses are to close the computers screens and shred or cover documents with residents' personal information. Also, nurses are to provide privacy by closing the door or curtain when administering medications.6) On 03/03/2026 at 3:48 PM unattended paperwork with Resident's medical information was observed on top of the third-floor medication cart #2.On 03/03/2026 at 3:50 PM Staff F, RN revealed the paperwork should not have been left unattended.7) Observation on 03/03/2026 at 3:54 PM on the facility's third floor revealed medication cart #1 was unattended and paperwork with resident's medical information on top of the cart. (photo evidence).On 03/03/2026 at 3:55 PM Staff G, RN was made aware of identified concern noted on the third-floor medication cart #1.8) During a blood glucose check observation on 03/03/2026 at 4:04 PM Staff G, RN was observed entering a resident's room and leaving the third-floor medication cart#1 unlocked and the computer screen open with resident information visible. (photo evidence).Interview on 03/03/2026 at 4:14 PM Staff G, RN stated: I am supposed to close the computer screen and turn over any paperwork with residents' information. Record review of the facility's policy titled HIPAA Policy date implemented: 11/27/2019 revealed Policy: It is the policy of this facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. Policy Explanation and Compliance Guidelines: 6. Examples of violations include, but are not limited to: e. Leaving a secured application unattended while logged on.

Based on observations, interviews and record reviews facility failed to keep residents' environment free of accident hazards on one (third-floor) out of four Soiled Utility Rooms that contained Biohazardous materials, on two (first and third floor) Clean Utility Rooms which locked from the inside and did not contain a call light, the Sprinkler Room which locked from the inside and contained hazardous materials and for one (Resident #142) out of three sampled residents during medication administration as evidenced by:1) Observation of an unlocked Soiled Utility Room on the third floor2) Observation of an unlocked Clean Utility Room on the first and third floor3) Observation of an unlocked Sprinkler Room on the first floor4) Observation of facility's staff leaving a lancet on top of the third-floor medication cart #1 and unattended at Resident #142's bedside.There were 206 residents residing in the facility at the time of survey. The findings included.On 03/02/2026 at 9:16 AM observational tour on the third floor revealed an unlocked Soiled Utility Room containing Biohazardous materials; at 9:20 AM the Clean Utility Room door was noted unlocked the room had an inside lock and no call light. There was no staff in both rooms.On 03/02/2026 at 9:20 AM the Assistant Director of Nursing (ADON) was made aware of the identified concerns. Interview on 03/02/2026 at 9:22 AM Staff A, Registered Nurse (RN) stated, We do not lock the clean utility room. when asked if a resident could enter the room and lock themselves inside Staff A, RN replied, Yes. On 03/02/2026 at 9:42 AM during observational tour on the first floor an unlocked clean utility room that can be locked from the inside, had no call light and no staff inside.On 03/02/2026 9:47 AM, the first floor RN Supervisor was made aware of the identified concern and stated, We don' t keep it locked. Surveyor asked if it is safe for residents who wanders going inside and the first floor RN Supervisor replied, No. Observation of the first floor on 03/02/2026 at 9:50 AM revealed an unlocked door to the Sprinkler Room with no staff inside.On 03/02/2026 at 9:59 AM a tour of The Sprinkler room was conducted with the Maintenance Director, the Facility's Administrator and The Regional Director of Clinical Services. The room door was able to be locked from inside and contained materials and equipment potentially hazardous to residents.Interview on 03/02/2026 at 10:34 AM conducted with the Maintenance Director and the Facility's Administrator revealed the clean utility rooms have a closet lock that can be unlocked with any item including a penny or pencil. The Soiled utility doors are kept locked because there are biohazard and sharps containers that could hurt residents. The Sprinkler room should be kept locked because there is hazardous equipment inside. During a blood glucose check observation on 03/03/2026 at 4:04 PM, Staff G, RN was observed entering a resident's room and leaving the third-floor medication cart#1 unlocked with a lancet on top (photo). Upon returning to the medication cart, Staff G, RN was made aware of the identified concern and revealed medications and supplies are to be locked in the cart and the computer screen closed for safety of residents.On 03/03/2026 at 4:13 PM during a blood glucose check observation, Staff G, RN performed hand hygiene and left a lancet at the bedside on the side table of Resident#142 (photo). Staff RN returned to bedside and was made aware of the identified concern. Record review of a demographic sheet revealed Resident#142 was admitted on [DATE] diagnosis that included: Type 2 Diabetes Mellitus.Record review of a Quarterly Minimum Data Set reference dated 12/23/25 revealed Resident #142 had no cognitive impairment.Record review of Resident # 152's physician's order sheet revealed an order dated 6/27/2025 to obtain blood sugar two times a day. Record review of a care plan initiated on 06/26/2025 and revised on 07/01/2025 revealed Resident#142 had interventions of self-care deficit.Interview on 03/03/2026 at 12:42 PM the Director of Nursing (DON) revealed nurses are to secure all medications and supplies in the medication carts and lock the medication carts when unattended for safety.Record review of the Facility's Policy titled, Accidents and Supervision dated 1/16/2019 revealed Policy:The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes Identifying hazard(s) and risk(s). Evaluating and analyzing hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s). Monitoring for effectiveness and modifying interventions when necessary.

Based on observations, interviews and records reviewed the facility did not honor resident's right to a dignified experience for one (Resident #77) out of two sampled residents with Percutaneous Enteral Gastronomy (PEG) feeding pumps. Resident #77's PEG pump was overtly visible while the resident received enteral feeding in common areas. there were nine residents residing in the facility with PEG tube feeding pumps at the time of the survey. The findings include. On 03/02/2026 at 11:48 AM Resident #77 was observed in the hallway seated in a wheelchair with enteral feeding in progress via Percutaneous Endoscopic Gastrostomy (PEG) with the system uncovered (photo evidence). Observation on 03/03/2026 at 1:45 PM revealed Resident #77 in the dining area seated in wheelchair during activities amongst other residents and the enteral feeding was in progress via PEG and not covered (photo evidence).Record review of Resident #77's clinical records documented the resident was re-admitted on [DATE] with diagnosis that included but not limited to: DementiaRecord review of a physician's orders sheet revealed Resident #77 had orders dated 7/29/25 for Enhanced Barrier Precautions related to PEG tube every shift.On 03/03/2026 at 1:57 PM Staff E, Certified Nursing Assistant, was present during activities supervising residents stated: I don't know if the tube feeding should be covered. I will ask the nurse. On 03/03/2026 at 1:59 PM, the second floor Registered Nurse (RN) supervisor was asked about the facility's protocol regarding dignity for residents with enteral feeding and stated, I think the tube feeding for [Resident #77] should be covered while the resident is not in the room.During an interview on 3/04/2026 at 3:02 PM, the Director of Nursing (DON) was asked if nurses are permitted to administer enteral feedings in common areas and the DON replied, No. Record review of a Quarterly Minimum Data Set (MDS) reference dated 02/06/2026 revealed Resident #77 has severe cognitive impairment, dependent on activities of daily living and had a feeding tube. Record review of a care plan initiated on 04/16/2024 and revised on 02/05/2026 revealed Resident#77 had a self-care deficit with interventions that included but not limited to provide assistance only in the areas difficult for the resident. Record review of facility's policy and procedure titled Residents Rights dated 3/1/2021 indicated.Policy: It is the policy of the facility to provide Resident Rights in accordance with State and Federal regulations.Procedure: The facility will follow the Resident Rights as follows:The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must protect and promote the rights of each resident, including each of the following rights.

Based on observations, interviews and record reviews, facility failed to properly store and label medications on two (first-floor medication cart #1 and the second-floor medication cart #1) out of eight medication carts as evidenced by: 1) Staff left a normal saline syringe on top of the first-floor medication cart #1 during medication administration. 2)An illegible label of a stock medication on the first-floor medication cart #1. 3) Second-floor medication cart #1 left unlocked. There were 206 residents residing in the facility at the time of survey. The findings included.During a medication administration observation on 03/05/2026 at 8:07 AM Staff H, Registered Nurse (RN) removed a pill from a bottle to administer to a resident, however the expiration date and open date were not legible (photo). Staff H, RN was unable to read the expiration date. The 1st floor supervisor RN was made aware and took a new bottle to cart. Staff H, RN entered the resident's room with medication, leaving a syringe with normal saline on top of the first-floor medication cart #1 (photo).Interview on 03/04/2026 at 2:01 PM Staff H, RN stated, I used the syringe to flush a midline and should lock it in the cart when unattended and should verify the correct dosage and read the expiration date on medication bottles before administering. 3) During a blood glucose check observation on 03/03/2026 at 4:04 PM, Staff G, RN was observed entering a resident's room and leaving the third-floor medication cart #1 unlocked, a lancet on top of the cart. Upon returning to the medication cart, Staff G, RN was made aware of the identified concern and revealed medications and supplies are to be locked in the cart. On 03/03/2026 at 12:42 PM the Director of Nursing (DON) revealed nurses are to secure all medications and supplies in the medication carts and lock the medication carts when unattended for safety. Record review of the facility's policy and procedure titled, Labeling of Medications Storage of Drugs and Biologicals dated 3/2020 revealed Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility Will be labeled and stored in accordance with current state, federal regulations. Purpose: The purpose of this procedure is to ensure the accurate labeling of all medications and biologicals to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines:All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices.Medication labels must be legible at all times. Record review of the facility's policy titled, Medication Administration and Documentation -General undated revealed Policy: Medication Administration and Documentation shall occur in a timely and accurate manner. 7. The medication cart must be locked when out of nurse's view.

Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to failed to properly store and label medications during medication administration; failed to prevent accident hazards and failed to protect resident's privacy resulting in repeated deficient practice. The facility was cited for Label/Store Drugs and Biologicals, Personal Privacy/Confidentiality of Records and Free of Accident Hazards/Supervision/Devices in 2024. This repeated deficiency practice has the potential to affect any of the 206 residents residing in the facility. The findings included: Record review of the facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure (issued June 2021) documented the following: Policy-It is the policy of this facility to develop, implement and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 2) The QAA Committee shall be interdisciplinary and meet alongside Risk Management Committee: a) Consist at a minimum of: The Director of Nursing Services, The Medical Director and at least three other members of the facility's staff; b) Meet a least quarterly and as needed to coordinate and evaluate activities under the QAPI Program and c) Develop and implement appropriate plans of action to correct identified quality deficiencies.Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 12/19/25 for November 2025 and 2/27/26 for January 2026: documented the facility had a QAA Committee meeting quarterly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads.On 3/05/26 at 1:50 PM, interview with the Administrator/QAA. She stated, The QAA Committee meets monthly. We meet the last Thursday of the month. Committee members are: Administrator, DON, Medical Director and Department Heads and also some line staff such as a nurse, certified nursing assistant (cna) and maintenance. The purpose of the QAA committee is to have a continuous quality program, where we review the areas that we think need improvement, review parts of the patient care, infection control, dietary and environmental. Also, to evaluate our performance and see where we can have improvement. We take a proactive approach instead of a reactive approach.

Based on observations, interviews and record review the facility failed to ensure the walk-in freezer was working properly. The curtains in the walk-in freezer contained ice. This has the potential to affect one hundred and ninety-eight out of two-hundred and six residents who eat orally residing in the facility at the time of the survey.The findings included: Record review of the Physical Environment Policy and Procedure (issued 3/2020); Policy: It is the policy of the facility to provide a safe environment in accordance to State and Federal regulations; Procedure: 2) The facility will maintain all essential mechanical and electrical equipment in safe operating condition.Review of the Freezer Defrost and Maintenance Policy and Procedure (no written date); Policy-All freezer units are equipped with an automatic defrost cycles as designed by the manufacturer. The defrost cycle operates automatically during scheduled off-peak hours to maintain normal freezer function. Dietary and Maintenance departments are to ensure proper freezer operation and sanitation; Procedure: Dietary Responsibilities-Dietary staff conduct routine daily observation of freezer interiors during normal operations; Minor condensation or light frost that may occur from routine door openings will be removed and If staff observe unusual or persistent ice accumulation, a work order will be submitted to Maintenance.Observation of the initial kitchen tour of the Walk-in Freezer with the Dietary Director on 3/02/26 at 8:09 AM revealed the freezer curtains contained ice on them. Photographic evidence submittedInterview with the Dietary Director on 3/02/26 at 8:10 AM. He stated, The ice should not be there. He attempted to scrape and remove the ice from the freezer curtains.Second observation of the Walk-in Freezer with the Dietary Director on 3/03/26 at 9:30 AM revealed the freezer curtains contained ice on them. Photographic evidence submittedInterview with the Dietary Director on 3/03/26 at 9:31 AM. He revealed there is still ice on them but not as much as yesterday. Maybe the latch on the freezer is not working right.

Based on observation, interview, and record review the facility failed to ensure the safety for one out of nine sampled residents as evidenced by 1) Resident #54, a vulnerable resident with orders for bilateral floor mats was observed in bed with one floor mat 2) failed to ensure three out of four soiled utility rooms were locked. There were 201 residents residing in the facility at the time of survey. The findings included: During initial observation on 08/12/24 at 08:20 AM Resident #54 was observed there in bed, there was mat on the floor to the right side of Resident #54's bed. On 08/13/24 at 09:24 AM Resident # 54 was asleep in bed and bilateral floor mats observed in place. On 08/14/24 at 07:47 AM Resident # 54 was in bed being fed breakfast and one floor mat was against the wall and one on the floor at the right side of the bed. During an interview on 08/14/24 at 09:30 AM Licensed Practical Nurse (LPN) (Staff C) stated: The resident is supposed to have two floor mats, if during rounds I see any of the resident's mats are missing and the resident is in bed I would make sure to look around the room for the other mat and put it in place, if the mats were not in the room I would call maintenance for new mats. The resident has orders for bilateral floor mats while in bed. Interview on 08/14/24 at 09:41 AM Certified Nursing assistant (CNA) (Staff D) stated: I am assigned to the resident, the resident has two floor mats, one on each side of the bed, when I do my rounds, if one of the floor mats is missing, I talk to the nurse first and then I will make sure the floor mat is put in place. Interview on 08/15/24 at 08:40 AM, the Director of Nursing (DON) revealed there is a running list of the equipment each resident should have at the nurses' station . Review of the medical records for Resident #54 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to seizures, Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the Physician's Orders Sheet for August 2024 revealed Resident #54 had orders that included but not limited to: 8/9/24- bilateral floor mats on each side of bed every shift for safety. Record review of Resident # 54's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score-unable to be determined. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional status documented resident is dependent for care. Record review of Resident #54 's Care Plans Reference Date 07/31/2024 revealed: Resident is at risk for falls and injuries related to poor sitting and standing balance, cognitive impaired and treatment with antidepressant. History of falls in the facility. Exhibits period of agitation, restlessness, hanging the legs out of bed, at risk for falls. On 7/19/24: Fall in facility, discharge to hospital for evaluation, Left forehead abrasion, right eye redness. Resident will have minimized risk of falls and fall related injury through the next review date. Interventions include- Fall in facility bilateral floor mats, mattress bolsters as indicated . Review of the facility policy and procedures titled Accidents ad Hazards dated 01/16/2019 states: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazards) and risk(s) 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary. 48906 On 08/13/24 at 8:53 AM while on the second floor, Staff F, Registered Nurses (RN) was observed carrying a tied plastic bag with trash and entering the Biohazard room without using a code or key. Staff F, RN exited the Biohazard room and performed hand hygiene. When asked about the code for door to the Biohazard room, Staff F, RN stated: I opened The Biohazard room door without a code. This room is supposed to have a code. On 8/13/24 at 09:00 AM while on the ground floor, Staff G, Certified Nursing Assistant (CNA) was observed carrying a tied plastic bag with trash an entered the Biohazard room without using a code or key. After Staff G, CNA exited the Biohazard room and asked about the code to the Biohazard room; Staff G, CNA stated: I do not need a code to enter the Biohazard room. On 08/13/24 at 9:19 AM The Director of Nursing (DON) revealed; there are four biohazard rooms in the facility. each room is locked with a key or code. The doors are expected to be locked automatically once staff exit the room, the purpose for keeping it locked is for residents' safety and infection control. On 8/13/24 at 9:26 AM A tour was conducted of four out of four Biohazard rooms with the DON. On the fourth (4th) floor The DON entered the Biohazard room with a code. On the third (3rd) floor the DON entered without a code. On the second (2nd) floor the DON entered the Biohazard room without a code. On the ground floor the DON entered Biohazard room without a key. The DON then informed Maintenance staff of the issue. Record review of Policy entitled, Bio-hazardous Waste Management Plan revealed Policy: It is the policy of the facility to provide care and services related to Biohazardous waste in accordance to State and Federal regulations. Procedure: 7. The facility will provide an onsite storage area designated for Biohazardous waste. Class III

Based on observation and interviews, the facility failed to provide privacy for residents on one out of eight medications carts as evidenced an observation of residents' personal health information visible on an electronic medication administration screen left unattended. There were 201 residents residing the facility at the time of survey. The findings included: On 8/12/24 at 9:52 AM observation on the third floor unattended medication cart #2 revealed residents' personal health information visible on the electronic medication administration screen. Staff E, Registered Nurse (RN) exited a resident's room and was approached by the surveyor. When asked why the computer screen was left open, Staff E, RN replied, I left the computer screen open because I went into the room quickly. I am supposed to close the screen when away from the medication cart. Record review of the facility's Policy: HIPAA. Date implemented: 11/27/2019. Policy: It is the policy of the facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents. 2. All employees are expected to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents.

Based on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident number 199) out of three residents reviewed for hospital discharges. Resident number 199 was coded as being discharged to the hospital but the resident was discharged home. There were 201 residents residing in the facility at the time of the survey. The findings included: Record review of the MDS (Minimum Data Set) Assessment Completion and Accuracy Policy and Procedure (issued 9/2020) documented: Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development; Procedure: 2) The completed MDS is verified and signed by the MDS Coordinator. Staff members who complete portion of the assessment attest to the accuracy of their sections by signature and 5) The assessment will accurately reflect the resident's status. Closed record review of the Demographic Face Sheet for Resident number 199 documented the resident was admitted on [DATE] with a diagnosis of cerebral infarction, atrial fibrillation, hypertension and osteoarthritis. The resident was discharged home on 7/02/2024. Review of the Discharge Return Not Anticipated MDS (Minimum Data Set), dated 7/02/2024 for Resident number 199 documented: The discharge-return was not anticipated; It was a planned discharge; Discharge to acute hospital; discharge date was 7/02/2024. The MDS was incorrect. The resident was discharged home and not to the hospital. Review of the Physician's Order Sheet dated July 2024 for Resident number 199 documented: Discharge Home on 7/02/2024 with home health services (Revision date 7/01/2024). Review of the Discharge Care Plan for Resident number 199 (written 3/27/2024) documented the resident required short term care at the facility for rehabilitation and would return to community or prior living arrangements. Review of the IDT (Interdisciplinary Team) Discharge Progress Note dated 7/02/2024 at 12:55 for Resident number 199 documented: Resident was discharged on [DATE]. Resident was admitted to facility for: For rehabilitation, for community re-integration. Resident being discharged to own home. Review of the Ombudsman Form dated 7/02/24 for Resident number 199 documented the resident was discharged home on 7/02/2024. The form was sent to the Ombudsman on 7/09/2024. On 8/14/24 at 9:04 AM, interview with the Social Services Director. She stated, I fax the forms to the Ombudsman weekly. For [ ] for the 7/02/2024 discharge, the form was sent on 7/09/2024. She was discharged home. On 8/14/24 at 11:25 AM, interview and record review with Staff A Registered Nurse (RN), MDS Coordinator. She stated, Discharge Return Not Anticipated MDS, dated [DATE] says she went to the hospital. The POS for July 2024 says she was discharged home on 7/02/24. The Discharge Progress note dated 7/02/24 says she went home. The MDS dated [DATE] is incorrect. On 8/15/24 at 7:32 AM, interview and record review with the Director of Nursing (DON). He stated, This patient was discharged on [DATE]. This was a rehab patient. This patient was discharged home. The MDS Discharge Return Not Anticipated, dated 7/02/24 says the resident was discharged to the hospital. He confirmed the MDS was incorrect.

Based on observation, interview and record review the facility failed to ensure medications were stored safely for one out of nine sampled residents (Resident #51). As evidenced by two ointments, one medicated powder and one cream were observed on the overbed table in Resident #51's room. The findings include: During initial observation on 08/12/24 at 07:58 AM Resident# 51 was in bed asleep, medications (creams, ointments, medicated powder) were observed on overbed table (Photo available). On 08/13/24 at 09:11 AM Resident #51 was observed in geriatric chair asleep in the room. On 08/14/24 at 08:56 AM the resident in room receiving care from Certified Nursing Assistant (CNAs) (Staff B). Review of the medical records for Resident #51 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Cerebral Infarction due to embolism of left posterior cerebral artery. Review of the Physician's Orders Sheet for August 2024 revealed Resident #51 had orders that included but not limited to: Barrier cream to sacral area and buttocks-every shift for preventative and as needed for after incontinent episodes. Record review of Resident # 51's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score (BIMS) of four out of fifteen which suggests severe cognitive impairment. Record review of Resident # 51's Care Plans Reference Dated 07/10/2024 documented: Resident has an Activities of Daily Life (ADL) Self Care Deficit & is at Risk for Complications and decline, ADLs may Fluctuate throughout the Course of Day. Requires maximum/substantial to total staff Assistance with ADL's. Interview on 08/14/24 at 09:20 AM Certified Nursing Assistant (CNA), (Staff B) stated: I am the CNA assigned to the resident, I used soap and cream to clean the resident, then apply barrier cream and medicated powder. I store the items after use away in the resident's bedside drawer. Interview on 08/14/24 at 09:24 AM Licensed Practical Nurse (LPN) (Staff C) stated: stated the barrier cream we use at the facility are single used packages that are stored at the nurses' station, sometimes the family brings items that they want us to use like a lotion or powder, we would store those items in the bed side drawer in a plastic bag. I usually do my rounds several times during my shift and if I notice anything in the patients' room that is not supposed to be there, I will make sure I take care of it (store the item, dispose of the item etc.). Interview on 08/15/24 at 08:34 AM the Director of Nursing (DON) revealed after seeing the photo of the medicated powder, cream lotion on the overbed table reported Staff B confirmed that he left the medicated powder, ointments and cream treatments on the overbed table. Review of the facility policy titled Labeling of Medications, Storage of Drugs and Biologicals dated 3/2020 states: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations.

Based on observations, records reviews and interviews, the facility failed to ensure dignity during dining for one (Resident #90) out of 40 residents who are dependent on assistance with eating. As evidenced by one facility staff standing while feeding the resident. The findings include: In an observation on 04/10/23 at 09:12 AM, Resident #90 is dressed and in the wheelchair with eyes closed. In an observation on 04/11/23 at 08:47 AM, Staff C, a Diet Technician was observed standing while feeding resident #90 breakfast. Staff C stated, There is no chair in the room for me to sit down in and feed the resident. This resident eats pureed food and needs assistance with eating. In an observation on 04/13/23 at 08:02 AM, Resident #90 was in the wheelchair. Staff D, Certified Nursing Assistant (CNA) pulled a chair to resident #90. Staff D washed hands in the restroom. Prepared tray to serve the resident. Staff D sat in the chair to feed the resident. The meal was pureed and thickened liquids. Resident #90's left hand arm is observed to be contracted, the resident holds it to chest & the right arm is underneath the blanket. Record review of Resident #90 medical records revealed, medical diagnoses of dementia, glaucoma, Alzheimer's Disease. The diet is regular, nectar thickened liquids, pureed. In the physician orders, it states, document meals, intake and output. Point of care for meal consumption for breakfast, lunch and dinner and fluids. Fortified cereal at breakfast time. Record review of the minimum data set, quarterly review dated 2/14/23 documents, the Brief Interview of Mental Status score is a 3 meaning severe mental impairment. Rejection of care is behavior not exhibited. Bed mobility is extensive assistance with two plus assists. Transfer is total dependent with two plus assists. Eating is extensive assistance with one assist. Toileting is extensive assistance with one support. No weight loss or gain in the past month or 6 months. No swallowing disorder symptoms. No dental issues. No speech therapies. In care plan, it is noted in Activities of Daily living: Self Care Deficit, needs extensive to total assistance with activity of daily living. Diagnosis of Chronic Obstructive Pulmonary Disease, Alzheimer's, Dementia, Osteoarthritis, History of compression fracture T-12. Will not develop complication related to decline in activities of daily living by next review date. Target Date is 05/12/2023. On 04/13/23 at 09:08 AM, in an interview with the Registered Dietitian and Staff E, a Registered Diet Technician (Staff E) it was revealed, when asked about sitting with residents while assisting residents to eat. The Registered Dietitian stated, We usually sit 100 percent of the time. Sometimes there are no chairs available. We can ask a staff member to bring a chair for us. Sometimes, there is a chair in the room. I was helping a resident eat the other day. The chair was hard. We may stand because we are repositioning the resident in the chair or assisting them. We know we must sit because of dignity concerns. On 04/13/23 at 12:16 PM, in an interview with the Diet Technician (Staff C). When asked about assisting residents to eat during meals. Staff C stated, My job is to assist residents with eating breakfast and lunch. I assist with the certified nursing assistant (C N A) during mealtimes. I may assist the residents in their room or in the dining room. That day that you observed me, I asked the CNA to bring me a chair to sit. The CNA did not come back to me. That's when you walked in. In some resident rooms there are chairs. I assisted the resident with eating because her roommate was eating her breakfast. I didn't want to leave her without her eating her breakfast. I'm aware that we are to sit down with the residents during meals. On 04/13/23 at 01:20 PM, in an interview with the Director of Nursing (DON) revealed, when was asked about how staff can get chairs during mealtimes to assist the resident with eating. The DON stated, They are in the activity area and dining room. Staff know to sit down as it is a dignity issue and respect to the patient. To be at the same eye level. We have had in-services on that in the past. Speech therapy has given in-services for how to assist residents while eating in the past month. Review of the facility's Policy and Procedure titled, Promoting/Maintaining resident dignity during mealtime issued on 3/2020. On guideline number six it states, All staff will be seated, if possible, while feeding a resident. In the policy and procedure for resident rights dated 3-1-2021. In 30-A it states, promoting resident independence and dignity in dining (such as avoidance of disposable utensils and dishes, using bibs instead of napkins, dining room conducive to pleasant dining).

Based on observations, interviews, and record review, the facility failed to follow physician orders for oxygen therapy as prescribed for one (Resident #118) out of 3 residents sampled. The Findings Included: During observation on 04/10/2023 at 08:56 AM, Resident #118 was observed sitting in the wheelchair in the room, the oxygen (02) was running at 3 liters per minute (LPM), via nasal cannula, the 02 tubing observed was not dated, no dated supplies were observed around the 02 concentrator. On 04/11/23 at 08:46 AM, Resident #118 was observed in the room in the wheelchair watching television, there was no 02 running, stated today is a great day, 02 tubing observed in a plastic bag dated 4/10/23. On 4/12/23 at 10:30AM, Resident #118 was observed in the Activities room fixing puzzles with other residents, no distress was noted. Review of the medical records for Resident #118 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Chronic respiratory failure with hypercapnia, Chronic obstructive pulmonary disease unspecified (COPD), Obstructive sleep apnea (adult), Pneumonia unspecified organism and Influenza due to other identified influenza virus with other respiratory manifestations. Review of the Physician's Orders Sheet for April 2023 revealed, Resident #118 had orders that included but were not limited to: From 2/06/22-4/11/23-Oxygen @ 2L/m via nasal cannula as needed. From 04/11/23 oxygen at 2-3LPM via nasal cannula as needed. Medications included: Budesonide suspension for nebulization; 0.5 milligram (mg)/2 milliliter (mL) inhalation twice A Day for Shortness of breath. Ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL- inhaled content of one vial for 15 minutes every six hours while awake for COPD. Bilevel Positive Airway Pressure (BiPAP) machine at night and as needed (PRN) with settings 18/8/ 35%, backup rate 12 beats per minute (bpm) on at bedtime and off in the morning while awake and PRN. Record review of Resident #118 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) is 15, indicating the resident is cognitively intact. Section G for Functional Status documented resident requires supervision for eating and extensive assistance with all other Activities of Daily Living (ADLS). Section J for Health Conditions documented resident experiences Shortness of breath or trouble breathing when lying flat. Section O for Treatments and Procedures documented resident received oxygen therapy in the last 14 days. Record review of Resident # 118's Care Plans Reference Date 04/12/2023 revealed, Resident has potential for difficulty breathing related to COPD, and Respiratory Failure. Multiple hospitalization s related to respiratory diagnosis. Interventions included but were not limited to: BIPAP as ordered by physician (MD), Maintain precautions/care as indicated. Respiratory Therapy Evaluation and Treatment as indicated. Nebulizer/Inhalation Treatment as indicated. Maintain precautions/care as per MD orders. Review of the Physician progress notes for Resident #118 dated 04/07/23 timestamped 15:23 documented, Patient with several hospitalization s in the last year for her COPD. Currently in no acute exacerbation. Doing great on BiPAP machine at night as recommended. She was found in the hall, with no acute distress, conversational, at room air sating above 94%. Continue using BiPAP and nasal cannula as needed as oriented, as well all her nebulizer treatment. During interview on 04/11/23 at 03:46 PM, the Director of Nursing (DON) stated, when asked about care orders for oxygen tubing, the DON stated our policy states, we change the tubing weekly and as needed, we do not need an order. When asked who informs the direct care staff about this policy, the DON stated the nurses are aware of the policy and we have a respiratory therapist on site. Regarding oxygen orders, the DON stated all the continuous oxygen orders are prescribed at 2-3 Liters per minute, the as needed oxygen orders for residents are specific, but we will look into changing those orders. The Surveyor informed the DON of the observation findings concerning Resident # 118 oxygen observed at 3LPM and no dates on tubing to show when the last time it was changed. The DON acknowledged the observation findings and stated he will be working with his nurses to continue to improve patient care and do in-services. Interview on 04/12/23 at 10:01 AM, a Registered Nurse on the 2nd floor (Staff A) stated, when asked about the care of oxygen tubing for residents, she stated, she changes the residents' oxygen tubing once a week and as needed. Asked if there was an order on the Treatment Administration Record (TAR) to sign off when they change the tubing, and the nurse was not sure if there were any specific orders that they would sign off on. Staff A stated, she will check with her supervisor and let the surveyor know. Interview on 04/12/23 at 11:00 AM, a Registered Nurse on the 2nd floor, (Staff B) when asked about the care of oxygen tubing stated, she changes the residents' oxygen tubing as needed. Review of the facility's policy and procedure titled, Standards and Guidelines: SG Respiratory Care and Oxygen Administration revised 10/2022 states: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. Step 1. verify that there is a physician's order for respiratory procedures or oxygen use. Step 10. Oxygen, trach and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. Tubing order may be recorded in the clinical record, but it is not required. The Facility failed to follow the physician order for oxygen and changing tubing for Resident #118.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns as evidenced by not implementing an effective plan of action to correct identified quality deficiencies in problem-prone areas, related to respiratory/tracheostomy care and suctioning as evidenced by repeated deficient practice during consecutive annual surveys. Cross reference F695 Respiratory/Tracheostomy Care and Suctioning. The facility had deficient practice during the last recertification survey conducted in 2022. The facility had a census of 191 residents at the time of the survey. The findings included: Record review of the facility's survey history revealed, during the annual survey exit dated 01/03/2022, deficient practice was cited related to F 695- Respiratory/Tracheostomy Care and Suctioning. F 695 was also cited during the current annual recertification survey exit dated 04/13/2023. Review of the facility's plan of correction for the last annual survey with an exit date 01/03/2022 related to F 695 Respiratory/ Tracheostomy Care and Suctioning indicated as part of the correction measures revealed that A facility wide audit was conducted of all residents requiring Respiratory Services (Oxygen) to ensure residents Oxygen therapy via Nasal Cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery and frequency. Licensed Nurses were re-educated by DON/designee on Quality of Care: Respiratory Care/Orders. Following MD orders when providing Respiratory Care/Oxygen. During an interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 04/13/2023 at 01:57pm it was revealed, the Risk Manager and Quality Assurance Performance Improvement (QAPI) Committee meets once a month on the third Thursday each month. The Committee is the NHA, DON, ADON, the Medical Director, the Social Services Director, Infection Preventions, Minimum Data Set (MDS), Restorative Nursing, Human Resources (HR,) Dietitian, Plant Operations, Activities Director, Rehabilitation Director, and Environmental Services Director. The NHA stated they always get the Qualtity Assurance Performance Improvement (QAPI) reports from Pharmacy, Nephrologist services, and Diagnostic companies contracted with facility, but they do not come every month. The NHA stated there are several ways for the committee to have access and identify concerns and mentioned grievances, any other concern discussed with residents and/or family, staff and the Safety Committee which is integrated by the certified nurse assistants (CNAs, Nursing, Maintenance, Housekeeping, Dietary). They stated they review any concern or incident brought by the Maintenance Department to the committee, and reports taken from the Resident Council that is brought up by Activities and/or Director of Social Services (DSS). The NHA stated they receive concerns brought by Human Resources (HR) and they do hold townhall meetings monthly before QAPI and the QAPI Committee can get the reports and concerns from other sources different to QAPI members and the Safety Committee. The NHA stated they also look at the Certification and Survey Provider Enhanced Reports (CASPER) reports and any Agency for Health Care Administration (AHCA) complaint survey and the results from previous surveys. The NHA revealed the different performance improvement plans (PIP) the facility has opened and have all of them ongoing (without mentioning any PIP for the deficient practice cited related to Respiratory/Tracheostomy Care and Suctioning, she explained how the ongoing process is to measure effectiveness of their intervention. During the interview DON stated there is not an open PIP for F 695 at this time. When asked about the deficiency found regarding oxygen treatment which was cited in the previous annual survey, The DON explained they started doing in service with nursing staff immediately after he was made aware of it, and staff received one to one service to make sure the oxygen level follows the doctor's order and staff will be triple checking the orders. The DON stated he spoke with the doctor and explained the patient (Resident #118) can be up to three liters per minute, and he gave a new order, and they updated the care plan. When asked about the effectiveness of their QAPI regarding the previous cited deficiency, the DON stated before this survey the physician's orders were change to the 2-3 liters per minute for all continuous medication, but they did not change the PRN order which was done now. Review of QAPI meetings signing sheet dated 01/23/2023, 02/23/2023, 03/23/2023 reviewed and revealed no concerns. The facility's QAPI Committee met monthly. Reviewed QAPI Program issued 06/10/2021 revealed: 11. Governance and leadership- b. Governing oversight responsibilities included, but are not limited to the following: iii. Ensuring the program is ongoing, defined, implemented, maintained, and addresses identified priorities. vi. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness. Review Policy and Procedures on QAPI effective date 10/02/2019 revealed: PURPOSE STATEMENT: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. POLICY STATEMENT: It is the intent of this facility to conduct an ongoing Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. QAPI supports the overall goals of the facility and examines both outcomes and processes relevant to these outcomes with the objective of improvement the organization's overall performance. GUIDELINES: 6.- The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. 7. The QAPI committee will review and coordinate audits and assessments based on the QAPI calendar. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: d. Problem areas-the aspect of care has tended in the past to produce problems for staff or residents.

Based on observations, interviews and record review the facility failed to 1) store food under sanitary condition by ensuring the proper temperatures in the walk-in freezer, 2) ensure the walk-in freezer was working properly and 3) Store food under sanitary condition by ensuring resident's food items were dated and labeled in refrigerators in Nourishment Rooms. The food items in the walk-in freezer were soft to the touch and frozen nutritional treats were melted. This has the potential to affect 115 out of 130 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the Food Storage: Cold Foods Policy and Procedure (Original 5/2014, Revised 9/2017, 4/2018); Policy Statement-All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code; Procedures-3) Freezer temperatures will be maintained at a temperature of 0 degrees F (Fahrenheit) or below; 4) An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. Review of the Food: Safe Handling for Foods from Visitors Policy and Procedure (Original 9/2017, Revised 7/2019); Policy Statement-Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors; Procedures-4) When food items are intended for later consumption, the responsible facility staff member will: Ensure that the food is stored separate or easily distinguishable from the facility food, Label food with the resident name and the current date. Observation during the initial kitchen tour on 1/10/22 at 8:58 AM with the Dietary Director revealed the walk-in freezer interior temperature was 30 degrees F (Fahrenheit). The food was not frozen and soft to the touch. Items noted in the walk-in freezer were: French Toast, Pie Crusts, Biscuits, Vanilla Frozen Nutritional Treats. The Vanilla Frozen Nutritional Treat was soft to the touch and melted. Photographic evidence submitted. Interview with the Dietary Director on 1/10/22 at 9:00 AM revealed that he turned down the temperatures in the walk-in freezer to take inventory and that the food in the walk-in freezer were soft to the touch. He confirmed that the temperature in the walk-in freezer should be 0 degrees F or below. Review of the Walk-in Freezer Temperature Log for January 2022 documented the following: On 1/05/22 PM (Post Meridiem) Temperature-20 degrees F; 1/06/22 PM Temperature-20 degrees F; 1/07/22 PM Temperature-20 degrees F; 1/08/22 PM Temperature-20 degrees F and 1/09/22 PM Temperature-20 degrees F. Second observation of kitchen walk-in freezer on 1/11/22 at 9:30 AM with the Dietary Director revealed the walk-in freezer interior temperature was 0 degrees F. The food was hard and frozen to the touch. Interview with the Dietary Director on 1/11/22 at 9:34 AM revealed that he called the Air Conditioning (AC) Company to in-service the walk-in freezer to see if the freezer was working on yesterday. He stated, They came on last night, took the temperatures and everything was okay. Interview with the Corporate District Kitchen Manager on 1/11/22 at 9:36 AM revealed the walk-in freezer temperature should be 0 degrees F or below and that food items in the walk-in freezer should not be soft to the touch or melted. Review of the walk-in freezer invoice from the AC company dated 1/10/22 documented the following: Not reaching temp do to dirty condenser coil and ref (refrigerator) charge. Cleaned dirty condenser coil and adjusted ref charge. System working at this time. Interview with the Dietary Director on 1/11/22 at 11:25 AM. He confirmed the walk-in freezer invoice from the AC company dated 1/10/22 was not reaching the proper temperature and had a dirty condenser coil. He revealed that the dietary worker taking the temperatures in the PM in the walk-in freezer should have immediately notified him when the temperatures were not at the proper level and that the dietary staff would be re-educated on how to properly record temperatures and to alert him when the temperatures are out of range. Interview with the Corporate District Kitchen Manager on 1/11/22 at 11:28 AM. He stated, We will be conducting in-service today after lunch. Observation of the 1st Floor Nourishment Room on 1/11/22 at 10:31 AM. The refrigerator contained four lunch bags, two were labeled with the resident's name and dates on them and the other two lunch bags were employees lunches. The lunch bags were not labeled nor dated. Photographic evidence submitted. 01/11/22 10:39 AM Observation of the 3rd Floor Nourishment Room on 1/11/22 at 10:39 AM. The refrigerator contained three lunch bags, two were labeled with the resident's name and dates on them and one lunch bag was an employee lunch. The lunch bag was not labeled nor dated. Interview with the DON (Director of Nursing ) on 1/11/22 at 11:21 AM. She revealed that the refrigerators in the Nourishment rooms on the floors are to be used only for resident's food brought from the outside. The employees lunch bags are not supposed to be in stored in them. Also, food stored in the refrigerators must be labeled with the resident's name and the current date.

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 583 Resident's Rights related to Resident's Privacy as evidenced by a posted sign containing resident health information, repeated deficient practices related to F 641 as evidenced by inaccurate coding of resident assessment. repeated deficient practices related to F 656 comprehensive residents centered care plan related to development and implementing resident's respiratory care plan, repeated deficient practices related to F 686 Quality of Care as evidenced by the facility failed to provide care and services related to pressure ulcers, repeated deficient practices related to F 695 Quality of Care as evidenced by not providing adequate Respiratory Care for two residents, repeated deficient practices related to F 812 Food procurement, store/prepare/serve/sanitary as evidenced by facility failed to ensure proper temperature in the walking freezer, the facility failed to ensure the walking freezer was working properly and to store food under sanitary condition in the refrigerator, repeated deficient practices related to F 880 Infection Prevention and Control as evidenced by the staff failed to follow infection control procedures during wound care by failing to perform hand hygiene, failed to properly dispose biohazard materials, repeated deficient practices related to F 908 Essential Equipment/Safe Operating Condition as evidenced by the facility failed to maintain the walking freezer working properly. The finding included: Record review of the facility's survey history revealed, during a recertification and complaint investigation survey with exit dated October 31, 2019, resident's privacy was cited related to a staff administering medication to a resident in and did not provide privacy. Comprehensive resident centered care plan was cited related to the resident's care plan not implemented based on the facility's failure to inform the physician the resident's skin issues. Food Procurement, Store/Prepare/Serve/Sanitary and Essential Equipment/Safe Operating Condition were cited related to no thermometer located inside the unit. Infection Prevention and Control was cited related to the facility failure to report a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a prior survey in February 2019 the facility was cited related to Accuracy of Assessments, Quality of Care related to care of pressure ulcer, Quality of Care related to Respiratory Care. During this recertification, Relicensure and complaint investigation survey with exit date January 13, 2022 the facility was cited F 583 for resident rights as evidenced by a posted sign containing residents health information, F 641 resident assessment as evidenced by the resident Minimum Data Set was inaccurately coded, F 656 for comprehensive resident centered care plan related to development and implemented resident's respiratory care plan, Quality of Care as evidenced by the failure to provide care and services for a pressure ulcer and not providing adequate respiratory care for two residents (Cross Referenced F 686 and F 695). The facility was cited for Food Procurement/Store/Prepare/Serve/Sanitary as evidenced by the facility failed to ensure proper temperature in the walking freezer, to ensure the walking freezer was working properly and to store food under sanitary condition in the refrigerator (Cross Referenced F 812). Review of the Federal Provider History Profile Report revealed that the facility had deficiencies cited related to infection control during annual surveys conducted in 01/2018, 09/2018, 02/2019 and this survey, the facility was cited for infection prevention and control related to staff failure to follow infection control procedures during wound care by failing to perform hand hygiene, failed to properly dispose biohazard materials (Cross Referenced F 880). Essential Equipment/Safe Operating Condition was cited as due to the facility's failure to maintain the walk in freezer was working properly (Cross Referenced F 908). During an interview with the Director of Nursing and the Administrator on 1/13/2022 at 4:44 PM. The Director of Nursing stated the facility administration identified deficiency before the recertification survey, it was lack of training of the newly hired staff and staff from the agencies. Training for Infection Control is always important, and customer services. The Dietary Director/designee was educated to be accountable to complete the temperature log. In-services Education are ongoing for all departments. Accuracy of Assessments, the Corporate Minimum Data Set (MDS) Coordinator nurse was called to the facility to audit all resident's assessments and provided training to the MDS staff. Assistant of Director of Nursing did an audit for all residents receiving Oxygen therapy, and in-services education will be instructed to all nurses. Infection Prevention and Control training was ongoing. Privacy and Resident's Rights, the facility administration will provide in-services education on Residents Rights and Privacy, also an evaluation process interviewing residents and taking it to the Quality Assurance and Performing Improvement (QAPI) meetings. The wound care nurse received a one-to-one training education, and the wound care doctor will receive an in-services education for wound care procedures. They stated the QAA/QAPI meeting was held the last Thursday of every month. Last month the QAA/QAPI meeting did not meet due to the facility outbreak.

Based on observation, interview and record review, the facility failed to maintain the privacy for 1 (Resident # 62) out of one resident reviewed for privacy as evidenced by, posting a visible handwritten sign on the wall of Resident # 62's room with Personal Health Information (PHI) related to Resident # 62's dietary orders. There were one hundred-thirty residents residing in the facility at the time of this survey. The findings are the following: Observation on 01/10/22 at 12:00 PM revealed Resident # 62 was in the room, lying in bed. Resident # 62 was able to answer questions with yes or no responses but not able to elaborate during the interview. A sign was observed on the wall behind Resident # 62 the sign posted on the wall indicated in English and Spanish : (Sunday) 01-09-2022, Resident # 62's name, room number and bed. Has Nectar thickened liquids (Photographic evidence obtained). During this observation Staff A, a Certified Nursing Assistant (CNA) entered the room. Staff A was asked about the sign. Staff A stated that she had not noticed the sign displaying private information and exited the room. When asked, Resident # 62 did not state anything about the sign. Observation on 01/11/2022 at 11:25 AM revealed Resident # 62 in bed, the sign displaying private and protected information was still attached to the wall behind Resident # 62's bed. Resident # 62 was unable to say who put the sign on the wall. Observation on 01/12/2022 at 9:45 AM, Resident # 62 was observed in bed, awake, alert and oriented to person. The sign containing private and protected information was still attached to the wall. On 01/12/2022 at 9:48 AM, during an interview Staff B, a Licensed Practical Nurse (LPN) stated she did not notice the sign on the wall containing private information about Resident # 62. Staff B stated: That sign is not supposed to be there because of privacy. Staff B stated she was aware Resident #62 is on thickened liquids (nectar) but did not know who put the sign on the wall. On 01/12/2022 at 9:55 AM, the Director of Nursing (DON) revealed she did not know about the sign on the wall and no staff had reported to her that any family member for Resident #62 had asked to put the sign on the wall or educated on not posting information with private information on resident's condition in areas where it might be seen by others. The DON looked at the handwritten sign and re-stated she does not know who posted the sign on the wall. Interview with Staff C, CNA on 01/12/2022 at 10:00 AM revealed she did not notice the sign and did not know who put the sign on the wall. On 01/13/2022 at 10:45 AM, the DON reported that she had contacted Resident # 62's family on 01/13/2022 and the family revealed they did not put the sign on the wall. The DON added that it may have been a staff in the facility that put the sign on the wall. Record review of Resident # 62's Demographic Face revealed last date of admission was 03/10/2020 and original date of admission on 02/19/2020. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . etc. Record review of the Resident # 62's Minimum Date Set (MDS) Annual dated 11/16/2021 revealed Brief Interview for Mental Status (BIMS) score of 11 out of 15 and the section for nutritional approaches indicated mechanically altered diet. Record review of Resident #62's care plan dated 02/21/2020 last reviewed 11/17/2021 revealed Resident #62 was at risk related to Mechanically/altered diet, assisted with meals. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 62's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Policy and Procedures on Resident Rights last revised on 08/16/2018 revealed as a Policy Statement All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. Under Guidelines it is stated: 1.- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. Privacy and confidentiality. 3. The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity. 6. The unauthorized release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.

Based on observation, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident #136) out of one resident investigated for Hospice Care. There were 12 residents receiving Hospice Care and services at the time of survey. The finding included: Observation of Resident # 136 on 01/10/22 at 9:36 AM revealed the resident seated in her room sitting in her wheelchair. Observation of Resident # 136 on 01/12/22 10:31 AM revealed the resident sitting in wheelchair in her room. The resident stated she is feeling good. Record review of Quarterly Minimum Data Set (MDS) Section O for Special Treatments, Procedures, and Programs dated 12/23/2021 revealed the resident was receiving Hospice Care. On 01/13/2022 at 11:02 PM, during an interview Registered Nurse (RN), Staff D stated that Resident # 136 was not receiving Hospice Care. Staff D stated, I don't provide palliative care for the resident. I provide regular care to the resident. On 1/13/2022 at 3:20 PM, the Minimum Data Set (MDS) coordinator stated during an interview that Section O of the MDS showed that the resident was receiving hospice care at the time of the assessment. The MDS coordinator revealed that the assessment was incorrectly coded. Review of Facility Policies and Procedures for Resident Assessment, Last Reviewed Date: 07/31/2018, revealed Guideline: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 7-If data is conflicting, appears in error, or requires further clarification, Minimum Data Set Coordinator will verify with the resident, resident representative, licensed and non-licensed staff and /or physician to ensure data is accurate. 8-Any data or documentation found with inaccuracies during the assessment completion process must be documented as MDS Clarification Note in the resident's record with correct data, with whom and when they verified data, what MDS assessment involved with Assessment Reference Date (ARD) and a dated signature of person writing the note.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan related to respiratory care for 1 (Resident #58) out of 10 sampled residents reviewed for respiratory care. There were 130 residents residing in the facility during the survey. The findings included: During the initial tour of the facility on 01/10/22 at 10:27 AM, Resident #58 was observed in his room sitting in a wheelchair. The resident was alert, but appeared to be hard of hearing when attempting to speak to him and the televisions volume was loud. An oxygen concentrator was observed at the resident's bedside, but it was not in use. On 01/11/22 at 09:10 AM, Resident #58 was observed in his room sitting in a wheelchair, the oxygen concentrator was on at 3 liters/minute, but the oxygen was not in use by the resident. The tubing was observed on top of the concentrator. The television's volume was loud and Resident #58 reported in Spanish that he was a little hard of hearing. On 01/12/22 at 09:42 AM, Resident #58 was observed sitting in a wheelchair. The oxygen concentrator was at the bedside, was turned off and not in use by the resident. During the review of Resident #58's medical record, it noted the resident was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Dated 11/08/21 - Respiratory special procedures to be provided including respiratory muscle trainer, Incentive Spirometry, Vibratory positive expiratory pressure (PEP) therapy, Percussion/Postural/Drainage etc. Twice per day on Monday, Tuesday, Wednesday, Thursday, and Friday. Dated 11/07/21 - Oxygen Therapy - Oxygen via nasal cannula (NC) at 2 liters per minute prn (as needed). During the review of the Admission Minimum Data Set (MDS) dated [DATE], Section O, Special Treatments, Procedures and Programs, 0400D-Respiratory Therapy-1. Total Minutes-150 minutes. 2. Days: 5 days. The number of days this therapy was administered for at least 15 minutes a day in the last 7 days. During the review of Resident #58's care plans, there was no care plan found to document the use of the respiratory special procedures and oxygen therapy. On 01/13/22 at 05:14 PM, the Director of Nurses (DON) was asked to find the respiratory care plan. A care was found with the problem start date 11/07/2021: Resident at risk for Cardiovascular Complications DX (diagnosis) of CHF ([CONDITION(S)]), [CONDITION(S)] (Hypertension), HLD (Hypersensitivity Lung Disease), [CONDITION(S)], Mitral Valve Regurgitation, Ascending Aortic Aneurysm, Respiratory Complications DX CHF, [CONDITION(S)] Complications HX (History) of [CONDITION(S)] ([CONDITION(S)] Accident). The goal was - Resident will not develop cardiac complications. The target date was 02/05/2022. The approaches include Medications as ordered; Observe and report to MD (medical doctor) for chest pain; Observe and report to MD edema; Observe and report to MD for worsening of weakness; Observe for shortness of breath, changes in sputum, report to MD, and Routine vitals. The care plan didn't include approaches for respiratory special procedures and oxygen therapy. The DON reported she would have the MDS Coordinator bring the respiratory care plan. During an interview on 01/13/22 at 5:25 PM with Staff G, a Registered Nurse MDS Coordinator, Staff G presented the care plan used for resident #58's respiratory care. The care plan presented was the Resident at risk for Cardiovascular Complications DX (diagnosis) of CHF ([CONDITION(S)]), [CONDITION(S)] (Hypertension), HLD (Hypersensitivity Lung Disease), [CONDITION(S)], Mitral Valve Regurgitation, Ascending Aortic Aneurysm, Respiratory Complications DX CHF, [CONDITION(S)] Complications HX (History) of [CONDITION(S)] ([CONDITION(S)] Accident). Staff G was unable to show the respiratory approaches of respiratory special procedures and oxygen therapy on the care plan.

Based on observation, record review and interview, it was determined the facility failed to provide necessary care and services to a sacral pressure ulcer for 1 (Resident #134) out of 3 sampled residents reviewed for pressure ulcers. There were 130 residents residing in the facility during the survey. The findings included: During the initial tour on 01/10/22 at 10:18 AM, Resident #134 was observed in bed asleep and laying on her right side. The resident was wearing a mask and the resident right arm was bent at the elbow and appeared to be contracted. On 01/12/22 at 09:26 AM, Resident #134 was observed in bed awake, the resident did not respond when spoken to, the resident was in a low bed, laying on her back, and pillows were elevating her legs. The resident had 2 siderails up, and an air mattress was on the bed. On 01/12/22 at 09:55 AM, Staff E, the Wound Care Registered Nurse was interviewed. Staff E reported she had finished with wound care for the day. She reported, she started the wound care at approximately 6:45 AM. Staff E was asked about the wound care provided to Resident #134. Staff E reported, the wound care doctor came to facility on Mondays to make notes and measure the resident's wounds. She presented the physician's weekly wound care sheet dated 01/10/22 to be used for the week. The wound care sheet documented that Resident #134's wounds had deteriorated, the wound location, consent for treatment, code status, wound etiology, exudates, tissue type, primary dressing, secondary dressing, peri wound treatment and the frequency for the wound care. Staff E, showed the wound care orders starting on 01/10/22 included: For the Stage 4 on the right ear - cleanse with normal saline pat dry, apply triple antibiotic ointment cover with border gauze and skin prep daily. For the Stage 4 Sacral Wound - cleanse with normal saline pat dry and apply Santyl ointment and Calcium Alginate cover with gauze with border and skin prep in peri wound site daily. The wound care doctor's measurements on Monday, 01/10/22 included: Sacrum - 4.0x6.5x.8, Tissue Type - 20% Necrosis, 20% slough, 30% granulation, 30% muscle/Fascia, serosanguinous exudate ( thin, pink, and watery drainage). Right ear - 1.2x.5x.1, Tissue type-10% granulation, 90% cartilage, exudate-serosanguineous light. During record review it was revealed resident #134 was admitted to the facility on [DATE]. The residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Do Not Resuscitate (DNR)order. On 01/13/22 at 08:36 AM, wound care was observed with Staff E, the wound care nurse and Staff F, Certified Nursing Assistant (CNA). Staff E reported, Resident #134 had been medicated for pain prior to her starting wound care. Staff E was observed to sanitize her hands, prepared dressings at the wound care cart, Santyl placed in medicine cup, Calcium Alginate dressing, Staff E, checked the resident's armband, and explained the procedure to the resident. Went to wash her hands and left the dressings at bedside. The dressing was completed to the right ear, Staff E, cleaned the wound with normal saline. The wound was observed to be red and mainly at the top of the ear lobe. Staff E washed her hands, returned to the resident's bedside, and put on clean gloves, applied triple antibiotic, applied skin prep, and applied the border dressing cover. Staff E washed her hands, applied gloves, the resident's incontinence pad was removed and there was no dressing on the Stage 4 sacral wound. Staff E reported sometimes the dressing is missing when she completes the wound care. There appeared to be bloody drainage and urine in the incontinence brief. Staff E reported, this was new and the blood was hematuria and the blood was not from the sacral wound. The sacral wound had a large open area of missing tissue with slight redness. Staff E cleaned the sacral wound with normal saline, applied Santyl, applied gauze, skin prep with the dirty gloves on. Staff E realized she did not change her dirty gloves and applied the wound care treatment with dirty gloves on. Staff E went to wash her hands. Then Staff E went to the wound care cart to document the completion of the wound care in the computer. Staff E informed Staff D, the unit's Registered Nurse about observing blood and urine in the incontinence pad. Staff E did not go back and re-do the sacral wound care treatment to ensure the sacral wound did not become contaminated and infected since her gloves were not changed and hand hygiene was not performed before applying the wound care treatment. On 01/13/22 at 09:33 AM, the Assistant Director of Nurses was informed about the dressing change observation, blood on incontinent brief/incontinence pad, possible cross contamination during dressing change and Staff F, CNA was observed carrying the red biohazardous bag from Resident #134's room and a clear garbage bag. The red biohazardous bag had the dirty and discarded wound care dressings and supplies inside. The policy and procedure for wound care and infection control was requested. During the medical record review of the Wound Management Section of the medical record included documentation that the Right ear Pressure Ulcer was identified on 09/27/2021 and was in house acquired. The Sacrum Pressure Ulcer was present on 08/17/2020 and the resident was admitted with the wound. During the review of Resident #134's Minimum Data Set (MDS) it was noted a Significant Change MDS was completed on 10/05/2020 & 04/06/2021. The 12/23/2021 MDS Quarterly Assessment documented the presence of the 2 stage 4 pressure ulcers: Section M for Skin Conditions item M0100: Determination of Pressure Ulcer Risk. A: indicated that the resident has a stage 1 or greater., C: indicated checked mark for clinical assessment. Question in section M150 - Is this resident at risk of developing Pressure Ulcers- Response indicated Yes Item M210 for Unhealed Pressure Ulcer(s) was documented as Yes Item M0300 for Current Number of Unhealed Pressure Ulcers at each Stage indicated Item M300D coded that the resident has 1 (one ) Stage 4 Pressure Ulcer (Full thickness tissue loss with exposed bone, tendon or muscle Slough or eschar may be present. It often includes undermining and tunneling). The MDS also indicated that the Pressure ulcer was present upon admission. M1200- Skin and Ulcer Treatments indicated the resident treatments included pressure reducing device for chair, pressure reducing device for bed and Pressure Ulcer Care. Review of Resident #134's care plans documented- Problem: Patient is at Risk for further skin breakdown secondary to Decreased Mobility diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 09/27/2021: New Right Ear Pressure Ulcer. 1/03/21, Poor appetite. 10/18/2021: Left Hand Pressure (Resolved 11/01/2021). Category - Skin Integrity; Start Date : 04/06/2021. Last Reviewed/Revised 01/12/2022 at 04:51 indicated: Goal(s) - Patient will demonstrate Skin Integrity Free from Further Pressure Ulcer development over a Boney Prominence through NRD (Next Review Date). Target Date: 03/24/2022. (Long Term Goal); Approach(s) ; Approach: Right Ear Tx (treatment) in place. Approach: Skin treatment to sacral area changed. Approach: Appetite stimulant as per MD (Medical Doctor). Approach: (Medical Director) will Re-Evaluate staging of Right Ear Pressure Ulcer. Approach: Apply skin prep to Right Hip & cover with [MEDICATION(S)] dressing as preventive measure 3 x per week Approach: AIR MATTRESS LAL/AP (Low Air Loss/Alternating Pressure) WITH BOLSTERS, CHECK FOR FUNCTIONALITY AND SETTING Every Shift Approach: Tylenol (acetaminophen) [OTC] (over the Counter) tablet; 325 mg (milligram); amt (amount): 2 tab(tablets); oral Special Instructions: Give Tylenol 2 tab (650 mg) milligrams by mouth, 30 minutes before wound treatment. Approach: Skin Treatment to Sacral area Pressure Ulcer as per MD orders. Approach: Weekly Skin Assessment Approach: Turn and Re position every 2-3 hours Approach: See current Physicians Orders for Current Treatment as ordered by Physician Approach: Report changes in Skin Status to Physician Approach: Minimize Pressure Over a Boney Prominence Approach: Complete Braden Scale Risk Assessment, Quarterly & PRN (as needed) Approach: Reposition/Shift Weight to relieve Pressure every 2-3 hours Review of the facility's policy and procedure for Wound Care dated 4/2020 documented: Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds, and the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care procedures and treatments should be performed according to physician orders. 7. Wound care treatment should be performed according to physician orders. Review of the facility's policy and procedure for Infection Control Guidelines for All Nursing Procedures, Revised August 2012, documented in General Guidelines: 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 2. Transmission Based Precautions will be used whenever measures more stringent than standard precautions are needed to prevent the spread of infection. 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin. 4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol based hand rub containing 60-95% [MEDICATION(S)] or [MEDICATION(S)] for all the following situations: f. Before moving from a contaminated body site to a clean body site during resident care. 5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes or blood and body fluids or other potentially infectious materials.

Based on observation, record review and interview the facility failed to ensure respiratory care and services were being provided to meet professional standards for 2 (Resident #56 and Resident # 98) out of 10 residents reviewed for respiratory services; as evidenced by the facility failed to ensure Resident # 56 had orders for oxygen therapy before administering oxygen therapy. 2) failed to ensure Resident # 98 was receiving oxygen therapy at the correct ordered rate. The findings included: Record review of the Oxygen Administration-Nasal Cannula Clinical Practice Guideline Policy and Procedure, effective date 10/23/20 documented: Purpose: Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery and frequency. Guidelines Steps: 1) Check the resident's medical record to confirm the presence of a complete and appropriate physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident # 56 on 1/10/22 at 2:54 PM revealed the resident's oxygen running at 5 LPM (Liters Per Minute) via nasal cannula. Review of the Demographic Face Sheet for Resident #56 documented the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . discharged on [DATE] to the hospital. Review of the Minimum Data Service (MDS) Annual, dated 11/12/21 for Resident # 56 documented the resident's Mental Status (BIMS) Summary Score was not scored, indicating cognitive impairment and section O was coded as not receiving oxygen therapy. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 2 Liters (L) per minute PRN (as needed) was D/C (discontinued) by the physician on 9/04/21. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses' Progress Notes dated January 9, 2022 to January 10, 2022 documented the resident received oxygen 2 L via NC. Interview and record review with the Director of Nursing on 1/13/22 at 11:24 AM revealed the September 2021, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON revealed that no order was given for this resident to continue receiving oxygen after this date and she should have not been receiving oxygen. Observation of Resident # 98 on 01/10/2022 at 10:03 AM. Resident was observed in room seated in bedside chair watching television, resident alert and oriented to person, time and place. Oxygen running at 2.5 Liters Per Minute (LPM). Observation of Resident # 98 on 01/11/22 at 09:09 AM . Oxygen in place running at 2.5 LPM. No distress was noted. Record review of clinical records revealed the resident was admitted to the facility on [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set Section C dated 12/09/2021 revealed the Brief Interview for Mental Status (BIMS) Summary Score was 15 out of 15 indicating the resident is cognitively intact. Review of Quarterly Minimum Data Set Section G dated 12/09/2021 revealed the resident needed extensive assistance with one-person physical assistance for bed mobility, transfer, walk, locomotion, dressing and personal hygiene. The resident needed limited assistance with one-person physical assistance for toilet use. The resident needed supervision for eating. Review of Quarterly Minimum Data Set Section O for Special Treatments dated 12/09/2021 revealed the resident was receiving oxygen therapy. Review of Resident # 98's Care Plan last reviewed date 1/10/2022 revealed the resident has respiratory problems and at risk for difficulty breathing due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: Resident will not exhibit signs of respiratory distress . Approach: Respiratory special procedures to be provided including (respiratory muscle trainer, incentive spirometry, Vibratory PEP therapy.) . Oxygen therapy: Head of bed elevated to alleviate shortness of breath lying flat related to [CONDITION(S)]; Oxygen Therapy: Oxygen via nasal cannula at 2 Liters per minute as needed. Interview with Staff D, a Registered Nurse (RN) on 1/13/2022 at 11:07 AM revealed, the resident should be receiving oxygen therapy as needed at 2 LPM.

Based on record review, observation and interview, the facility failed to revise a falls care plan with effective interventions to prevent a fall with major injury for one (resident #87) out of three residents sampled for accidents out of 35 residents whose care plans were reviewed. The resident had a high risk for falling and suffered four falls within a five month period. Adequate interventions were not implemented until the resident sustained [REDACTED]. This had the potential to affect 160 residents in the facility that required the assistance of one or two staff members for transferring. The findings included: Record review of the facility's policy and procedures titled, Falls, dated 06/01/15, Revised 08/16/18 revealed, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. It was indicated that if a fall occurred the following actions would be taken, but not limited to, the Interdisciplinary Team (IDT) would determine the root cause of the fall, if possible. Further review of the policy and procedures revealed, Interdisciplinary Team (IDT)/Director of Nursing (DON) or designee reviews during the Risk Meeting. Identify additional referrals, consult, and interventions. Document resident response to intervention. Document at Risk review in clinical medical record. Record review of the medical facesheet for resident #87 revealed, the resident was admitted to the facility originally on 04/20/2018, and readmitted on [DATE]. Observation on 09/11/2018 at 11:19 am revealed, resident #87 in the activities room seated in her wheelchair with a chair alarm attached and lap tray in place. The resident was alert, but not interviewable. She was dressed and groomed, wearing her glasses, and not in any pain or distress, or exhibiting any abnormal behaviors. Record review of the Significant change in status Minimum Data Set ((MDS) dated [DATE] revealed, resident #87 was coded as being unable to complete the Brief Interview for Mental Status (BIMS) indicating that the resident was cognitively impaired. The resident suffered from memory problems, and was moderately impaired for cognitive skills for daily decision making; her decisions were poor and required cues and supervision. Resident #87 was coded as requiring extensive assistance with two person physical assist with transfers. Further review of the MDS revealed the resident had a fall with a major injury, a fracture. Record review of the nursing assessments for resident #87 revealed that the resident had falls on 05/10/2018, 07/08/2018, 07/12/2018, and 08/05/2018. Further review indicated that on 07/12/2018 resident #87 was found on the floor on her right side and stated that she was trying to transfer from her wheelchair to the bed. The resident complained of pain to her right hip. The physician was notified, gave orders for x-rays and neurological check observations, and to send the resident to the hospital after the results were obtained. Record review of the x-ray report dated 07/12/2018 revealed, resident #87 had an acute [MEDICAL CONDITION] femoral neck. Record review of the telephone physician's orders [REDACTED].#87 to the hospital for acute [MEDICAL CONDITION] femoral neck. Record review of the nursing admission assessment dated [DATE] revealed, resident #87 returned back to the facility after receiving right hip surgery with 14 surgical staples. The resident was evaluated for the risk of falls and received a score of 26. It was indicated that a resident who scored a 10 or higher was at risk. Record review of the falls care plan dated 04/20/2018 revealed, resident #87 was care planned for the risk of falls due to balance problems, [MEDICAL CONDITION] medication treatment, and medical diagnoses. The goal included that the resident would not sustain a fall by utilizing fall precautions through next review date of 10/17/2018. The interventions documented on the resident's care plan after her falls on 05/10/2018 and 07/08/2018, prior to her fall with a major injury, included observation and 72 hour neurological checks. In addition, one of the interventions indicated reminding the resident to call for assistance prior to activities of daily living and transfers. After resident #87's fall with a major injury on 07/12/2018, and her fall on 08/05/2018, the interventions included, but not limited to, half lap tray when out of bed, mattress on the floor, and providing with large print magazines and materials. Also, multiple textiles to control anxiety levels to a minimum, lap buddy when out of bed, and alarm while in bed and while in chair. In an interview with the Certified Nursing Assistant (Staff E) and the Registered Nurse (Staff F) on 09/12/2018 at 10:17 am revealed, when Staff E worked with resident #87, she was calm and other times she tried to get out bed. She was present for one of the resident's falls, which was a few months ago. Staff E found her on the floor, she called the nurse to help the resident get back to the bed. She could not remember if the resident suffered any injuries, but since then the resident had no falls on her shift. However, she was aware that resident #87 had a fall where she suffered a fracture. She constantly monitored the resident, and provided assistance to the resident first by putting her in her wheelchair with the lap tray in place. She made sure that resident #87 went to activities and informed other nursing staff to watch the resident while she was helping other residents. Her alarm was in place, and the floormats were in position while the resident was in bed. Staff F was not present for any of the resident's falls, but made sure that resident #87's alarm worked properly, made frequent rounds to check on her, ensured that the lap tray was in place. Record review and interview with the Director of Nursing (DON) and the Nurse Supervisor (Staff C) on 09/12/2018 at 11:01 am revealed, when resident #87 was admitted to the facility on [DATE] she was a high risk for falls. Review of the nursing admission record dated 04/20/2018 revealed, the resident had a score of 13, which meant she was high risk. When a resident was high risk, the nurse would start a baseline care plan and inform nursing assistants that the resident was a high risk. Next, therapy was made aware and they would assess the resident and put them in the rehab program. The interdisciplinary team would schedule a care plan meeting with the resident and family and discuss the holistic approach to the resident's care. An individualized fall risk care plan was developed for the resident with interventions such as fall risk screening, monitoring the side effects of the resident's medications and communicating with the physician, and making sure that staff were assisting in activities of daily living (ADL) care. Resident #87 had four falls since being admitted , and one of the falls she suffered a fracture to the right femoral neck. She had a fall on 05/10/2018 and did not suffer any injuries. The resident was assessed and placed back in bed, and the family and physician were notified; review of the physician's telephone order dated 05/10/2018 revealed orders for 72 hours of neurological checks. Nursing staff were made aware to monitor resident #87 and take her to activities. Her care plan was updated to include the physician's orders [REDACTED]. Both the DON and Staff C said that besides updating the resident's care plan and monitoring the resident, they did not reassess her for the risk of falls; another fall risk evaluation was not completed. The resident had another fall on 07/08/18, she said that she was trying to transfer from her wheelchair to the bed; resident #87 was assessed and suffered no injuries. Review of the physician's telephone order indicated neurological checks for 72 hours. The intervention that was put into place after the fall was reminding resident #87 to ask for assistance prior to ADL care and transfers. A fall risk reevaluation was not completed for the resident. She fell again on 07/12/2018, four days later at 10:40 am; she was trying to transfer from her wheelchair to the bed. Resident #87 complained of pain to her right hip and was medicated with Tylenol. X-rays were completed, and results showed an acute [MEDICAL CONDITION] femoral neck; she was sent to the hospital. Resident #87 returned back to the facility, and was reassessed for the risk of falls at the time of admission. Her fall risk score went up to a 26. Her care plan was updated, and the new interventions that were put into place were floormats, and large printed materials to reduce anxiety. A half lap tray at first, but the resident was still trying to get up, so it was changed to a full lap buddy. Resident #87 fell again on 08/05/2018, she was found sitting on the floor beside her bed; she said that she wanted to walk. After the fall, an alarm for her bed and chair was put into place. Whenever a resident had one to two falls, they had a risk committee meeting and completed a root cause analysis, and implemented what was being discussed. Review of the Electronic Medical Record for resident #87 revealed, only two Interdisciplinary (IDT) notes regarding falls dated 04/26/2018 and 08/09/2018; both of the notes did not indicate a root cause analysis or interventions for the resident's falls. The facility did not have a fall risk program for high risk residents. When asked if specific interventions such as floormats or a chair and bed alarm could have been implemented prior to the resident's fall with a major injury on 07/12/2018, both staff members said that they first needed to speak with the corporate consultant before answering the question. Interview with the DON on 09/13/2018 at 11:00 am revealed, that after speaking with the corporate consultant, she said that the reason why they did not implement the fall interventions prior to the resident #87's fall on 07/12/2018 was because they wanted to use the least restrictive interventions such as monitoring the resident in front of the nurses' station, bringing her to activities where the CNAs rotated and monitored every 30 minutes. The DON said that these interventions implemented prior to the resident's fall on 07/12/2018 were effective. However, the only fall risk evaluations that were completed were at the time of admission and readmission.

Based on record review, observation and interview, the facility failed to ensure that appropriate fall precautions were in place to prevent a fall with a major injury for one (resident #87) out of three residents sampled for accidents. The resident had a high risk for falling and suffered four falls within a five month period. Adequate interventions were not implemented until the resident sustained [REDACTED]. This had the potential to affect 160 residents in the facility that required assistance of one or two staff members for transferring. The findings included: Record review of the facility's policy and procedures titled, Falls, dated 06/01/15, Revised 08/16/18 revealed, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition. Appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. It was indicated that if a fall occurred the following actions would be taken, but not limited to, the Interdisciplinary Team (IDT) would determine the root cause of the fall, if possible. Further review of the policy and procedures revealed, Interdisciplinary Team (IDT)/Director of Nursing (DON) or designee reviews during the Risk Meeting. Identify additional referrals, consult, and interventions. Document resident response to intervention. Document at Risk review in clinical medical record. Record review of the medical facesheet for resident #87 revealed, the resident was admitted to the facility originally on 04/20/2018, and readmitted on [DATE]. Observation on 09/11/2018 at 11:19 am revealed, resident #87 in the activities room seated in her wheelchair with a chair alarm attached and lap tray in place. The resident was alert, but not interviewable. She was dressed and groomed, wearing her glasses, and not in any pain or distress, or exhibiting any abnormal behaviors. Record review of the Significant change in status Minimum Data Set ((MDS) dated [DATE] revealed, resident #87 was coded as being unable to complete the Brief Interview for Mental Status (BIMS) indicating that the resident was cognitively impaired. The resident suffered from memory problems, and was moderately impaired for cognitive skills for daily decision making; her decisions were poor and required cues and supervision. Resident #87 was coded as requiring extensive assistance with two person physical assist with transfers. Further review of the MDS revealed the resident had a fall with a major injury, a fracture. Record review of the nursing assessments for resident #87 revealed that the resident had falls on 05/10/2018, 07/08/2018, 07/12/2018, and 08/05/2018. Further review indicated that on 07/12/2018 resident #87 was found on the floor on her right side and stated that she was trying to transfer from her wheelchair to the bed. The resident complained of pain to her right hip. The physician was notified, gave orders for x-rays and neurological check observations, and to send the resident to the hospital after the results were obtained. Record review of the x-ray report dated 07/12/2018 revealed, resident #87 had an acute [MEDICAL CONDITION] femoral neck. Record review of the telephone physician's orders [REDACTED].#87 to the hospital for acute [MEDICAL CONDITION] femoral neck. Record review of the nursing admission assessment dated [DATE] revealed, resident #87 returned back to the facility after receiving right hip surgery with 14 surgical staples. The resident was evaluated for the risk of falls and received a score of 26. It was indicated that a resident who scored a 10 or higher was at risk. Record review of the falls care plan dated 04/20/2018 revealed, resident #87 was care planned for the risk of falls due to balance problems, [MEDICAL CONDITION] medication treatment, and medical diagnoses. The goal included that the resident would not sustain a fall by utilizing fall precautions through next review date of 10/17/2018. The interventions documented on the resident's care plan after her falls on 05/10/2018 and 07/08/2018, prior to her fall with a major injury, included observation and 72 hour neurological checks. In addition, one of the interventions indicated reminding the resident to call for assistance prior to activities of daily living and transfers. After resident #87's fall with a major injury on 07/12/2018, and her fall on 08/05/2018, the interventions included, but not limited to, half lap tray when out of bed, mattress on the floor, and providing with large print magazines and materials. Also, multiple textiles to control anxiety levels to a minimum, lap buddy when out of bed, and alarm while in bed and while in chair. In an interview with the Certified Nursing Assistant (Staff E) and the Registered Nurse (Staff F) on 09/12/2018 at 10:17 am revealed, when Staff E worked with resident #87, she was calm and other times she tried to get out bed. She was present for one of the resident's falls, which was a few months ago. Staff E found her on the floor, she called the nurse to help the resident get back to the bed. She could not remember if the resident suffered any injuries, but since then the resident had no falls on her shift. However, she was aware that resident #87 had a fall where she suffered a fracture. She constantly monitored the resident, and provided assistance to the resident first by putting her in her wheelchair with the lap tray in place. She made sure that resident #87 went to activities and informed other nursing staff to watch the resident while she was helping other residents. Her alarm was in place, and the floormats were in position while the resident was in bed. Staff F was not present for any of the resident's falls, but made sure that resident #87's alarm worked properly, made frequent rounds to check on her, ensured that the lap tray was in place. Record review and interview with the Director of Nursing (DON) and the Nurse Supervisor (Staff C) on 09/12/2018 at 11:01 am revealed, when resident #87 was admitted to the facility on [DATE] she was a high risk for falls. Review of the nursing admission record dated 04/20/2018 revealed, the resident had a score of 13, which meant she was high risk. When a resident was high risk, the nurse would start a baseline care plan and inform nursing assistants that the resident was a high risk. Next, therapy was made aware and they would assess the resident and put them in the rehab program. The interdisciplinary team would schedule a care plan meeting with the resident and family and discuss the holistic approach to the resident's care. An individualized fall risk care plan was developed for the resident with interventions such as fall risk screening, monitoring the side effects of the resident's medications and communicating with the physician, and making sure that staff were assisting in activities of daily living (ADL) care. Resident #87 had four falls since being admitted , and one of the falls she suffered a fracture to the right femoral neck. She had a fall on 05/10/2018 and did not suffer any injuries. The resident was assessed and placed back in bed, and the family and physician were notified; review of the physician's telephone order dated 05/10/2018 revealed orders for 72 hours of neurological checks. Nursing staff were made aware to monitor resident #87 and take her to activities. Her care plan was updated to include the physician's orders [REDACTED]. Both the DON and Staff C said that besides updating the resident's care plan and monitoring the resident, they did not reassess her for the risk of falls; another fall risk evaluation was not completed. The resident had another fall on 07/08/18, she said that she was trying to transfer from her wheelchair to the bed; resident #87 was assessed and suffered no injuries. Review of the physician's telephone order indicated neurological checks for 72 hours. The intervention that was put into place after the fall was reminding resident #87 to ask for assistance prior to ADL care and transfers. A fall risk reevaluation was not completed for the resident. She fell again on 07/12/2018, four days later at 10:40 am; she was trying to transfer from her wheelchair to the bed. Resident #87 complained of pain to her right hip and was medicated with Tylenol. X-rays were completed, and results showed an acute [MEDICAL CONDITION] femoral neck; she was sent to the hospital. Resident #87 returned back to the facility, and was reassessed for the risk of falls at the time of admission. Her fall risk score went up to a 26. Her care plan was updated, and the new interventions that were put into place were floormats, and large printed materials to reduce anxiety. A half lap tray at first, but the resident was still trying to get up, so it was changed to a full lap buddy. Resident #87 fell again on 08/05/2018, she was found sitting on the floor beside her bed; she said that she wanted to walk. After the fall, an alarm for her bed and chair was put into place. Whenever a resident had one to two falls, they had a risk committee meeting and completed a root cause analysis, and implemented what was being discussed. Review of the Electronic Medical Record for resident #87 revealed, only two Interdisciplinary (IDT) notes regarding falls dated 04/26/2018 and 08/09/2018; both of the notes did not indicate a root cause analysis or interventions for the resident's falls. The facility did not have a fall risk program for high risk residents. When asked if specific interventions such as floormats or a chair and bed alarm could have been implemented prior to the resident's fall with a major injury on 07/12/2018, both staff members said that they first needed to speak with the corporate consultant before answering the question. Interview with the DON on 09/13/2018 at 11:00 am revealed, that after speaking with the corporate consultant, she said that the reason why they did not implement the fall interventions prior to the resident #87's fall on 07/12/2018 was because they wanted to use the least restrictive interventions such as monitoring the resident in front of the nurses' station, bringing her to activities where the CNAs rotated and monitored every 30 minutes. The DON said that these interventions implemented prior to the resident's fall on 07/12/2018 were effective. However, the only fall risk evaluations that were completed were at the time of admission and readmission.

Based on observation, interview and record review, the facility failed to follow professional nursing standards of practice for an unresponsive resident with a hypoglycemic episode as evidenced by failure to document the results of a repeat blood sugar and document offering simple carbohydrates based on the facility Hypoglycemic Management Protocol for one (Resident #442) out of one hundred and eleven (111) residents with a [DIAGNOSES REDACTED]. On January 10, 2018, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's administrator was informed of the existence of immediate jeopardy on January 11, 2018. The facility's completed allegation of compliance included: -Specific to the subject of the citations: Resident #442 was assessed by the facility on January 10, 2018 identify changes in conation. 911 notification completed and arrival of Emergency Management System (EMS) staff to the facility at 11:00 A.M. Immediate assistance provided by EMS staff to include IV placement and [MEDICATION NAME] administration, and transfer to advanced medical care facility. Assessments: -Assessments were completed to identify all residents at risk for Immediate Jeopardy to included all residents with a [DIAGNOSES REDACTED]. An audit was conducted on January 11, 2018 of resident with Diabetes Mellitus to include blood glucose levels for the past 60 days of less than 70 ml/dl (milliliter/deciliter)or outside call set by the MD (medical doctor) to ensure MD notification had been completed. An audit was conducted on January 11, 2018 of all resident transfers to advanced medical care in past 60 days. -On January 11, 2018, additional [MEDICATION NAME] was obtained from the pharmacy and placed on each floor. Training: -Re-education was initiated on January 11, 2018 to all Licence Nurses including Diabetes Mellitus, Hypoglycemic management and location and access to [MEDICATION NAME], documentation of glucose monitoring to include follow up actions. Evidence that Licensed Nurses were re-trained was submitted by the facility via e-mail on January 12, 2018 at 10:24 P.M. Observational verification was completed: 1) On 01/12/18 at 04:22 PM of Second floor medication room with the replacement crash cart contents included [MEDICATION NAME] 1mg/ml (quantity 3); 2) On 01/12/2018 at 4:29 PM of Third floor medication room contents of replaced Emergency crash cart kit included [MEDICATION NAME] 1mg/ml (quantity 3); and 3) random intervews were completed with licensed nursing staff on all floors to verify re-education competency. The immediate jeopardy began on January, 10, 2018 and was removed on January 12, 2018. The scope and severity was decreased to isolated/D. The findings included: Record review of the face sheet revealed Resident #442 was admitted on [DATE] and discharged on [DATE]. The [DIAGNOSES REDACTED]. Review of the 24 hour report for Resident #442, dated 1/10/2018, revealed no mention of Resident #442 change in condition related to low blood sugar (hypoglycemic). On 1/10/2018 Resident # 442 was sent to the hospital. Record review of the Physician Order Sheet (POS) for January 2018 for Resident #442 revealed full code, [MEDICATION NAME] 5 milligrams (mg) 1 tablet by mouth twice daily for Diabetes Mellitus, accucheck twice daily at 6:00 A.M. and 4:00 P.M. and call medical doctor for blood sugar greater than 250 milligrams / deciliter (mg / dL). Record review of the telephone order for Resident #442, dated 1/10/2018, revealed send resident to hospital via rescue. Record review of the Medication Administration Record [REDACTED].M. was 68. There was no repeat accucheck documented and no additional nurse's notes indicating the Hypoglycemic Management protocol was followed for administering simple carbohydrates. The MAR indicated [REDACTED].M. medication administration. Record review of the Situation, Background, Assessment, Recommendation (SBAR), dated 1/10/2018, for Resident #442 revealed change in condition and noted Resident #442 was unresponsive. Resident #442 was on hypoglycemic medications was checked. Full code was checked. Primary medical doctor was notified on 1/10/2018 at 11:35 A.M. Call for 911 was checked. At 8:00 A.M. Resident #442 ate 75 percent breakfast and was showered by Certified Nursing Assistant (CNA). At 9:00 A.M. medications were given including [MEDICATION NAME]. Resident noted with mild shortness of breath, oxygen provided via nasal cannula at 2 liters per minute. Director of Nursing (DON) went into the room and spoke to the resident. She asked how she felt and resident responded she was feeling better now that she had received oxygen. The DON left the room at 9:15 A.M. and called the doctor regarding the [MEDICAL CONDITION] noted to both upper extremities and message was left. At 9:45 A.M. rounded on resident, noted sitting in wheel chair in stable condition and denied having any distress at this time. At 10:50 A.M. therapist went inside the room and observed the resident with eyes closed and she tried to wake Resident #442. Resident #442 was unresponsive and at the same time Registered Nurse/Staff Y was close by and heard the therapist calling Resident #442 two times. Registered Nurse/Staff Y then proceeded to go inside the room and noted Resident #442 unresponsive sitting on the wheel chair. Resident #442 was immediately transferred to the bed and the CNA passing by was instructed to call for help and the other nurse on the unit called rescue. Respiratory therapist arrived with the crash cart. Vital signs assessed: Blood Pressure (BP) was 110/68, temperature was 98 Fahrenheit, respirations 22, pulse 72, oxygen saturation was 91 percent on 2 liters of oxygen and blood sugar was 24 mg / dL. Resident #442 was full code, staff at center in the room assisting the resident when rescue arrived and immediately took over for the resident. Intravenous (IV) line was started by rescue who administered 5 percent [MEDICATION NAME] (D5W) Intravenous Fluids and [MEDICATION NAME] IV push. Resident #442 was re-assessed with [REDACTED]. Resident responding to name at the time of the transfer with eyes fully open. Physician was notified and family was also notified. Record review of the meal intake for Resident #442, dated 1/10/2018, revealed breakfast intake at 8:02 A.M. was 75 percent and 240 milliliters (ml) of fluid. Record review of the nurse's notes, dated 1/10/2018, at 11:30 P.M., revealed Resident #442 was admitted to the hospital. Record review of the physician progress notes [REDACTED].M., revealed notified Resident #442's blood sugar was low and rescue was called and resident was stabilized. Transferred to hospital. Blood sugar normal will be kept in observation due to mild elevation of cardiac enzymes. During an observation on 1/10/2018 at approximately 11:00 A.M., Licensed Practical Nurse (LPN)/Staff Q had called on the phone about receiving [MEDICATION NAME]. Observation on 1/10/2018 at 11:14 A.M. revealed fire rescue was in Resident #442's room already and the police had arrived. The door was closed for Resident # 442. Observation on 1/10/2018 at 11:33 A.M. revealed Resident #442 was alert. Resident #442 had an IV connected, was stabilized and transported out of the facility via rescue in a stretcher. During an interview on 1/10/2018 at 2:07 P.M., Registered Nurse (RN)/Staff Y revealed Resident #442 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Registered Nurse/Staff Y noted Resident #442 received an oral diabetic medication of [MEDICATION NAME] 5 mg one tablet twice daily and blood sugar checks were twice daily at 6:00 A.M. and 4:00 P.M. RN/Staff Y noted if the blood sugar (BS) was over 250 mg / dL to call the doctor. RN/Staff Y mentioned Resident #442 was not on insulin. RN/Staff Y said the accucheck was performed on 1/10/2018 at 6:00 A.M., was 68 mg / dL. RN/Staff Y noted Resident #442 ate 75 percent of the breakfast and was managed with oral diabetic medications. RN/Staff Y explained Resident #442 had received her 9:00 A.M. medications on 1/10/2018 and was talking at that time. RN/Staff Y mentioned later on Resident #442 was sitting in the chair on 1/10/2018 and the therapist went into the room to take Resident #442 to therapy. The therapist called Resident #442 twice by name. Resident #442 was unresponsive, but was breathing and had a pulse. RN/Staff Y stated she asked a certified nursing assistant to call another nurse. RN/Staff Y explained the crash cart was next to the nurse's station, but did not have any emergency medications on it only items such as oxygen, mask, suction machine. RN/Staff Y mentioned Licensed Practical Nurse (LPN)/Staff Q called 911 (emergency rescue number), the supervisor and the doctor. RN/Staff Y stated the blood sugar for Resident #442 was 24 and she could not give sugar gel, since Resident #442 was unresponsive. RN/Staff Y explained LPN/Staff Q called the supervisor to get the [MEDICATION NAME]. RN/Staff Y noted the [MEDICATION NAME] was in the supervisor office in an emergency kit. RN/Staff Y confirmed there was no [MEDICATION NAME] in the medication room on the ground floor. The emergency crash kit on the ground floor had IV fluids and kit for starting an IV, but no other medications and not [MEDICATION NAME]. RN/Staff Y stated rescue came within 15 minutes and they started an IV line with IV fluids and gave [MEDICATION NAME] IV to Resident #442. RN/Staff Y said Resident #442 responded by name and then was sent to the hospital according to the attending doctor's orders. RN/Staff Y was asked about the facility hypoglycemic protocol and responded if the resident was responsive and had low BS she might give juice and for a resident with low blood sugar and unresponsive she would call the doctor and give [MEDICATION NAME]. RN/Staff Y noted the [MEDICATION NAME] was on the second floor in the supervisors office and it might take 5 to 10 minutes to get the [MEDICATION NAME] to the resident. RN/Staff Y noted she was with Resident #442 when the supervisor was looking for the [MEDICATION NAME]. RN/Staff Y confirmed it was a concern the [MEDICATION NAME] was not on the crash cart or in the ground floor medication room: [MEDICATION NAME] needs to be in the medication room or medication cart or emergency crash cart. During an interview on 1/10/2018 at 2:46 P.M., LPN/Staff Q revealed someone called her, there was a code blue in the room of Resident #442 and she went to get the crash cart. LPN/Staff Q noted it was after 11:00 A.M. and she brought the crash cart to the room of Resident #442. LPN/Staff Q stated she called rescue at the nurses station and sent the accucheck machine so the blood sugar could be taken by the other nurse. The other RN/Staff Y had told her to get the [MEDICATION NAME]. LPN/Staff Q mentioned she called the operator for the supervisor to call her. LPN/Staff Q noted the [MEDICATION NAME] was in the emergency kit in the supervisors office on the second floor - it was not held in the medication room or the crash cart on the ground floor. LPN/Staff Q said she went to the second floor to look for the supervisor and by then rescue came and had gone to the room. LPN/Staff Q was asked about the hypoglycemic protocol in an unresponsive diabetic resident and noted if the blood sugar was less than 50 and a resident was unresponsive then she would call the supervisor, get the [MEDICATION NAME], call the doctor after the resident was stabilized. LPN/Staff Q acknowledged: It would be a better idea to grab the [MEDICATION NAME] from the medication room in the ground floor. During an interview on 1/10/2018 at 3:57 P.M. Assistant Director of Nursing (ADON)/Registered Nurse (RN)/Staff Z said Resident #442 had a change in condition. ADON/Staff Z said she did not receive the message about getting the [MEDICATION NAME] and did not take out the [MEDICATION NAME]. ADON/Staff Z stated the ground floor operator said she needed to come down. ADON/Staff Z mentioned when she arrived on the ground floor, rescue was there already and was getting the IV line for Resident #442. ADON/Staff Z noted she did not administer [MEDICATION NAME] to Resident #442. ADON/Staff Z noted [MEDICATION NAME] was stored locked in the pyxis in the supervisor's office on the second floor. ADON/Staff Z confirmed for an unresponsive resident with a low blood sugar one would administer [MEDICATION NAME]. ADON/Staff Z stated Resident #442's blood sugar was 144 mg / dL when she left the facility in stable condition. ADON/Staff Z confirmed [MEDICATION NAME] was not stored in the ground floor medication room. Interview on 1/11/2018 at 10:25 A.M. with the Director of Nursing (DON), revealed Resident #442 had accucheck at 6:00 A.M. and 4:00 P.M. The DON mentioned RN/Staff ZZ had taken the blood sugar for Resident #442 and it was 68 on 1/10/2018 at 6:00 A.M. The DON stated she spoke to RN/Staff ZZ this morning and he gave pudding and repeated the blood sugar (BS), it was 122. The DON said RN/Staff ZZ was not sure if he documented this, but the blood sugar check was completed before he left. The DON explained hypoglycemic interventions for a responsive resident might include simple sugars such as orange juice or pudding and staff would give report to the next shift. The DON confirmed she did not see any documentation of a repeated blood sugar or documented interventions after the BS was 68 mg / dL on 1/10/2018 at 6:00 A.M. and the doctor was not called at that time. The DON acknowledged I would expect this to be documented. The DON stated in the morning on 1/10/2018 RN/Staff Y came to her and noted at 9:00 A.M. Resident #442 had mild shortness of breath. Resident #442 received oxygen and a breathing treatment with her routine medications. The DON said between 9:00 A.M. to 9:15 A.M. she spoke to Resident #442 and asked how she felt. Resident #442 replied she was feeling better. Resident #442 had [MEDICAL CONDITION] in the upper extremities in both arms, the DON told the RN/Staff Y to call the doctor. The DON said the therapist was going to take Resident #442 to therapy at approximately 10:50 A.M. and Resident #442 had her eyes closed and was unresponsive. The DON mentioned 911 was called, since Resident #442 was full code. The DON noted a supervisor was contacted. The DON mentioned [MEDICATION NAME] was not administered by the supervisor to Resident #442. The DON said they did not delay the treatment when the supervisor came down, since 911 rescue staff was already in Resident #442 room and they had intervened. The DON explained the blood sugar was brought up after rescue staff took over. The BS was 144 mg / dL when Resident #442 left the facility to the hospital. The DON explained for a unresponsive hypoglycemic resident the staff would take the blood sugar level and vitals signs, call the supervisor for assistance to assess the resident, check in the record if they were full code or not. If the resident was full code, then they would call 911 rescue. For blood sugar concerns the staff would review the order, the supervisor would obtain the [MEDICATION NAME] from the pyxis machine on the second floor in the supervisor office. The DON said the staff might page the supervisor or ask the switch board operator to locate the supervisor. The DON confirmed there was no [MEDICATION NAME] on the ground floor medication room. Review of the facility policy revised on 09/17/2015 revealed for diabetes mellitus: Recognize, manage, document and treatment of [REDACTED]. Diabetes is a disorder in which there is relative absolute lack of insulin. [DIAGNOSES REDACTED] (blood sugar below reference ranges). If abnormal conditions exits, notify the physician (for [DIAGNOSES REDACTED], follow steps in the Glycemic Management Flowchart). Review of facility [DIAGNOSES REDACTED] Management Algorithm revised on 09/1/2015 revealed Is the resident's blood sugar less than 70 mg / dL or parameter otherwise determined by medical doctor - is the resident awake and able to swallow? If No - administer [MEDICATION NAME] Intramuscular (IM), assess vital signs and notify medical doctor. Recheck blood sugar after 15 minutes. Is repeat glucose greater than 70, responsive and able to swallow? If No - Repeat 1 mg [MEDICATION NAME] IM, call medical doctor and call 911. Recheck blood sugar after 15 minutes. Did resident respond? If No - Notify medical doctor and await Emergency Medical Staff direction. Notify Family and Complete SBAR.

Based on observation, interview and record review, the facility failed to coordinate the care for a resident with Diabetes Mellitus with appropriate hypoglycemic diabetic protocol for an unresponsive resident experiencing a hypoglycemic episode for one (Resident #442) of one hundred and eleven (111) residents with a [DIAGNOSES REDACTED]. On January 10, 2018, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's administrator was informed of the existence of immediate jeopardy on January 11, 2018. The facility's completed allegation of compliance included: -Specific to the subject of the citations: Resident #442 was assessed by the facility on January 10, 2018 identify changes in conation. 911 notification completed and arrival of Emergency Management System (EMS) to the facility at 11:00 A.M. Immediate assistance provided by EMS to include IV placement and [MEDICATION NAME] administration, and transfer to advanced medical care. Assessments: -Assessments were completed to identify all residents at risk for Immediate Jeopardy to included all residents with a [DIAGNOSES REDACTED]. An audit was conducted on January 11, 2018 of resident with Diabetes Mellitus to include blood glucose levels for the past 60 days of less than 70 ml/dl (milliliter/deciliter)or outside call set by the MD (medical doctor) to ensure MD notification had been completed. An audit was conducted on January 11, 2018 of all resident transfers to advanced medical care in past 60 days. -On January 11, 2018, additional [MEDICATION NAME] was obtained from the pharmacy and placed on each floor. Training: -Re-education was initiated on January 11, 2018 to all License Nurses including Diabetes Mellitus, Hypoglycemic management and location and access to [MEDICATION NAME], documentation of glucose monitoring to include follow up actions. Evidence that Licensed Nurses were re-trained was submitted by the facility via e-mail on January 12, 2018 at 10:24 P.M. Observational verification was completed: 1) On 01/12/18 at 04:22 PM of Second floor medication room with the replacement crash cart contents included [MEDICATION NAME] 1mg/ml (quantity 3); 2) On 01/12/2018 at 4:29 PM of Third floor medication room contents of replaced Emergency crash cart kit included [MEDICATION NAME] 1mg/ml (quantity 3); and 3) random intervews were completed with licensed nursing staff on all floors to verify re-education competency. The immediate jeopardy began on January, 10, 2018 and was removed on January 12, 2018. The scope and severity was decreased to isolated/D. The finding included: Record review of the face sheet revealed Resident #442's admission on 1/3/2018 and discharge on 1/10/2018. The [DIAGNOSES REDACTED]. Review of the 24-hour report for Resident #442 dated 1/10/2018 revealed no mention of Resident #442 change in condition related to low blood sugar (hypoglycemic). On 1/10/2018, Resident #442 was sent to the hospital. Record review of the Physician Order Sheet (POS) for January 2018 for Resident #442 revealed full code, [MEDICATION NAME] 5 mg 1 tablet by mouth twice daily for Diabetes Mellitus, accucheck twice daily at 6:00 A.M. and 4:00 P.M. and call medical doctor for blood sugar greater than 250 milligrams/deciliter (mg/dL). Record review of the telephone order for Resident #442 dated 1/10/2018 revealed send resident to hospital via rescue. Record review of the Medication Administration Record [REDACTED].M. was 68 mg/dL. There was no repeat accucheck documented and no additional nurse's notes indicating the Hypoglycemic Management protocol was followed for administering simple carbohydrates. The MAR indicated [REDACTED].M. medication administration. Record review of the Situation, Background, Assessment, Recommendation (SBAR) dated 1/10/2018 for Resident #442 revealed change in condition and noted Resident #442 was unresponsive. Resident was on hypoglycemic medications was checked. Full code was checked. Primary medical doctor was notified on 1/10/2018 at 11:35 A.M. Call for 911 was checked. At 8:00 A.M., Resident #442 ate 75 % breakfast and was showered by Certified Nursing Assistant (CNA). At 9:00 A.M., medications were given including [MEDICATION NAME]. Resident noted with mild shortness of breath, oxygen provided via nasal cannula at 2 liters per minute. Director of Nursing (DON) went into the room and spoke to the resident. She asked how she felt and resident responded she was feeling better now that she had received oxygen. The DON left the room at 9:15 A.M. and called the doctor regarding the [MEDICAL CONDITION] noted to both upper extremities and message was left. At 9:45 A.M. rounded on resident, noted sitting in wheel chair in stable condition and denied having any distress at this time. At 10:50 A.M. therapist went inside the room and observed the resident with eyes closed and she tried to wake Resident #442. Resident #442 was unresponsive and at the same time, Registered Nurse (RN)/Staff Y was close by and heard the therapist calling Resident #442 two times. RN/Staff Y then proceeded to go inside the room and noted Resident #442 unresponsive sitting on the wheel chair. Resident #442 was immediately transferred to the bed and the CNA passing by was instructed to call for help and the other nurse on the unit called rescue. Respiratory therapist arrived with the crash cart. Vital signs assessed: Blood Pressure (BP) was 110/68, temperature was 98 Fahrenheit, respirations 22, pulse 72, oxygen saturation was 91 percent on 2 liters of oxygen and blood sugar was 24. Resident #442 was full code, staff at center in the room assisting the resident when rescue arrived and immediately took over for the resident. Rescue staff started intravenous (IV) line. Rescue staff administered 5 percent [MEDICATION NAME] (D5W) Intravenous Fluids and [MEDICATION NAME] IV push. Resident #442 was re-assessed with [REDACTED]. Resident responding to name at the time of the transfer with eyes fully open. Physician and family were notified. Record review of the meal intake for Resident #442 dated 1/10/2018 revealed breakfast intake at 8:02 A.M. was 75 percent and 240 milliliters (ml) of fluid. Record review of the nurse's notes dated 1/10/2018 at 11:30 P.M. revealed Resident #442 was admitted to the hospital. Record review of the physician progress notes [REDACTED].M. for Resident #442 revealed notification blood sugar was low and rescue was called and resident was stabilized. Transferred to hospital. Blood sugar normal will be kept in observation due to mild elevation of cardiac enzymes. Observation on 1/10/2018 at approximately 11:00 A.M. revealed Licensed Practical Nurse (LPN)/Staff Q had called on the phone about receiving [MEDICATION NAME]. Observation on 1/10/2018 at 11:14 A.M. revealed that fire rescue staff was in the room for Resident #442 already and the police had arrived. The door was closed for Resident #442. Observation on 1/10/2018 at 11:33 A.M. revealed Resident #442 was alert. Resident #442 had an IV connected, was stabilized and transported out of the facility via rescue in a stretcher. Interview on 1/10/2018 at 2:07 P.M. with Registered Nurse (RN) Staff Y revealed Resident #442 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. RN/Staff Y noted Resident #442 received an oral diabetic medication of [MEDICATION NAME] 5 mg one tablet twice daily and blood sugar checks were twice daily at 6:00 A.M. and 4:00 P.M. RN/Staff Y noted if the blood sugar (BS) was over 250 mg/dL to call the doctor. RN/Staff Y mentioned Resident #442 was not on insulin. RN/Staff Y said the accucheck performed on 1/10/2018 at 6:00 A.M. was 68. RN/Staff Y noted Resident #442 ate 75 percent of the breakfast and was managed with oral diabetic medications. RN/Staff Y explained Resident #442 had received her 9:00 A.M. medications on 1/10/2018 and was talking at that time. RN/Staff Y mentioned later on Resident #442 was sitting in the chair on 1/10/2018 and the therapist went into the room to take Resident #442 to therapy. The therapist called Resident #442 twice by name. Resident #442 was unresponsive, but was breathing and had a pulse. RN/Staff Y stated she asked a certified nursing assistant to call another nurse. RN/Staff Y explained the crash cart was next to the nurse's station but did not have any emergency medications on it, only items such as oxygen, mask, and suction machine. RN/Staff Y mentioned LPN/Staff Q called 911 (emergency rescue number), the supervisor and the doctor. RN/Staff Y stated the blood sugar for Resident #442 was 24 mg/dL and she could not give sugar gel, since Resident #442 was unresponsive. RN/Staff Y explained LPN/Staff Q called the supervisor to get the [MEDICATION NAME]. RN/Staff Y noted the [MEDICATION NAME] was in the supervisor office in an emergency kit. RN/Staff Y confirmed there was no [MEDICATION NAME] in the medication room on the ground floor. The emergency crash kit on the ground floor had IV fluids and kit for starting an IV but no other medications and not [MEDICATION NAME]. RN/Staff Y stated rescue staff came within 15 minutes and they started an IV line with IV fluids and gave [MEDICATION NAME] IV to Resident #442. RN/Staff Y said Resident #442 responded by name and then was sent to the hospital according to the attending doctor's orders. RN/Staff Y was asked about the facility hypoglycemic protocol and responded if the resident was responsive and had low BS she might give juice and for a resident with low BS and unresponsive she would call the doctor and give [MEDICATION NAME]. RN/Staff Y noted the [MEDICATION NAME] was on the second floor in the supervisor's office and it might take 5 to 10 minutes to get the [MEDICATION NAME] to the resident. RN/Staff Y noted she was with Resident #442 when the supervisor was looking for the [MEDICATION NAME]. RN/Staff Y confirmed it was a concern the [MEDICATION NAME] was not on the crash cart or in the ground floor medication room: [MEDICATION NAME] needs to be in the medication room or medication cart or emergency crash cart. Interview on 1/10/2018 at 2:46 P.M. with LPN/Staff Q revealed someone called her that there was a code blue in the room of Resident #442 and she went to get the crash cart. LPN/Staff Q noted it was after 11:00 A.M. and she brought the crash cart to the room of Resident #442. LPN/Staff Q stated she called rescue at the nurse's station and sent the accucheck machine so the other nurse could take the blood sugar. The other RN/Staff Y had told her to get the [MEDICATION NAME]. LPN/Staff Q mentioned she called the operator for the supervisor to call her. LPN/Staff Q noted the [MEDICATION NAME] was in the emergency kit in the supervisor's office on the second floor - it was not held in the medication room or the crash cart on the ground floor. LPN/Staff Q said she went to the second floor to look for the supervisor and by then rescue staff came and had gone to the room. LPN/Staff Q was asked about the hypoglycemic protocol in an unresponsive diabetic resident and noted if the blood sugar was less than 50 mg/dL for example and a resident was unresponsive then she would call the supervisor, get the [MEDICATION NAME], call the doctor after the resident was stabilized. LPN/Staff Q acknowledged: It would be a better idea to grab the [MEDICATION NAME] from the medication room in the ground floor. During an interview on 1/10/2018 at 3:57 P.M., Assistant Director of Nursing (ADON)/Registered Nurse (RN)/ Staff Z said Resident #442 had a change in condition. ADON/Staff Z said she did not receive the message about getting the [MEDICATION NAME] and did not take out the [MEDICATION NAME]. ADON/Staff Z stated the ground floor operator said she needed to come down. ADON/Staff Z mentioned when she arrived on the ground floor, rescue staff was there already and was getting the IV line for Resident #442. ADON/Staff Z noted she did not administer [MEDICATION NAME] to Resident #442. ADON/Staff Z noted [MEDICATION NAME] was stored locked in the pyxis in the supervisor's office on the second floor. ADON/Staff Z confirmed for an unresponsive resident with a low blood sugar one would administer [MEDICATION NAME]. ADON/Staff Z stated Resident #442 Blood sugar was 144 mg/dL when she left the facility in stable condition. ADON/Staff Z confirmed [MEDICATION NAME] was not stored in the ground floor medication room. Interview on 1/11/2018 at 10:25 A.M. with the Director of Nursing (DON)/RN revealed Resident #442 had accucheck at 6:00 A.M. and 4:00 P.M. The DON mentioned RN/Staff ZZ had taken the blood sugar for Resident #442 and it was 68 mg/dL on 1/10/2018 at 6:00 A.M. The DON stated she spoke to RN/Staff ZZ this morning and he gave pudding and repeated the blood sugar and it was 122. The DON said RN/Staff ZZ was not sure if he documented this, but the blood sugar check was completed before he left. The DON explained hypoglycemic interventions for a responsive resident might include simple sugars such as orange juice or pudding and staff would give report to the next shift. The DON confirmed she did not see any documentation of a repeated blood sugar or documented interventions after the BS was 68 mg/dL on 1/10/2018 at 6:00 A.M. and the doctor was not called at that time. The DON acknowledged, I would expect this to be documented. The DON stated in the morning on 1/10/2018 the RN/Staff Y came to her and noted at 9:00 A.M. Resident #442 had mild shortness of breath. Resident #442 received oxygen and a breathing treatment with her routine medications. The DON said between 9:00 A.M. to 9:15 A.M. she spoke to Resident #442 and asked how she felt. Resident #442 replied she was feeling better. Resident #442 had [MEDICAL CONDITION] in the upper extremities in both arms, the DON told RN/Staff Y to call the doctor. The DON said the therapist was going to take Resident #442 to therapy at approximately 10:50 A.M. and Resident #442 had her eyes closed and was unresponsive. The DON mentioned 911 was called, since Resident #442 was full code. The DON noted a supervisor was contacted. The DON mentioned [MEDICATION NAME] was not administered by the supervisor to Resident #442. The DON said they did not delay the treatment when the supervisor came down, since 911 rescue staff was already in Resident #442 room and they had intervened. The DON explained the blood sugar was brought up after rescue staff took over. The BS was 144 mg/dL when Resident #442 left the facility to the hospital. The DON explained for a unresponsive hypoglycemic resident the staff would take the blood sugar level and vital signs, call the supervisor for assistance to assess the resident, check in the record if they were full code or not. If the resident was full code, then they would call 911 rescue. For blood sugar concerns the staff would review the order, the supervisor would obtain the [MEDICATION NAME] from the Pyxis machine on the second floor in the supervisor office. The DON said the staff might page the supervisor or ask the switchboard operator to locate the supervisor. The DON confirmed there was no [MEDICATION NAME] on the ground floor medication room. Review of the facility policy revised on 09/17/2015 revealed for diabetes mellitus: Recognize, manage, document and treatment of [REDACTED]. Diabetes is a disorder in which there is relative absolute lack of insulin. [DIAGNOSES REDACTED] (blood sugar below reference ranges). If abnormal conditions exits, notify the physician (for [DIAGNOSES REDACTED], follow steps in the Glycemic Management Flowchart). Review of facility [DIAGNOSES REDACTED] Management Algorithm revised on 09/1/2015 revealed Is the resident's blood sugar less than 70 mg/dL or parameter otherwise determined by medical doctor - is the resident awake and able to swallow? If No - administer [MEDICATION NAME] Intramuscular (IM), assess vital signs and notify medical doctor. Recheck blood sugar after 15 minutes. Is repeat glucose greater than 70, responsive and able to swallow? If No - Repeat 1 mg [MEDICATION NAME] IM, call medical doctor and call 911. Recheck blood sugar after 15 minutes. Did resident respond? If No - Notify medical doctor and await Emergency Medical Staff direction. Notify Family and Complete SBAR.

Based on observation, record review and interview, the facility failed to ensure effective administration to enable residents to attain or maintain their highest practicable well-being as evidenced by failure to ensure staff was following professional nursing standards of practice, failure to oversee care and ensure the facility's [DIAGNOSES REDACTED] protocol was implemented during a hypoglycemic emergency; and failure to ensure emergency medication was readily available to staff responsible for provide care during an emergency. This has the potential to affect one hundred and eleven (111) residents with a [DIAGNOSES REDACTED]. Refer to F658 and F684. On January 10, 2018, it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's administrator was informed of the existence of immediate jeopardy on January 11, 2018. The facility's completed allegation of compliance included: -Specific to the subject of the citations: Resident #442 was assessed by the facility on January 10, 2018 identify changes in conation. 911 notification completed and arrival of Emergency Management System (EMS) to the facility at 11:00 am. Immediate assistance provided by EMS to include IV placement and [MEDICATION NAME] administration, and transfer to advanced medical care. Assessments: -Assessments were completed to identify all residents at risk for Immediate Jeopardy to included all residents with a [DIAGNOSES REDACTED]. An audit was conducted on January 11, 2018 of resident with Diabetes Mellitus to include blood glucose levels for the past 60 days of less than 70 ml/dl (milliliter/deciliter)or outside call set by the MD (medical doctor) to ensure MD notification had been completed. An audit was conducted on January 11, 2018 of all resident transfers to advanced medical care in past 60 days. -On January 11, 2018, additional [MEDICATION NAME] was obtained from the pharmacy and placed on each floor. Training: -Re-education was initiated on January 11, 2018 to all Licence Nurses including Diabetes Mellitus, Hypoglycemic management and location and access to [MEDICATION NAME], documentation of glucose monitoring to include follow up actions. Evidence that Licensed Nurses were re-trained was submitted by the facility via e-mail on January 12, 2018 at 10:24 PM. Observational verification was completed: 1) On 01/12/18 at 04:22 PM of Second floor medication room with the replacement crash cart contents included [MEDICATION NAME] 1mg/ml (quantity 3); 2) On 01/12/2018 at 4:29 PM of Third floor medication room contents of replaced Emergency crash cart kit included [MEDICATION NAME] 1mg/ml (quantity 3); and 3) random intervews were completed with licensed nursing staff on all floors to verify re-education competency. The immediate jeopardy began on January, 10, 2018 and was removed on January 12, 2018. The scope and severity was decreased to isolated/D. The finding included: Review of the Administrator's Job Description (updated December 2011) revealed: Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilities included: Monitor each departments activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, and ensure resident needs are being addressed. Consult with department managers to concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement in services. Review of the Organizational Chart provided indicated the Administrator is responsible for oversight of the Director of Nursing as well as other Department Directors. During interview on 1/11/18 at 2:03 P.M., the Nursing Home Administrator (NHA) said she was concerned about the identified immediate jeopardy. The NHA said the night nurse followed the policy regarding the hypoglycemic protocol according to an interview the Director of Nursing (DON) had with the 11:00 p.m.-7:00 a.m. shift nurse. He told the DON he gave the resident pudding and he re-checked the blood sugar which was 122. He failed to document this, but he has the ability to document this as a late entry. The [MEDICATION NAME] was not given by the facility, but it was given by rescue staff. We understand the issue that the medication was not available and we will be reviewing this and bringing it to QA (Quality Assurance). During interview on 1/16/2017 at 4:19 P.M., the NHA said I am overall responsible for the entire facility. This includes budgeting, operational procedures, hiring, retention and employee engagement. Of course, I am also responsible for regulatory process. I am also the Risk Manager (RM) so I have to prepare and analyze data. This is done by root cause analysis. I track and trend any noted concerns. This is followed in QA meetings for problem resolutions. As the RM, I review every abuse case and adverse incidents following the same procedures. I conduct all meetings related to operational procedures. This includes the daily clinical meeting. I am responsible for the i-care customer service program. This is a staff training with 30 modules. I conduct this training program beginning with orientation. I oversee all departments. I am the QA Ambassador so I am responsible to review all identified concerns and develop and track all action plans. I submitted the allegation of compliance with back up materials as well as a written statement related to the immediate jeopardy situation. During an interview on 1/16/18 at 9:46 A.M., the Nursing Home Administrator/Risk Manager stated, We have now put the [MEDICATION NAME] on each Emergency Crash Cart on each floor. Three [MEDICATION NAME] are on each cart with four crash carts in the building. We conducted all in-services for 67 nurses, reviewed all resident's transfer and discharges to the hospital and went back to October 2017 thru January 2018 and no one has left the building with hyper or hypo glycemic episodes. We have reviewed all orders one by one and have a meeting scheduled this week with the medical doctors. Some medical doctors say they do not want to have a standing order and they want to control their own patients. We have divided everyone that was on oral medications, auditing every morning and night, any administration especially the diabetics daily based on the action plan. I do not agree that this was a concern because we were following the policy.

Based on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to diabetic management and availability of medication in an emergency response situation. This has the potential to affect one hundred and eleven (111) residents with a [DIAGNOSES REDACTED]. On (MONTH) 10, (YEAR), it was determined the findings of the survey posed immediate jeopardy to the health and safety of the residents admitted to the facility. The facility's administrator was informed of the existence of immediate jeopardy on (MONTH) 11, (YEAR). The facility's completed allegation of compliance included: -Specific to the subject of the citations: Resident #442 was assessed by the facility on (MONTH) 10, (YEAR) identify changes in conation. 911 notification completed and arrival of Emergency Management System (EMS) to the facility at 11:00 am. Immediate assistance provided by EMS to include IV placement and [MEDICATION NAME] administration, and transfer to advanced medical care. Assessments: -Assessments were completed to identify all residents at risk for Immediate Jeopardy to included all residents with a [DIAGNOSES REDACTED]. An audit was conducted on (MONTH) 11, (YEAR) of resident with Diabetes Mellitus to include blood glucose levels for the past 60 days of less than 70 ml/dl (milliliter/deciliter)or outside call set by the MD (medical doctor) to ensure MD notification had been completed. An audit was conducted on (MONTH) 11, (YEAR) of all resident transfers to advanced medical care in past 60 days. -On (MONTH) 11, (YEAR), additional [MEDICATION NAME] was obtained from the pharmacy and placed on each floor. Training: -Re-education was initiated on (MONTH) 11, (YEAR) to all Licence Nurses including Diabetes Mellitus, Hypoglycemic management and location and access to [MEDICATION NAME], documentation of glucose monitoring to include follow up actions. Evidence that Licensed Nurses were re-trained was submitted by the facility via e-mail on (MONTH) 12, (YEAR) at 10:24 PM. Observational verification was completed: 1) On 01/12/18 at 04:22 PM of Second floor medication room with the replacement crash cart contents included [MEDICATION NAME] 1mg/ml (quantity 3); 2) On 01/12/2018 at 4:29 PM of Third floor medication room contents of replaced Emergency crash cart kit included [MEDICATION NAME] 1mg/ml (quantity 3); and 3) random intervews were completed with licensed nursing staff on all floors to verify re-education competency. The immediate jeopardy began on January, 10, (YEAR) and was removed on (MONTH) 12, (YEAR). The scope and severity was decreased to isolated/D. The findings included: During an interview on 1/12/18 at 1:49 P.M., the Nursing Home Administrator/Risk Manager revealed the Quality Assurance Assessment (QAA) committee meets monthly on the fourth/last Thursday of the month. The QAA committee consisted of the following: Corporate Compliance Officer, Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions Director, Social Services Director, Medical Records Directory, Director of Dietary Department, Activities Director, Director of Maintenance, Director of Housekeeping and Laundry, Clinical Coordinator, Business Office Representative, MDS Representative, Rehab Supervisor, Education, Restorative Nurse, Wound Care Nurse, Nursing Supervisor and Chaplain. She stated, We have never had a problem with diabetic management before this incident this week. Record review of the QAA Committee Sign-in Sheets last year revealed the facility had a QAA Committee meeting monthly. Review of the Quality Improvement/Risk Management monthly agenda last year revealed no issues or concerns with the diabetic management related to residents with hyper or hypo glycemic episodes was discussed during the year before this survey. Interview on 1/16/18 at 9:46 A.M., the Nursing Home Administrator/Risk Manager stated, We have now put the [MEDICATION NAME] on each Emergency Crash Cart on each floor. Three [MEDICATION NAME]'s are on each cart with four crash carts in the building. We conducted all in-services for 67 nurses, reviewed all resident's transfer and discharges to the hospital and went back to (MONTH) (YEAR) thru (MONTH) (YEAR) and no one has left the building with hyper or hypo glycemic episodes. We have reviewed all orders one by one and have a meeting scheduled this week with the medical doctors. Some medical doctors say they don't want to have a standing order and they want to control their own patients. We have divided everyone that was on oral medications, auditing every morning and night, any administration especially the diabetics daily based on the action plan. I don't agree that this was a concern because we were following the policy.

Based on record review, observation, and interview, the facility failed to ensure that 1 of 51 sampled residents (resident #239) were free from neglect. The facility neglected to provide the necessary psychiatric services by failing to adequately implement the resident's care plan, by failing to monitor the resident's behaviors, and by failing to obtain physician ordered psychiatric consultations. These failures potentially resulted in the death of resident #239. The injuries sustained by resident #239 and the incident surrounding the resident's death were of a severe nature and warranted the determination of Immediate Jeopardy. The findings include: During record review of the facility's 1-day immediate report dated [DATE], the following was documented: "On [DATE] at approximately 3:18 PM. Resident was observed lying face first on the concrete (with the left side of the face towards the concrete) on the courtyard. Resident was observed with her leg stretched out. Resident was assessed and found to have a large open wound on the right upper arm and slight bruise on her left upper arm. Resident was unresponsive and warm to touch. Resident's eyes were open and had shallow respirations. Resident was found with no pulse. CPR (Cardio [MEDICAL CONDITION] Resescutation) was initiated. Rescue arrived at approximately 3:25 PM and resident continues to recieve CPR. Resident was transferred to ... Hospital for medical evaluation and treatment. Family was notified of the incident and transfer of resident to the hospital. Attempted to call to physician to be aware of incident. Physician's office called back with notice that resident expired. Family made aware resident died ." During interview with the maintenance director on [DATE] at 6:00 PM, the following was reported, on [DATE] when he heard the resident was found on the ground, he went up to the resident's room and found the room door closed. When he entered, he saw the window was open, the window screen was sitting on the floor, the window lock and screw were on the window rail, and there was a foot stool by the window. The maintenance director reported, he had no idea how the resident was able to remove the window locks. The maintenance director didn't divulge whether the resident had jumped, fell or was pushed from the room window. He only revealed the findings in the resident's room after the resident was found lying face first in the facility's concrete courtyard. During observation of resident room [ROOM NUMBER], resident #239's previous room, on [DATE] at 6:00 PM, the room was observed to be locked. The maintenance director brought a key to unlock the door. No residents were in the room. Bed A did not have any sheets or covers, just the bare blue mattress. Bed B was made and covered with a gray-blue bedspread. The window was closed and had a window lock/clamp in place. The window screen was in place. The maintenance director reported, he was asked by the police to keep the room the way it was observed on [DATE]. When asked about the foot stool not being in the room, he reported, it was removed because it belonged to resident #239's roommate. The roommate was transferred to room [ROOM NUMBER] after the incident. When asked about maintenance on the facility's windows, it was reported the facility had a Housing and Urban Development (HUD) inspection and failed because they only had screws in place to lock the windows. The HUD inspection took place on [DATE]. Their plan of correction was to install window locks on all the windows inside residents' rooms. It was reported this was completed on [DATE] and it included room [ROOM NUMBER]. During interview with Nurse C on [DATE] at 6:33 PM, it was reported, on [DATE] nurse C was on the way to the pantry when a family member alerted him to a resident on the floor on the patio. Nurse C reported, "I went to the patio with other nurses and saw the resident facing down on the floor. An LPN and I turned her up and started CPR. The case manager and ground floor LPN called 911. A lot of people came including supervisors and the administrator, 911 arrived, continued CPR and took her to the hospital." Nurse C didn't didn't divulge whether the resident had jumped, or fell or was pushed from the room window. During interview with the Nurse Case Manager, staff A, on [DATE] at 6:36 PM about the resident incident, it was reported, it was after 3:00 PM and she was at the nurses' station with her back to the hallway. She was charting. She heard a family member saying there was a resident on the floor outside. She went out to the patio where there was a nurse who usually works 11:00 PM to 7:00 AM turning the resident. The nurse said there was blood, so she went to the nurses' station, took the crash cart and pushed it out to the courtyard. She asked who the resident was and somebody said it was resident #239 from the 3rd floor. She called the unit and asked a nurse to come down and identify the resident. She asked if 911 was called, they said they were trying. She called 911 and was able to get through. She saw the nurses doing CPR and stayed until rescue came. The case manager didn't didn't divulge whether the resident jumped, fell or was pushed from the room window. During record review of resident #239's medical record, it was revealed that there was an initial psychiatric assessment dated [DATE] which documented the resident had previous hospitalization s due to chronic depression after the resident's husband died unexpectedly. The assessment documented a [DIAGNOSES REDACTED]. The assessment was completed by a facility psychiatrist. Also, an initial Psychological Diagnostic Evaluation dated [DATE] documented the resident had a [DIAGNOSES REDACTED]. A subsequent Psychiatric follow-up assessment dated [DATE] documented the resident continued with chronic depression, severe anxiety and the resident was currently doing well emotionally on [MEDICAL CONDITION] treatments. Also, [DIAGNOSES REDACTED]. Review of the behavioral assessment/[MEDICAL CONDITION] medication management plan dated [DATE] revealed the behavioral checklist did not have any behaviors identified. The behavioral assessment/[MEDICAL CONDITION] quarterly review dated [DATE] indicated the problem was that the resident gets paranoid, ambulates well, and socializes but has history of altered mental status, when medication is adjusted. The goal indicated that the resident would adjust to the medication. The intervention was that the Medical Doctor (MD) and patient agreed on the present anxiety dose. The following nurses progress notes document the resident behaviors: Review of nurses' progress notes dated [DATE] timed at 1:00 PM documented the resident was alert and oriented times two (2). The resident complained the roommate did not follow her verbal commands. The resident was instructed not to command the roommate. The resident was educated to call the nurse for any complaints. At 3:00 PM, the resident was walking in her room. The note documented the resident did not get along with the roommate and a report was given to the incoming nurse to follow-up on the behaviors. At 8:45 PM, notes documented the resident was alert and oriented times two (2) and gave a complaint about the roommate. The resident was redirected and instructed and monitored by staff. The resident at that time was anxious. Emotional support was given and medications were given as per order-- [MEDICATION NAME] 0.5 mg. Nurse progress notes dated [DATE] at 9:00 PM documented the resident was in the hallway sitting in the chair talking with fell ow residents. The note indicated that the resident appeared manic at the time. The resident was re-directed and medication was given. The resident was alert and oriented times two (2) at the time. The resident's roommate was not involved and the resident denied any discomfort. Nurses' progress notes dated [DATE] at 9:00 AM documented the resident was sitting in the hallway and the resident liked to talk to other residents. The resident was giving her point of view on everything around her room and talked to everybody that passed by in the hallway including other residents, staff, and family members of other residents. She was instructed regarding the inappropriate behavior. Emotional support was provided by staff and the resident was able to understand the re-direction. Nurses' progress notes dated [DATE] at 2:00 PM revealed the resident was invloved with other residents' personal issues and was trying to solve everybody's life. The notes documented the resident liked to counsel other residents and get involved in their private conversations. She was re-instructed regarding the inappropriate behavior and emotional support was provided. The resident was able to understand the redirection, according to the note. Nurses' progress notes dated [DATE] at 8:40 PM revealed the resident was alert and oriented times three (3). The resident reported she could not sleep. Emotional support and a snack were given and staff would to continue to monitor. At 9:15 PM, the resident continued with difficulty sleeping and [MEDICATION NAME] 10 mg by mouth (PO) as needed (PRN) was given. By 10:00 PM the resident was in bed sleeping, according to the note. Nurses' progress notes dated [DATE] at 8:30 PM documented the resident was awake and demanding sleep medication. The resident had periods of anxiety and wanted to take care of other residents. The resident was sometimes verbally aggressive with staff and other residents. The resident was re-directed and instructed about her PRN sleep medication and about her behavior with residents and staff. The resident verbalized understanding. Staff would continue to monitor the residents behavior. Nurses' progress notes dated [DATE] at 7:00 AM documented the resident complained of not sleeping well and was demanding sleep medication to be given every night. The resident was aware that this medication was given (PRN) as needed. Nurses' progress notes dated [DATE] at 8:40 PM documented the resident complained of [MEDICAL CONDITION] and requested her medication to sleep. Fluids were encouraged and were tolerated well and safety measures were maintained. At 9:10 PM, the resident was still complaining of [MEDICAL CONDITION] and medication was given as per the doctor's order,[MEDICATION NAME] mg po and [MEDICATION NAME] 0.5 mg for anxiety. Emotional support was given. At 10:20 PM the resident was in bed, calm and quiet. Nurses' progress notes dated [DATE] at 12:00 AM indicated the resident was in bed awake. She complained of [MEDICAL CONDITION] and requested a sleeping pill. She was re-directed and a snack and fluids were given. A back rub was given and tolerated well. The note documented the resident was able to sleep for only ,[DATE] hours at a time and the supervisor was aware and requested continued monitoring. Nurses' notes dated [DATE] at 10:30 PM documented the resident was awake and was alert and oriented times three (3). The resident was informed to take [MEDICATION NAME] at the time it was given, but the resident wanted to keep the medication in her room or in her pocket. She was re-directed to take the medicine at that time. The resident became agitated and anxious, because the medication was kept by the nurse until the resident was ready to take the medication. Nurses' notes dated [DATE] at 7:30 PM revealed the resident was out of bed and was oriented times three (3). The resident was sitting in the hallway and was displaying inappropriate behavior. The resident was talking about the staff and the other residents. This included sometimes using offensive language in Spanish. There were periods of mood changes noted. The resident was re-directed to keep calm and emotional support was given. A snack was offered and fluids were given and were tolerated well. Nurses' notes dated [DATE] at 9:20 PM documented the resident was very talkative with staff and other residents and was getting into other residents problems. The resident wanted to get involved in everything that happened around her, although she was not involved with the situation. Nurses' notes dated [DATE] at 10:00 AM documented the resident was yelling at a CNA and telling her to leave the room. The resident was re-directed. The resident was observed to be angry at the time. Nurses' notes dated [DATE] at 6:40 PM revealed the MD was called regarding the resident's behavior. Nurse A was interviewed on [DATE] at 4:50 PM in regard to documentation on the [DATE] nurses' notes about the resident becoming aggressive because she wanted to perform the staff's duties such as placing residents in bed, taking them to the bathroom, and transferring them to the wheelchair. When the resident was re-directed, she became upset. The [DATE] at 10:30 PM nurses note was discussed, the nurse reported he went to give the resident the medication and the resident wanted to save it in her room or in her pocket. The resident became upset when he told her to take it in his presence. In regards to the note from [DATE], the nurse reported the resident had inappropriate behavior and was mocking staff and using offensive language to other residents such as "you are crazy, you are fat." Nurse A reported, the residents periods of mood change were serious at times, such as sarcastically laughing at staff and residents. Regarding the note dated [DATE], the nurse stated he called the resident's primary care physician(PCP) in order to obtain an order for [REDACTED]. The nurse stated he wrote a telephone order (TO) for a psychiatric consult. The nurse stated he called the primary psychiatrist's office and left a message with the answering service. He informed the 7:00 AM - 3:00 PM shift nurse of the order and the 7:00 AM - 3:00 PM unit secretary attempted to contact the primary psychiatrist by leaving another voice mail message. The nurse was never notified that the primary psychiatrist no longer worked at the facility. Nor did nursing receive a memo indicating who was going to cover or provide the psychiatric consultation. Nurse A reported, the 3rd floor psychiatrist came to the unit on [DATE] on the 7:00 AM - 3:00 PM shift to conduct psychiatric evaluations. The nurse reported, the resident's primary nurse on the 7:00 AM -3:00 PM shift reported the 3rd floor psychiatrist came to see the resident on [DATE] and the resident refused the consultation. Nurse A reported, the 7:00 AM - 3:00 PM primary nurse told him the resident said, she was not crazy. There was no documentation in resident #239's record from the psychiatrist or the primary nurse about the residents refusal of the psychiatric consultation. Review of the Interdisciplinary Monthly Focused Charting revealed there was no documentation since [DATE]. The [DATE] Interdisciplinary Monthly Focused Charting documented the resident was oriented times three (3). The note documented no signs or symptoms (s/s) of depression. It also noted good sleep patterns and activities of daily living (ADL)'s grooming daily. Most of the time the resident was watching TV with other residents. She refused to participate in social activity programs. She was encouraged to participate in the social activity program. The [DATE] Interdisciplinary Monthly Focused Charting documented the resident was restless at times, oriented times three (3). She refused all activity participation. The [DATE] Interdisciplinary Monthly Focused Charting documented the resident was restless at times. The [DATE] Interdisciplinary Monthly Focused Charting documented the resident was restless/fidgety at times, her depression was under treatment, and she remained sitting in the hallway interacting with other residents most of the time. The [DATE] Interdisciplinary Monthly Focused Charting documented resident #239's depression was under treatment, emotional support was provided by the nurse and she refused to participate in social activities program. It noted that she remained in the hallway interacting with other residents most of the time. The [DATE] Interdisciplinary Monthly Focused Charting revealed the resident was restless and fidgety at times, had periods of depression and a poor appetite. The note documented she remained in the hallway interacting with other residents most of the time and sometimes remained in her room. Emotional support was provided by nursing staff. Signs and symptoms of depression were noted. [MEDICATION NAME] 20 mg, [MEDICATION NAME] 2 mg by mouth (PO) at night (HS), and [MEDICATION NAME] 0.25 mg twice a day (BID) [MEDICATION NAME] [DIAGNOSES REDACTED]. On [DATE], the resident had a sad facial expression at times, was restlessness and fidgety at times, was anxious, and did not want to participate in social activities. Emotional support was provided. On [DATE], the resident presented a sad facial expression at times and was restless/fidgety at times. The interdisciplinary comment form was noted to be blank. On [DATE], the resident was restless and fidgety at times, the resident was [MEDICATION NAME] mg at bedtime for [MEDICAL CONDITION]. On [DATE], the resident was oriented times three (3) and had periods of anxiety. Emotional support was provided. On [DATE], a new order for [MEDICATION NAME] 20 mg after breakfast was ordered. The resident complained of not sleeping with the new order [MEDICATION NAME] mg at HS ([DATE] ). On [DATE], an order was writtten to discontinue (D/C) [MEDICATION NAME] 20 mg po bid, and D/C [MEDICATION NAME] 50 mg po at HS. The resident was sitting in the hallway interacting with other residents, refused to participate in social activities, she likes to be standing at the others doors, and talk to everybody. On [DATE], there were no behaviors noted on the form and no comments on the interdisciplinary monthly focus charting. On ,[DATE], the resident had a sad facial expression and difficulty sleeping at times, oriented x 3 continues with some behaviors, the resident very involved in other residents personal issues, trying to solve everybody's life, she liked to counsel other residents, and get involved in their private conversations. Instructed resident about inappropriate behavior, emotional support by staff and nurse provided, resident refused sometimes to participate in social activity program, no S/S of complications disease process, falls and aspiration precautions maintained. A physician order [REDACTED]. Physician order [REDACTED].M. and HS for Anxiety. Physician order [REDACTED]. On [DATE] [MEDICATION NAME] 10 mg was decreased to PRN for [MEDICAL CONDITION]. On [DATE] [MEDICATION NAME] 10 mg as needed (PRN) was discontinued and [MEDICATION NAME] 10 mg was ordered Q HS for Chronic [MEDICAL CONDITION]. Physician order [REDACTED]. On [DATE], an order for [REDACTED]. Physician order [REDACTED]. A [DATE], physician order [REDACTED]. Eval )." There was no documentation to demonstrate the psychiatric consultation was completed, as ordered. On [DATE], a physician order [REDACTED]. During a telephone interview with the resident's primary psychiatrist on [DATE] at 10:10 AM it was reported, the facility staff never contacted him to report any changes in the resident's behavior. It was reported, during his visits with the resident, she was clinically depressed. His last visit was conducted on [DATE]. During a telephone interview with third floor psychiatrist on [DATE] at 10:45 AM, it was reported, he never saw resident #239, and the resident was not on his caseload. The psychiatrist reported, he never saw the resident for a psychiatric evaluation and he wasn't contacted to conduct a psychiatric evaluation for the resident. During an interview with the Social worker for the second and third unit/floor on [DATE] at approximately 11:52 AM, it was revealed the resident was a friendly resident. The resident used to go around and talk to the residents and staff. She liked to go to the beauty parlor. She was usually walking around on the unit, talking to residents and staff. She was anxious at times and had difficulty sleeping. She was also, at times, verbally abusive with staff because she wanted things done when and how she wanted and with other residents she wanted them to do what she wanted. Sometimes she was demanding in a bad way. During an interview with the administrator on [DATE] at 3:10 PM, it was revealed the facility's investigation into the incident was still ongoing. It was pending a police report . The administrator reported, "we're trying to get a report from rescue and an autopsy report." The administrator was asked about the lack of nurses notes for 15 days regarding the resident. The administrator reported, he had no idea why there was a gap of 15 days in nurses' notes leading up to the [DATE] incident with the resident. He said, "Per our plan of care, nurses are supposed to write if any behaviors are present." He said he was sure there was a care plan for mood and behaviors in place for resident #239. When asked to identify what measures the facility had in place to prevent a similar incident from happening again, he explained, when it happened they checked all the windows in every room and tightened the clamps. He reported, they had CNAs and nurses do hourly rounds, and he did rounds twice daily. He reported, the resident's family member came to the facility on [DATE] at approximately 5:00 - 6:00 PM because they notified her that an incident had happened and that her family member had to be transported to the hospital. The hospital or police notified her also. The administrator reported, window clamps were put on the windows from [DATE]-[DATE] and were inspected on [DATE] by the maintenance director. He reported, this included room [ROOM NUMBER]. The administrator reported, he did not know what happened. The administrator did not divulge whether the resident jumped, or fell or was pushed from the room window. During an interview with CNA #1, who worked on the 3:00 PM to 11:00 PM shift on the 3rd floor, on [DATE] at 5:59 PM, it was reported resident #239 was very talkative and social and never aggressive. She reported, on the day of the incident she was doing her job in another resident's room and heard someone in the hallway say that resident #239 fell . She said, she looked outside because she thought the resident was in the hallway and saw resident #239's CNA and nurse go into the elevator. She looked out the window in room [ROOM NUMBER] or 305 and saw resident #239 on the ground face up with nurses doing CPR. During an interview with the third floor Minimum Data Set (MDS) nurse and care plan coordinator on [DATE] at 6:00 PM, it was reported, the resident was demanding with her roommate, but she did not observe any other behaviors. The MDS nurse revealed, she does not initiate care plans for mood and behavior, only for [MEDICAL CONDITION] medications and side effects. The MDS nurse reported to the resident's primary nurse on the 7:00 AM - 3:00 PM shift that there was a psychiatric consult scheduled for the resident. When she requested feedback from the psychiatric consult on [DATE], the primary nurse responded the psychiatrist had seen her; however there was no documentation of that visit. During an interview with the activity therapy assistant on [DATE] at 6:20 PM, it was revealed, the resident's behavior varied from day to day. There were days were she was in the hallway talking to residents and staff. The resident was observed to be fully dressed and had applied full make-up. On other days, she would look un-kept and did not leave her room. She stated, the resident never participated in the program activities, not even when there were special events. Approximately three (3) days prior to going to the hospital, the resident was observed to be sitting in the hallway or lying in bed, she was not wearing any makeup, and the resident told her she did not feel like doing anything. Then she proceeded to assist the resident to fill out her menu and the resident was able to choose her meals. During an interview conducted with the Nurse A on [DATE] at 6:30 PM, it was reported, the week prior to the incident, the resident did not want to leave her room. The resident requested snacks to be brought to her room. When she finished with the meal trays she would place it on a small table outside her room. She did not like anyone to enter her room. When staff entered her room she would follow them to see what they were doing. Nurse A reported, in the beginning of May, there was an occasion in which the resident requested a snack of chocolate pudding. The resident stated, "You bring me the snack, because I'm afraid someone will pour something for sleep in my pudding." The nurse responded that she was already taking sleep medication. The resident responded, "but if I'm asleep someone will steal from me." The resident was observed to be wearing no make-up and was dressed in a night gown. The days she did leave her room several weeks prior to the incident, she was fully dressed and wearing make-up, stating she used to be a "beauty queen" and used to be a very wealthy person. The resident was observed to be talkative, demeaning, and sarcastic with staff and residents. The nurse stated, there were no additional notes after [DATE] due to the resident withdrawing to the room, and that this was a "typical behavior" for her. The resident would have her door shut in the afternoon when she was in her room. The resident would leave the floor at times to look for clothing in the laundry, or attend an appointment in the beauty parlor, however "she always asked for permission." An interview conducted with Nurse E on [DATE] at 7:00 PM, revealed, approximately two weeks prior to the incident, the resident was very talkative, stating she had to give her information in reference to what was happening on the unit. When the nurse re-directed her, she would hold her by the shoulder requesting for the nurse to pay attention to her. The resident would sit front of the station monitoring call lights and assisting the residents with transferring in the wheelchair and to the toilet. When the staff re-directed her on her behavior she would become upset. The nurse stated that Nurse A obtained an order for [REDACTED]. The nurse passed by the resident's room and observed the door to be shut. Later, she was approached by a nurse that stated, the resident was on the floor in the patio area. During an interview conducted with Nurse B on [DATE] at 7:30 PM, it was revealed the resident was always complaining of missing items. The day before the incident, the nurse supervisor was making her rounds and the resident called her. When she walked into the resident's room, the resident asked her to sit on the bed. The resident complained that another resident (her good friend, according to the supervisor) had taken her chair and some of her clothing from her room. The supervisor responded to the resident by explaining for her not to forget that when she complained of missing clothing, it would turn up the next day in the laundry. In reference to the chair, she was not able to take the chair away from the other resident, and she would provide her with another chair. During the conversation the resident's family member walked into the room and stated that she brought additional personal items and not to worry that the missing robe would turn up. Nurse B reported, the day the incident occurred she was called and went to the patio and observed the nurse administering CPR. She was surprised with the little amount of blood there was on the patio floor. She relieved the nurse and continued with the chest compressions until fire rescue arrived, and they took over. She observed a laceration of the right arm, muscle tissue exposed, and no blood. During an interview conducted with the resident's PCP on [DATE] at 10:30 AM, it was reported the resident's behavior was that of a [MEDICAL CONDITION]; however she did not have the [DIAGNOSES REDACTED]. of side effects. On [DATE], these medications were discontinued. The PCP stated that he increased [MEDICATION NAME] mg HS from a PRN to a standard HS dose on [DATE] due to the resident complaining of [MEDICAL CONDITION]. He said that, approximately three months ago, the resident stated there was a man in her room during the night, and she was afraid. The physician responded that it was probably staff from the facility. He indicated that when he visited her she was observed to be in her room groomed, nicely dressed, with make-up was applied. She would talk about her husband being a political prisoner and how he died . When she voiced the issue in reference to her husband, he would tell her "don't think about that, look how nice and pretty you look." He said he tried to distract her from those thoughts. He saw her as clinically stable, however, he stated, "I' m not a psychiatrist." The last visit that he had with the resident in May ([DATE]) she stated she was feeling very tired, sleepy and she wanted to stay in bed. Record review of resident #239's social services documentation revealed a [DATE] a quarterly assessment documented the resident had a sad or anxious mood. It also noted, a sad, worried facial expression, that her mood and behavior was easily altered, that she had periods of anxiety at times, and that she was verbally abusive with staff and other residents at times. She was receiving the anti-depressant and anti-anxiety medications [MEDICATION NAME] and [MEDICATION NAME], and [MEDICATION NAME] for [MEDICAL CONDITION]. The note did not document Psychiatric/Psychological interventions for the quarter. The note documented, the care plan goal that resident #239's mood and behavior will continue to be monitored by staff for any changes and documented the resident may have safety and emotional support provided to her at all times. Record review of a social services quarterly assessment dated [DATE] revealed, documentation about the residents sad or anxious mood and mood persistence were marked as problems. The resident had a sad, worried facial expression, her mood was easily altered, and she had periods of anxiety and difficulty sleeping at times. The note documented, the Psychiatric/Psychological intervention was the resident was seen by the psychiatrist in ,[DATE]. The care plan goal was mood and behavior would continue to be monitored by staff for any changes. Safety and emotional support provided to her at all times by staff. During an interview with the resident's social worker on [DATE] at 12:30 PM, it was revealed the resident was very depressed at times. She was very protective/overprotective with residents. At times, when she wanted something she was verbally abusive. When she wanted something that she could not get right then, she would get anxious. Anxiousness and depression were moods that she exhibited. The resident was on medications for [MEDICAL CONDITION] and depression. The social worker explained that the resident was demanding, for example, when she wanted a resident to go to her room and the resident said, "no,"

Based on record review and interview, the facility failed to provide adequate medically related social services to 1 of 13 residents reviewed for behavioral and emotional status (Resident #239). The facility failed to adequately identify and monitor problem behaviors and failed to include appropriate social service interventions. These failures potentially resulted in the unexpected death of resident #239. The injuries sustained by the resident and the incident surrounding the resident's death were of a severe nature and warranted the determination of Immediate Jeopardy. On [DATE] it was determined that the facility had implemented measures that warrented the lowering of the scope and severity to a "D." The facility, however, did remain out of compliance with F250. The findings include: Record review of resident #239's medical record revealed the resident was admitted to the facility on [DATE]. During record review of the facility's 1-day immediate report dated [DATE], the following was documented: "On [DATE] at approximately 3:18 PM. Resident was observed lying face first on the concrete (with the left side of the face towards the concrete) on the courtyard. Resident was observed with her leg stretched out. Resident was assessed and found to have a large open wound on the right upper arm and slight bruise on her left upper arm. Resident was unresponsive and warm to touch. Resident's eyes were open and had shallow respirations. Resident was found with no pulse. CPR (Cardio Pulmonary Resescutation) was initiated. Rescue arrived at approximately 3:25 PM and resident continues to recieve CPR. Resident was transferred to ... Hospital for medical evaluation and treatment. Family was notified of the incident and transfer of resident to the hospital. Attempted to call to physician to be aware of incident. Physician's office called back with notice that resident expired. Family made aware resident died ." During interview with the maintenance director on [DATE] at 6:00 PM, the following was reported, on [DATE] when he heard the resident was found on the ground, he went up to the resident's room and found the room door closed. When he entered, he saw the window was open, the window screen was sitting on the floor, the window lock and screw were on the window rail, and there was a foot stool by the window. The maintenance director reported, he had no idea how the resident was able to remove the window locks. The maintenance director didn't divulge whether the resident had jumped, fell or was pushed from the room window. He only revealed the findings in the resident's room after the resident was found lying face first in the facility's concrete courtyard. During record review of resident #239's medical record, it was revealed that there was an initial psychiatric assessment dated [DATE] which documented the resident had previous hospitalization s due to chronic depression after the resident's husband died unexpectedly. The assessment documented a [DIAGNOSES REDACTED]. The assessment was completed by a facility psychiatrist. Also, an initial Psychological Diagnostic Evaluation dated [DATE] documented the resident had a [DIAGNOSES REDACTED]. A subsequent Psychiatric follow-up assessment dated [DATE] documented the resident continued with chronic depression, severe anxiety and the resident was currently doing well emotionally on psychotropic treatments. Also, [DIAGNOSES REDACTED]. A physician order [REDACTED]. Physician order [REDACTED].M. and HS for Anxiety. Physician order [REDACTED]. On [DATE] Zolpidem 10 mg was decreased to PRN for Insomnia. On [DATE] Zolpidem 10 mg as needed (PRN) was discontinued and Zolpidem 10 mg was ordered Q HS for Chronic Insomnia. Physician order [REDACTED]. On [DATE], an order for [REDACTED]. Physician order [REDACTED]. A [DATE], physician order [REDACTED]. Eval )." There was no documentation to demonstrate the psychiatric consultation was completed, as ordered. During an interview with the Social worker for the second and third unit/floor on [DATE] at approximately 11:52 AM, it was revealed the resident was a friendly resident. The resident used to go around and talk to the residents and staff. She liked to go to the beauty parlor. She was usually walking around on the unit, talking to residents and staff. She was anxious at times and had difficulty sleeping. She was also, at times, verbally abusive with staff because she wanted things done when and how she wanted and with other residents she wanted them to do what she wanted. Sometimes she was demanding in a bad way. Record review of resident #239's social services documentation revealed a [DATE] a quarterly assessment documented the resident had a sad or anxious mood. It also noted, a sad, worried facial expression, that her mood and behavior was easily altered, that she had periods of anxiety at times, and that she was verbally abusive with staff and other residents at times. She was receiving the anti-depressant and anti-anxiety medications Cymbalta and Alprazolam, and Zolpidem for Insomnia. The note did not document Psychiatric/Psychological interventions for the quarter. The note documented, the care plan goal that resident #239's mood and behavior will continue to be monitored by staff for any changes and documented the resident may have safety and emotional support provided to her at all times. Record review of a social services quarterly assessment dated [DATE] revealed, documentation about the residents sad or anxious mood and mood persistence were marked as problems. The resident had a sad, worried facial expression, her mood was easily altered, and she had periods of anxiety and difficulty sleeping at times. The note documented, the Psychiatric/Psychological intervention was the resident was seen by the psychiatrist in ,[DATE]. The care plan goal was mood and behavior would continue to be monitored by staff for any changes. Safety and emotional support provided to her at all times by staff. During a subsequent interview with the resident's social worker on [DATE] at 12:30 PM, it was revealed the resident was very depressed at times. She was very protective/overprotective with residents. At times, when she wanted something she was verbally abusive. When she wanted something that she could not get right then, she would get anxious. Anxiousness and depression were moods that she exhibited. The resident was on medications for insomnia and depression. The social worker explained that the resident was demanding, for example, when she wanted a resident to go to her room and the resident said, "no," she would get anxious. She was very protective of the residents. She was worried about them. She demanded the nurses to give her the medications when she wanted and would get anxious if things were not her way. The social worker reported, this was not a concern for her because it did not happen frequently. The [DATE] social services quarterly assessment was reviewed with the social services worker. The social worker revealed, she believed the resident had mood problems that were not frequent, only at times. She did not see a problem with this because it was infrequent and the resident was very friendly and sociable. The social worker reported, the mood and behavior care plan was designed based on her observation of the resident, all disciplines' notes and assessments for example the nurses notes and psychiatric evaluations. During an interview with the social services director on [DATE] at 4:40 PM revealed, she is assigned to the ground and 1st floor and the social worker is assigned to the second and floor/units. The director reported, for the past month or so the social worker has been doing annuals, quarterlies, and attending care plan meetings for mood and behaviors. "When she has a question, she calls her, but I do not oversee her assessments on each resident." The director reported, she was aware this is a problem and that is why there was need for another social worker. She said, she had a big work load because she was on ground floor which is for residents admitted for therapy. She said there used to be another social services worker, but that person left about eight (8) months ago and there has not been another hired. The administrator and the Director of Nursing (DON) were aware of this.

Based on observation, clinical record review and staff interview the facility failed to identify behaviors in order to ensure appropriate care and services were provided to reach and maintain the highest level of mental and psychosocial functioning for 1 of 13 (#239 ) residents sampled for behaviors. The failure to identify and monitor the resident's behaviors potentially resulted in the unexpected death of resident #239. The injures sustained by the resident and the incident surrounding the resident's death were of a severe nature and warranted the determination of Immediate Jeopardy. The findings include: Clinical record review for sampled resident #239 revealed an admission record face sheet which documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Information dated [DATE] documented, the resident was an [AGE] year old female transferred from the hospital via stretcher. The resident was alert, awake and oriented times two. The resident was in stable condition, for further care and observation. Review of an initial psychosocial assessment dated [DATE] revealed that the evaluation was conducted by the Social Services Director. Upon evaluation, Resident #239 was noted to be anxious. She was on [MEDICATION NAME] and was noted to be an appropriate candidate for psychotherapy. Review of an initial psychiatric assessment dated [DATE] documented the resident had previous hospitalization s due to chronic depression when her husband died unexpectedly and had a [DIAGNOSES REDACTED]. Review of subsequent psychiatric assessments and follow-ups revealed the following dates of the visits with notation: On [DATE]- The resident was dysphoric and had depression and anxiety. On [DATE]- The resident was dysphoric and had depression and anxiety. A note at the bottom of the document documented that the resident had severe problems with [MEDICAL CONDITION] which were stabilized by the combination [MEDICATION NAME]. On [DATE]- The resident was dysphoric with a [MEDICATION NAME] affect. She had a lack of energy/ lack of enthusiasm. A note on the assessment documented the resident woke up about one month prior feeling very down/depressed which had not improved. The medication [MEDICATION NAME] was increased one month ago, unsuccessfully. The document noted Axis I [MEDICAL CONDITION] as a diagnosis. On [DATE]- The resident was had a history of [REDACTED]. It noted that the depression appeared to be stabilizing due to the resident reporting feeling better. A note on the document documented the [MEDICATION NAME]/[MEDICATION NAME] combination seemed to be improving the resident's severe depression but it was still too close to a severe depressive period to determine improvement. On [DATE]- The resident continued reporting pervasive depression, that it was somehwat better, but that it was still very intense. She was dysphoric and had a [DIAGNOSES REDACTED]. [MEDICATION NAME] was increased to 30 mg BID and [MEDICATION NAME] was reduced to .25 mg BID. The order [MEDICATION NAME] kept the same. On [DATE]- The resident's [MEDICAL CONDITION] was not getting any better with the [MEDICATION NAME]/[MEDICATION NAME] XR combination. She was dysphoric with a [MEDICATION NAME] affect. The document noted a [DIAGNOSES REDACTED]. On [DATE]- The resident had chronic depression and severe anxiety. She was dysphoric and had a noted [DIAGNOSES REDACTED]. Review of an initial psychological diagnostic evaluation dated [DATE] revealed the resident had a [DIAGNOSES REDACTED]. Review of a social services quarterly assessment dated [DATE] identified a problem that resident #239 had a sad or anxious mood with periods of restlessness. The assessment documented another problem that the mood was persistant but, the resident's mood was easily altered. The assessment documented the resident had difficulty sleeping at times. A psychiatric intervention on the assessment documented the resident saw the psychiatrist on [DATE]. The noted care plan goals for social service intervention revealed, the social worker and staff would continue to monitor psychosocial needs as they arose and would provide daily TLC (tender loving care) and emotional support. Review of the Behavioral Assessment/[MEDICAL CONDITION] medication management plan dated [DATE] revealed the behavioral checklist did not have any behaviors identified. The Behavioral Assessment/[MEDICAL CONDITION] Quarterly Review dated [DATE] documented a problem was the resident gets paranoid, ambulates well, and socializes but, has a history of altered mental status when medications were adjusted. The goal was for the resident to adjust to the medication. The intervention documented the MD and patient agreed on the present anxiety dose. Review of the facility's nurses notes revealed the resident presented behaviors on the following dates with notation: On [DATE]- 1:00 PM- The resident complained that her roommate didn't follow her commands. At 3:00 PM- The resident doesn't get along with her roommate and a report was given to the oncoming nurse to follow-up with the behaviors. At 8:45 PM- The resident was anxious about her roommate. On [DATE]- The resident appeared manic. On [DATE]- The resident was instructed regarding inappropriate behavior. On [DATE]- The resident continued with difficulty sleeping. On [DATE]- The resident was very involved with other residents' personal issues and was trying to counsel them by getting involved in their private conversation. The resident was instructed regarding the inappropriate behavior. On [DATE]- The resident was awake and demanding her sleep medication. She had periods of anxiety and wanted to take care of other residents. She was sometimes verbally agressive with staff and other residents. On [DATE]- 8:40 PM - The resident complained of [MEDICAL CONDITION]. At 9:10 PM- The resident again complained of [MEDICAL CONDITION] and was [MEDICATION NAME]. On [DATE]- Resident complained of [MEDICAL CONDITION] and was only able to sleep ,[DATE] hours. On [DATE]- The resident attempted to pocket [MEDICATION NAME] medication. When the nurse refused to allow her to keep the medication, she became agitated. On [DATE]- The resident was ambulating in the hallway and was entering all resident rooms. On [DATE]- The resident was sitting in the hallway and was noted with inappropriate behavior. She was talking about staff and other residents sometimes using offensive language. On [DATE]- The resident was very talkative with staff and other residents and was trying to get involved with other residents' problems. She wanted to get involved with everything going on around her although it did not invlove her. On [DATE]- The resident was yelling at a CNA. On [DATE]- The resident's MD was called regarding her behavior. On [DATE]- The resident was sitting in the hallway talking, with behaviors present. From [DATE] to [DATE], when the resident passed away, there were no nurses notes in the medical record, except a [DATE] note documenting, "see SBAR (Situation Background Assessment Request)." Review of a [DATE] physician order [REDACTED]. Eval )." There was no documentation to demonstrate psychiatric consultation was completed as ordered. Review of the medication record mood/behavior monitoring for [DATE] revealed, the resident was unable to sleep on [DATE]. However, there was no corresponding nurses' note for that date documenting sleeplessness. The resident experienced panic attack behavior on [DATE] and there was no corresponding nurses' note for that date. Review of the medication record mood/behavior monitoring for [DATE] revealed, the resident was unable to sleep on [DATE], [DATE], and [DATE]. However, there were no corresponding nurses' notes on those dates to document the sleeplessness. The resident experienced panic attack behavior on [DATE], [DATE], and [DATE] and there was no corresponding nurses notes. Review of the medication record mood/behavior monitoring for [DATE] revealed, the resident had [MEDICAL CONDITION] on [DATE]. However, there was no nurse's note corresponding to the behavior. The resident exhibited the behavior of pacing in the halls on [DATE] and there was no corresponding nurses note. The facility was aware of resident #239's [DIAGNOSES REDACTED]. She constantly exhibited behaviors that staff identified as needing re-direction. However, the only noted interventions for the resident's behaviors were re-direction, providing snacks, providing medications, and on occasion, giving her a back rub. Despite the interventions, the resident continued to exhibit these behaviors. At one point during the resident's stay at the nursing home, she missed a physician ordered psychiatric consultation. This appeared to be due to a lack of communication between nursing staff and the psychiatrist office. It was determined the psychiatrist that he residnt was supposed to see for the consultation no longer provided services at the facility. This was not communicated to the Primary Care Physician (PCP) or nursing staff. During an interview with the Director of Nurses (DON) on [DATE] at 5:47 PM, about the lack of nursing notes for 15 days, from [DATE] to [DATE], for resident #239, it was reported, this happened because of the resident's payer source (the facility does charting by exception for residents with her payer source). During interview on [DATE] at 6:30 PM, Nurse A reported, the reason for the lack of nurses notes was because the resident had withdrawn to her room for that period of time. There were no nurses notes documenting the resident had withdrawn to her room despite staff reporting it was a common behavior for resident #239.

Based on observation, interview and record review, the facility failed to ensure its environment was free from accident hazards. This was evident regarding an incident where resident #239 was found in the courtyard, was transported to a local hospital, and was pronounced deceased after a potential fall from the resident's room window. These failures potentially resulted in the death of resident #239. The injuries sustained by resident #239 and the incident surrounding the resident's death were of a severe nature and warranted the determination of Immediate Jeopardy. The findings include: During record review of the facility's 1-day immediate report dated [DATE], the following was documented: "On [DATE] at approximately 3:18 PM. Resident was observed lying face first on the concrete (with the left side of the face towards the concrete) on the courtyard. Resident was observed with her leg stretched out. Resident was assessed and found to have a large open wound on the right upper arm and slight bruise on her left upper arm. Resident was unresponsive and warm to touch. Resident's eyes were open and had shallow respirations. Resident was found with no pulse. CPR (Cardio Pulmonary Resescutation) was initiated. Rescue arrived at approximately 3:25 PM and resident continues to recieve CPR. Resident was transferred to ... Hospital for medical evaluation and treatment. Family was notified of the incident and transfer of resident to the hospital. Attempted to call to physician to be aware of incident. Physician's office called back with notice that resident expired. Family made aware resident died ." During interview with the maintenance director on [DATE] at 6:00 PM, the following was reported, on [DATE] when he heard the resident was found on the ground, he went up to the resident's room and found the room door closed. When he entered, he saw the window was open, the window screen was sitting on the floor, the window lock and screw were on the window rail, and there was a foot stool by the window. The maintenance director reported, he had no idea how the resident was able to remove the window locks. The maintenance director didn't divulge whether the resident jumped, fell or was pushed from the room window. He only revealed the findings in the resident's room after the resident was found lying face first in the facility's concrete courtyard. During observation of resident room #310, resident #239's previous room, on [DATE] at 6:00 PM, the room was observed to be locked. The maintenance director brought a key to unlock the door. No residents were in the room. Bed A did not have any sheets or covers, just the bare blue mattress. Bed B was made and covered with a gray-blue bedspread. The window was closed and had a window lock/clamp in place. The window screen was in place. The maintenance director reported, he was asked by the police to keep the room the way it was observed on [DATE]. When asked about the foot stool not being in the room, he reported, it was removed because it belonged to resident #239's roommate. The roommate was transferred to room #334 after the incident. When asked about maintenance on the facility's windows, it was reported the facility had a Housing and Urban Development (HUD) inspection and failed because they only had screws in place to lock the windows. The HUD inspection took place on [DATE]. Their plan of correction was to install window locks on all the windows inside residents' rooms. It was reported this was completed on [DATE] and it included room #310. The above interview with the maintenance director was the only interview in which facility staff acknowledged that resident #239's room window was open, the screen was off the window and a foot stool was found next to the window on [DATE]. During an interview with the administrator on [DATE] at 3:10 PM, it was revealed the facility's investigation into the incident was still ongoing. It was pending a police report . The administrator reported, "we're trying to get a report from rescue and an autopsy report." The administrator was asked about the lack of nurses notes for 15 days regarding the resident. The administrator reported, he had no idea why there was a gap of 15 days in nurses' notes leading up to the [DATE] incident with the resident. He said, "Per our plan of care, nurses are supposed to write if any behaviors are present." He said he was sure there was a care plan for mood and behaviors in place for resident #239. When asked to identify what measures the facility had in place to prevent a similar incident from happening again, he explained, when it happened they checked all the windows in every room and tightened the clamps. He reported, they had CNAs and nurses do hourly rounds, and he did rounds twice daily. He reported, the resident's family member came to the facility on [DATE] at approximately 5:00 - 6:00 PM because they notified her that an incident had happened and that her family member had to be transported to the hospital. The hospital or police notified her also. The administrator reported, window clamps were put on the windows from [DATE]-[DATE] and were inspected on [DATE] by the maintenance director. He reported, this included room #310. The administrator reported, he did not know what happened. The administrator didn not divulge whether the resident jumped, or fell or was pushed from the room window. During an interview with resident #239's family member #1, about resident #239, on [DATE] at 9:34 AM it was revealed, on [DATE], she received a call from the nursing home. She was told that her aunt had a heart attack while walking in the garden. She went to the hospital to which resident #239 had been transported. Upon seeing the condition of her aunt, she and her husband decided to contact the medical examiner (ME) and request an autopsy. The family member reported, she was told by nursing home staff that nobody saw anything happen with the resident. The family member reported, she was with resident #239 the day before the incident. She reported, the resident suffered from depression related to her husband's death during an argument. She reported, on [DATE], the resident seemed to be down. She was talking to a head nurse while the niece stood in the door. The resident accused an employee of stealing from her. When she asked the resident what had happened, the resident said that she had to report a theft. She calmed the resident down and told her not to worry, that they would purchase another of whichever item was stolen. Then, the resident stated to the niece, " Take me home." The niece told the resident that she could not take her home. This was the first time the resident had made a statement like that to her. Interview with family member #1 on [DATE] at 11:57 AM revealed, when she visited the resident in her room on [DATE], the window clamp was not in place. During an interview with the administrator on [DATE] at 11:03 AM it was reported the facility's investigation into the [DATE] incident was still ongoing. It was still pending the autopsy and the Miami Dade police report. As a facility, he said "we have interviewed all the witnesses and investigated the circumstances around it." He reported, it was an injury of unknown origin. He said that nobody saw or knew how the resident fell . He stated, the resident looked intact to him, physically and that there was practically no blood in the area. He said there was a slight amount of blood from the elbow. He indicated that, prior to resident #239's admission to the nursing home, she was hospitalized for [REDACTED]. There were psychological evaluations done on her which were requested by the PCP. The resident had been refusing the evaluations. When asked if he or anyone in the facility had identified any problems with resident #239's care, he said yes, he believed there was a psychiatric consult to be done in April or May which the resident missed. The administrator reported, the resident's record was reviewed on [DATE] by the DON, the care consultant, and the chief nursing executive who are Registered Nurses. It was an interdisciplinary review with all three (3) shift nurses in charge of the resident, the social worker and himself. He reported, they thoroughly reviewed the record but the outcome was still inconclusive. The resident's behavioral situation and medications, including side effects had been reviewed and she had no suicidal thoughts. He said he spoke with the 3rd floor psychiatrist last week who said he did not believe the resident had any suicidal ideations. When asked if the resident had been seen by the 3rd floor psychiatrist he stated, "I believe so." He reported, problems with assessments, care plans, or behavior monitoring, if any, had not been reported to him. The medical director was called and informed of the incident. He came in and reviewed the resident's chart. He looked at the resident's room and at the patio. He said, there was no physical evidence that the resident could have done what she did. When asked to explain, what he meant by the statement that there was no physical evidence that the resident could have done what she did, the administrator said he was "trying to rule out anything; just theorizing." The administrator did not divulge whether the resident jumped, fell , or was pushed from the resident room window. During an interview with the recieving hospital's emergency room (ER) Registered Nurse on [DATE] at 9:00 AM, it was reported she was present in the ER when resident #239 arrived via rescue on [DATE]. She reported, the resident came to the ER in cardiac arrest. She was told the resident was found on the floor at the nursing home. The ER Nurse asked for witnesses and was told that there were none. The ER nurse referenced the medical record and provided the following information: 911 received the call from the nursing home at 15:22 (3:22 PM); 911 arrived at the nursing home at 15:28 (3:26 PM). Upon 911's arrival at the nursing home, the resident was asystolic, had no pulse and was not breathing. The resident was then intubated. Upon resident #239's arrival to the ER at 15:52 (3:52 PM), her pupils were dilated, she had no pulse, and she was not breathing. Resident #239 was given Advanced Cardiac Life Support (ACLS) medications and CPR, both of which were unsuccessful. The ER MD pronounced the resident deceased at 16:00 (4:00 PM). The RN reported resident #239 had an open fracture to the left elbow and that her right arm was wrapped when she came into the ER. Under the wrap was a 27 centimeter open wound. There was an abrasion on the left leg. There were no noticeable facial or head injuries. During an interview with a Miami Dade County Medical Examiner's office investigator on [DATE] at 2:50 PM, it was reported she referenced a report from her office and said, there were multiple blunt force injuries to resident #239's body. The doctor had ruled the death a suicide and indicated that the decedent jumped 39.4 feet from the 3rd floor. Record review of the Miami Dade County Medical Examiner Department Autopsy Protocol document revealed, it was dated [DATE] at 11:30 AM. The noted cause of death was multiple blunt inuries. More specific findings of the autopsy were noted on page 4 of the document. The findings included: 1) Blunt head injury a) Ecchymoses of face and scalp b) Subdural and subarachnoid hemorhage 2) Fracture/ dislocation between sixth cervical and first thoracic vertebrae 3) Blunt chest injuries: a) Contusions of skin b) Multiple bilateral rib fractures c) Incomplete sternal fracture d) Fracture of right clavicle e) Small bilateral hemothoraces f) Bilateral contusions and lacerations of lungs g) Epicardial contusion and laceration h) Lacerations of aorta 4) Blunt abdominal injuries: a) Contusions of skin b) Lacerations of liver c) Lacerations of spleen d) Laceration of right kidney e) Laceration of right adrenal gland f) Small hemoperitoneum 5) Blunt injuries of pelvis a) Contusion of left hip b) Fracture/ separations of bilateral pubic rami and bilateral sacroiliac joints 6) Blunt injuries of extremeties a) Contusions and avulsion of right upper extremity. b) Contusions and open, complex fracture of left distal humerus and proximal radius and ulna c) Contusions and abrasions of left lower extremity d) Small contusions of right lower extremity 7) Mild coronary atherosclerosis 8) Mild to moderate aortic atherosclerosis 9) [DIAGNOSES REDACTED] 10) Endometrial polyp 11) status [REDACTED].

Based on record review, observation and interview, the facility administrator failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to coordinate and obtain necessary psychiatric services for 1 of 13 residents (resident #239) sampled for behaviors. The inability of the facility to coordinate and obtain the necessary psychiatric services potentially resulted in the death of resident #239. The injuries sustained by the resident and the incident surrounding the resident's death were of a severe nature and warranted the determination of Immediate Jeopardy. The findings include: During record review of the facility's 1-day immediate report dated [DATE], the following was documented: "On [DATE] at approximately 3:18 PM. Resident was observed lying face first on the concrete (with the left side of the face towards the concrete) on the courtyard. Resident was observed with her leg stretched out. Resident was assessed and found to have a large open wound on the right upper arm and slight bruise on her left upper arm. Resident was unresponsive and warm to touch. Resident's eyes were open and had shallow respirations. Resident was found with no pulse. CPR (Cardio [MEDICAL CONDITION] Resescutation) was initiated. Rescue arrived at approximately 3:25 PM and resident continues to recieve CPR. Resident was transferred to ... Hospital for medical evaluation and treatment. Family was notified of the incident and transfer of resident to the hospital. Attempted to call to physician to be aware of incident. Physician's office called back with notice that resident expired. Family made aware resident died ." During interview with the maintenance director on [DATE] at 6:00 PM, the following was reported, on [DATE] when he heard the resident was found on the ground, he went up to the resident's room and found the room door closed. When he entered, he saw the window was open, the window screen was sitting on the floor, the window lock and screw were on the window rail, and there was a foot stool by the window. The maintenance director reported, he had no idea how the resident was able to remove the window locks. The maintenance director didn't divulge whether the resident had jumped, fell or was pushed from the room window. He only revealed the findings in the resident's room after the resident was found lying face first in the facility's concrete courtyard. During observation of resident room [ROOM NUMBER], resident #239's previous room, on [DATE] at 6:00 PM, the room was observed to be locked. The maintenance director brought a key to unlock the door. No residents were in the room. Bed A did not have any sheets or covers, just the bare blue mattress. Bed B was made and covered with a gray-blue bedspread. The window was closed and had a window lock/clamp in place. The window screen was in place. The maintenance director reported, he was asked by the police to keep the room the way it was observed on [DATE]. When asked about the foot stool not being in the room, he reported, it was removed because it belonged to resident #239's roommate. The roommate was transferred to room [ROOM NUMBER] after the incident. When asked about maintenance on the facility's windows, it was reported the facility had a Housing and Urban Development (HUD) inspection and failed because they only had screws in place to lock the windows. The HUD inspection took place on [DATE]. Their plan of correction was to install window locks on all the windows inside residents' rooms. It was reported this was completed on [DATE] and it included room [ROOM NUMBER]. The above interview with the maintenance director was the only interview in which facility staff acknowledged that resident #239's room window was open, the screen was off the window and a foot stool was found next to the window on [DATE]. During an interview with the administrator on [DATE] at 3:10 PM, it was revealed the facility's investigation into the incident was still ongoing. It was pending a police report . The administrator reported, "we're trying to get a report from rescue and an autopsy report." The administrator was asked about the lack of nurses notes for 15 days regarding the resident. The administrator reported, he had no idea why there was a gap of 15 days in nurses' notes leading up to the [DATE] incident with the resident. He said, "Per our plan of care, nurses are supposed to write if any behaviors are present." He said he was sure there was a care plan for mood and behaviors in place for resident #239. When asked to identify what measures the facility had in place to prevent a similar incident from happening again, he explained, when it happened they checked all the windows in every room and tightened the clamps. He reported, they had CNAs and nurses do hourly rounds, and he did rounds twice daily. He reported, the resident's family member came to the facility on [DATE] at approximately 5:00 - 6:00 PM because they notified her that an incident had happened and that her family member had to be transported to the hospital. The hospital or police notified her also. The administrator reported, window clamps were put on the windows from [DATE]-[DATE] and were inspected on [DATE] by the maintenance director. He reported, this included room [ROOM NUMBER]. The administrator reported, he did not know what happened. The administrator didn't not divulge whether the resident jumped, or fell or was pushed from the room window. During an interview with the administrator on [DATE] at 11:03 AM it was reported the facility's investigation into the [DATE] incident was still ongoing. It was still pending the autopsy and the Miami Dade police report. As a facility, he said "we have interviewed all the witnesses and investigated the circumstances around it." He reported, it was an injury of unknown origin. He said that nobody saw or knew how the resident fell . He stated, the resident looked intact to him, physically and that there was practically no blood in the area. He said there was a slight amount of blood from the elbow. He indicated that, prior to resident #239's admission to the nursing home, she was hospitalized for [REDACTED]. There were psychological evaluations done on her which were requested by the PCP. The resident had been refusing the evaluations. When asked if he or anyone in the facility had identified any problems with resident #239's care, he said yes, he believed there was a psychiatric consult to be done in April or May which the resident missed. The administrator reported, the resident's record was reviewed on [DATE] by the DON, the care consultant, and the chief nursing executive who are Registered Nurses. It was an interdisciplinary review with all three (3) shift nurses in charge of the resident, the social worker and himself. He reported, they thoroughly reviewed the record but the outcome was still inconclusive. The resident's behavioral situation and medications, including side effects had been reviewed and she had no suicidal thoughts. He said he spoke with the 3rd floor psychiatrist last week who said he did not believe the resident had any [MEDICAL CONDITION]. When asked if the resident had been seen by the 3rd floor psychiatrist he stated, "I believe so." He reported, problems with assessments, care plans, or behavior monitoring, if any, had not been reported to him. The medical director was called and informed of the incident. He came in and reviewed the resident's chart. He looked at the resident's room and at the patio. He said, there was no physical evidence that the resident could have done what she did. When asked to explain, what he meant by the statement that there was no physical evidence that the resident could have done what she did, the administrator said he was "trying to rule out anything; just theorizing." The administrator did not divulge whether the resident jumped, fell , or was pushed from the resident room window.

Based on interview, observation and record review, the facility failed to provide necessary care and services that would allow 2 of 10 sampled residents (#3 and #249) with pain to attain the highest practicable physical, mental and psychosocial well-being. This was evidenced by the lack of assessment and coordination of pain management. The findings include: 1) During observation of the wound care treatment for [REDACTED]. The RN removed the dressing from the resident's right heel revealing a small amount of serous drainage. The RN applied the normal saline to the resident's right heel and proceeded to clean the right heel with the 4x4 gauze. The CNA held the resident's foot. During the care, the resident moaned, groaned, grimaced and attempted to remove her right foot from the CNA's hands. The RN, with the CNA repeating the question, asked the resident if she was in pain. The resident said "si (yes, in Spanish)" and nodded her head. The RN then voiced that the procedure would continue. The RN once again applied normal saline and proceeded to clean the resident's right heel. The resident moaned, grimaced and attempted to remove her right foot from the CNA's hands. The RN continued the wound treatment and she applied Santyl to the right heel. The resident moaned, groaned and grimaced throughout the procedure including when the dressing was being applied. Interview with the LPN on 06/07/2012 at 9:07 AM revealed, resident #3 was administered Tylenol 500mg at 8 AM. The LPN further revealed, when she observed the resident grimacing she would administer the Tylenol but, there wasn't an order to administer pain medication prior to wound care. The LPN confirmed, the Tylenol was only given that morning for the month of June 2012 and there was no routine pain medication ordered for resident #3. Interview with the Minimum Data Set (MDS) Coordinator on 06/06/2012 at 9:09 AM revealed, documentation of non-verbal pain observation is done quarterly. After surveyor intervention, a physician order was obtained for Tylenol #3 (2 tabs) via peg-daily-(give half hour) prior to wound treatment. Observation of the right heel wound treatment on 06/07/2012 at 8:19 AM revealed, resident #3 did not display any discomfort during the procedure. The order for Tylenol #3 was administered 30 minutes prior to wound treatment. Review of the medical record revealed resident #3 was admitted [DATE]. The resident was not administered pain medication prior to daily wound care treatments. There was no physician order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pain assessment was only documented that morning of the wound treatment. The physician order for [REDACTED]. Review of the care plan dated 5/15/2012 revealed the resident was admitted with a closed hemorrhagic blister to the right heel. The care plan documented the resident was at risk for pain. The goal was that the resident will have right heel decubitus less than 3.1cm x 3.5cm x 0.3cm by the next review date. The approach was to give pain management with Tylenol as needed. Review of the care plan dated 12/05/2011 for pain revealed resident #3 was at risk for pain secondary to a decubitus to the right heel. On 5/24/2012 pain management with Tylenol as needed. Goal: Resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving intervention through next review date. Approach: Monitor and report to nurse any signs and symptoms of pain such as crying/moaning, facial grimace, guarding, complaints of pain, restlessness and change in behavior. The Care plan dated 10/31/2011 for Resident has impaired communication problem understanding others. Goal: Resident will respond to yes and no questions using verbal and/or non-verbal answers through next review date. Intervention: Anticipate and meet needs per physical/non-verbal indicators of discomfort/distress and follow up as directed. 2) Interview with resident #249 on 06/05/2012 at 10:59 AM revealed she had pain in her left leg with no relief after medication. The resident further stated, the nursing staff was aware of her pain. Observation of the resident's left foot revealed it was red, swollen, shiny and inflamed. The resident pointed at her left thigh towards her left foot to identify the source of the pain. Interview with resident #249 on 06/05/2012 at 5:05 PM revealed she was experiencing pain in her left foot. Interview with resident #249 on 06/06/2012 at 2:46 PM revealed she had pain in her left foot. Interview with resident #249 on 06/07/2012 at 7:52 PM revealed that she had pain in her left foot. Observation of resident #249's left foot with the MDS Coordinator on 06/07/2012 at 8:11 AM confirmed that resident #249's left foot was red, swollen and shiny. Interview with the RN assigned to resident #249 on 06/07/2012 at 8:13 AM revealed, she gave resident #249 Tylenol on 06/04/2012 due to a complaint of pain. The RN further stated, resident #249 always cried out in pain even before the needle touched her skin during accucheck. Observation of resident #249's left foot with the RN assigned to the resident on 06/07/2012 at 8:14 AM, confirmed the left foot was red, swollen and shiny. Interview with the 7:00 AM - 3:00 PM CNA on 06/07/2012 at 11:23 AM revealed, resident #249 complained of pain in her left leg, the left foot was red and it had been like that for days. The CNA further stated, she reported the pain and redness to the nurse. Interview with the 11:00 PM - 7:00 AM CNA assigned to resident #249 on 06/07/2012 at 11:32 AM revealed, the night and morning nurses were aware the resident had pain in her left foot and the left foot was red. The CNA further confirmed, the left foot had been red for days. Review of the Podiatry notes dated 5/14/2012 revealed additional [DIAGNOSES REDACTED]. Contact my office if there is any change to condition, pain, or any other concerns. Review of the care plan dated 5/10/2012 revealed, resident #249 had a Left 5th toe wound. The approach was to report to the physician changes in skin status i.e signs and symptoms of infection, non-healing. Review of the care plan dated 5/10/2012 revealed the resident was at risk for pain related to [DIAGNOSES REDACTED]. The goal was for the resident to state /demonstrate relief or reduction in pain intensity within one hour after receiving intervention through next review date. The interventions were 1) to monitor and report to nurse any signs and symptoms of pain such as: crying/moaning, facial grimaces, guarding, complaints of pain, restlessness, change in behavior. 2) Report changes in pain location/type. 3) Provide comfort measures as needed such as: relaxation techniques and /or repositioning. 4) Administer medication as ordered. 5) Monitor for effectiveness and for possible side effects from medication. 6) Invite, encourage, remind and escort to preferred activities consistent with the resident's interest as a diversion from pain. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Tylenol was not administered for the months of April, May, or June 2012. There was no order for routine pain administration. There was no assessment of the residents' feet including checking for pedal pulse after administration of the anti-fungal cream that was prescribed for 10 days ending 5/31/2012. The physician was not notified that the status of the left foot had changed. The resident was not transferred out of her bed until after surveyor intervention. After surveyor intervention the physician was notified and an order dated 6/7/2012 revealed: 1. Maintain legs elevated as tolerated x one week using pillow. 2. [MEDICATION NAME] 500mg by mouth every 12 hours x 10 days. Tylenol 325mg two tablets by mouth every 6 hours x 5 days then as needed. 3. D/C Tylenol 500mg every 6 hours as needed. Review of the facility's pain policy revealed: Pain is a stressor, unrelieved it can cause both physical and psychological strain. Without proper management it can actually lead to pathological changes such as complications with immobility and [MEDICAL CONDITION]. Each resident identified with pain will have ongoing assessment, a monitoring system and a specific plan of care to address these issues. 1c. If resident ' s pain is not relieved with medication regimen or comfort measures or, if there is break through pain: notify physician, document findings in the clinical record, ensure the care plan is current, include any changes on CNA care plan. For existing residents exhibiting pain that is not relieved by current medication/comfort measures: notify physician, document findings in clinical record, ensure that the care plan is current, include any changes on CNA care plan.

Based on clinical record review and staff interview, the Medical Director failed to adequately coordinate psychiatric services for 1 of 13 (Resident # 239) residents sampled for behaviors. The findings include: During review of the third floor consultation list, it was determined sampled resident #239 was on the list for a Psychiatric Evaluation on [DATE]. A few names on the list were crossed out. Resident #239's name was not. During clinical record review for sampled resident #239, it determined the last psychiatric follow-up was conducted on [DATE]. Review of the nurses notes dated [DATE] at 6:40 PM revealed, the resident's Primary Care Physician (PCP) was called regarding the resident's behavior and new orders were received. Review of a Physician order [REDACTED]." A Physician order [REDACTED]." During a telephone interview with the Psychiatrist, covering the third floor, on [DATE] at 10:45 AM. The Psychiatrist reported he never saw resident #239 and the resident was not on his caseload. The third floor was supposed to be covered by the facility's Psychiatrist. The Psychiatrist reported he never saw the resident for a psychiatric evaluation, and was never contacted to conduct a psychiatric evaluation for the resident. Also, he reported staff never contacted him due to any changes in resident #239's behavior. Nurse A was interviewed on [DATE] at 4:50 PM in regard to documentation on the [DATE] nurses' notes about the resident becoming aggressive because she wanted to perform the staff's duties such as placing residents in bed, taking them to the bathroom, and transferring them to the wheelchair. When the resident was re-directed, she became upset. The [DATE] at 10:30 PM nurses note was discussed, the nurse reported he went to give the resident the medication and the resident wanted to save it in her room or in her pocket. The resident became upset when he told her to take it in his presence. In regards to the note from [DATE], the nurse reported the resident had inappropriate behavior and was mocking staff and using offensive language to other residents such as "you are crazy, you are fat." Nurse A reported, the residents periods of mood change were serious at times, such as sarcastically laughing at staff and residents. Regarding the note dated [DATE], the nurse stated he called the resident's primary care physician(PCP) in order to obtain an order for [REDACTED]. The nurse stated he wrote a telephone order (TO) for a psychiatric consult. The nurse stated he called the primary psychiatrist's office and left a message with the answering service. He informed the 7:00 AM - 3:00 PM shift nurse of the order and the 7:00 AM - 3:00 PM unit secretary attempted to contact the primary psychiatrist by leaving another voice mail message. The nurse was never notified that the primary psychiatrist no longer worked at the facility. Nor did nursing receive a memo indicating who was going to cover or provide the psychiatric consultation. Nurse A reported, the 3rd floor psychiatrist came to the unit on [DATE] on the 7:00 AM - 3:00 PM shift to conduct psychiatric evaluations. The nurse reported, the resident's primary nurse on the 7:00 AM -3:00 PM shift reported the 3rd floor psychiatrist came to see the resident on [DATE] and the resident refused the consultation. Nurse A reported, the 7:00 AM - 3:00 PM primary nurse told him the resident said, she was not crazy. There was no documentation in resident #239's record from the psychiatrist or the primary nurse about the residents refusal of the psychiatric consultation. During an interview conducted with the resident's PCP on [DATE] at 10:30 AM, it was reported the resident's behavior was that of a [MEDICAL CONDITION]; however she did not have the [DIAGNOSES REDACTED]. of side effects. On [DATE], these medications were discontinued. The PCP stated that he increased [MEDICATION NAME] mg HS from a PRN to a standard HS dose on [DATE] due to the resident complaining of [MEDICAL CONDITION]. He said that, approximately three months ago, the resident stated there was a man in her room during the night, and she was afraid. The physician responded that it was probably staff from the facility. He indicated that when he visited her she was observed to be in her room groomed, nicely dressed, with make-up was applied. She would talk about her husband being a political prisoner and how he died . When she voiced the issue in reference to her husband, he would tell her "don't think about that, look how nice and pretty you look." He said he tried to distract her from those thoughts. He saw her as clinically stable, however, he stated, "I' m not a psychiatrist." The last visit that he had with the resident in May ([DATE]) she stated she was feeling very tired, sleepy and she wanted to stay in bed. During an interview with the administrator on [DATE] at 11:03 AM it was reported the facility's investigation into the [DATE] incident was still ongoing. It was still pending the autopsy and the Miami Dade police report. As a facility, he said "we have interviewed all the witnesses and investigated the circumstances around it." He reported, it was an injury of unknown origin. He said that nobody saw or knew how the resident fell . He stated, the resident looked intact to him, physically and that there was practically no blood in the area. He said there was a slight amount of blood from the elbow. He indicated that, prior to resident #239's admission to the nursing home, she was hospitalized for [REDACTED]. There were psychological evaluations done on her which were requested by the PCP. The resident had been refusing the evaluations. When asked if he or anyone in the facility had identified any problems with resident #239's care, he said yes, he believed there was a psychiatric consult to be done in April or May which the resident missed. The administrator reported, the resident's record was reviewed on [DATE] by the DON, the care consultant, and the chief nursing executive who are Registered Nurses. It was an interdisciplinary review with all three (3) shift nurses in charge of the resident, the social worker and himself. He reported, they thoroughly reviewed the record but the outcome was still inconclusive. The resident's behavioral situation and medications, including side effects had been reviewed and she had no suicidal thoughts. He said he spoke with the 3rd floor psychiatrist last week who said he did not believe the resident had any [MEDICAL CONDITION]. When asked if the resident had been seen by the 3rd floor psychiatrist he stated, "I believe so." He reported, problems with assessments, care plans, or behavior monitoring, if any, had not been reported to him. The medical director was called and informed of the incident. He came in and reviewed the resident's chart. He looked at the resident's room and at the patio. He said, there was no physical evidence that the resident could have done what she did. When asked to explain, what he meant by the statement that there was no physical evidence that the resident could have done what she did, the administrator said he was "trying to rule out anything; just theorizing." The administrator did not divulge whether the resident jumped, fell , or was pushed from the resident room window. An interview conducted with the Medical Director on [DATE] at 11:30 AM revealed that he has worked at the facility for a total of nine (9) years as a Physician, and that he has been the Medical Director for approximately two (2) years. The Medical Director reported that he meets with the facility staff on a weekly basis and conducts rounds with the DON. In addition, he reported meeting with the Administrator and the DON to discuss patient care and related issues with patients and family members. When a Physician does not respond to the calls or come to see the patients, the facility contacts him. The Medical Director stated that he ensures coordination of resident care facility wide by meeting with the staff and conducting a monthly report regarding falls, medications, and wounds. He submits the report to the corporate office. The Medical Director reported that, when the facility staff has difficulty obtaining consultations or other medical services he attempts to arrange for another physician to go. He also attempts to find alternative consultants to see the patient. The Medical Director reported the facility informed him the resident's Psychiatrist gave notice and was not coming back. The facility told him they had someone to replace him, however he doesn't remember the name. The Medical Director stated he was not aware there was a Telephone Order written for a Psychiatric Consultation dated [DATE] and that there was no response from the Psychiatrist's office. He stated if he had known, he would have called the Psychiatrist. The Medical Director stated that, in the event there is a change in consulting Physicians, the DON and the Nursing Supervisor are responsible to notify the staff. When asked if he was informed of the incident that took place on [DATE] and which resulted in the death of resident #239, he responded that he spoke with the attending Physician and the DON. He said, "Believe me I don't think it was possible for the resident to climb on the air conditioning. Basically, from what I know she did not fly out the window." When asked if he had the opportunity to read the nurses' notes which described the resident's behaviors, he responded, "I only read the Physicians' notes. I spoke with the resident's primary Physician and he stated the resident was happy, if anything her mood improved." When asked if the staff ever communicated behaviors documented at length in resident #239's [DATE] through [DATE] nurses' notes, he responded, "No, they did not." When asked if he ever saw the resident, he responded "No, I did not." The physician agreed that the noted behaviors did not correspond with a Depressed Mood Diagnosis, however, they told him that the resident was happier than before, when she was living at an Assisted Living Facility. During an interview with a Miami Dade County Medical Examiner's office investigator on [DATE] at 2:50 PM, it was reported she referenced a report from her office and said, there were multiple [MEDICATION NAME] force injuries to resident #239's body. The doctor had ruled the death a suicide and indicated that the decedent jumped 39.4 feet from the 3rd floor. Record review of the Miami Dade County Medical Examiner Department Autopsy Protocol document revealed, it was dated [DATE] at 11:30 AM. The noted cause of death was multiple [MEDICATION NAME] inuries. More specific findings of the autopsy were noted on page 4 of the document. The findings included: 1) [MEDICATION NAME] head injury a) Ecchymoses of face and scalp b) Subdural and subarachnoid hemorhage 2) Fracture/ dislocation between sixth cervical and first [MEDICATION NAME] vertebrae 3) [MEDICATION NAME] chest injuries: a) Contusions of skin b) Multiple bilateral rib fractures c) Incomplete sternal fracture d) Fracture of right clavicle e) Small bilateral hemothoraces f) Bilateral contusions and lacerations of lungs g) Epicardial contusion and laceration h) Lacerations of aorta 4) [MEDICATION NAME] abdominal injuries: a) Contusions of skin b) Lacerations of liver c) Lacerations of spleen d) Laceration of right kidney e) Laceration of right adrenal gland f) Small hemoperitoneum 5) [MEDICATION NAME] injuries of pelvis a) Contusion of left hip b) Fracture/ separations of bilateral pubic rami and bilateral sacroiliac joints 6) [MEDICATION NAME] injuries of extremeties a) Contusions and avulsion of right upper extremity. b) Contusions and open, complex fracture of left distal humerus and proximal radius and ulna c) Contusions and abrasions of left lower extremity d) Small contusions of right lower extremity 7) Mild coronary [MEDICAL CONDITION] 8) Mild to moderate aortic [MEDICAL CONDITION] 9) [MEDICAL CONDITION] 10) Endometrial polyp 11) status [REDACTED].