Every finding on record at Wedgewood Healthcare and Rehabilitation Center

Based on observation interview and record review the facility failed to accommodate mobility needs related to personal access to a motorized wheelchair for one resident (#4) out of three residents sampled for accessibility.Findings included: During an interview on 05/26/2026 at 1:27 p.m., Resident #4 voiced their unhappiness with their current living situation at the facility. Resident #4 stated they wanted to get up and be out of bed more but given their condition of Multiple Sclerosis (MS) they know it is a process for the staff to get him up and expressed concern for not having his powerchair (also known as motorized wheelchair). Resident #4 stated when he was still living independently in a home they would use the powerchair to get around, visit friends, as well as go to the grocery store. Resident #4 stated when he came to the facility with their powerchair on the day of admission, the facility took the chair to be evaluated and was told the chair was not in good enough condition to bring into the facility. He stated maintenance put the chair in the shed until someone could pick it up. Resident #4 voiced they told multiple staff members they were very unhappy not having the use of their powerchair because that was their only real independence in getting around. Resident #4 stated being told their chair could not be used and they would be provided a standard manual wheelchair. The resident stated that they have MS and only have the use of one hand. He stated when the staff gets him up into the manual wheelchair the only option he has is to spin in circles. He stated this was the only movement their physical limitations would allow, or to be stuck wherever the CNAs (Certified Nursing Assistants) put him without any way of moving around the facility or independently going back to their room. Resident #4 stated they were still fairly young, cognitively intact, and was accustomed to living somewhat independently before this, and now they feel as though they are trapped in a small room with only their one roommate who is minimally verbal. Resident #4 stated in the year he has been at the facility no one ever gave him any inclination that obtaining a new powerchair was a possibility. He stated he was never assessed for use of a powerchair and was not offered to repair or replace the powerchair. He said if he could use a powerchair again, it would be life changing. Review of the record revealed Resident #4 was admitted into the facility in May 2025 with diagnoses of Multiple Sclerosis (MS) ,muscle wasting and atrophy, not elsewhere classified, multiple sites, need for assistance with personal care, other abnormalities of gait and mobility, and Major Depressive disorder, single episode, unspecified among other diagnoses. A review of the Resident #4's quarterly Minimum Data Set (MDS) dated [DATE], Section C, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15; meaning the resident is cognitively fully intact. Section GG showed Resident #4 had impairment on the upper and lower extremities. Section GG0120 showed the resident uses a wheelchair for mobility. The Mobility assessment revealed the resident was dependent or required maximal assistance. Section GG0170 revealed the resident was assessed for the use of a manual wheelchair, but not a motorized one. A review of the care plan for Resident #4, last revised on 03/06/2026, showed the following focuses:Resident #4 has Multiple Sclerosis (MS) with interventions to include: PT (Physical Therapy), OT (Occupational Therapy), Speech therapy (ST) evaluate and treat as ordered.Resident #4 prefers independent activities such as watching TV, family visits and interacting with staff, with interventions to include; inviting the resident to scheduled activities and the resident needs assistance/escort to community life functions.Resident #4 has ADL (Activities of daily living) self-care deficit r/t (related to) activity intolerance and impaired mobility. Interventions included PT, OT, evaluation and treat as per MD (medical doctor's) orders. Review of progress notes for Resident #4 revealed the following: - A physician progress note dated 05/22/2026 revealed the resident has progressive MS, frustrated with their increased weakness affecting their mobility and that resident continues to express their frustrations with their current situation.- A psych note dated 05/20/2026 showed resident reported ongoing grief related to the loss of their [family member]. They also expressed sadness due to [another family member] being very sick and their [other family member] being ill as well. Resident described feeling down, but stated that getting up out of bed and being active helps them feel better.- An activities note dated 01/09/2026 showed resident was alert and able to make their own decision pertaining to activities.- A physician progress note dated 02/10/2026 showed the resident reported that their stress-related symptoms continue to occur. Resident today reports that those stress-related symptoms continue unchanged. They have been having anxiety symptoms. They have been troubled by feelings of frustration. They had been experiencing anhedonia or loss of pleasure . In an interview with the Director of Therapy (DOT) on 05/26/2026 at 4:01 p.m., the director stated the resident had done extensive therapy with them and the resident had not shown improvement. The director stated for a resident to use a powerchair in the facility, they have to be screened by PT to make sure it would be safe for the resident as well as the other residents in the facility. They stated they consider things like the ability to maneuver the powerchair independently, cognitive function, and also determine the resident's eligibility. The director confirmed Resident #4 had a powerchair he brought from home that was not in good condition so the facility removed it. Therapy director confirmed no one from therapy worked with the resident on the chair or discussed the possibility of a new or replacement powerchair. The DOT stated Resident #4 was not assessed for eligibility to the use of a powerchair as the facility felt his powerchair was not in good enough condition to do the evaluation. The Director of Therapy stated the facility did not have any extra powerchairs for the resident to use in order to conduct the evaluation. An interview was conducted with the Nursing Home Administrator (NHA) on 05/26/2026 at 4:27 p.m. The NHA confirmed the facility took away the powerchair of Resident #4 upon admission as it was found to be in poor condition with some bugs found in it. She stated maintenance held the chair in the shed as Resident #4 was still paying for it. The NHA stated ultimately the vendor came to retrieve it. The NHA confirmed they did not work with Resident #4 on replacing the powerchair. The NHA stated Resident #4 was fully cognitively intact and a younger man, compared to many other residents in the facility, and voiced understanding that the resident losing the use of their powerchair, may result in loss of some independence. The NHA agreed this would be a concern for the resident. The NHA acknowledged the resident was not living at their highest level of independence. The NHA stated not being aware Resident #4 wanted a new powerchair and therefore never addressed the issue. Review of a facility policy titled, Motorized Wheelchair Use Process, Revised 4/29/2026 revealed: Purpose: Each resident who utilizes a motorized wheelchair will be evaluated to ensure the resident is able to safely maneuver the device without placing self or others at risk for injury.Procedure:The motorized wheelchair assessment shall be completed by therapy for each resident who utilizes the device upon admission or prior to utilizing the device freely about the facility.The resident/legal representative will provide the motorized wheelchair and shall be responsible for repairs and maintenance of the device.Continued use of the motorized wheelchair will be reviewed quarterly and as needed.The facility will prohibit and/or restrict the use of the motorized wheelchair should the resident be unable to safely maneuver the device and/or is non-compliant with safe operation.The facility will prohibit use of the motorized wheelchair if the device becomes unsafe to operate, is not maintained routinely, and/or any other reason that poses a risk for continued use.The facility is not liable for or responsible for storing the motorized wheelchair when continued use is prohibited.

Based on observation and interview, the facility failed to ensure residents and visitors were provided with an updated/current Daily Staffing Census posting during one of four days observed. Findings included: On 12/16/2024 at 9:00 a.m., the building was entered and met with Staff B, the front desk receptionist. While in the lobby and at the front desk, the Daily Census Staffing Form was observed placed in a clear plastic envelope and placed where residents and visitors could view it. Review of the Daily Census Staffing Form revealed it was dated 12/15/2024, which was the previous day from this observation. It was determined the front lobby desk did not have the up- to- date Daily Census Staffing form for review. Interview with Staff B revealed she was not sure who was responsible for updating the form, but she knew the form was usually updated every day to reflect accurate nursing numbers for each shift. Staff B confirmed the form was not reflective of the current date. On 12/19/2024 at 7:37 a.m., an interview with Staff G, Staffing Coordinator revealed she was the staff member who typically updated the Daily Census Staffing form Monday through Fridays and would update and change the form in the morning when she came in; which was typically at 7:00 a.m. or a little after 7:00 a.m. Staff G said when she was not working on most weekends, a weekend nurse supervisor would update the form and place the updated form on the reception desk in the front lobby. Staff G confirmed the lobby front desk was the only place where this form/document was kept for visitor/residents review. Staff G confirmed she was not able to get to the Daily Census Staffing form on Monday 12/16/2024 in a timely manner. She also confirmed the form was not accurate to reflect that date, and it was reflective of day 12/15/2024. A review of the Posting Direct Care Daily Staffing Numbers policy and procedure dated 4/6/2022, revealed: Facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The policy interpretation and implementation section revealed; (Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADL), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physician's of change of condition.) 1. The information record on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift; 1) Registered Nurses 2) Licensed Practical nurses or licensed vocational nurses (as defined under State law). 3) Certified Nurse Aides. e. Clear and readable format. f. In a prominent place readily accessible to residents and visitors. 2. Public access to posted nurse staffing data. The facility will, upon oral or written request, make nurse staffing data available. 3. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the Director of Nursing Services' office and filed. 4. Inquiries concerning our direct care staffing information should be referred to the Director of Nursing Services or the Administrator.

Based on observation, interview, and record review, the facility failed to ensure all resident room bathrooms were provided and maintained with a fully operational call light system in one of six hall//units, to include the 600 hall/unit. Findings included: On 12/16/2024 at 9:30 a.m., 2:00 p.m., 12/17/2024 at 8:00 a.m., 1:00 p.m., 12/18/2024 at 2:00 p.m., and 12/19/2024 at 7:28 a.m. the following resident rooms were observed in the 600 secured/dementia unit: 1. room [ROOM NUMBER] bathroom metal hand rail had a white fabric call cord wrapped and tied to the wall hand rail. It was tied and wrapped in a manner that prevented it to appropriately actuate the call system if pulled below the hand rail. 2. room [ROOM NUMBER] bathroom wall mounted call system was missing a cord to pull and actuate the alarm. 3. room [ROOM NUMBER] bathroom hand rail had a white fabric call cord wrapped and tied to the wall hand rail. It was tied and wrapped in a manner that prevented it to appropriately actuate the call system if pulled below the hand rail. 4. room [ROOM NUMBER] bathroom wall mounted call system was missing a cord to pull and actuate the alarm. 5. room [ROOM NUMBER] bathroom hand rail had a white fabric call cord wrapped and tied to the wall hand rail. It was tied and wrapped in a manner that prevented it to appropriately actuate the call system if pulled below the hand rail. 6. room [ROOM NUMBER] bathroom hand rail had a white fabric call cord wrapped and tied to the wall hand rail. It was tied and wrapped in a manner that prevented it to appropriately actuate the call system if pulled below the hand rail. On 12/19/2024 at 7:30 a.m., interviews with Staff C and Staff D, Certified Nursing Assistants (CNAs), both confirmed the above listed resident room bathrooms with either missing call light cords, or call light cords that were wrapped around the bathroom wall hand bars. Staff C and Staff D also confirmed if a resident were on the floor in the bathroom, they would either not be able to reach the cord because it was missing, or would not be able to pull on the cord to make it actuate due to being wrapped or tied around the hand bar. Staff C and staff D revealed they usually observed rooms and bathrooms for safety and equipment maintenance but there were times when the residents in this dementia/secured unit would pull off the cords or mess with the cords. Staff C and Staff D confirmed they should have caught those missing cords and cords tied around the hand rails before. On 12/19/2024 at 7:47 a.m., an interview with Staff F, 500/600/700 Unit Manager, confirmed call light cords should be within reach when the resident was in bed as well as within reach and accessible in the resident bathrooms. Staff F confirmed there were several resident bathrooms that were either missing call light cords or cords wrapped around on hand rails, making it difficult to actuate the call system should a resident need to use it. Staff F confirmed the 600 unit was a dementia/secured unit and most of the residents do not use the call light due to their cognitive deficits. However, all call lights needed to be maintained to use in both resident rooms and resident bathrooms, as well as a community shower room. The Director of Nursing (DON) provided the Call Bells policy and procedure dated 4/1/2022, for review. The Policy stated; It is the policy of the facility that all residents are to have access to call bells at all times, even if it is generally believed that the resident is unable to use it. Staff are expected to be as vigilant as possible in keeping the call bell within reach of the resident. It is acknowledged that some residents have the capability to remove or move away from the call bell. The facility provides a variety of types of call bells to assist each resident in having the best means of communicating with staff. The call system must be accessible to residents: - While in their bed - Other sleeping accommodations within the resident's room and for situations where the resident chair is on the opposite side of the call light, a manual bell will be offered/ The System must be accessible to residents who sustain a fall The guidelines section of the policy revealed; 1. Explain and demonstrate the use of the call light to the new resident. 2. Be sure the call light is plugged in and within reach at all times. 3. Report any defective call lights to Maintenance. 4. Residents should be provided with an alternate device to alert staff of need. 5. Answer the resident's call light courteously and as soon as possible. Photographic evidence was obtained.

Based on observation, interview, and record review, the facility failed to honor and maintain resident dignity related to staff not knocking or announcing prior to entering occupied rooms for three (#94, #9, and #22) of thirty-eight sampled residents. Findings included: 1. On 12/16/2024 at 9:55 a.m., Resident #94 was observed in her room and seated in her wheelchair next to her bed. Resident #94 was noted dressed for the day and well groomed. She was observed to reside in the secured/dementia unit, and was residing in a room by herself. She had no initial concerns other than staff just coming in her room without knocking. She revealed this happened during the day and night and she got especially startled when she was in bed and sleeping and staff came in her room without her knowing. Resident #94 revealed there were times when staff yelled out to her while at the side of her bed and she knew they did not knock before coming in the room. She revealed she had spoken to a nurse about it but things had not changed. On 12/16/2024 at 1:10 p.m., while touring the 600 Secured unit, Staff C, Certified Nursing Assistant (CNA) was observed to walk into Resident #94's room without first knocking and/or announcing herself. Resident #94 was in the room during the time of the observation. On 12/17/2024 at 7:20 a.m., while on the 600 Secured unit, Staff C was observed walking into Resident #94's room without first knocking and/or announcing herself. Resident #94 was in her room and seated in her wheelchair during the time of the observation. On 12/18/2024 at 11:12 a.m., an interview was conducted with Resident #94. She was in her room and seated in her wheelchair. During the interview, Staff C walked into the room without first knocking and/or announcing herself. Staff C reached the middle of the room and then said she did not knock and should have before coming in the room. On 12/19/2024 at 8:15 a.m., an interview with Staff F, Unit Manager for 500/600/700 halls, confirmed all staff should knock and announce prior to going in resident rooms. She said usually would monitor staff and walk up and down the hallways to ensure this was happening. She had to provide verbal education to staff on the unit at times, and also revealed facility wide education had been provided to all staff in the past. A review of Resident #94's medical record revealed she was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include but not limited to: cognitive communication deficit, Alzheimer's, and need for assistance with ADLs. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 8 of 15, which indicated moderate cognitive impairment. 50434 2. During an observation on 12/16/2024 at 9:50 a.m., a Certified Nurse Assistant (CNA) entered the room of Resident #9 and turned the light on. The staff member did not knock, announce themselves or let Resident #9 know they were coming in and turning the light on. During an observation 12/16/2024 at 11:09 a.m., a housekeeping staff member was observed entering room [ROOM NUMBER] without knocking or announcing himself. During an observation on 12/17/24 at 2:19 p.m., two housekeeping staff members entered room [ROOM NUMBER] without knocking or announcing themselves. They were working on replacing the privacy curtain. They did not speak to the residents to tell them what they were doing. 3. During an observation on 12/18/2024 at 10:03 a.m., a CNA was observed entering Resident #22's room, they flipped the light switch on, walked to Resident #22's bed and knocked on the foot board of the bed, stating It's time to get ready for Dialysis. During an interview on 12/18/2024 at 10:45 a.m., Staff H, CNA, stated before she entered a resident's room, she would knock or announce herself before entering the rooms of the residents. She stated that in the mornings, they go in and out of different resident rooms and it was a habit to just walk into their rooms and turn their lights on without knocking or announcing themselves. During an interview on 12/18/2024 at 10:45 a.m., Staff I, CNA, stated before she entered a room she would knock on the door and announce herself. She stated, you should let the resident know you are going to turn on their lights, because some residents like having their lights off. During an interview on 12/18/2024 at 2:35 p.m., Staff F, Licensed Practical Nurse (LPN), Unit Manager stated her expectation of staff was that they knocked on doors before entering the resident's room and asked the resident if it was okay to turn their light on. During an interview on 12/18/2024 at 2:51 p.m., with Director of Nursing (DON), he stated he would expect staff to knock before entering rooms and to announce them self. A review of the Dignity policy and procedure dated 4/1/2022, was conducted and revealed the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy interpretation and implementation section revealed; 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self worth. 7. Residents' private space and property shall be respected at all times. a. Staff will announce themselves and request permission before entering residents' rooms.

Based on observation, interview, and record review, the facility failed to ensure communication between the facility and the Dialysis Center for one (#22) out of 24 residents sampled. Findings Included: During an interview on 12/16/2024 at 9:50 a.m., Resident #22, stated he had concerns about not receiving medications on time. He stated that he had had a cough for a few weeks and what they were giving him was not working. During an interview on 12/18/2024 at 10:00 a.m., Resident #22, stated he reminded staff to check his vitals when he got back from dialysis. He stated they did not check his AV (Arteriovenous) fistula when he returned from dialysis. During an observation on 12/18/2024 at 10:00 a.m., a red binder was observed on Resident #22's bedside table. Inside the binder was a Communication Sheet, dated 12/16/2024, with Resident #22's name, room number, and vitals pre-dialysis and post dialysis on it. There was no other writing on the sheet. Review of Resident #22's admission record revealed an admitted [DATE] and a re-admitted [DATE]. Resident #22 was admitted to the facility with diagnoses not limited to of muscle wasting and atrophy, unspecified abnormalities of gait and mobility, need for assistance with personal care, type 2 diabetes, legal blindness, dependence on renal dialysis, end stage renal disease, and major depressive disorder. Review of Resident #22's Minimum Data Set (MDS) dated [DATE] revealed Section C. Cognitive, a Brief Interview Mental Status (BIMS) of 15 out of 15 which indicated intact cognition. Review of Section GG, Functional Status revealed no impairment to upper/lower extremity, set up and clean up assistance with eating, oral hygiene, personal hygiene. Supervision Touching for toileting hygiene, upper/lower body dressing. Partial moderate assistance for shower/bathe. Review of Section O. Special Treatments revealed dialysis. Review of Resident #22's medical record revealed: Progress Notes: No progress notes were found for communication with dialysis. Miscellaneous Document Tab: Review of the Misc tab revealed progress notes from dialysis for the dates of 12/16/2024, 12/10/2024, and 11/272024. During an interview on 12/18/2024 at 10:45 a.m., Staff H, Certified Nurse Assistant (CNA) stated Resident #22 was a blind resident but could do a lot for himself. She stated she helped him get to the bathroom. She stated during mealtimes she made sure he knew where the plate was and where everything on his plate was located. She stated he was on dialysis and went on Monday, Wednesdays and Fridays. She stated she made sure he was up and dressed for his 12:00 p.m., chair time. During an interview on 12/18/2024 at 11:30 a.m., Staff A, Licensed Practical Nurse (LPN) stated Resident #22 was a blind resident who was on dialysis. She stated Resident #22 had a binder that he took with him to dialysis and dialysis would add notes to the book for communication. During an interview on 12/18/2024 at 2:35 p.m., Staff F, Licensed Practical Nurse (LPN), Unit Manager, stated residents on dialysis had a communication book they used. She stated residents took it with them to dialysis and dialysis sent it back with the resident. She stated the dialysis center had not been putting any notes in the books, so they called and requested the report. She thought the communication sheets from the book got scanned into the Electronic Medical Record (EMR). During an interview on 12/18/2024 at 2:51 p.m., the Director of Nursing, (DON) stated they had paper tools that allow them to communicate with dialysis. He stated dialysis was not writing on the form so they requested their reports weekly, on Mondays. He stated when they called, they checked to see if there were any changes in orders, or concerns with weights. He stated they hold the reports in a book located at the nurse's station for the dietician to review on Tuesdays. Once the dietician reviewed the reports it was scanned into the miscellaneous folder of the resident's EMR. During an interview on 12/18/2024 at 5:00 p.m., the DON brought a 128-page fax of dialysis reports for Resident #22. The fax cover page was dated 12/18/2024. The DON stated he requested for them today because he wanted to make sure he had them all. He stated all the notes were not in Resident #22's EMR because they do not have a full-time medical records clerk. Photographic evidence obtained. During an interview on 12/18/2024 at 5:30 p.m., the DON brought in Resident #22's dialysis communication book and revealed there was no new communication from dialysis in the book and stated he would have to call them to get the report. During an interview on 12/19/2024 at 10:19 a.m., the Dietician stated for dialysis residents she called the dialysis dietician directly and got the post dry weights and the target dry weights. She documented her notes in the resident's EMR. She updated her notes every quarter or as necessary. She stated Resident #22 just triggered to have his weights reviewed this week. She stated she just got a hold of dialysis center today. She stated she trusts the weights that were in his chart because he had been stable. She stated that she did not review dialysis reports weekly. Review of the facilities policy dated April 1st, 2022, titled dialysis communication, revealed, Purpose To provide ongoing communication and collaboration between the nursing home and dialysis provider regarding dialysis care and services, assessment of the resident's condition and ongoing monitoring for complications as needed. Policy The facility will utilize the dialysis communication forum each time a resident attends dialysis as a tool to relay pertinent information regarding the residence condition and coordinate care and services with the dialysis provider. Procedure 1. The licensed nurse will complete & the portions of that it dialysis communication forum that includes A. the facility's name and contact information B. Code status C. Allergies D. Diet E. The name and contact information for the dialysis center where the resident will be receiving treatment. F. Who transported the resident to dialysis G. Resident vital signs H. Medications administered I. PermaCath or shunt condition prior to dialysis J. Any change in condition, physician orders or lab work completed since the residents' last dialysis treatment K. What time does the resident left for dialysis L. The resident's full name date of birth attending physician medical record and room numbers 2. The licensed nurse will document any changes in condition and the MRI. 3. The original dialysis communication form will be sent with the resident to dialysis. 4. The bottom portion of the form will be completed and signed by the dialysis center personnel. Information included in this section A. Residents vital signs including pre and post dialysis weight. B. Dialysis start and end times C. Any new recommendations from the dialysis center D. PermaCath/shunt site condition E. Any change in condition including any event that may have occurred while at dialysis F. Lab values G. Medications received at dialysis 5. The completed form will then be sent back to the nursing home with the resident or transportation company. 6. The receiving nurse will review the dialysis communication form for any pertinent information or recommendations to be addressed. 7. The licensed nurse will document any changes in condition and the ER. 8. A copy of the dialysis communication form will be maintained as part of the residence medical record.

Based on observation, interview, and record review, the facility failed to provide care and services for three (#90, #58, and #80) of thirty-eight sampled residents related to 1. Staff did not identify and treat a skin tear on Resident #90's right arm; 2. Lack of insulin monitoring for Resident #58; and 3. Lack of monitoring for blood thinners for Resident #80. Findings included: 1. On 12/16/2024 at 10:45 a.m. and 2:30 a.m., Resident #90 was observed seated in a chair in the activities/lounge area with other residents seated next to her. Staff were in the same room either interacting with Resident #90 or interacting with other residents in this room. Resident #90 was pleasant and was able to answer simple yes and no questions. Further observations revealed Resident #90 had several wounds on her right arm. She was observed rubbing her right arm with her left hand. Her right arm had four very small scabbed over lesions as well as one open wound/skin tear that was approximately one inch by one inch in size. The wound/skin was open to air with no evidence of bandages on her arm. The resident had cognitive deficits and could not express what happened. There were two Certified Nursing Assistants, Staff C and Staff D, in the room and they were both asked if they knew what happened to Resident #90's arm. Staff C was shown the open wound/skin tear on Resident #90's right arm and she confirmed the wound/skin tear was open to air. She revealed Resident #90 picked at her arms as a behavior. Neither Staff C or Staff D could say how Resident #90 obtained the open area on her right arm. On 12/17/2024 at 7:20 a.m. Resident #90 was observed in the secured unit seated in a chair in the activities lounge. She was observed dressed for the day and was wearing a short sleeved shirt. Resident #90's right arm was again observed with an open wound/skin tear which was approximately one inch by one inch in size. Her arm was observed without a bandage. Staff E, Licensed Practical Nurse (LPN) was in the immediate area, at her medication cart and preparing medications for other residents in the room. Staff E said she was familiar with all the residents in the unit and she had two aides who were working with her today. Staff E said she knew Resident #90 and that she predominantly spoke Spanish. Staff E said the resident had impaired cognition preventing her from speaking about her medical care. Staff E could not remember if Resident #90 had any recent falls without first looking at her medical record. She confirmed the wound/skin tear on Resident #90's right arm was one inch by one inch in size, with slight drainage and was open to air. Staff E revealed she was not sure what happened or how long ago the wound/skin tear happened. She was able to say the resident picked at the wound and that was why there was no bandage on it. Staff E then looked in the record and revealed the skin tear happened as a result from room mate altercation on around 12/5/2024. Review of Resident #90's medical record revealed she was admitted to the facility on [DATE]. Review of the current diagnosis sheet revealed diagnoses to include but not limited to: Muscle weakness, Need for assistance with personal care, Dementia, and Alzheimer's. Review of the current Physician's Order Sheet dated for the month of 12/2024, revealed the following but not limited to: 1. Clean right leg with NSS, apply xeroform and covered with adhesive gauze until heal. Keep clean and dry - Every night shift and x 8 hrs as need for management. (12/17/2024) 2. Monitor laceration to head until heal x shift for 1 month. (11/19/2024) 3. Weekly skin sweeps x night shift x Monday (10/21/2024) Review of the nurse progress notes dated from admitted [DATE] through to current 12/18/2024 did not reveal any type of wound/skin tear on Resident #90's right arm. Further, there was no documentation identifying any incidents that created a large wound/skin tear on her right arm. Review of the Nurse Weekly skin observation sheets dated, revealed: 1. 11/24/2024 - Blank with nothing documented. No documentation to support skin tear on R arm. 2. 11/26/2024 - Blank with nothing documented. No documentation to support skin tear on R arm. 3. 12/3/2024 - Checked Yes for skin issues Note for location revealed; Healing scab to front of head scalp. There was no documentation to support skin tear on R arm. 4. 12/10/2024 - Blank with nothing documented. No documentation to support skin tear on R arm. 5. 12/17/2024 - Checked yes for skin issues. Documentation in notes revealed healing scab to right forearm and forehead. Note: This note identified old scabbed areas, but did not indicate the current open skin tear on the right arm. On 12/18/2024 at 11:55 a.m., Staff F, LPN, 500/600/700 revealed the resident had been identified in the record and progress notes of an incident between Resident #90 and another resident on 12/5/2024 and that Resident #90 received a laceration on her head. Staff F revealed there was no evidence of a skin tear on the right arm during that incident. Staff F revealed she could not find any documentation that supported identifying that skin tear until the review of yesterday's evening (12/17/2024) nursing assessment. Staff F did not know Resident #90 had a skin tear on her right arm on 12/16/2024 or 12/17/2024 and not until it was brought to her attention on the morning of 12/18/2024. She revealed it is an expectation that staff were observing the resident and doing skin checks on a daily basis. She could not say why this skin tear was not identified and reported/investigated on 12/16/2024 at the very least. Staff F further confirmed there was no documented evidence of the Physician and family being notified of this R arm skin tear. 48441 2. A review of Resident #58's Admission Record showed an initial admitted [DATE] with a recent readmitted [DATE]. According to the Admission Record, Resident #58 had diagnoses not limited to Type II Diabetes and heart failure. A review of Resident #58's current physician orders showed the following orders related to his diabetes: -Empagliflozin oral tablet 25 milligrams (mg) give one tablet by mouth one time a day -Insulin Glargine subcutaneous solution pen-injector 100 units/milliliter (u/ml), inject 25 units subcutaneously at bedtime for DM (Diabetes Mellitus) On 12/19/2024 at 11:46 a.m., an interview was conducted with Staff M, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff M stated when administration of any injectable insulin, a resident would have a finger stick to check their blood sugar. Staff M stated this was a routine practice and when the order was in the medical record there was the opportunity to check the blood sugar prior to injection of insulin. Staff M stated Resident #58 had Lantus, brand name for Glargine, ordered at nighttime and agreed the resident should have his blood sugar checked prior to administration. Upon review of Resident #58's physician orders, Staff M stated there were no physician orders to check the blood sugar prior to administration nor orders to monitor the resident for any potential side effects and/or adverse effects for a diabetic patient. A review of Resident #58's care plan dated 12/15/2024, showed a focus are of Diabetes Mellitus with interventions to include but not limited to: -Blood sugar as ordered by doctor. - Check all of body for breaks and skin and treat promptly as ordered by doctor. -Diabetes medication as ordered by doctor. Monitor and document for side effects and effectiveness -Monitor/document/ report PRN (as needed) any signs and symptoms of hyperglycemia. -Monitor/document/report PRN any signs and symptoms of hypoglycemia. On 12/19/2024 at 3:30 p.m., an interview was conducted with the primary physician for Resident #58. The primary physician for Resident #58 stated he was very familiar with the resident. The primary physician stated Resident #58 had recently returned from the hospital. The primary physician stated normally we would check the resident's accu-check for the first three days to determine further determination of the resident's insulin regimen and/or blood sugar check frequencies. The primary physician stated hypoglycemia was more of a concern for residents on insulin injectable. The primary physician agreed Resident #58 should have had his blood sugar checked for the first three days minimum upon his return to the facility. Upon request for a policy and/ or procedure for monitoring a resident on injectable insulin, the facility denied such policy existed in their facility. 50434 3. During an interview on 12/16/2024 at 12:15 p.m., Resident #80 was observed in bed dressed in a hospital gown. Resident #80 was observed with a dark red liquid flowing from her nose into her mouth. Resident #80 had a towel over her shoulder that had bright red spots on it. Resident #80 stated she had been having nosebleeds frequently. She stated any time she moved her head or sneezed her nose started to bleed. She stated staff was aware of it. During an interview on 12/17/2024 at 4:00 p.m., Resident #80 stated she had not had a nose bleed today. Resident #80 was observed to not have her oxygen cannulas on and the oxygen compression machine was off. She stated she was very happy that she had not had a nosebleed today. Review of Resident #80's admission record revealed an admitted [DATE]. Resident #80 was admitted to the facility with diagnoses not limited to nonrheumatic aortic valve stenosis, acute embolism and thrombosis of unspecified deep veins of right lower extremity, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #80's Quarterly Minimum Data Set (MDS) dated [DATE] Section C. Cognitive, revealed a Brief Interview for Mental Status (BIMS) of 14 out 15 which indicated intact cognition. Review of Section GG, Functional Status revealed no impairment to upper/lower extremity. Resident #80 was dependent for toileting. Set up or clean up assistance eating, shower/bathe. Review of Section N, Medications revealed Antidepressant, Anticoagulant, Opioid, Antiplatelet. Review of Section O, Special Therapy, Oxygen therapy, Continuous. Review of Resident #80's Medical Record revealed: Orders: Start Date: 11/22/2023 Clopidogrel Bisulfate Oral Tablet &5 mg (Clopidogel Bisulfate) give one tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris Start Date: 10/18/2024 Eliquis Oral Tablet 5 MG (Apixaban) give one tablet by mouth two times a day for Deep Vein Thrombosis (DVT) Start Date: 11/24/2023 Anticoagulants- check for bleeding and bruising Q shift every shift for monitoring Review of Resident #80's Orders revealed no orders for the monitoring of Nosebleeds. Review of Resident #80's Medication Administration Record (MAR) for December revealed: Clopidogrel Bisulfate Oral Tablet 5 MGF nosebleeds (Clopidogel Bisulfate) was given December 1st through December 19th. Eliquis Oral Tablet 5 MG (Apixaban) was given December 1st through December 18th. Anticoagulants- check for bleeding and bruising Q shift every shift for monitoring was completed for December 1st through December 18th with no indications of bleeding. Review of Resident #80's Care Plan dated 03/08/2024 revealed: Focus: [Resident #80] is on anticoagulant therapy Goal: [Resident #80] will be free from discomfort or adverse reactions related to anticoagulant use through the review date Interventions: [Resident #80] is on anticoagulant therapy-Administer Anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Labs as ordered. Report abnormal lab results to MD. Monitor/document/report PRN adverse reactions of anticoagulant therapy. Review of Resident #80's care plan revealed no focus, goal or interventions related to Nosebleeds. Review of Resident #80's progress notes revealed: 09/16/2024-Hospice Note: Hold Plavix x 7 days Hold Eliquis x 7 days for epistaxis 08/19/2024 HX of Progress Note CC: Epistaxis focusing on nurse's report of nose bleeding. Per Nurse she was bleeding from both Nares. Currently on Eliquis. She is seen resting in bed, states bleeding stopped. No bleeding noted at time of assessment. Hold Eliquis for 72 hours. During an interview on 12/18/2024 at 10:45 a.m., Staff H, Certified Nurse Assistant (CNA), stated Resident #80 was a total care resident and could make her needs known. She stated Resident #80 had nosebleeds and depending on the severity of the nosebleeds they did different things. She stated, On Monday it was hard to tell if it was blood or pasta sauce on her face. She stated the resident was known to pick her nose and cause it to bleed. The staff had to keep tissues out of her room, so she was not putting them in her nose. She stated the resident's oxygen had humidity with it but the resident liked to take it off because she did not like the liquid in her nose. She stated if the nosebleed was bad she would let the nurse know. She stated she had witnessed Resident #80 sneeze and her nose began to bleed a lot. During an interview on 12/18/2024 at 11:30 a.m., Staff A, Licensed Practical Nurse (LPN), stated Resident #80 had nosebleeds and hospice was aware. She stated when Resident #80's nosebleeds they provided her with gauze. She stated if the nose bleed continued for 30 minutes she would call hospice who would tell her to stop the blood thinners. She stated sometimes if the resident was having a nose bleed and her blood thinner was due, she would just go ahead and hold it and then call Hospice for orders. She stated she used to document notes about Resident #80's nose bleeding in her charts but recently she had not been documenting notes. During an interview on 12/18/2024 at 2:35 p.m., Staff F, LPN, Unit Manager stated she was new and still getting to know who the residents were. She was not aware of Resident #80 having nosebleeds. She stated as a nurse, she would document the nosebleeds in the resident's chart. She stated she was unsure if the nurses were documenting anything about her nosebleeds. During a phone interview on 12/18/2024 at 4:47 p.m., the Medical Physician stated he was not aware of the frequency of nosebleeds. He stated he would expect staff to document the nosebleeds and communicate with him. He stated even with Resident #80 being on Hospice he would expect for them to communicate with him as well. He stated it would potentially be inappropriate for Resident #80 to continue blood thinners, while having the nosebleeds. He stated now knowing he would need to do a reconciliation of her medication, a gradual dose reduction (GDR) and do an exam of her of nose to find out what might be causing nosebleeds. Review of the facilities policy dated April 1, 2022, titled Charting and Documentation revealed: Policy Statement All services provided to the resident, or any changes in the residence medical or mental condition, shall be documented in the residence medical record. Policy Interpretation and Implementation 1. Observations, medications administered, services performed, etcetera, will be documented in the resident's clinical records. A. The facility utilizes the methodology of charting by exception. 2. Injuries may only be recorded in the residence clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the residents' medical chart as permitted by facility policy. 3. Incidents, accidents, or changes in the residence condition must be recorded. 4. Information documented, in the resident's clinical record is confidential and may only be released in accordance with state law and facility policy. 5. To ensure consistency and charting and documentation of the resident's clinical record, only approved abbreviations and symbols may be used when recording entries in the residents clinical records. 6. Documentation of procedures and treatment shall include care specific details and shall include at a minimum A. the date and time the procedure/treatment was provided B. The name and title of the individual who provided the care C. The assessment data and/or any unusual findings obtained during the procedure/treatment D. How the resident tolerated the procedure/treatment E. Whether the resident refused the procedure/treatment F. Notification of family, physician or other staff, if indicated G. The signature and title of the individual documenting Review of the facilities policy dated April 1 2022, titled Change In Condition revealed: Policy The facility will notify the resident, his or her attending physician, and are representative of changes in the residence medical mental condition and or status (e.g, changes in level of care). Change in the resident status or condition can be addressed by a staff member. The staff member noticing a change in the residence condition shall report to the nursing supervisor/charge nurse and initiate further evaluation. The nurse or the nursing supervisor/charge nurse should: Policy Interpretation and Implementation 1. Notify the residents attending physician or on call physician when there has been: D. I need to alter the residence medical treatment H. Instructions to notify the physician or physician extender of changes in the residence condition. 8. The nurse/nurse supervisor/charge nurse will record in the residence medical record information relative to changes in the residence medical mental condition or status. All attempts to notify the attending physician and the party responsible will be documented. The facility was asked to provide a policy on monitoring a resident on anticoagulants and a policy was not provided.

Based on observation, interview, and record review, the facility did not ensure a resident centered care plan was developed for two (#73 and #109) out of 24 residents sampled. Findings Included: 1. During an observation on 12/16/2024 at 9:32 a.m., Resident #73 was observed in his room dressed for the day with one shoe on and the other shoe off. Resident #72 was observed sitting next to his bed in a wheelchair with a blanket over his head. Attempted to interview Resident #73 and he did not respond to any questions. During an observation on 12/18/2024 at 11:30 a.m., Resident #73 was observed sitting in a wheelchair dressed for the day, in the 800 hall. Review of Resident #73 admission record revealed an admitted [DATE]. Resident #73 was admitted to the facility with diagnoses not limited to Parkinson's disease without dyskinesia, without mention of fluctuations, Mood disorder due to known psychological condition with depressive features, Major depressive disorder, recurrent, unspecified, and Post Traumatic Stress Disorder (PTSD), unspecified. Review of Resident #73's Minimum Data Set (MDS) dated [DATE] revealed in section C - Cognition, a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated severe cognitive impairment. Review of Section I, Active diagnosis, revealed Parkinson's disease, Malnutrition, Anxiety Disorder, Depression, Post Traumatic Stress Disorder. A review of Resident #73's care plan revealed no focus, goal, or interventions related to PTSD. During an interview on 12/18/2024 at 10:45 a.m., Staff I, Certified Nurse Assistant (CNA) stated Resident #73 had behaviors of refusing care, she stated she had worked with him for a while, so she knew how to que him to help him complete ADL care. She was not sure if Resident #73 had a diagnosis of PTSD but could see where he would because he sometimes starts asking if they are in a battlefield. She stated he was in the army for a long time. She stated that when the resident started to exhibit behaviors, she would redirect him. She stated he liked hot chocolate, so she used that as an incentive. During an interview on 12/19/2024 at 10:38 a.m., Staff J, MDS Coordinator Director, Staff K, Registered Nurse (RN), and Staff L, Licensed Practical Nurse (LPN), stated they looked at the history and physical and the physician orders, and used that to build their care plans. They usually started the individual care plan from the day the resident came in and was completed by day 6. They went to clinical meetings daily, with the Director of Nursing (DON), Unit Managers, Social Services, and Therapy. Staff J, MDS Coordinator Director discussed any changes and translated it to the team. Staff L, LPN reviewed the orders daily for any order changes. Staff L, LPN printed antibiotics that were active. The social worker would let them know the advance directives in the morning meetings and the same thing for changes to advanced directives. Social services was the one who put in the actual careplan for the advanced directive. The care plan for PTSD was included in the behavioral care plan. They stated there was not a separate care plan for PTSD. 48441 2. A review of Resident #109's Admission Record showed an admitted [DATE]. A review of Resident #109's current physician orders showed an order dated 10/30/2024 for Do Not Resuscitate A review of Resident #109's care plan showed a focus area of Advance Directive must be current and reflect the resident/family/Responsible Party's decision. [resident] current decision is: Full Code. Interventions included: -Notify staff caring for resident regarding advance directive. -Provide and renew information regarding advanced directives with resident family responsible party including DNR -Provide emotional support during decision making process -Review advanced directives decision with resident family responsible party to ensure there is still an agreement. [photographic evidence obtained] A review of the facility's policy titled, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates, effective April 1, 2022, showed the following policy statement: Bedrock care will follow a uniform process for initiating the baseline care plan upon admission, the comprehensive care plan upon CAA completion, and ensuring care plans are updated to reflect the resident status. Baseline Care Plan: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The base line care plan will: Be developed within 48 hours of a residence admission include the minimum health care information necessary to properly care for a resident including, but not limited to: o Initial goals based on admission orders o Physician orders, o Dietary orders o Therapy services o Social services and o PASARR recommendations, if applicable Comprehensive Care Plan: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under Any services that would otherwise be required under but are not provided due to the resident's exercise of rights under including the right to refuse treatment. Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. A comprehensive care plan must be: Develop within seven days after completion of the comprehensive assessment. o Upon completion of the resident's Comprehensive Admission MSDS /CAA's, the IDT (Interdisciplinary Team) will validate the Care Areas triggered have been addressed in the comprehensive care plans in [electronic medical records]. o After completion of the comprehensive care plans in the electronic medical record, staff nurses and interdisciplinary team members are responsible for updating the residents care plans electronically to accurately reflect changes in the residents needs and preferences. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will: o Meet professional standards of quality. o Be provided by qualified persons in accordance with each resident's plan of care. o Be culturally competent and trauma informed.

Based on observations, interviews, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on 10/20/2022 and was cited at F689 (s/s D). On 12/07/2022 a revisit survey was conducted in conjunction with a complaint survey and the facility was recited at F689 (s/s G). The facility had developed a Plan of Correction with a completion date 11/20/2022. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings included: A review of the facility policy titled Transfer/Mobility Evaluation Low Lift with an effective date of 11/30/2014 and a revision date of 11/1/2019 indicated the following: Policy: Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs. Procedure: 1-Residents will be reviewed by facility personnel to determine the appropriate lifting strategy, on admission, quarterly, and with a significant change in physical/mobility condition. Appropriate lifting strategies: Extensive Assistance: Performed part of the activity but help was provided with weight bearing support and can follow directions. On 12/6/2022 at 9:55 a.m. Resident #1 was observed seated in her bed by the window in her room. The resident was alert and able to answer questions related to her care. The resident was observed to be wearing a sling to the left arm with an additional neck support across the sling. The resident stated, I was being put back in my bed by an aide when she tripped and we both fell to the floor. She stated the aide tried to pick her up but they fell again. She stated the aide had fallen on top of her and hurt her shoulder. She stated the doctors told her the left arm was broken. Resident #1 stated the incident happened over a week ago but she did not recall the exact date. She stated she thought it was on a Wednesday, but she did not go to the hospital right away. Resident #1 stated, I think it would have been better if therapy was helping me in and out of my bed because I don't think the aide has enough training to help me the right way. She stated she is receiving therapy to help her get stronger because she had a few strokes. She stated the aide did not go and get anyone to help her after the fall. She stated she was not seen by the nurse after the fall until a few days later. On 12/6/2022 at 9:45 an interview was conducted with Staff A, Licensed Practical Nurse (LPN). She stated a fall would need to be reported immediately and the resident would need to be assessed and treated for any injuries. She stated administration, the family, and the provider would need to be notified. On 12/6/2022 at 9:50 a.m. an interview was conducted with Staff B, LPN. She stated she did not recall any recent falls. She stated the nurses have to report any falls immediately and do an assessment with vitals and neurological checks on the residents who experience a fall. She stated she would notify administration, the family, and the doctor of a fall. On 12/6/2022 at 10:10 a.m. an interview was conducted with Staff C, Registered Nurse (RN). She stated she was currently caring for Resident #1. She stated the resident had a fall recently and she was responsible for providing care for the resident the past two days. The nurse stated Resident #1 is a Hoyer lift for all transfers by two staff members. She stated the resident currently had an intravenous line because she was receiving antibiotics. On 12/6/2022 at 10:30 a.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D stated she was providing care for Resident #1. She stated she was aware the resident had a fall and the resident was currently a Hoyer lift for all transfers. She stated they have to use two people to complete the transfers for Resident #1. On 12/6/2022 at 10:40 a.m. an interview was conducted with Staff E, LPN. She stated if a resident has a fall the first thing to do is assess the resident and provide any care needed. She stated they would report the fall to administration, the doctor, and the family right away. She stated if the resident had an injury and needed to go to the hospital they would call 911. On 12/6/2022 at 11:05 a.m. an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated she was familiar with Resident #1 and the department had provided rehabilitation services for the resident. She stated Resident #1 was assessed by therapy to be a maximum assist for transfers. She stated she was part of the care planning committee and all therapy recommendations are brought to meetings to assure residents are care planned for the proper level of care needed. She stated she was aware of the fall Resident #1 had suffered. She stated Resident #1 complained of pain in her left arm when one of the speech therapists went in to assist her with a meal. She stated Resident #1 told the speech therapist about the fall and it was relayed to nursing. The DOR stated the roommate of Resident #1 had witnessed the fall. She stated the roommate was Resident #2 and she was still a resident in the facility. On 12/06/2022 at 11:20 a.m. an interview was conducted with Resident #2. The resident stated she was the roommate of Resident #1 at the time of her fall. She stated a nurse aide (did not recall her name) brought Resident #1 into the room in a wheelchair and was going to put her in the bed. She stated the aide lifted Resident #1 up by putting her arms all the way around her waist and picking her up out of the chair. She stated both the resident and the aide fell to the floor. She stated the aide was on top of Resident #1. She stated the aide got up and tried to pick up Resident #1 off the floor and they both fell again. She stated the third time she just barely got Resident #1's bottom on the bed and struggled to get her in bed the rest of the way. She stated the aide did not call for help or go get a nurse or another aide to come in and look at Resident #1 after the event. She stated a couple of days later Resident #1 was complaining to someone about her arm hurting and then the nurse came in to look at her. She stated they took an X-ray of Resident #1 and she was transferred to the hospital. She stated the aides were not using a lift to get Resident #1 in and out of bed and she never witnessed two people transferring Resident #1. She stated Resident #1 was a little lady so they were all just lifting her up by her waist and putting her in the chair or back to bed. She stated she did not say anything to anyone because if you get involved it can be a problem. She stated she had a husband in the facility as well and she wants to make sure he is not hurt by anyone. On 12/6/2022 at 1:20 p.m. an interview was conducted with the Nursing Home Administrator (NHA). He stated the Interdisciplinary Team (IDT) is responsible for the investigation of all falls. He stated all staff are trained on fall prevention and reporting of falls. He stated all staff are expected to report any fall to the appropriate party. He stated if there is a fall then all of the aides are required to report to the nurse immediately, assessments and checks are to be done, and nurses are to get all information related to the event so they can determine what happened. He stated the facility had one incident with an injury recently, but it was not a fall. He stated Resident #1 complained of pain on 11/28/2022 in her left shoulder to the nurse and the nurse did an assessment. He stated the doctor ordered an X-ray and it was discovered Resident #1 had a fracture. He stated Resident #1 was sent out to the hospital and they began to investigate what had happened. The NHA stated they interviewed the resident and she told them somebody had fallen on top of her. He stated they identified an agency aide (Staff F, agency CNA) based on the residents description. He stated they interviewed Staff F, CNA and she explained what happened. The NHA stated Staff F told him she transferred Resident #1 by herself and did a stand and pivot transfer without any problems. He stated Staff F told him the resident had a dizzy spell after she sat her on the bed and the resident fell back, so she grabbed her left arm and leaned over the top of her to save her from hitting her head. The NHA stated Staff F told him she did not report the incident to anyone at the time because she did not feel that there was any fall or anything to report due to the fact that Resident #1 was fine and safely in bed. The NHA stated Staff F said she did not report the dizzy spell either. The NHA stated he did take statements from all of the people he interviewed. On 12/6/2022 at 2:23 p.m. an interview was conducted with the DOR. She stated when a resident is assessed to be a maximum assist it means the therapist or other staff member is having to do all the work (75% of the lifting) to complete the transfer. The staff will need to do all the lifting and guide the resident safely to a chair or the bed during the transfer. She stated a gait belt is used for these types of transfers and both nurses and aides are trained to do these lifts safely. She stated gait belts are accessible to all staff and are kept both in therapy and in the laundry areas of the facility. On 12/6/2022 at 2:34 p.m. an interview was conducted with Staff G, Speech Therapist. Staff G stated she went in to Resident #1's room to assist with her breakfast and observe her modified diet around 8:00 a.m. on 11/28/2022. She stated the resident was leaning to the right side because she is unable to use her left arm due to a stoke. She stated she lifted her to sit her upright and the resident stated she was having pain in her left shoulder area. She stated Resident #1 told her she was dropped by a nurse aide a couple of days before. She stated she set her up to eat, let her start on breakfast, and went to tell the nurse what Resident #1 reported to her. She stated the nurse came in to look at the resident and got an order for an X-ray. On 12/6/2022 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON). She stated the therapy department does train the staff how to transfer a resident safely. She stated the IDT team meets daily and they review falls and care plan interventions. She stated therapy is in the IDT meetings and they do convey all transfer information in the meeting for each resident. She stated the floor managers are also in the meetings and they are responsible for making sure the information is disseminated to the aides. She stated all aides get training on proper transfers as part of their role and schooling. She stated the nurses are responsible for supervision of the aides and if inappropriate transfers are being done the nurse would stop them immediately. The DON stated she was made aware of Resident #1 complaining of pain by the nurse and an X-ray was ordered. The DON stated she started an investigation and identified Staff F, agency aide as the person who cared for Resident #1. She stated she called Staff F to get her statement and she placed the aide on the do not return list for the agency. She stated she did that because I did not feel warm and fuzzy after going through the investigation with her. She was a little bit uncooperative with me. To me it took tooth and nail to get to the bottom of what happened. She was adamant about there being no fall. The DON stated Staff F did not report the incident to anyone. The DON stated the roommate was vague and seemed a little shy to tell her what had happened. She stated the roommate told her she really did not think much of it. The DON stated she did not want the roommate to think she was badgering her or putting her into a situation she was uncomfortable with. The DON stated she did not recall anyone using the word drop but she stated the resident did say someone had fallen on top of her. The DON confirmed the aides have access to gait belts and stated it is best practice to use one when transferring a resident. She stated aides can get a gait belt anytime. On 12/6/2022 at 4:36 p.m. an interview was conducted with Resident #1's family member. He stated the facility called him to let him know Resident #1 had a fall and his understanding was an aide was trying to get the resident in the bed and the aide lost her balance and she fell with the resident. He stated one of the nurses called him and said there was an accident and the resident suffered a fracture on her left shoulder. He stated Resident #1 had suffered two pretty severe strokes and since then she has been unable to help herself. He stated the resident definitely has to be assisted because she cannot use her left hand and her left leg at all. A review of the medical record for Resident #1 revealed an admitted [DATE] with a diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty walking, muscle weakness, unsteadiness on feet, and neurologic neglect syndrome. A review of the hospital record revealed Resident #1 was transferred on 11/29/2022 and treated for a fracture of the left humerus. The resident was readmitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment was completed for Resident #1 on 8/11/22 which indicated under Section G-Functional Status, transfers between surfaces including to or from bed, chair, wheelchair, standing position required extensive assistance by two + persons. A Brief Interview of Mental Status (BIMS) assessment in Section C-Cognitive Function was completed for Resident #1 on 8/11/22 with a score of 13, indicating intact cognition. A review of physical therapy notes indicated an evaluation was completed on 11/1/2022 for Resident #1 due to a history of a fall and need for strengthening to avoid falls. The evaluation indicated Resident #1 required substantial maximal assist for transfers chair/bed to chair. The evaluation indicated Resident #1 was unable to stand or balance on own. On 12/7/2022 at 11:32 a.m. an interview was conducted with Staff F, CNA. Staff F stated she was going to get Resident #1 ready to transfer to the bed. She stated she did a point to pivot turn and put the resident down on the bed and when she was releasing her she was going backwards so she got her with her arm and pulled her back towards her. She stated she grabbed her on the left upper shoulder area to bring her forward. She stated she was not fainting or nothing she was just too top heavy. She stated she asked the resident if she was ok and she said the resident denied being dizzy. She stated the resident said she was alright. She stated the resident never complained of any pain. She stated the roommate was in the room. She stated she did not use a gait belt at the time because she did not think one was necessary. She stated she had received training on how to use a gait belt before. She stated she was not certain if a gait belt was available for use in the facility. She stated the resident was not able to stand on her own and she needed a lot of assistance and she did have to lift her. She stated she did not let anyone know what had happened to the resident because she did not think it was an incident or injury. She restated the resident did not have a dizzy spell or faint. She stated she was not aware the resident had an injury from the event. On 12/07/2022 at 12:25 p.m. Resident #1 was observed seated in the bed in her room with the bed all the way up and the head of bed elevated. The resident was watching television. The resident stated the aide put the bed up when she was changing her brief earlier this morning. The resident has a sling to her left arm in place and appears clean, dry and has no odors. A second surveyor is present in the room. The resident reiterated what happened to her arm and stated, The aide was trying to put me to bed and I fell on the floor and she fell on top of me. It happened right down there at the bottom of my bed. It was such a shock, I was in pain and I told her my shoulder hurt, but I think she was just as shocked as I was when it happened. She did not go and get any help or tell anyone it happened because no one came to check me out. On 12/07/2022 Resident #2 was seated with the head of bed elevated in her bed. The television is on and she is awaiting lunch. The resident has no signs of distress and is no longer in isolation. A second surveyor is in the room. The resident reiterated what she witnessed related to the fall with Resident #1. She stated I told you exactly what happened and it was the truth. The curtain was open and I could see everything that went on. The aide tried to lift her up by herself and [Resident #1] fell and the aide fell on top of her. The aide tried to get her up again and fell again on top of her. Then she finally got her on the bed after the third time. I did not tell the DON all the details because I did not want to get anyone in trouble and was worried about mine and my husband's care. On 12/7/2022 at 2:51 p.m. a telephone interview was conducted with the Primary Care Physician (PCP) for Resident #1. The PCP stated he was informed the resident had a fracture. He stated Resident #1 fell and his understanding was that she slipped and fell and that the aide was with her at the time and they both fell . The PCP stated Resident #1 has always been a little bit on the weak side but overall stable and she has never really had any significant improvements with function during her stay. He stated he was informed by the management team the incident was investigated and the aide tried to help her and the aide and the resident fell to the floor. The PCP stated he saw the resident on Monday night and she seemed the same but having some pain in the arm and he did not see any other significant problems. The PCP stated, It was an unfortunate incident that occurred. On 12/7/2022 at 5:37 p.m. with the NHA and the DON. A review of the POC related to falls was conducted. The NHA stated the previously cited fall involved an agency aide who had left a resident to get the nurse when a resident fell . The DON stated all licensed staff were provided education and training related to fall prevention and adherence to fall interventions as outlined in a residents care plan after the recertification survey. The DON stated all newly hired staff were included in the training plan. The DON stated for agency staff she works with one particular agency and the falls education is being provided by the marketing manager of the agency who is also clinical. The DON stated Resident #1's care plan was part of the audits completed to assure all interventions were in place for falls. The DON and NHA stated the biggest take away related to Resident #1's incident was the staff's perception of an incident or change of status. The DON stated she has in serviced the staff to report timely even if they think it is not an issue. She stated she thought the staff did learn how a situation can look ok but not really be ok.

Based on observation, interview, and record review, the facility failed to 1.) provide adequate supervision to related to falls with an injury for one (#49) of two sampled residents and 2.) ensure the mattresses fit the beds properly for one (#63) of eight affected residents for a facility with a census of 116 residents. Findings included: 1. An interview on 10/18/22 at 2:18 p.m. with Resident #49 revealed he had fallen out of bed last Friday, 10/14/22. He was turned on his left side, his lower extremities, knees, and lower legs were hanging off the bed. The resident was in a semi-fetal position. He stated he fell out of bed after the aide left him too close to the right side of the bed and he slid off the bed. He stated the aide was changing his brief and she said he was bleeding. She left to go get the nurse and he slid off. He fell on the floor and hit his head and left shoulder. He stated the bandage on his left forehead was from the fall. The bed was in a normal position and no floor mats were beside the bed. The TV was on and the call light within reach. He had fluids and snacks on his bedside table. A second interview and observation with Resident #49 was conducted on 10/18/22 at 3:00 p.m. He stated the facility had not changed his dressing since he came back from the hospital. He went to the dermatologist yesterday and they changed the dressing. He said he thought two people were moving him in the bed before the fall, but he was not sure. There were no floor mats noted. An observation of Resident #49 conducted on 10/20/22 at 1:30 p.m. revealed he was lying in bed. There were no floor mats at the bedside. An observation of Resident #49 was conducted on 10/20/22 at 3:00 p.m. with the Director of Nursing (DON). The resident was lying on his left side. He had floor mats at his bedside and the dressing was removed from his forehead. Review of the clinical record revealed Resident #49 was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to low back pain, low back pain, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)], diabetes, occlusion and stenosis of bilateral carotids, stage III pressure ulcers of sacral, depression, seizures, stiffness of left hip and left knee, gastrostomy, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 15 (cognitively intact). He required extensive assistance of two persons for bed mobility. Review of the nursing care plan and aide Kardex showed the resident had a bariatric bed and required assistance of 2 with bed mobility. Review of the care plans showed Resident #49 was at risk for falls related to deconditioning. Interventions included but were not limited to bilateral floor mats while in bed as of 02/09/2022; ensure that resident was in the middle of the bed; reposition as needed as of 10/14/22; low bed in lowest position at all times, except for care as of 06/25/21; Send to ER [emergency room ] for evaluation/ treatment, returned the same day neuro-checks as of 10/14/22 ADL [activities of daily living] self-care plan showed a performance deficit related to [CONDITION(S)] [cerebral; vascular accident] with limitation of movements to lower extremities showed intervention included but not limited to the resident had a bariatric bed and required assistance of 2 with bed mobility as of 09/25/2020. Record review of the Bed Mobility ADL task showed 26 out of 59 bed mobilities were performed with one person assist and 33 out of 59 were performed with two persons assist. Review of a Fall Report dated 10/14/22 showed nursing was notified that the patient fell on the floor. The resident was assessed. Vitals were within normal limits. Skin tear to left shoulder, left buttock, forehead. Normal Saline, pat dry, and cover with dressing. Resident stated he had pain of 2/10. He denied pain medication. Asked him how he fell three plus times. Resident was anxious and repeated he is sorry and did not know how he fell . He was helped back into bed with the assist of the resident's aide on shift and the other hall nurse. No injuries were observed at time of incident. He was oriented to person, place, time, and situation. No witness found. Attending physician was notified on 10/14/22 at 8:01 a.m. Completed by Staff G, Licensed Practical Nurse (LPN) Review of a Change in Condition dated 10/14/22 at 7:10 a.m. showed wound care and vitals were performed. The resident was on anticoagulant. His blood pressure was 115/72 on 10/14/22 at 7:19 a.m. He had a skin abrasion. He was not having any pain. Neurological evaluation was not clinically applicable to the change in condition being reported. Nursing was notified by the Certified Nursing Assistant (CNA) that the resident was on the floor. Assessed vitals and head-to-toe assessment. the vitals were within normal limit. Pain was 2/10. Resident stated he hit head. He had a 2 x 3 cm abrasion to the middle of his forehead. It was cleaned and dressed. Completed by Staff G, LPN Review of Neurological checks showed they were performed on 10/14/22 at 5:30 a.m., 5:45 a.m., 6:00 a.m., 6:15 a.m. performed by Staff G, LPN Review of the Hospital Transfer form filled out on 10/14/22 at 8:56 a.m. showed resident fell this morning, hematoma noted to his right forehead. Attending physician notified and order received to send resident to the hospital for evaluation. Called POA, and phone not in service. Completed by Staff H, Registered Nurse, Unit Manager (RN) (UM) Record review of the progress notes showed: On 10/14/22 at 7:27 a.m. Staff G, LPN showed was notified by the aide that the resident was found on the floor. Vitals were taken and within normal limits. His pain was 2/10 reported from resident. Resident was helped back into bed with help of other hall nurse and CNA with Hoyer lift. He had a wound to his bottom, his left hip, his left shoulder, and forehead. Cleansed his wounds with normal saline, pat dry with gauze and covered with dry sterile dressing. The Advanced Registered Nurse Practitioner (ARNP) was called. The report was passed on to the oncoming nurse. Completed by Staff G, LPN On 10/14/22 at 9:48 a.m. the family was called for notification of fall and transfer to hospital. No answer for three different family members. Per Staff H, RN, UM Review of physician orders show a lack of orders for wound care for left forehead. Record review revealed no Skin Sheets were documented showing description of skin and wounds. An interview with Staff H, Registered Nurse (RN), Unit Manager (UM) on 10/18/22 at 2:40 p.m. revealed he had fallen, and she filled out the paperwork to send with him to the hospital. She was working the 7-3 shift and he fell on the 11-7 shift. Staff I, Certified Nursing Assistant (CNA) which was an agency aide, went to dress the resident. Staff G, LPN had told her in report he had fallen, and he had a bruise on his head. Staff H, RN called the physician and he said to send him to the hospital for evaluation. Staff H stated the nurse left the facility. She did not try to call Staff G, LPN for more information about the fall. An interview with Staff I, CNA involved in fall on 10/19/22 at 10:01 a.m. revealed that Resident #49 fell last Friday. She said she went in to change his brief, she did not remember what time it was. He was facing the window, or on his left side; he always wanted to be on his left side. She rolled him over to his right side, to change him. She noticed he did not have a dressing on his bottom. She pulled him over to the middle of the bed. and went to get the nurse. As she was walking down the hall to get the nurse, the Nursing Home Administrator (NHA) came out of the room, from the hall. He said, hey, where you at. The resident is on the floor. Staff I and the two floor nurses ran in to get him up. We put the Hoyer pad under him and lifted him back in bed. She stated, He had a little scrape on his forehead, like a carpet burn, it was not leaking, it looked like a flesh wound. Staff G, LPN, checked him. She stated she put the brief back on. Staff G left the room after she put a band-aid on his head. Staff I stated one of his shoulders had a bruise on it. She did not know if the bruise had been there before the fall or not. At close of shift she went to the 7-3 aide and gave a report. She stated she let her know he was to have vital signs taken every 15 minutes. He did not tell her anything was hurting. She stated she was the only one in the room turning him. He helped her a little bit and kept grabbing at the enabler. She stated he clinched the enabler on the right side of the bed. She stated she had worked with him a while back. He was able to be moved with one person. Staff I, CNA stated that everyone moved him with one person assist, he was a one person assist. An interview with the Director of Nursing (DON) on 10/19/22 at 12:18 p.m. revealed they were to perform Interdisciplinary Team (IDT) meetings post falls. The DON was unable to find any documentation regarding an IDT meeting. She verified the care plan showed that bed mobility required 2 persons for Resident #49, and it was not always performed with two persons. She stated she spoke with Staff G, LPN and Staff I CNA. The aide was agency and was placed on the Do Not Return list. The DON stated she was not aware if they reported the incident to any regulatory agencies, she would have to check with the Risk Manager which was the NHA. When asked about documentation regarding the description of the head and shoulder wound, assessment performed, description of how resident was found, environmental elements, etc. the DON stated she would investigate. Record review of the facility's policy, Fall Management, revised on 07/29/2019 showed residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: is to identify residents at risk for falls and establish / modify interventions to decrease the risk of a future fall (s) and minimize the potential for a resulting injury. B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors; w. Update the resident's care plan with interventions. C. Post Fall Strategies: 1. Resident will be evaluated, and post fall care provided; 2. Initiate neurological checks as per policy or as directed by physician order. 3. Notify the physician and resident representative. 4. Re-evaluate fall risk utilizing the Post Fall Evaluation; 5. Update care plan with intervention (s). 6. Initiate post fall documentation within 72 hours. 7 Interdisciplinary Team to review fall documentation. 8. Review resident within 7 days. D. QAPI: 1. review fall trends monthly during QAPI. Record review of the facility's Action Sheet, Resident Safety, not dated showed Establish a resident fall program that includes .prompt medical attention for residents who are injured from falls. Notification of staff, residents' family and physician regarding falls and any changes in resident condition. Implementation of preventative measures. Ongoing monitoring of resident falls. Ongoing monitoring of staff response to resident call system. Documentation of facts related falls in resident care records, such as: time resident found. Location of fall. Nursing assessment of resident's injury from fall. Medical care given after fall. Implementation of preventative measures. 2. An observation was conducted on 10/17/22 at 3:59 p.m. of a nine (9) inch gap between the headboard and the mattress of Resident #63's bed. Immediately following the observation, the Maintenance Director confirmed the findings and removed 2 4-5 inch bolsters from the head of bed under the bed frame. He stated that measurements for spacing between the mattresses and headboard/footboard were done annually then he changed it to quarterly. On 10/17/22 at 4:07 p.m., the Nursing Home Administrator (NHA) observed the gap between Resident #63's mattress and headboard. The Maintenance Director notified the NHA that bolsters were found under the bed frame. The NHA stated, at 4:14 p.m. on 10/17/22, that the bolsters had been put at the top and the bottom of the residents mattress and had fixed the issue. The NHA provided on 10/18/22 at 9:00 a.m., a full house audit of mattress and headboard/footboard placements. He identified three findings , however after reviewing the audit, it indicated that 8 beds were found to have issues with gaps between mattresses and headboard and/or footboards. On 10/18/22 at 9:20 a.m., the NHA stated the Food and Drug Administration (FDA) had not documented a certain measurement between mattress and head/foot board. The Maintenance Director stated on 10/18/22 at 9:23 a.m. that the x's on the audit were the ones that had needed to be adjusted as many were that the mattresses had slid down. The NHA stated ultimately they (the beds) had all been fixed. A Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment, June 21, 2006, identified that the space between the mattress and headboard was an unmeasured zone but to be used in reference for the reporting of entrapment incidents. The illustrations included with the guidance showed how a human head could become entrapped in the space between mattress and headboard. This information was located at: https://www.fda.gov/medical-devices/hospital-beds/guide-modifying-bed-systems-and-using-accessories-reduce-risk-entrapment. According to Reference.com (https://www.reference.com/science/average-size-human-head- d028e431bf3), the average human head measures 6-7 inches in width.

Based on record review, staff interview and policy review the facility failed to have all required members participate in two monthly Quality Assurance Committee meetings (1/30/22 and 5/26/22) of nine monthly Quality Assurance Committee meetings. Findings included: The facility provided their policy titled, Performance Improvement Committee (Quality Assurance). The policy showed the committee will meet to review, recommend and act upon activities of the facility, performance improvement teams and/or departmental activities. The procedure showed, #6.The committee will maintain a record of attendees and a description of the topics discussed. During the Quality Assurance review meeting held with the Nursing Home Administrator (NHA) on 10/20/2020 at 1:00 p.m. it was confirmed the committee met once a month. In review of the sign in sheet it was revealed the Medical Director, a required key member, did not participate on the Quality Assurance meetings for January 30, 2022, and May 26, 2022. Additional review of the signature sheets revealed no documented evidence that a Quality Assurance meeting was held on May 2021, June 2021, November 2021, and December 2021. The facility failed to provide documented evidence (signature sheets).

Based on observations, record reviews, and interviews, the facility failed to ensure one (#28) out of five residents sampled for unnecessary medications was administered pain medication per the parameters ordered by the physician. Findings included: Resident #28 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #28's October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Acetaminophen Extended Release (ER) 650 milligram (mg) - Give 1 tablet by mouth every 6 hours as needed for pain levels 1-6, started 8/25/22, discontinued on 10/7/22. - Acetaminophen Extended Release (ER) 650 milligram (mg) - Give 1 tablet by mouth every 6 hours as needed for pain levels 1-6, started 10/7/22. - [MEDICATION(S)] Tablet 5-325 mg ([MEDICATION(S)]-Acetaminophen) - Give 1 tablet by mouth every 6 hours as needed for pain, start date 8/25/22 and discontinued 10/7/22. - [MEDICATION(S)] Tablet 5-325 mg ([MEDICATION(S)]-Acetaminophen) - Give 1 tablet by mouth every 6 hours as needed for pain levels 7-10, start date 10/7/22. The October Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A recommendation, dated 7/8/22, indicated the Consultant Pharmacist identified that Resident #28's as needed order for [MEDICATION(S)] was to be administered for a pain level of 7 to 10 and had been given 34 times for a pain level of less than 7 in June. Resident #28's care plan indicated that the resident had chronic back pain due to spinal stenosis, arthritis, radiculopathy, and bilateral knee and hip pain. The interventions included: administer analgesia as per orders. On 10/20/22 at 11:15 a.m., during an interview with Staff Member J, Licensed Practical Nurse (LPN), she stated Resident #28 hated when the staff member was not at the facility because she made sure the resident got pain meds on time. In an interview with the Director of Nursing (DON) on 10/20/22 at 2:10 p.m., she said she would expect staff to reach out to the physician regarding pain management and knew the patient insisted on getting [MEDICATION(S)] instead of Tylenol.

Based on observations, record review, and interviews, the facility failed to ensure one resident (#101) was assessed and monitored appropriately after [CONDITION(S)] of six residents receiving [CONDITION(S)]. Findings included: A review of the Admission Record for Resident #101 revealed he was initially admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #101 had a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating severe impairment. Section O Special Treatments, Procedures, and Programs indicated [CONDITION(S)] was performed while a resident. A review of the Order Recap Report for the dates of 08/01/22 to 10/31/22 revealed the following orders related to [CONDITION(S)]: Hemodialysis- Monday, Wednesday, and Friday. There were no orders related to assessing for bruit and thrill. A review of the Medication Administration Records and Treatment Administration Records for the months of August 2022 to October 2022 revealed no documentation related to assessing for bruit and thrill. A review of the progress notes from August 2022 to October 2022 only revealed two notes related to assessing and monitoring the bruit and thrill: 09/09/22 at 23:36 (11:30 p.m.) - Continues on [CONDITION(S)]. Left port is clean, dry, intact, no swelling, no redness noted. No adverse reactions noted. 09/09/22 at 09:00 (9:00 a.m.) - [CONDITION(S)] status is hemodialysis. Bruit and thrill present. Left port is clean, dry, intact, no swelling and no redness noted at this time. Currently Leave of Absence (LOA) to [CONDITION(S)] at this time. A review of the care plans revealed a care plan, initiated on 7/4/22, for hemodialysis related to renal failure. Interventions included but were not limited to monitor, document, and report as needed any signs and symptoms of infection to access site. On 10/20/22 at 9:00 a.m., Staff Q, Licensed Practical Nurse (LPN), stated she checks the bruit and thrill every day and they did not have to document anything because it was a standard in nursing. She stated they must check it because it can clog up and get infected. Staff Q, LPN, touched the site on the left arm with her fingers and stated you can feel it here. A dressing was on the left arm. She stated she was going to remove the dressing today. Staff Q stated, as a nurse, she knew she had to assess the site. On 10/20/22 at 11:52 a.m., the Director of Nursing (DON) stated if a resident had a bruit and thrill, they have to assess the site. She would not expect to see an order in place to check the bruit and thrill because it was a standard. The DON stated the assessments were documented on the [CONDITION(S)] sheets, but she wanted to check to make sure. Her expectation was for nurses to check the bruit and thrill and document this on the [CONDITION(S)] communication sheets. When asked about assessing the site the other four days the resident did not have [CONDITION(S)], the DON did not respond. She then stated she would check on this and follow up. On 10/20/22 at 1:51 p.m., the DON reported there was an order in place, but the order fell off when Resident #101 went to the hospital in July (2022).

Based on observations, record reviews, and interviews the facility failed to ensure one resident (#63) out of thirty-seven sampled residents received treatment and services to prevent further decrease in range of motion. Findings included: Review of the Admission Record showed Resident #63 was admitted on [DATE]. The Admission Record included diagnoses not limited to multiple sclerosis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, not elsewhere classified stiffness of right elbow, right upper contracture of muscle, and right-hand contracture of muscle. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #63 had a Brief Interview for Mental Status (BIMS) score of 12, indicative of moderate cognitive impairment. The MDS indicated the resident was totally dependent upon one person for eating, dressing, and personal hygiene and had range of motion (ROM) impairment to bilateral upper and lower extremities resulting in a functional limitation. The resident received two days of Occupational Therapy (OT) starting on 7/28/22 and had not received any Physical Therapy (PT) during that time. On 10/17/22 at 11:47 a.m., Resident #63 stated both hands were balled up like a fist, right arm can't straighten, left arm can straighten a little. The observation indicated two splints were sitting on the resident's bedside dresser. (Photographic Evidence Obtained) The resident reported, They don't come as often as they used to. An observation, on 10/18/22 at 9:53 a.m., identified two splints for Resident #63 were sitting on the bedside dresser. On 10/19/22 at 1:24 p.m., an observation revealed Resident #63's two splints were sitting on the bedside dresser. A review of Resident #63's Order Summary Report included the following active physician orders as of 10/19/22: - May have restorative/maintenance programs as indicated, dated 2/15/22. - Right (R) elbow splint wearing schedule: on with am (morning) care, off with pm (evening) care. Skin checks pre and post donning, dated 2/15/22. The care plan for Resident #63 indicated the resident had an Activity of Daily Living (ADL) self-care performance deficit r/t (related to) impaired balance, limited ROM, paraparesis, and is totally dependent on staff for her ADLs, initiated 11/16/18 and revised 3/23/22. The interventions included but was not limited to, Right hand and elbow splint per MD order, initiated on 11/16/18 and revised on 4/15/19. Staff J, Licensed Practical Nurse (LPN) stated, on 10/19/22 at 1:34 p.m., that therapy was supposed to put Resident #63's splints on, the task was not listed on her charting, so she did not do them, and did not know how many hours the resident was supposed to wear them, She (Resident #63) hates them. The September 2022 Medication Administration Record (MAR) identified Resident #63 had not resisted care and did not include orders for nursing to apply splints, the Treatment Administration Record (TAR) did not include orders for applying the splints. A review of the October 2022 MAR and TAR identified the resident had not resisted care and did not include orders instructing nurses to apply splints. On 10/19/22 at 1:53 p.m., Staff N, Occupational Therapist (OT) reported Resident #63 was not currently on therapy's caseload and when someone was discharged from therapy, they were put on a restorative referral, that restorative staff were trained to put splints on and nurses got orders from the physician. The staff member reviewed the resident's therapy chart and stated the resident ended with bilateral elbow orthosis and the restorative order was to wear seven times a week for 3 -4 hours a day. The OT provided a Therapy Communication to Restorative Nursing Program form, dated 9/21/22. The communicative identified Resident #63 was dependent on ADLs and the resident needs were: - Passive range of motion Right Upper Extremity (RUE). - Left Upper Extremity (LUE) Assisted active range of motion (AAROM), shoulder, elbow, and wrist. - Passive range of motion Left (L) hand. - Donn/apply R/L elbow splint 7x/wk (seven times a week) 3-4 hours. The form recommendations were documented as Decreased ROM & (and) strength and instructed staff to perform a skin check prior to donning splint. The communication form was signed by the therapist and included the initials of the restorative aide. On 10/19/22 at 2:12 p.m., the Director of Nursing (DON) stated Resident #63 hated the splints and would have to check whether therapy or restorative was done with the splints. Staff P, Licensed Practical Nurse (LPN)/Unit Manager of 700 and 800 halls, did not add any information to the interview. The DON reviewed the Therapy to Restorative Communication form and stated she did not know anything about it and wanted to speak with the restorative aide. The facility care Kardex, as of 10/19/22, indicated Right hand and elbow splint per MD order. The Restorative task instructed staff to apply right hand splint first, then right elbow splint for up to 8 hours daily. Precautions: oxygen (O2) continuous, skin integrity at risk, at risk for further contractures, multiple sclerosis (MS) with right side affected. The 30-day documentation did not include how many minutes the splints had been worn. The task also did not indicate the type of restorative program provided to Resident #63 during the previous 30 days. An interview was conducted on 10/19/22 at 3:03 p.m., with the DON and Staff O, Restorative CNA. Staff O described currently doing weights on the floor and backing up central supply. The staff member stated the facility was trying to reinitiate the restorative program and sometimes the splints are put on and then the floor CNA was asked to take it off. The DON stated the facility does not have a restorative program and had not had one since she got to the facility in July (2022). The DON stated the Therapy to Restorative Communication form should go to the stand-up meeting. The DON identified the facility had a lot of agency staff and she could not leave donning braces/splints to anyone, the person would need to be trained. On 10/20/22 at 11:09 a.m., Staff J, LPN stated Resident #63 did refuse to wear splints a couple times a week, Says that they are painful. On 10/19/22 at 5:04 p.m., a request was made to the DON for a policy regarding the facility's restorative program. The DON stated, We don't have a restorative program.

Based on observations, interview and record review the facility failed to perform accurate skin assessments for one resident (#43) of 37 sampled residents. Findings included: An observation on 10/17/22 at 1:40 p.m. showed Resident #43 lying in bed. The hospice nurse was assessing the resident. It was noted he had multiple reddened skin areas on his right arm. He appeared to be reaching for items in the sky and trying to take his clothes off. He was observed again on 10/18/22 at 12:55 p.m. and he was being fed by an aide. He had oxygen in place via a nasal cannula. He was continuing to try to remove his clothes. Five reddened/abrasions were noted on his right arm. One above his elbow, one below his elbow, one above his wrist and two between the elbow and wrist. They were not bleeding nor were they covered. Review of the Admission Record showed Resident #43 was admitted on [DATE] and readmitted on [DATE]. The review showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set, dated dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 05 (severely impaired). Section M, Skin Conditions showed no skin issues. Review of the Weekly Skin Integrity Sheets dated 10/18/22, 10/3/22, 9/26/22, 9/19/22, 9/15/22 and 9/8/22 showed he had areas on his right arm. Review of a Standard of Care meeting on 09/26/22 showed an Interdisciplinary Team Meeting was held to discuss unavoidable wounds, that he was a hospice resident, and continues with wound care to his right heel and sacrum area. Review of the physician note dated 10/18/22 showed the resident was total care with unavoidable wounds. Review of care plans showed has potential/actual impairment to skin related to fragile skin: sacrum wound and right heel blister. Interventions included but not limited to administer treatment per MD order, air mattress, keep skin clean and dry, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface as of 09/01/22 During an interview with the Director of Nursing (DON) on 10/18/22 at 1:45 p.m. she stated if an incident occurred, they would fill out an incident report and put an intervention into place and it would be documented in the progress notes. She stated if they should find an abrasion or bruising it should be documented on the Weekly Skin Sheets. The DON observed the 5 areas on his right arm and verified they were reddened areas. She stated the resident was a hospice resident and it was expected for him to have areas on his skin. She stated hospice should be documenting the areas on their notes. When asked if the facility was also responsible for the resident, she stated Yes, I see what you are saying, it should be documented somewhere. She reviewed the chart and was unable to find any documentation. A second interview with the DON on 10/19/22 at 9:40 a.m. revealed she had not found any documentation about his reddened skin areas. Record review of the facility's policy titled, Clinical Guideline Skin and Wound, dated 0401/2017, revealed on admission/readmission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Licensed nurse to document presence of skin impairment/new skin impairment when observed and weekly until resolved. Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. Develop individualized goals and interventions and document on the care plan and the CNA Kardex. Monitor resident's response to treatment and modify treatment as indicate. Evaluate the effectiveness of interventions, and progress toward goals during the care management meeting as needed.

Based on observations, record reviews and interviews the facility failed to ensure activities met the interest and needs of two residents (#63, and #38) out of the sample of thirty-seven residents. Findings included: 1. Resident #63 was observed and interviewed on 10/17/22 at 11:19 a.m., the resident stated, Don't know of any (activities) they only come sometimes, only sometimes. An activity calendar was posted on the wall, approximately 3 feet from the resident's bed and mid-torso to the resident. The resident identified she was unable to read the calendar that was printed on the 8.5 x 11 inch sheet of paper. Resident #63 reported getting out of bed on certain days then the facility parks her wherever they want. The care plan for Resident #63, initiated on 11/14/18 and revised on 9/7/22, identified the resident was dependent on staff for her activities needs, she can make her needs known, enjoys visits from her [family member] and enjoys watching TV, also likes to socialize when she's up. Activities will continue to visit for social contact and inform of calendars of events, and cognitive deficits. The interventions included: - Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print holders if resident lacks hard strength, task segmentation), Compatible with individual needs and abilities; and Age appropriate. - Invite the resident to scheduled activities. On 10/18/22 at 1:51 p.m., Resident #63 was observed sitting in a wheelchair, outside of the activity room at the end of the 800-hall, across from the nursing station by herself. A review of the 1:1 Activities Binder identified Resident #63 had received visits from the Activity department eight times, August 11th and 25th, September 1st, 8th, 16th, and 29th, and October 5th and 12th in eighty-one days (approximately 12 weeks). The 1:1 log identified the resident attended one church service in those 12 weeks. On 10/19/22 at 1:24 p.m., Resident #63 reported just sitting by the nursing station yesterday (10/18/22). Resident #63 stated, didn't go anywhere or do anything, just sat there. An interview was conducted on 10/19/22 at 9:47 a.m., with the Activity Director (AD). The AD explained the department passed out activities packets which contained a newsletter with trivia and history, a coloring page, and sometimes a crossword or a word search puzzle. She stated for bedridden residents we have a bubble machine that they really like, and also have an [Brand Name] oven that the ingredients are taken into the resident room and mixed together approximately once a month. The AD stated room visits are done on Fridays, sometimes on Wednesdays or Thursdays, an ice cream cart every Tuesday from 2-3 p.m. and a popcorn cart every Wednesday. The AD explained residents are told about activities when the calendars are handed out at the beginning of the month, and when we do assessments. Assessments are completed on admission, annually and when there was a change in condition. She reported Staff A, Activity Assistant (AA) passed out activity packets today, and when they had extra time they did manicures, reporting they did two manicures yesterday. The AD reported there were two activity staff who worked Monday - Friday, on the weekends activity packets were left at the nursing stations and staff passed them out. A review of the activity calendar identified Shopping for Residents was scheduled for 10:00 a.m. twice a month on Fridays. The other activity available on those Fridays was at 9:00 a.m., Activity Packet and Bingo # (a game in which a Bingo letter and number for that day is written on the board in each resident's room. Then the resident's would mark it on their card). The AD stated the residents are unable to go shopping due to the facility van being in the shop and the activity staff ask residents if they need anything from a big-box store and the staff go shopping for them. She stated about once a week she takes some residents next door to the big-box pharmacy store. An observation was conducted of the activity room on the 700-800 hall with the AD. Staff M, Activity Assistant was observed doing the nails of the one female in the room with a male resident sitting at the table. The AD indicated Staff M had handed out Thursday's activity packet instead of Wednesday's. Staff M stated she would pass out today's (Wednesday) also. Staff M reported she prints out 30 activity packets a day. The facility census was 116 on 10/17/22. A review of the October 2022 Activity Calendar identified every day at 9:00 a.m. an activity packet and a bingo # were passed out, an assortment of 10:00 a.m. activities during the weekday and the last resident activity started at 2:00 p.m. The calendar identified activity packets were passed out on Saturday and Sundays, 10:00 a.m. on Saturdays were Self-directed Activities and 10:00 a.m. Sunday activity was TV Church Service. The calendar did not identify any other activities on Saturday or Sunday and the latest activity during the current week was on 10/20/22 at 3:00 p.m., and was a food council meeting. In an additional interview the AD confirmed on 10/19/22 at 10:59 a.m., the Shopping for Residents twice a month on Fridays was not an activity for the residents, and the Saturday activities were self-directed after staff passed out the activity packets, and the Sunday 10:00 a.m. church service could be watched on their TVs. She stated the facility did not have a van available since before she got to the facility in July 2022 due to being in the shop waiting for a special part. The AD confirmed there was no outside music programs and that a pastor comes twice a month on Thursdays. The AD stated, on 10/19/22 at 1:41 p.m , Staff M visited Resident #63 once a week and admitted the resident wasn't someone that she saw very often and did not know what (type of activity) the resident liked to do. On 10/20/20 at 9:39 a.m., the AD did not know if Staff M documented when she visited Resident #63 to socialize. The AD stated Resident #63 did not come out of her room for activities. On 10/20/22 at 9:43 a.m., Staff M, AA stated she visits Resident #63 maybe once every couple of weeks. She stated the visits are approximately 10 minutes and she converses with resident. The AA reported the resident doesn't get out of bed that often, says she wants to stay in the hallway, and does not want to stay out of bed very long. Staff M stated visits to the resident do not get documented all the time. Staff J, Licensed Practical Nurse (LPN) stated, on 10/20/22 at 11:09 a.m., the resident will stay out of bed for about for 3 - 3 1/2 hours and does not usually ask to go back to bed. If something was going on we will take her in (activities) and the resident does not refuse group activities I haven't heard her refuse. The policy titled, Social Activities, effective 11/30/2014 and revised 3/13/2019, indicated, The social activities are modified to meet the basic needs of love and belonging in residents who experience deficits in judgment, reasoning, and perception. The activities focus on acceptance of the individual and the stimulation of learned social responses. The procedure identified the following: - 1. Social Activities shall be offered at minimum 2-3 times per day. - 2. Social Activities shall be offered in a variety of settings and locations. 2. A medical record review was conducted for Resident #38 on 10/17/2022 which revealed the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/22 at 10:00 a.m. the resident was observed in a low bed, hospital gown, and call light within reach. Resident #38 was unable to have a conversation due to her cognitive decline. On 10/17/22 at 2:23 p.m. Resident #38 was observed still in bed. Resident #38 lays in a scooped mattress, low bed, air mattress. The resident was asked if she had eaten, she couldn't remember, her roommate (#79) stated that she is fed, and she did have lunch. The following observations were conducted: Observation: 10/18/22 at 10:06 a.m., Resident #38 was observed this morning with a different gown on, an extra blanket on her bed and a change of clothing and brief on the bed, she is scheduled to have a shower this morning as per the roommate. Roommate reports that she gets her shower on Tuesdays. Resident began to yell and stated that it's too cold for her shower and she wasn't going to take one today. Call light is within reach, bed in the lowest position. No other voiced concerns. Observation: 10/18/22 at 1:20 p.m., Resident #38 was observed in her room sleeping, roommate reports the resident had refused a shower but did receive a bed bath. Observation: 10/19/22 at 11:14 a.m., Resident #38 was in a low bed, with a blanket up to her chin and the call light within reach. Resident does appear groomed and has a different gown on today. Roommate states the resident likes to have many blankets on her bed. The roommate was asked if anyone comes in to offer activities to the resident, she reports the resident is unable to do anything. Roommate was asked if anyone comes in to sit and talk with her or offer any kind of socialization. Roommate confirmed no one comes in to offer her any activities. Resident has been observed randomly throughout the survey lying in bed, she has not left the room or had any visitors. A medical record review was conducted for activity notes and the medical record was silent. There was no progress note to indicate any type of activity was being offered to the resident. An interview was conducted with the Director of Activities on 10/19/2022 at 11:18 a.m., in regard to providing activities or 1:1 activity for the residents. She reported she documents all her 1:1 interaction with residents on her log. A review of the activity log/participation record was conducted which revealed no entries for Resident #38. On 10/19/22 at 12:51 p.m., an interview with the Activities Director (AD) was conducted in regard to activities being provided to Resident #38. She reports Resident #38 doesn't eat ice cream and has been offered the activity packet, but she has not been interested, she has always declined. The AD reports the resident's refusals should be in her care plan for activities and in her progress notes. She was asked to bring in her notes since surveyor was unable to locate any notes in the resident's medical record. On 10/19/22 at 1:44 p.m., an interview with the AD confirmed she had no notes, and the resident did not have any documentation that she was offered activities or the resident declined. A review of the facility's policy titled, Social Activities was conducted, dated 11/30/2014 with a revision date of 3/13/2019, showed, Purpose; To provide opportunities for socialization regardless of one's cognitive limitations. Social activities shall be offered at minimum 2-3 times per day. Attendance and participation shall be documented on the individual's participation record by the Community Life Assistance.

Based on observations, medical record review, staff interviews and facility policy, the facility did not implement the plan of care for activities for one resident (#38) and failed to develop and implement a nutritional plan of care for one resident (#3) related to weight loss for a sample of 37 sampled residents. Findings included: 1. A medical record review was conducted for Resident #38 on 10/17/2022 which revealed the resident was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/22 at 10:00 a.m. the resident was observed in a low bed, hospital gown, and call light within reach. Resident #38 was unable to have a conversation due to her cognitive decline. On 10/17/22 at 2:23 p.m. Resident #38 was observed still in bed. Resident #38 lays in a scooped mattress, low bed, air mattress. The resident was asked if she had eaten, she couldn't remember, her roommate (#79) stated that she is fed, and she did have lunch. The following observations were conducted: Observation: 10/18/22 at 10:06 a.m., Resident #38 was observed this morning with a different gown on, an extra blanket on her bed and a change of clothing and brief on the bed, she is scheduled to have a shower this morning as per the roommate. Roommate reports that she gets her shower on Tuesdays. Resident began to yell and stated that it's too cold for her shower and she wasn't going to take one today. Call light is within reach, bed in the lowest position. No other voiced concerns. Observation: 10/18/22 at 1:20 p.m., Resident #38 was observed in her room sleeping, roommate reports the resident had refused a shower but did receive a bed bath. Observation: 10/19/22 at 11:14 a.m., Resident #38 was in a low bed, with a blanket up to her chin and the call light within reach. Resident does appear groomed and has a different gown on today. Roommate states the resident likes to have many blankets on her bed. The roommate was asked if anyone comes in to offer activities to the resident, she reports the resident is unable to do anything. Roommate was asked if anyone comes in to sit and talk with her or offer any kind of socialization. Roommate confirmed no one comes in to offer her any activities. Resident has been observed randomly throughout the survey lying in bed, she has not left the room or had any visitors. A review of Resident #38's plan of care was conducted for Activities, dated 6/03/2020 with a revision date of 10/17/2022 and a target date of 11/13/2022. The focus area for Resident #38 was she is dependent on staff for activities, and she enjoys socializing with others. She will continue to engage in daily activities that she finds meaningful. Activities will continue to visit for social contact and inform of calendar and events. As an intervention the facility is to provide in room activities of choice as indicated. Included in her Care Plan for the risk of falls related to deconditioning gait and balance problems, the facility should provide diversional activities as needed, with an effective date of 2/9/22, and the resident needs activities that minimize the potential for falls while providing diversion and distraction sitting with resident, therapeutic communication. A medical record review was conducted for activity notes and the medical record was silent. There was no progress note to indicate any type of activity was being offered to the resident. An interview was conducted with the Director of Activities on 10/19/2022 at 11:18 a.m., in regard to providing activities or 1:1 activity for the residents. She reported she documents all her 1:1 interaction with residents on her log. A review of the activity log/participation record was conducted which revealed no entries for Resident #38. On 10/19/22 at 12:51 p.m., an interview with the Activities Director (AD) was conducted in regard to activities being provided to Resident #38. She reports Resident #38 doesn't eat ice cream and has been offered the activity packet, but she has not been interested, she has always declined. The AD reports the resident's refusals should be in her care plan for activities and in her progress notes. She was asked to bring in her notes since surveyor was unable to locate any notes in the resident's medical record. On 10/19/22 at 1:44 p.m., an interview with the AD confirmed she had no notes, and the resident did not have any documentation that she was offered activities or the resident declined. A review of the facility's policy titled, Social Activities was conducted, dated 11/30/2014 with a revision date of 3/13/2019, showed, Purpose; To provide opportunities for socialization regardless of one's cognitive limitations. Social activities shall be offered at minimum 2-3 times per day. Attendance and participation shall be documented on the individual's participation record by the Community Life Assistance. 2. A medical record review was conducted for Resident #3. The Admission Record showed Resident #3 was admitted to the facility on [DATE] with a re-admitted [DATE]. Resident #3 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietary review note dated 9/30/22 showed, weight loss note- triggered for a -5% change (comparison weight 9/7/22, 156.8 lbs (pounds) -6.0%, -9.4 lbs.) Diet is regular diet. Dysphagia advanced texture. Nectar thickened fluids consistency. Receiving Add large entree, starch, veg (vegetable) portions all meals. History of weight loss. Possibly due to disease progression. Current nutritional supplement is fortified foods, receives insulin. Dependent dinner eats 50-100% of meals. Recommend health shake BID (two times a day) and weekly weights. Review of a dietary note on 3/4/22 showed, .Will continue to monitor PO (taken by mouth) Intake, weekly weights, RD (Registered Dietician) to f/u (follow up) PRN (as needed). Review of a dietary note on 9/9/22 showed, .Recommend fortified foods and weekly weights. The medical record for Resident #3 indicated the following weights taken: 9/19/22 - 155 pounds 9/09/22 - 161 pounds 9/07/22 - 156 pounds 8/03/22 - 172 pounds 7/01/22-177 pounds 6/06/22 - 182 pounds 4/08/22 - 178 pounds 3/14/22 - 175 pounds 3/08/22 - 172 pounds 3/02/22 - 172 pounds No weekly weights were taken after 3/14/22 and with no explanation documented in the medical record . Resident #3 lost 11.43 lbs. in six months. Review of the plan of care with a focus area for nutritional problems, with an effective date 10/11/2021 and revision date of 9/30/22, had an intervention that read: weights as available/tolerated. The recommendation of weekly weights by the Registered Dietician, on 3/4/22, was not developed as a focus for a care plan or an intervention. On 10/20/22 at 10:49 a.m., an interview was conducted with the Director of Nursing and the Regional Director of Clinical Services. They reported the Registered Dietician at the time had not brought forward the recommendation for the weekly weights onto Resident #3's plan of care. The facility policy for Weighing the Resident, with a revision date of 10/4/2021 was obtained. Under the heading Procedures showed: Weights will be completed as indicated and documented in the clinical record and Consult with the Director of Dietary Services and/or dietician and notify the interdisciplinary team in order to update the plan of care.

Based on observation, interview and record review the facility failed to present the baseline care plan to the resident and responsible party for one resident (#107) of 37 sampled residents. Findings included: Review of the Admission Record revealed Resident #107 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Admission Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Resident #107 was noted as totally dependent for bed mobility and transfers and required two people to assist. An interview with Resident #107 on 10/17/22 at 11:00 a.m. revealed no one had reviewed his care plan with him since he had been at the facility. On 10/19/22 at 12:55 p.m. Staff A Registered Nurse (RN) MDS stated the admission nurse performs the baseline care plan. The next morning, we have a meeting and update the care plan in the computer. The admission nurse was to review the baseline care plan with the resident and family. The first care planning meeting was to be around day 14-21 depending on the resident's availability and family. The baseline care plan should be signed by the resident / family and the admission nurse. She verified that Resident #107's baseline care plan had not been signed and dated by anyone. On 10/19/22 at 12:55 p.m. Staff B, Licensed Practical Nurse (LPN) MDS stated the care planning meeting should have already been done. She left the room to find documentation regarding the meeting. On 10/19/22 at 12:55 p.m. Staff C, LPN, MDS stated she had a meeting with the resident and therapy yesterday, 10/18/22. She stated the care planning meeting was late. She stated that she will be meeting with the [family member]. Record review of the facility's policy titled, Plans of Care, revised 09/25/2017, showed an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirements.

Based on record reviews and interviews, the facility failed to respond to dietary grievances in a timely and appropriate manner for three residents (#210, #103, and #308) out of the sampled thirty-seven residents. Findings included: 1. A review of the Monthly Grievance Log for October 2022 revealed a grievance filed by Resident #210 related to dietary concerns dated 10/12(2022). The form indicated the person assigned to the grievance was the Certified Dietary Manager (CDM). The resolution was noted as food preferences updated and monitor trays. The Complaint/Grievance Report dated 10/12/22 revealed the grievance was communicated to the CDM. The concern was breakfast was cold. The results of action taken indicated the CDM spoke with resident about her breakfast tray. CDM will continue to monitor breakfast tray, the form also indicated the grievance was resolved and the complainant was satisfied. On 10/19/22 at 2:30 p.m., the Social Services Director (SSD) reported she writes the grievances on the log and reports any dietary related grievances to the CDM. She stated Resident #210's grievance was related to cold food. On 10/19/22 at 2:35 p.m., the CDM reported she checked Resident #210's tray for seven days after she received the grievance but did not document anything. She also checked the temperature of test trays. Resident #210 submitted the grievance on the 12th. She stated the last test tray was done on 10/10/22. The CDM stated she checked on her to make sure her food was warm enough for five to seven days. Resident #210 reported the food was only warm per the resident on the days she came to check on her food. The CDM stated after that, she reported the concern to one of the hallway monitors. The Resident Tray Assessment Report indicated the last test tray was done on 10/10/22. On 10/19/22 at 3:10 p.m., Resident #210 stated she continues to have issues with cold food. She stated, The fake eggs are always cold. Luckily, I have people from my church to bring me food. On 10/20/22 at 9:00 a.m., the CDM stated she wanted to bring to my attention that temperatures are taken daily, and they had no issues with cold food before the food left the kitchen. A review of the Admission Record for Resident #210 revealed she was initially admitted into the facility on [DATE]. According to the Admission/Readmission Data Collection form, dated 10/07/2022, the resident was alert and oriented to person, place, and time. Her memory was noted as ok. 2. On 10/17/22 at 11:55 a.m., Resident #103 stated one night she woke up in a sweat and because her blood sugar was 68 after the nurse checked it. The nurse told her she didn't have snacks and proceeded to look in the resident's drawer for a snack. The nurse found two pieces of candy in her drawer that she could eat. They have never offered her a snack. Resident #103 stated the food was always cold especially the eggs. On 10/18/22 at 9:17 a.m., Resident #103 reported she was not offered a snack yesterday and that scares her. She also stated, the eggs were cold this morning. A review of the Admission Record revealed Resident #103 was initially admitted into the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C, Cognitive Patterns of the 5-Day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. A review of the Point of Care (POC) task tab for snacks revealed the following: Snacks were not offered on 09/27-09/29, 10/02-10/07, and 10/09-10/11, No Response 10/13, 10/14, and 10/18. 3. On 10/20/22 at 12:39 p.m., Resident #308 stated she was not getting snacks and did not know they had a refrigerator for residents to get snacks until she heard someone in the hall ask for a snack. She stated she did not know the process of things. A review of the Admission Record revealed Resident #308 was initially admitted into the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns, of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a BIMS score of 09 out of 15, indicating moderately impaired. On 10/20/22 at 10:26 a.m., the Nursing Home Administrator (NHA) reported snacks are always delivered to each unit by the dietary aides and snacks are always available. CNAs will bring snacks to residents, but they must ask for them. They have bananas, peanut butter and jelly sandwiches, crackers, and oatmeal cream pies available. Snacks are available if a resident requests a snack throughout the night. Resident #103 brought the concern to him about the snacks on a surprised visit on Thursday night. He spoke to the resident about 4:00 a.m. The NHA reported he followed up with her and asked if she had issues with her blood sugar dropping again. He explained to Resident #103 that she could always ask for a snack and there was a refrigerator on the unit. He stated she was very happy and that he personally addressed this issue. He reported the nurse didn't know that snacks were available because she was an agency nurse. The NHA stated he told her to get an aide next time because they are typically more involved with getting snacks. The NHA reported the concern was resolved because she received a snack that night and because she had some snacks of her own in the room. The nurse took a snack out of her drawer that night. He also checked with other residents to see if they had any issues with not receiving snacks. He did not write a grievance because the problem was resolved right then but he would double check to see if there was a grievance. The taking of temperatures of the test trays was an adequate response to the cold food concern stated the NHA. The CDM could have mentioned that they can always reheat the food. They discuss all grievances in Quality Assurance (QA). The NHA reported he would want to see documentation that supports the resolution. The policy states a grievance must be resolved in seven days. On 10/19/22 at 12:00 p.m., the CDM reported snacks are given at 10:00 a.m., 2:00 p.m., and 8:00 p.m. Dietary staff deliver a cart in the par level rooms on each unit. She leaves bananas, oatmeal pies, sandwiches, and sometimes peanut butter and jelly sandwiches The CDM reported a concern about not receiving snacks was brought to her attention by Resident #308. Resident #308 wanted to know how she could get snacks. The concern was brought up in the morning meeting a few weeks ago. Sometimes the snack carts are full when she goes to refill the carts. The cart on Rosewood (200s, 300s, 400s, and 500s) was full most times when she went to refill the cart, but not completely full and the snack cart on the Southway (600s, 700s, and 800s) was always empty. She didn't do a grievance. CNAs are responsible for distributing snacks. She thinks the concern with not keeping the food warm after the food leaves the kitchen was because they have open carts and not warmers. Trays are passed timely on Rosewood but not timely on the Southway Unit. A review of the policy titled, Snacks, revised on 09/2017, revealed the following: 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. A review of the policy titled, Complaint/Grievances, with an effective date of 11/30/2014, revealed the following: Procedure Reporting The residence shall permit and respond to oral and written complaints from a source regarding an alleged violation of resident rights, quality of care or other matter without retaliation or the threat of retaliation. Investigation and Resolution The residence shall ensure investigation and resolution of complaints. A staff member will be designated to receive complaints. A log will be kept of all complaints and outcomes. Within 2 business days after the submission of a written complaint, a status report shall be provided by the residence to the complainant, the resident or the residents designated person indicating the steps that will be taken to address the concern. Within 7 days after the submission of a written complaint, the residence will give the complainant and if applicable the designated person a written decision explaining the residence investigation finding and actions to be taken for resolution.

Based on observations, record review, and interviews the facility failed to post staffing information on a daily basis, as evidenced by the nurse staffing information posted in front entrance dated seven days previously. Findings include: An observation was conducted, on 8/9/22 at 8:03 a.m., of the Daily Staffing posting. The posting, located in a clear envelope, was lying on the receptionist counter in the main entrance lobby. The posting was dated 8/2/22; photo evidence was obtained. The receptionist stated there was no one in the building to print the Staffing Information. The observation of the front lobby area, including table tops and bulletin boards did not reveal any other staff posting, An interview was conducted, on 8/9/22 at 8:05 a.m., with the Director of Nursing (DON) regarding posted staffing information. She stated they're bringing it up. The DON stated that yesterday's posting was located, they're bringing it up and walked out of the lobby area. Immediately following the interview with the DON, the receptionist stated that the staff posting was kept normally on top of the desk and indicated the area where the posting dated 8/2/22 had been located. The facility did not provide its policy regarding the posting of staff despite numerous requests.

Based on observation, interview and record review, the facility failed to maintain resident rooms on two of seven (200 Hall, 600 Hall) patient halls in a clean and sanitary manner related to dirty bathrooms, dirty privacy curtains and rusted overbed tables. Findings include: 1. Observations on 8/9/22 at 8:54 AM of the bathroom of Room 204 revealed that the toilet bowel exterior was noted to be soiled with brown substance. Closer inspection of the bathroom revealed a urinal was hanging on the handrail next to the toilet. A Female resident was noted to be exiting the room at this time and reported this was her room and it had not been cleaned. Observation of the wall plate hanging outside of the room it indicated the name of a female resident. (Photographic evidence obtained) Observation on 8/9/22 at 11:40 AM of the bathroom of Room 204 revealed the toilet continued to be soiled. Continued observation of the bathroom revealed the urinal was still hanging on the handrail next to the toilet. Observation on 8/9/22 at 3:30 PM of the bathroom in room 204 revealed the toilet continued to be soiled with a brown substance and the urinal was still noted to be hanging on the handrail next to the toilet. At this time a female resident was noted to be exiting the room and reported this was her room and the room had already been cleaned for the day. 2. Observations on 8/9/22 at 10:10 AM of the 600 halls revealed the following: -Room 601-dirty privacy curtain (Door bed). -Room 601-bathroom floor wet and covered by blanket. -Room 605-brown stain on bathroom wall by the handrail. -Room 605-Rusted overbed table (Door bed). -Room 609-Soiled privacy curtain (Door bed). -Room 609-Brown substance on the wall above the toilet. (Photographic evidence obtained) Interview on 8/9/22 at 11:11 AM with the Maintenance Director, revealed he was not aware of the leak in 601 bathroom. He reported staff would usually call to let him know. He reported, maybe it's just an overflow. Continued interview with the Maintenance Director at this time revealed the privacy curtains are the responsibility of the housekeeping department, and rust on furniture is the responsibility of the maintenance department. The Maintenance Director reported he was not aware of the rusted overbed table. Interview on 8/9/22 at 11:17 AM with the Housekeeping Account Manager revealed it is the responsibility of housekeeper to stock their cart, and to clean based on their assignment. She reported the housekeepers would revisit difficult rooms. She reported the manager should go around and make sure everything is in order. Continued interview with the Housekeeping Account Manager revealed the housekeeping department is responsible for maintaining the privacy curtains. She reported the housekeeping staff are supposed to spray and wipe walls, those walls that are scrapped up housekeeping will notify the manager who will then notify the maintenance department. She provided Cubical Curtain Cleaning Schedule which identified room 601 to be taken down laundered and replaced on 8/16/22 and room 609 to be taken down laundered and rehung on 8/17/22. She reported they do not have any extras, so all curtains must be laundered and rehung all in the same day. Continued interview with the housekeeping manager revealed the privacy curtains should be scheduled to be cleaned routinely, however, those that are soiled should be taken down and laundered right away. 3. Review of the facility policy titled General Hospitality Services Policies with an effective date of 11/30/2014 revealed the following: To provide clean, contamination-free surroundings for residents, visitors, and personnel. A clean environment is essential in preventing transmission of infection in the facility.

Based on observations, interviews, and record review, the facility did not administer [MEDICATION NAME] fluids in a timely manner to prevent harm for one (Resident # 7) of 3 residents sampled for intravenous (IV) fluid administration. The facility delayed physician ordered IV therapy to a resident who was at risk for dehydration related to [MEDICAL CONDITION], adult failure to thrive, severe protein-calorie malnutrition, dementia, and hypertension. The facility failed to transcribe physician's orders [REDACTED].#7. Findings included: A review of Resident #7's medical record revealed that Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #7's care plan initiated 11/9/18 revealed that Resident #7 was at risk for imbalanced nutrition related to cognitive loss, adult failure to thrive, advanced age, dementia, hypertension, history of severe protein-calorie malnutrition, and significant weight loss. Interventions initiated on 11/9/18 included administer medications as ordered, obtain and monitor lab/diagnostic work as ordered, report results to Medical Doctor (MD), and follow up as indicated. A review of Resident #7's physician's orders [REDACTED]. The ordered laboratory testing included Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Urinalysis (UA), Culture and Sensitivity (C&S), and ammonia level. A review of Resident #7's Progress Notes revealed an Electronic Medical Record (eMAR) Shift Level Administration Note, dated 10/09/20 at 06:18 AM, which stated that lab work was completed for CBC and CMP as well as collection for the UA and C&S testing. Resident #7's Progress Notes also revealed a Physician's Progress Note, dated on 10/09/2020 at 02:21 PM, completed by the facility's Medical Director who was also the resident's primary care physician. The Physician's Progress Note revealed that the Medical Director was alerted by nursing staff that Resident #7 had a poor appetite and increased weakness and lethargy. Blood work was obtained on 10/09/2020 and was reviewed by the Medical Director. The assessment documented in the Physician's Progress Note revealed that Resident #7 was experiencing increased confusion as indicated by a + + + sign in the note as well as generalized weakness. The Physician's Progress Note documented, under the section titled Impression, [MEDICAL CONDITION], dehydration, failure to thrive, and anorexia. The Physician's Progress Note documented, under the section titled Plan, 1/2 Normal Saline (NS) at 125 Cubic Centimeters (CC) an hour for 1 liter via IV, then 1/2 NS at 75 cc an hour for 48 hours total, recheck Basic Metabolic Panel (BMP) on 10/10/2020, order faxed to North and South side. A review of Resident #7's Telephone Orders revealed an undated order for 1/2 NS at 125 cc an hour for 1 liter, then 1/2 NS at 75 cc an hour for 48 hours, recheck BMP in AM. The Telephone Order was signed by a physician on 10/11/2020. A review of Resident #7's laboratory testing results, dated on 10/09/20, revealed an increased sodium level of 157 milliequivalents per liter (mEq/L). The laboratory testing results also revealed a hand written note at the bottom stating that the results were faxed to the Medical Director on 10/09/2020 at 01:45 PM. A second copy of the same laboratory testing results revealed that the laboratory results were reviewed by the Medical Director on 10/09/2020 with hand written orders at the bottom for 1/2 NS at 125 cc an hour for 1 liter IV, then 1/2 NS at 75 cc an hour for 48 hours, recheck BMP on 10/10/2020. A review of Resident #7's Progress Notes revealed a Nursing Progress Note, dated 10/11/2020 at 01:15 PM, documented by Staff R, Registered Nurse (RN). The note revealed that the Medical Director was in the facility and an order was received for 1/2 NS at 125 cc an hour for 1 liter IV, then 1/2 NS at 75 cc an hour for 48 hours, recheck BMP in the AM for dehydration. A Nursing Progress Note, dated 10/11/2020 at 03:11 PM revealed that Staff R, RN placed a 22 gauge IV to Resident #7's right forearm and that Resident #7 pulled out the IV line. A Progress Note, dated on 10/11/2020 at 04:40 PM revealed that Staff S, Licensed Practical Nurse (LPN) attempted two more times to access Resident #7's vein for IV placement but was not successful. The note also revealed that the Medical Director was notified following the procedure and a new order was given to send Resident #7 to the hospital due to dehydration. An interview was conducted on 10/17/20 at 12:21 PM with the Assistant Director of Nursing (ADON). The ADON stated that the labs are put into the computer by the 11 PM - 7 AM shift. The 11 PM - 7 AM staff put in the order for the lab work, put in a requisition, and put that in the lab book. The ADON then prints the labs that were supposed to be done and gives a copy to the floor nurse. The floor nurse was to check on the labs during their shift. The lab faxes the results to the facility and if lab results don't come, then the floor nurse was to follow up. Lab work could also be obtained from the lab's website. Lab work typically gets reviewed during morning meetings Monday through Friday. The ADON stated that Staff A, Registered Nurse/Unit Manager, had been assigned to follow up on lab work and that it was not always completed. An interview was conducted on 10/18/2020 at 2:37 PM with Staff M, LPN. Staff M, LPN stated that she was informed that Resident #7 was refusing to eat and drink for a day or two and she contacted the Medical Director. The Medical Director ordered some blood work as well as a UA C&S. The lab work came back on 10/09/2020 around 1:30 or 2:00 PM. Staff M, LPN stated that she did not receive a response by the end of her shift at 3 PM. Staff M, LPN stated that if an order was received from a physician, it should be implemented as soon as possible or it would be considered a delay in treatment. Medications and IV fluids can be pulled from the Emergency Drug Kit (EDK) until the prescription was received from the pharmacy. Observation of the facility's EDK kit contents list revealed that 1/2 NS was available in IV Kit A for administration. A follow up interview was conducted on 10/18/2020 at 6:26 PM with the ADON. The ADON stated that staff did not report to her that Resident #7 was not eating or drinking and that she was not aware of of the IV therapy being delayed. IV therapy should not have been delayed and nursing staff should have documented the Medical Director's response to the lab work that was done. The ADON stated that the facility did not have a Unit Manager for that side of the building or a weekend supervisor, which may have caused some of the lab work to not be followed up on. An interview was conducted on 10/20/2020 at 4:55 PM with Staff Q, an Attending Physician at the facility but not the Medical Director/Physician for Resident #7. Staff Q, Physician stated that sometimes the facility was late about performing labs, following orders, and starting IV's and that staff was not consistent about calling him with lab results or issues that came up. Staff Q, Physician stated that the facility used a lot of agency staff and that they were not familiar with the procedures that the facility used and that he had discussed the issues with supervisors at the facility. An interview was conducted on 10/23/2020 at 8:07 AM with Staff R, RN. Staff R, RN stated that she was informed on 10/11/2020 by another nurse that Resident #7 was not eating or drinking well and that the Medical Director was aware. The Medical Director gave her an order to start an IV that day and she was able to place the IV site but Resident #7 pulled it out and the Medical Director was notified. Staff S, LPN also attempted to start the IV but was unsuccessful. The Medical Director then gave an order to send Resident #7 to the hospital. Staff R, RN stated that the 1/2 NS was available in the EDK and that she had it ready to administer but she could not. A telephone interview was attempted with the facility's Medical Director on 10/20/2020 at 3:25 PM and 10/23/20 at 8:37 AM. A message was left with the Medical Director's Medical Assistant on both occasions, but a telephone call was not returned.

Based on interview and record review the facility failed to ensure a physician's order for a left hip x-ray due to pain was completed in a timely manner for one (#79) of 40 sampled residents, resulting in a delay of treatment. Findings included: Review of Resident #79's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred to the hospital for abnormal x-ray results on 4/27/19. Review of (Physician Name) Medical Inc. Medical History and Physical form dated 4/25/19 revealed 86 y/o ( year old) pt (patient) seen in the memory unit In the common area . patient also c/o (complained of) left hip pain. Staff reports that left hip pain is new symptom. No reported injury or fall. The Assessment section of the (Physician Name) Medical Inc. Medical History and Physical form dated 4/25/19 revealed #2. Left hip pain -x-ray ordered. Review of the paper medical record physician order sheet revealed a physician's order dated 4/25/19 for an x-ray of left hip due to patient c/o pain. Review of Resident #79's medical record showed no x-ray results for the 4/25/19 order for a left hip x-ray. Review of the physician order dated 4/27/19 X-ray to knee, hip, femur and pelvis to rule out fracture. Due to immobility one time only for pain. Review of Resident #79's nurse progress note dated 4/27/19 at 11:35 p.m. revealed resident c/o pain. MD (Physician) notified new order for x-ray to left hip. Femur, pelvis, knee. X-ray returned abnormal MD notified with new order to transfer to hospital, family notified, all safety measures maintained. Review of the left femur 1 view Radiology report dated 4/27/19 revealed a conclusion of chronic ununited left subcapital femoral neck fracture deformity. No acute osseous abnormalities. During an interview with the facility's Medical Director on 05/14/19 at 04:08 p.m. he stated his nurse practitioner was the one who ordered the x-ray on 4/25/19 and it should have been done. On 05/15/19 at 9:50 a.m. Staff O, Physical Therapy Assistant (PTA) stated from a physical therapy standpoint Resident #79's progress was up and down because of her dementia. The whole time she was on service with us she had tightness in her left hamstring, and we were doing ultrasound to decrease the tightness. We were doing some standing on the parallel bars with weight shifting to promote weight bearing on the left leg. The hamstring was tight enough that her foot wouldn't touch the ground so that's why we were working with her, to loosen the hamstring. For someone who had dementia she was clearer than you would think. She could tell you a few things. Throughout treatment she wasn't complaining of much pain. For example, we would try and stand her up and she would complain of pain in her leg. I would ask her if she was okay, and she would say yes, I am fine. Then on 4/25/19 she was in bed because she was on IV's and I went to roll her and she was in a lot of pain. I was like oooo and I talked to the nurse. Her legs weren't warm, there was no redness, and she didn't remember hitting or hurting the leg in any way but, it was noticeable that with any movement it made her jump in pain. Throughout her time in therapy we would put her in the calf buddy to help stretch out her hamstring and we would stand her up. She would have a little pain with that but that day, on the 25th, you couldn't even move the leg without her jumping in pain. I didn't do the ultrasound that day because I knew something wasn't right. When I got the nurse, she talked about how the resident was getting an x-ray. On 4/26 another therapist worked with her and per her note the ultrasound was not done because there was [MEDICAL CONDITION] to the left leg, and the resident was to have a left hip and knee x-ray. It looks like on the 26th the resident was up in the chair and all the therapist did was modify her chair and positioning. On the 26th the therapist did about 45 minutes of work, and that includes time with the patient, talking to nursing and getting the stuff ready. An interview was conducted on 5/14/19 at 5:47 p.m. with the facility's Administrator. She stated it was her expectation that if an x-ray was ordered on [DATE] then I expect the x-ray to have been done. On 5/15/19 at 11:49 a.m., an interview was conducted with the DON and Staff M, Regional Director of Clinical Services (RDCS). Both confirmed the x-ray that was ordered on [DATE] was not done. Staff M, RDCS said usually the nurse who sees the doctor writing the order will input the order or the nurse on the next shift will see the order flagged and input it into the computer. As Staff M, RDCS was saying this the DON was nodding her head yes. The DON then said, the order was never put into the computer and we have to get better about inputting orders.

Based on observation, interview and record review, the facility failed to provide the necessary supervision and effective and appropriate assistive devices to prevent falls for two of three sampled residents (Resident #1 and Resident #3). Resident #3 sustained a fall in the facility resulting in a C1 right lateral mass fracture and Resident #1 sustained 4 falls in a 23 day period while in the facility. Findings included: 1. An interview with Employee C, a certified nursing assistant (CNA), on 1/29/2016 at 11:54 a.m. revealed he has been caring for Resident #3 for about 5 months as he has a permanent assignment on the hall where she resides. He stated that on 12/11/2015 he was giving Resident #3 a shower as he normally had. He received assistance from another CNA to transfer her from the wheelchair to the shower chair using the sit to stand mechanical lift. Employee C stated Resident #3 had some weakness on one side. He could not recall which side but thought it was the left side. Following the transfer to the shower chair the other CNA left the shower room. Resident #3 was seated in the shower chair when Employee C realized he had forgotten the wash rag at the sink. I turned and walked to the sink to grab the rag and I heard her fall. It was weird. She was sitting in the hole of the shower chair and she was sitting right. I don't know what happened. Employee C stated the resident was positioned on her side when she fell , the side that she can't move. I saw blood coming out from her forehead and I called for the nurse. I ran out and got the nurse, Employee A, she was in the patient room right next to the shower room. I also called another CNA, Employee D, to help too. The nurse started to check if she was alright. The resident was cursing and saying my head. She was acting okay moving her legs but just saying my head. The nurse checked her pulse and vitals on the floor and then Employee C went to get the hoyer lift. The lift pad was placed underneath the resident while she was on her side. We all worked together to hold her. We held her head to not move it. When we got her into the wheelchair, Employee A looked to see where the blood was coming from and cleaned it up. They called the nurse supervisor, Employee B, and I think they called the ambulance and the doctor. They told me to put her in bed. Employee C stated he and Employee E, another CNA, placed the resident back in bed using the hoyer lift again. He did not think a nurse was present when she was moved back to the bed. He checked the resident's vitals until the ambulance came. Employee C stated he got scared because he had never had someone fall with blood coming out from the head before. We asked her if she was having pain and she said yes. Immediately following this interview with Employee C, he showed the surveyor the shower room where the incident had occurred. Employee C was asked to set up the shower chair in the position he had left Resident #3 on the date of the incident and to place a paper towel on the sink where the wash rag was left (photographs were then taken). The distance from the sink to the shower chair was approximately 6 feet. While in the shower room with Employee C he stated normally he has the towel and wash rag set up on a grab bar in the shower stall, but on the day of the fall he had forgotten it so he went over to the sink to retrieve it. A telephone interview was held on 1/29/2016 at 1:11 p.m. with Employee A, the licensed practical nurse (LPN) who assessed Resident #3 following the fall on 12/11/2015. Employee A stated she worked at the facility for 14 months as a LPN mostly on the 3:00 p.m.-11:00 p.m. shift on the South side (the unit where Resident #3 resided). Employee A stated she recalled the incident very well. I was talking to the aide who was taking care of Resident #3 just before he took her to the shower. After that I went into feed a resident and not even 5 minutes later, I heard the CNA calling for me. I quickly went into the bathroom. The patient was on the floor. She was lying sideways but with her face forward. Her left side was to the floor and her body was moved forward towards the floor. The aide said he had turned to get something, which I thought could have waited, and that's when she fell . I would say he was a couple of steps away from her. This resident used a lap table when she was in her wheelchair but the shower chair doesn't have that. I would hope that any time someone is in the shower chair that they would have a safety belt or something to hold them but there was none. The resident was not able to hold on by herself because she had weakness on one side from a stroke in the past. Somebody came in the bathroom and I told them to get help. I asked the resident questions and couldn't get her attention. She said that her head was hurting. I did not do any range of motion. We got her up using the hoyer lift and I supported her head and neck so her neck wouldn't be out of place. I wasn't sure if she had a neck injury but just to stay on the safe side I supported her head and neck. She was moved via hoyer lift to the wheelchair and then we got her into the bed using the hoyer as well. I supported her head while the other two aides supported her upper part and bottom. One was Employee C and the other may have been Employee D but I can't be sure. There could have been another person but I can't remember. I don't remember who called the ambulance. It is possible I called, but I don't remember. The ambulance did come and she left the facility by way of ambulance. A telephone interview on 1/29/2016 at 3:37 p.m. with Employee D, a CNA revealed she saw the red call light flashing from the shower room on the day of the event and entered to see if she could help. It was at that time, she saw Resident #3 flat faced on the ground with a pool of blood by her forehead. She could not recall how the resident's body was positioned. Employee C was present and I can't recall who else, maybe Employee E, a CNA When someone falls we don't move them. We immediately went to get the nurse, Employee A. Employee A came in and looked at the resident and instructed us to get her up with the hoyer lift. I made sure we had the proper hoyer pad and we gently rolled it under her. When the resident was going up in the mechanical lift someone was there holding her head and neck. I don't remember exactly who. We were very careful. After we got her in the wheelchair I left. I had no further involvement after that. I work on a different hall and I am not familiar with Resident #3 otherwise. An interview on 1/29/2016 at 3:58 p.m. with Employee E, a CNA revealed she has worked at the facility for about a year and usually works on the 3:00 p.m.-11:00 p.m. shift on the South side. Employee E stated I was on my lunch break when the incident occurred. When I was clocking back in, someone told me Resident #3 had fallen so I went in to see if I could offer assistance. I saw her in the chair on the hoyer pad and I assisted Employee C to move her to her room. I was holding her head and neck. The resident was verbalizing some, but not a whole lot. We moved her back to bed using the hoyer lift. I checked on her while they were waiting for the ambulance. I checked on her and at some point I kissed her head and she said oww that hurts so I told Employee A and Employee B so they could give her something for pain. I don't know what happened after that. I went back to my assignment. A telephone interview with Employee B, an LPN, on 1/29/2016 at 4:15 p.m. revealed he had worked at the facility for about a year and a half as the 3:00 p.m.-11:00 p.m. nurse supervisor. I remember the nurse, Employee A, sending a CNA for me. Employee B could not recall who the CNA was but said the aide told him Resident #3 had fallen in the shower and she thought she had hit her head. When I arrived in the shower room, Resident #3 was still on the floor. I think she was on her back but I can't be sure. I said let me call the doctor, don't move her. Employee B stated he left to call the doctor and started the paperwork so she could be sent out to the hospital. When I went back in to the shower room, they had gotten her up, cleaned her up and set her back in the chair. Employee A said she was going to place the resident on neuro checks and I said no you're not, she's going out. Employee B stated any time there is a head injury I send them out. They need a CT scan. Employee B called EMS (Emergency Medical Services) and I called the family and told them she was going to the hospital. When she came back from the hospital they said she had broke her neck. I was shocked. A review of Resident #3's clinical record revealed an admission record face sheet which indicated she had resided in the facility for over 2 years and had a recent hospital stay following the fall from 12/11/2015-12/15/2015. A review of Resident #3's most recent minimum data set assessment (MDS) prior to the 12/11/2015 fall revealed an assessment reference date of 9/24/2015. This assessment revealed a brief interview for mental status (BIMS) score of a 3 indicating severe cognitive impairment. The resident required physical help in part of the bathing activity with one person physical assistance (coded as a 3/2). The resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet, and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident had limited functional range of motion with impairment on both sides for upper and lower extremities. In addition, she had active [DIAGNOSES REDACTED]. A review of the resident's care plan for safety with an original implementation date of 10/10/2014 revealed the resident had the potential for injury associated with poor safety awareness, confusion, poor communication, psychoactive drug use, vision problems, gain/balance problems, incontinence, and history of falls. An approach associated with this care plan was to anticipate and meet the resident's needs. Continued review of the care plans revealed a care plan was also in place for an activity of daily living (ADL) self care performance deficit associated with dementia, limited mobility, CVA with left sided weakness, confusion, impaired balance and incontinence of bowel and bladder. An approach for this care plan was Bathing: Keep needed items in easy reach. An interview on 1/29/2016 at 3:25 p.m. with the MDS Director and the MDS coordinator revealed these care plans and approaches were in place at the time of the 12/11/2015 fall. A review of the SBAR (situation, background, appearance, and review) communication form and progress note dated 12/11/2015 revealed the CNA was attempting to shower the resident. Patient fell out of the shower chair to the floor. Noted scalp laceration (5 centimeter). Doctor notified. Family notified. Maintained C-spine alignment while doing transfer at all times. Noted laceration to scalp, skin tear to right knee and bruise. Recommendation from the physician was to send to the ER for CT scan and evaluation at 8:00 p.m. This note was signed by Employee A. A review of the hospital History and Physical dated 12/12/2015 revealed The patient presents for admission following a fall .The location of injury is head, neck. The injury is characterized by pain, bleeding and laceration .woman with progressive dementia was in the shower in the skilled nursing facility when she slipped and fell primarily onto her left side by report. The patient is unable to provide any history. She is in an ASPEN collar. She has an area of ecchymosis on her left knee, left elbow area, and an occipital scalp laceration. A review of the CT of the head without contrast (compared to CT from 7/16/2013) revealed an impression of small left frontal lobe subdural hematoma near the vertex without significant mass effect or midline shift. Small irregular area of high density in the right frontal lobe adjacent to an area of chronic infarct. This may represent minimal subarachnoid hemorrhage versus mineralization. A review of the CT of the spine cervical without contrast for a clinical indication of acute neck pain after trauma revealed an impression of Nondisplaced C1 right lateral mass fracture. Questionable impaction fracture of the right occipital condyle. Severe multilevel degenerative disc disease and facet arthropathy. General observations of Resident #3 on 1/29/2016 at 12:17 p.m. revealed a petite elderly female in bed with an ASPEN collar on her neck. The resident was pleasantly confused and answered Yes sir to any and all questions asked with no elaboration (i.e. Did you fall? - Yes sir How did you fall?- Yes sir). Additional observation on 1/29/2016 at 3:50 p.m. revealed the resident was in the day room seated in a wheelchair with a left side lap tray attached to the chair and the ASPEN collar around her neck. The resident's left arm was resting on the lap tray. An interview with the unit manager for Resident #3 at the time of this observation revealed this lap tray was in place prior to the incident on 12/11/2015. An interview on 1/29/2016 at 10:20 a.m. with the administrator and director of nursing (DON) revealed Resident #3 has lived at the facility since 2013. The resident had an incident on 6/20/2015 where she was lowered to the floor by staff as she began to slide. As a result of that event we changed her transfer status to two person with a gait belt. This was her only incident prior to the fall on 12/11/2015. According to the facility's investigation which included statements from the staff involved revealed that on 12/11/2015 Employee C, the regular CNA for the resident, was getting ready to give her a shower. Employee C and another CNA transferred her to the shower chair using the sit to stand mechanical lift. Employee C used the sit to stand because he can't adjust the height of the shower chair (like you could adjust the bed) and this was safer than the gait belt. The shower chair was against the wall in the shower room and the wheels were locked. She was sitting in the chair properly and the 2nd CNA left the shower room as Employee C said he was ok. The nurse, Employee A, had just been in the shower room and saw the resident in the shower chair prior to the fall and she was fine. Employee C went to reach back for the washcloth and towel and when he turned back around, she was on the floor. She has left sided weakness due to a stroke. This was nothing she has ever done before and she has always used the shower chair with one CNA The resident fell forward. The DON stated the resident must have put some pressure on her right side to readjust herself and fell forward. She fell on to her face and had a laceration on the right side of her forehead and a skin tear to the knee. Employee C screamed for the nurse. The nurse, Employee A, came in immediately and assessed the patient. The nurse had the resident's head in C-spine alignment, they got her up with a hoyer lift, placed her back in the w/c, and then placed her in bed using the hoyer lift and still maintaining the head in C-spine alignment. 911 was called to transfer her to the hospital. The DON was asked if it was normal to move a resident after they fall on their face? The DON said yes, if the nurse assesses the resident and feels comfortable to move them then it would be okay. It is the nurses judgement. Meanwhile, Resident #3 went to the hospital and was found to have a C1 fracture. She was placed in a neck collar and sent back to the facility 2-3 days later. Since the resident's return, she uses the shower bed only. We assessed all the shower chairs in the building to make sure it wasn't an equipment problem with no concerns found. We also reviewed all resident kardexes in-house to ensure accuracy of bathing/transfer status (i.e. one person/two person, shower chair, shower bed). Based on this review, we did make some changes, but it was all less restrictive and Occupational Therapy/Physical Therapy had already assessed them as less restrictive it was just a matter of updating the Kardex. Several residents already used shower beds prior to this event and there were no changes made for these residents. Education was completed on safe transfers. Dots were placed on doors with TL (total lift) G1 (gait belt with one), etc . and staff were re-educated on that. They were told that if they were unsure to check your person's kardex and if you feel the person needed a change in transfer status complete a referral to therapy and a stop and watch (a piece of paper for change in condition which anyone from any department can complete). Anytime someone sees that a patient looks different they fill out the stop and watch and hand it to the nurse. A review of the facility's investigative conclusion document completed by the nursing home administrator for Resident #3's fall revealed that on 12/18/2015 After a complete investigation, involving resident and staff interviews, chart review, shower room and shower chair investigation, and staff statements, we have come to the conclusion that based on Resident #3's physicality's, current C.N.A., Employee C, who has given her previous showers without incident, and accurate kardex and careplan's which were followed, that this was an accident that could not have been prevented. Resident #3 requires a 2 person assist to be brought into the shower room and shower chair, and than 1 person to assist with bathing which Employee C did. It was noted that Employee C walked over to the counter while Resident #3 was in the chair up against the wall in between the 2 public shower spaces. Within the time he stepped a few feet to get linen, Resident #3 had fallen on the floor with the brunt of her front and forehead. Nurse immediately called in to asses and Resident #3 was sent to the local hospital for evaluation. Neck brace placed and she was sent back to the facility with plan to use shower bed for all showers. Staff education given on safe transfers, low lift policy, kardex accuracy and SBAR. All shower chairs inspected by maintenance and in good working order. It is believed that while Resident #3's natural seated position involves her voluntarily re-positioning herself in her w/c, that she tried to in the shower chair and the bar that comes across the bottom from the front that would have assisted in leverage to push forward. 2. A review of Resident #1's clinical record revealed a resident face sheet with an admission date of [DATE] and relevant [DIAGNOSES REDACTED]. A review of the 11/1/15 admission data collection form fall risk evaluation revealed a score of 14 (total score of 10 or above deems resident at risk). A review of the interdisciplinary progress notes revealed an entry on 11/23/15 at 2:20 p.m. stating interdisciplinary (IDT) team meeting concerning fall on 11/19/15 at 9:00 a.m. Resident was found on floor on face. Resident stated she was standing up with attempts to walk and fell . Facial and right shoulder x-rays completed and both negative for fracture, neuro checks done and education of staff completed. Negative new medications started. Resident to be in common area when out of bed and not left at bedside. No other events noted. Will continue to monitor. Continued review of the IDT progress notes revealed an entry on 12/14/2015 stating IDT meeting concerning a fall on 12/7/15. Resident was found on floor in room: no injuries noted. Resident placed in common area. Neurochecks completed. Increase activities. Resident noted increased agitation. Xanax increased. Family and Medical Doctor (MD) aware. Fall on 12/10/15 at 6:30 p.m. Resident at nursing station. Pushed back in wheelchair causing wheelchair to fall backwards. Sent to hospital for CT scan. Neurochecks started upon return. Anti-rear tippers applied resident placed under supervision and medication reviewed. New order Xanax 1 mg twice a day as needed and Risperidone 2 mg twice a day. Resident continues to have outburst of yelling and not sleeping. On 12/12/15 resident found on floor laceration to back of right head. Resident sent to hospital for CT scan. Staples in place. Family requests lap buddy. Lap buddy in place. Physical restraint evaluation completed. Resident continues to be placed in common area also drop w/c seat in place. Increase activities and continued yelling and outburst. Family and MD aware. An interview with the administrator and DON on 1/29/2016 at 10:20 a.m. and for clarification purposes again on 1/29/2016 at 4:44 p.m. revealed Resident #1's first fall occurred on 11/19/15 at 9:00 a.m. The resident was hooked up to peg tube feeding in her room and attempted to get up and was found on the floor on her face by the nurse. Facial x-rays and right shoulder x-rays were completed and found to be negative. Neuro checks were put in place and she was placed in the common area. In addition, the Therapy Director educated Employee G, a Certified Occupational Therapy Assistant (COTA), to not leave the resident unattended. At the time of the event she did not have that approach in place and this was why education was provided to the therapist. Resident #1 was a very busy individual (constantly yelling out, would self propel about, grab onto your clothes, and would follow staff wherever they went). With any busy individual you don't want to leave them unattended. The DON stated I think people are under the assumption that you can't bring a resident who is hooked up to a peg out of the room but you can if the pump is covered up. The care plan was updated to keep the resident in common areas and keep busy in activities. Prior interventions to the care plan consisted of bed in low position and non-skid socks. Resident #1 sustained a 2nd fall on 12/7/15 at 2:00 p.m. At the time of this event, the resident was sitting in her room on the floor mat (fell from the low bed to the floor). She was unable to tell staff what happened. She had no injuries. The investigation revealed that the resident was left in her room by the Speech Therapist, Employee F, approximately an hour before the fall. Interventions were in place to get her up, put her in the common area, neuro- checks, and changes were made to increase her Xanax dosage and add Tramadol 50 mg three times a day for pain. Resident #1 sustained a 3rd fall, 3 days later, on 12/10/15 at 6:20 a.m. when she pushed herself backwards in the w/c and tilted backwards. She was at the North side nurses' station. She suffered a 2 x 1 laceration to the back of her head and was assessed right there by Employee B, LPN. She went out to the hospital for a CT scan which was negative and steristrips were applied to the laceration. The resident had never shown any tilting back behaviors in the past. Interventions put in place for this fall included anti-rear tippers, neuro checks and the Xanax went to routine 1 mg twice a day and Risperadal 0.5 mg twice a day was added. Resident #1 sustained a 4th fall on 12/12/15 around 7:20 a.m., two days after her 3rd fall and 5 days after her 2nd fall. In this incident, the resident flipped the whole w/c sideways at the nurses' station and sustained a cut to the right side of her head requiring 3 staples. She went out to the hospital again for another CT scan which was again negative. New interventions were put in place of a lap buddy, drop seat, discontinue Risperdal and Haldol was added 5 mg twice a day. An interview on 1/29/2016 at 1:40 p.m. with Employee G, a COTA revealed that on 11/19/2015 sometime in the morning the patient was in bed and I came in to do ADL care with her. I had worked on getting her dressed and up to her w/c. I remember she was hooked to the feeding tube because we had to maneuver her blouse around it. She transferred to the w/c and I informed the CNA when I left. I don't recall who the aide was. She was hooked up to the feeding tube so I left her in her room, but in hindsight I should have brought her out anyway. She wasn't highly anxious. She was just sitting in the chair sleeping when I left. After she fell my boss talked to me about it and asked me what I should have done differently? I said something like take her to activities but she was still hooked up to the feeding tube. I thought she would be okay. The CNA was aware. An interview on 1/29/2016 at 11:44 a.m. and 1:00 p.m. with Employee F, the ST revealed she worked with Resident #1 for 5 sessions, a whole week, as the other ST was on vacation. I was covering her patients that week. Resident #1 was a dysphagia elderly patient with a peg tube. We were doing trials of honey thick liquids, puree with a chin tuck and right head turn. We also did exercises for the swallow muscular utilizing tongue depressors for lingual resistance. She was a dementia patient probably a stage 6. The ST described stage 6 dementia as safety and judgement impaired; unable to communicate wants and needs effectively so the caregiver needs to anticipate their needs; they can participate in motor movements and visual attention to objects with cueing but in terms of communication they are at one sentence level often not relevant to current events, topics and what is going on in their environment. She was a very vocal sweet lady but difficult to perform exercises with due to the advanced dementia so a lot of the therapy was for quality of life and the caregiver (her son) was also trained. On 12/7/15 when I went to get her she was alone in her room with her roommate in her w/c seated between the bed and the bathroom (she was A bed). She was yelling give me water when I entered the room. At that time I did honey thick liquids and non-nutritive bolus sucker to train and provide feedback for chin tuck and right head turn. I also did exercise that day for lingual strength and range of motion. I signed the note at 4:44 p.m. but that isn't necessarily the time I saw her and I can't recall exactly when I saw her. I heard the next day that her fall occurred after I had left the room. As a ST that was poor judgement on my part as I am very in tune to the cognitive levels and it would have been my fault for not moving her out to the nurses' station where they could keep an eye on her. I take responsibility for that but my justification for leaving her in her room was because that was where I had found her. She was in the w/c when I came in and in the w/c when I left. I never attempt transfers as I am not trained to do that. The information about placing her in a high traffic area was in her kardex and I did not look at it. A telephone interview on 1/29/2016 at 4:07 p.m. with Employee B, a LPN, revealed he was the 3:00 p.m. - 11:00 p.m. supervisor on 12/10/15 when Resident #1 had fallen. Employee B stated I think the manager on duty witnessed the resident fall and screamed. A CNA came to the resident room where I was delivering care to report that a resident had fallen and they needed my help. I finished up with the resident in the room and then I headed to the nurses' station. Resident #1 was on the floor. She was saying don't call my son he is going to be real mad at me. She was bleeding from her head so I called the doctor to see if we could send her out since she hit her head. I checked her from head to toe, checked her range of motion, and talked to her. She just wanted to get up and didn't want her son to know. She was rolling over trying to get herself up so it was safer for us to assist her because she was going to get up one way or the other. Myself and another nurse cleaned her head to check the damage. It wasn't bad but with the head I still like them to go out for a CT scan. She went to the hospital and I can't recall if she went via 911 or non-emergency transport but she did go out. I can't recall if she got sutures or staples but she did return later that night. The manager on duty said she saw her go backwards in the w/c but she had never tipped her chair like that before as far as I was aware of.

Based on record review, interviews with facility nursing staff, the Attending Physician, the Medical Director and facility Administration, review of the facility ' s policy and procedure regarding changes in condition and physician notification and review of the Nurse Practice Act, the facility staff failed provide necessary care and services in accordance with acceptable standards of practice for two of eleven sampled residents reviewed for changes in condition and laboratory services. (Resident #1 and #3). Resident #1, an [AGE] year old resident, had laboratory tests collected on [DATE] that were not indicative of [MEDICAL CONDITION] or acute blood loss. Resident #1 was reported to have hematuria (blood in the urine) since [DATE]. The nursing staff failed to assess and document the hematuria and failed to notify the physician of the continued hematuria. Resident #1 also had abnormal lab values collected on [DATE] and the physician did not discover the results until [DATE]. On [DATE] at 7:30 PM, the resident was transferred to the hospital, where his lab values had markedly worsened. Resident #1 subsequently died on [DATE] at 11:39 PM. Resident #3, an [AGE] year old resident, was noted to have a low hemoglobin on [DATE]; the physician was not notified of the results until [DATE]. The resident was directly admitted to the hospital for a blood transfusion. The facility ' s current census was 113 residents. The lack of action taken by the nursing staff to assess, document and notify to the physician of abnormal laboratory results resulted in a delay in treatment and a transfer to higher level of care that resulted in Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: 1. Review of the Florida Nurse Practice Act Section 464.003 Definitions Part (3)(a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. (c) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Review of Potter and Perry's Fundamentals of Nursing 6th Ed. Chapter 15, Nursing Assessment page 292 revealed, "Diagnostic and Laboratory Data. The results of diagnostic and laboratory tests can identify or verify alterations questioned or identified during the nursing health history and physical examination [REDACTED] according to the disease process and treatments. In addition, the nurse uses laboratory data to evaluate the success or failure of nursing and medical interventions ...Observation and recording of client (resident) assessment is a legal and professional responsibility ...The American Nurses Association Policy Statement (2003) and Standards of Clinical Nursing Practice (1998) mandate accurate data collection and recording as independent functions essential to the role of the professional nurse." During a telephone interview on [DATE] at 11:27 AM, Employee A (Weekend Supervisor) stated that Employee I was the assigned nurse that day and she was called to the resident ' s room on Sunday ([DATE]) to assess the resident. His skin was cold and clammy. His oxygen saturation was " ok " and his vital signs were " ok. " She stated that his blood sugar was also within normal limits. She stated that the physician was notified, but by the time the physician called back the episode had subsided and the resident was back to his baseline. She stated that the physician ordered blood work for the morning. Employee A stated that the family was not in the facility during her assessment or when the resident was experienced his " episode. " She stated that the resident did not report any pain. She also stated that Employee I would have completed the assessment and should have documented in the nurses ' notes her assessment findings. Employee A stated that she spoke with the family later that day and did not recall if they were upset. She informed them of the episode and that the physician had been notified. She confirmed she did not document her assessment of the resident. During an interview on [DATE] at 2:10 PM, Employee I (LPN) stated that she cared for the resident on [DATE] during both the day and the evening shifts. She stated that the resident was his normal self and did not have any complaints of pain or changes in condition. She stated that the Nursing Supervisor did not come into the room that she recalled. No hematuria was observed and she had not received a history of hematuria in the past. No complaints of abdominal pain. She confirmed she did not document a narrative note regarding the resident ' s condition. Per the interview with Employee A, the resident did have a change in condition on [DATE] and the physician was notified and ordered a CBC and BMP for [DATE]. During an interview on [DATE] at 11:39 AM, Employee B stated that she was the assigned nurse on the 7 AM-3 PM shift on [DATE] and [DATE]. She stated that the resident did have blood in his urine and also stated that he " always had discolored urine. " The nurse stated that she did not document the bloody urine or the discolored urine in the nurses ' notes or report the findings to the physician. The nurse stated that during the day shift on [DATE], the resident did not report any abdominal pain. During an additional interview on [DATE] at 3:34 PM Employee B stated that on [DATE] the resident had an episode of low oxygen saturation. She stated that she administered oxygen to the resident and gave him his inhaler. She left the oxygen on just long enough for his saturations to return to normal. She then stated that she did not report the incident to the physician and confirmed she did not document on the Medication Administration Record. The nurse stated that she passed the episode on to the next shift in report. During an interview on [DATE] at 11:42 AM, Employee C stated that she was the evening shift (3 PM-11 PM) nurse on [DATE] and [DATE]. She stated that the resident did not have a lot of pain and was a " happy guy. " She stated that sometimes he did have blood in his urine. She stated that she would see the blood in his diaper. She stated that " someone " told her that it was normal for him and he had bloody urine for " a while " . She stated that that resident did not tell her that and could not recall if the family had given her the information. She stated that on [DATE], she was notified that the resident ' s blood work was abnormal and the physician wanted him sent to the hospital. She stated that she did not assess the resident because " he was in the process of going out. " She stated that the resident was confused and was not complaining of pain, he was wearing oxygen. She also stated that she did not inform the family of his transfer because they had already been informed. She stated that she was not informed of any hematuria or abdominal pain by a CNA. During an interview on [DATE] at 11:59 AM, Employee D (CNA) confirmed she was the day shift CNA on [DATE]. The CNA stated that the resident had blood in his urine. She stated that the blood was " quite a lot " that was bright red in color and was coming out in a thick clot. She stated that she immediately notified the nurse (Employee E). She was informed by the nurse that this was common for the resident and that the family had mentioned the bloody urine. She stated that the resident did not have any abdominal pain during her shift. During an interview on [DATE] at 12:18 PM Employee E (LPN) stated that she was assigned to the resident twice. She stated that the resident had bloody urine on [DATE] and that a CNA had reported it to her. She stated that when she went and assessed the resident, she noted " one small drop of blood. " The nurse stated that " when men are not circumcised, sometimes they have blood coming out of their penis. " She stated that she called the doctor and was informed that hematuria was part of his history. The nurse confirmed she did not document the hematuria or the physician notification. She stated that on [DATE], when she was assigned to the resident, she was not informed of any bloody urine or blood clots in a brief. During an interview on [DATE] at 1:27 PM, Employee F (CNA) confirmed she was the evening shift aide on [DATE]. She stated that the resident had " a lot of blood in his urine " and was complaining of stomach pain. She immediately reported both concerns to the nurse (Employee C). She stated that later that day, he went to the hospital. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. She stated that the resident had " hematuria for a while. " She stated that the physician was aware of the hematuria. Employee G stated that when she went down to the resident ' s room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that the resident was alert and was not complaining of any pain. She stated that he did not appear to be in any distress. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that she was not aware of any hematuria or abdominal pain. She stated that she did not recall any labs. She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 9:55 AM, Employee J (CNA) confirmed she worked the night shift of [DATE]. She stated that she noted a small amount of blood in the resident ' s brief and reported it to the nurse immediately. The nurse informed her that it was normal for that resident. During an interview on [DATE] at 10:15 AM, Employee K (LPN) stated that she worked the 11 PM-7 AM shift on ,[DATE] and [DATE]. She stated that on ,[DATE] she obtained a UA and noted " a lot of blood. " She stated that she asked the resident if he was having any pain and he stated no. She passed along to the day shift her findings and the day shift reported to the physician. She stated that on [DATE], she did not receive any reports of blood in the urine or abdominal pain. She stated that the resident was very quiet and did not complain much. During an interview on [DATE] at 11:48 AM, the Attending Physician stated that he knew the resident had a history of [REDACTED]. He stated that the resident was also recently diagnosed with [REDACTED]. The physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and looked in his binder (a communication tool the facility uses for the physicians to sign orders, lab results or other communications with the nurses) and noted that the resident ' s labs were collected on Monday [DATE]. He stated that he had not been notified of the results prior to him finding them on [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER that day. He stated that the resident ' s lab results were indicative of kidney failure and blood loss. The physician also stated that when he assessed the resident on [DATE], the resident did not have abdominal pain and was " hemodynamically stable " meaning his blood pressure and heart rate were normal. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or residents involved. During an interview on [DATE] at 3 PM, the Medical Director stated that gross/frank hematuria should be reported to the physician immediately regardless if the resident had a history of [REDACTED]. He also stated that the nurses and the physician should document the resident ' s hematuria and should have documented the history of hematuria. The Medical Director stated that the physicians rely on the nursing assessments to be accurate. He stated that the nurses should assess the residents at least on a daily basis including vital signs. The nurses should document any deviations from normal including hematuria, pain or any other physical complaint. He stated that the physician should be notified immediately with incidents including falls and injuries. The Medical Director stated that if a CNA reported a change in condition to the nurse, it would be the nurse ' s judgment of how quickly the assessment should be conducted. The Medical Director stated that the nurse should assess the resident regardless. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had " really low blood levels " and did nothing about it until Wednesday ([DATE]) evening. She stated that he complained of a stomach ache for three days and staff did not assess him. They only came into the room and stood 10 feet away and asked if he was ok. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a history of urinary bleeding (hematuria). She stated that he was " fine " prior to going into the facility and he was there for rehab. She stated that on Sunday [DATE], she and her husband were in the resident ' s room when he was complaining of stomach pain and the nursing supervisor; Employee A came in the room and said he was fine. The family member stated that the nurse did not assess the resident at all. She also stated that her sister in law was in the building on Monday, [DATE], when he was still complaining of stomach pain, and again, no one assessed him. On Tuesday, the family was not able to be in the facility. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that the day after he died , she went to the facility to pick up his belongings and spoke with the " head nurse. " She informed them that the nurses did not check on her father in law and it took two days for anyone to read the lab results. The family member stated that she felt the facility ' s treatment of [REDACTED]. She stated that he was not supposed to die the way he did, when he did. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident ' s hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(temperature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor. " At 6:45 PM, " resident leaving via non-emergency ambulance. No complaints of pain or distress. " No narrative notes were made on [DATE]. Review of the check off assessment per organ system assessment located on the front of the Skilled Nurses ' Notes revealed the nurse " checked " that the resident ' s abdomen was soft and he had no " bowel problems. " On [DATE], Employee B documented the resident ' s vital signs were within acceptable parameters and his abdomen was soft. The narrative notes documented a " breathing treatment " was given with effective results. On [DATE], Employee I was the assigned nurse, she documented the resident ' s abdomen was soft with no bowel problems noted. No narrative notes were documented on [DATE]. On [DATE], the resident was not in any distress and denied any discomfort. Incontinent care was provided by staff. On [DATE], no narrative notes were documented. On [DATE], " (Attending Physician) updated on UA with blood. Dr. to wait on culture results. " The nurses notes were reviewed from admission with no additional concerns noted. No additional documentation could be found related to the resident ' s abdominal pain or hematuria. Review of the Medical Record revealed a SBAR (Situation, Background, Assessment and Recommendation) Form that was not dated revealed the resident ' s blood pressure was ,[DATE] with a pulse of 66 and a respiratory rate of 17. He was afebrile. The nurse noted hematuria on the assessment. No additional assessment information was located. Review of the Laboratory Data revealed labs were collected on [DATE] that noted his kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was " waiting on culture. " Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses ' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. Review of the Hospital Notes dated [DATE] revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident " may die tonight. " The resident began to have worsening [MEDICAL CONDITION] that went to asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. Review of the Telephone Orders revealed on [DATE], Kayexelate 30 mg PO x1 dose now was ordered and to send to the ER for [MEDICAL CONDITION], acute [MEDICAL CONDITION] and hematuria. On [DATE] a CBC and BMP were ordered for the morning of [DATE]. On [DATE], a Urinalysis was ordered. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: " soft and non-tender. " He wanted the resident to go to the ER. The family was called and informed of the resident ' s condition by the physician. The resident was assessed by the physician on [DATE] in the morning, prior to the lab results being received at 7:12 PM. The resident " denies any ailments, denies SOB (shortness of breath), CP (Chest Pain), N/V (nausea/vomiting), or abdominal pain. " His abdomen was soft and non-tender. He was " hemodynamically stable. " During an interview on [DATE] at 11:05 AM, the Nurse Consultant and Director of Nurses confirmed the resident ' s abnormal labs, physician progress notes [REDACTED]. They confirmed the abnormal labs were received at the facility on [DATE] at 7:12 PM. Both confirmed the physician was not informed of the abnormal labs until [DATE], when the resident was transferred to the ER. The DON stated that the fax machine was located at the nurses ' station and the nurses were to notify the physician " within hours " of the receipt of the lab. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician ' s binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident ' s change in condition or lab results. The DON stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were reviewed during the clinical portion of the meeting. The DON stated that she had noted that the nurses were initialing the lab audit form that documented the physician notification. Review of the facility ' s policy entitled, " Change in Resident Condition " , revised on [DATE], revealed the policy of the facility was " the clinical nurse will recognize and appropriately intervene in the event of a change in resident condition. The physician/family/Responsible Party will be notified as soon as possible. " Under Procedure item 1. " The primary clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as soon as it occurs. This will also be documented in the 24 hour report. 2. The physician/family/responsible party will be notified as soon as possible to not limited to significant change, accident/incident, change in treatment, transfer/discharge. All physician ordered interventions will be immediately carried out by the clinical nurse overseen by nurse manager/supervisor. In the event of an emergency situation, 911 will be called and the physician/family/responsible party will be notified as soon as possible. 3. With change of resident status, the clinical nurse will gather subjective and objective assessment information, the nurse is responsible to complete an assessment of the resident ' s condition to including vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent and or physician and must document the date, time, party ' s notified, findings and details of the notification in the nurses ' notes. Notification of the physician and agent person of a significant change in status shall routinely occur during the shift in which it occurs. 4. Any contact to the attending physician regarding the resident ' s condition will be made by the nurse. 5. Document in medical record. The licensed nurse may use the SBAR for or document in the narrative form if necessary. 6. The supervisor will communicate to the MDS or case manager any significant changes in condition, which may warrant a reassessment. " Review of the facility ' s policy entitled Reporting Lab Results, revised on [DATE], revealed the policy was " to ensure timely reporting of lab results to the facility. " The procedure was " 1. Upon completion of the test, the lab will send written results to the facility ...3. The nurse will call or fax the abnormal results to the physician. 4. When the nurse has called or faxed the results to the physician, the nurse will write on the lab slip: 1. results faxed to Dr. __ at [PHONE NUMBER] on [DATE] at 3:00 PM. 2. Dr. __ called at 3:00 PM on [DATE], lab results reported to him. " Review of the facility ' s policy entitled, " Daily Skilled Nursing Progress Notes " , revised on [DATE], revealed the policy was " residents receiving skilled care shall have progress documented every shift (documented in 8 hour increments) in the medical record. " The procedure was " 1. The nurse shall utilize the Daily Skilled Nurses ' Notes to document resident ' s progress every shift. 2. The nurse will document on the Daily Skilled Nurses ' Note legibly with blank ink. The resident ' s name and date of the note will be noted ...4. The nurse will document abnormal findings in a narrative note on the form. The nurse will also document in a narrative noted the indications for continued skilled care using the skilled charting guideline ...6. All narrative entries must have the date, time and the nurses ' signatures with credentials. " The facility was comprised of two units, a long term care unit with a memory care hallway and a short term rehab unit. One of the hallways on the short term rehab unit was primarily used for Medicare patients recently admitted from the hospital. These residents required a higher level of care and were potentially more compromised with surgical wounds, infections and debilitation from prolonged hospital stays. The facility did not have routine set nursing assignments for the nurses and CNAs. During an interview on [DATE] at 4 PM, the Director of Nurses (DON) confirmed the staff assignments changed frequently. She stated that the goal was to have set assignments but due to accommodating staff ' s personal schedules, the nurses and CNAs were moved to different hallways to cover the staffing requirements. The DON confirmed that the nurses and the CNAs did not have an opportunity to know the residents especially on the Short Term Rehab hallway where the resident turnover was very quick. The DON also confirmed the acuity of the residents on the Short Term Hallway as being higher than other hallways in the facility. 2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Lab Data revealed a CBC was collected on [DATE]. The hemoglobin was 7.3 (low). Normal values were ,[DATE] in an adult male. The results were received in the facility on [DATE] at 7:05 PM. The physician was not notified until [DATE] at 8 PM. The resident was directly admitted to the hospital for a blood transfusion of 2 units of packed red blood cells. Review of the Nurses ' Notes revealed on [DATE], no narrative notes were documented. On [DATE] at 12:40 AM, the resident sustained [REDACTED]. No other documentation was noted related to abnormal lab values. On [DATE] the nurse documented the resident was on antibiotics for pneumonia and " will continue to monitor. " On [DATE] at 3:03 AM, " [MEDICATION NAME] added for pneumonia. " No other documentation was noted related to physician notification or lab values. On [DATE] at 12 AM, the resident was noted sitting on the floor mat, no injuries were noted. No other notes were located related to abnormal labs. Review of the physician progress notes [REDACTED]. A Foley Catheter was in place. On [DATE], the resident was noted with transient hematuria due to a possible kink in the Foley. On [DATE] the resident was noted with pneumonia and [MEDICATION NAME] was added. On [DATE], the resident was seen as a re-admission. He was sent to the hospital for a hemoglobin of 7.3 and was transfused with 2 units of packed red blood cells on [DATE]. He was readmitted back to the facility on [DATE]. Review of the telephone orders revealed the original CBC and BMP orders were entered directly into the computer to be collected on [DATE]. On [DATE] an order was written by the physician for " CBC, BMP done on [DATE], call in results to (attending physician). " The physician was in the building, assessed the resident and requested the labs on [DATE]. The labs were received at the facility two days prior on [DATE] at 7:05 PM and there was no documentation the physician was notified prior to [DATE] at 8 PM. During an interview on [DATE] at 2 PM, the Director of Nurses and the Nurse Consultant verified no nurses ' notes were documented that corresponded to abnormal labs or physician notification. Also, both confirmed the receipt of the lab on [DATE] at 7:05 PM and the physician was not notified until [DATE] at 8 PM. The DON confirmed the resident was directly admitted to the hospital for a blood transfusion on [DATE]. 3. Review of the Education provided to the nurses on [DATE] regarding notifying the physician of laboratory results timely revealed only 16 nurses attended. The facility implemented the following measures that resulted in the Immediate Jeopardy being removed on [DATE] at 1:45 PM. The measures included: 1. Educated 100% of all nurses educated on all three shifts. 2. Audited all in house residents for all labs since [DATE]. The results of the audit were reviewed and revealed 4 resident lab results were not in the clinical record, they were retrieved and noted to be within normal l

Based on resident record review, policy and procedure review and staff and resident interviews, it was determined that the facility Quality Assessment and Assurance Committee failed to put systemic measures in place to ensure that residents with laboratory tests had their results reported to the physician immediately upon receipt. The QA&A Committee also failed to identify and implement a plan of action for an identified concern related to laboratory result reporting and changes in condition. The facility administration failed to identify errors and omissions in Administration's implementation of facility policies for reporting laboratory test results timely, grievance/concern reporting and changes in resident condition for three of eleven sampled residents, Residents #1, #3 and #10. All three residents (#1, #3, and #10) resided on one hallway of the Short Term Rehab/Subacute side of the facility. The Attending Physician reported to the facility repeated concerns of the nursing staff 's failure to inform him of laboratory results. Resident #1, an [AGE] year old resident, was reported to have hematuria (blood in the urine) since [DATE]. The nursing staff failed to assess and document the hematuria and failed to notify the physician of the continued hematuria. Resident #1 had abnormal laboratory tests collected on [DATE] that were indicative of [MEDICAL CONDITION] or acute blood loss. Resident #1's physician did not discover the abnormal labs until [DATE]. On [DATE] at 7:30 PM, the resident was transferred to the hospital. His lab values had markedly worsened. Resident #1 subsequently died on [DATE] at 11:39 PM. Resident #1's family reported the resident's death and concerns with changes in condition and reporting lab results to the facility on [DATE]. Resident #3, an [AGE] year old resident, was noted to have a low hemoglobin on [DATE]; the physician was not notified of the results until [DATE]. The resident was directly admitted to the hospital for a blood transfusion. Resident #10, an [AGE] year old resident, was ordered to have a chest x-ray on [DATE]. The x-ray was not completed until [DATE] and the results were not given to the physician until [DATE] when the resident's antibiotic was increased to treat the pneumonia. The three incidents involving Resident #1, #3 and #10 were not investigated which resulted in no action plan being developed to address timely lab reporting and changes in condition. The facility's failure to appropriately identify and implement a plan of action to a known concern resulted in the findings of Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: Cross Refer to F 309 as it relates to the facility ' s failure to provide the necessary care and services to three of eleven residents. 1. Review of the facility's "Performance Improvement (Quality Assurance)" policy that was dated [DATE] and last revised on [DATE] revealed the policy included "The facility and organization will have an ongoing Performance Improvement Program with a design and scope that is ongoing and comprehensive dealing with a full range of services offered by the facility including the full range of departments that addresses all aspects of care. The Design and Scope of the program will systematically monitor and evaluate the quality and appropriateness of Resident Care, pursue opportunities to improve resident care, resolve identified problems and identify opportunities for improvement. Performance Improvement Program supports the overall goals of the facility and the organization and [MEDICATION NAME] both outcomes and processes relevant to these outcomes with the objective of improving the organization ' s performance." Under Procedure Item 3. "Key aspects of care, facility practice and quality of life may include but are not limited to: a. Medical Care, b. Clinical Care ...l. Medical Records ... " Item 4. " Important functional areas may include but are not limited to: ...c. Resident Assessment, d. Quality of Care ...f. Potential Adverse Events, g. continuity of care ... j. Information Management ... " Item 6. " The facility will identify areas for continuous quality monitoring and the monitoring tools to be used. These monitoring activities should focus on those processes that affect resident outcomes most significantly. This ongoing monitoring is used to establish the facility ' s baseline and the predictability of various outcomes. " Item 8. " ...Criteria for selecting aspects of care for improvement are based but not limited to: a. facility goals and objectives, b. high volume- the aspect of care occurs frequently or affects large numbers of residents, c. identification of potential or adverse events, d. high risk- residents that area at risk of serious consequences or are deprived of substantial benefits if the care is not provided correctly and in a timely fashion or on proper indication, e. problematic- the aspect of care has tended in the past to produce problems for staff or residents, f. high cost- the aspect of care involved a high cost either financial or personnel utilization, h. Regulatory- previous or current regulatory items or identified concerns. " Item 9. "Once an aspect of care or indicator has been identified or selected, the Performance Improvement Committee will "a. Assign a performance action team to address the identified area, examine, and improve the identified need. B. identify the goal of the performance improvement project. These goals must be objective, measurable and based on current knowledge or experience. These indicators should measure appropriate dimensions that address: i. appropriateness, ii. Effectiveness, iii. Timeliness, iv. Safety, v. respect and caring for residents, vi. Efficiency vii. Consistency with other programs/treatments/staff .... " Item 14. "The Performance Improvement Committee has the responsibility for designing and implementing action plans as needed to resolve identified resident care/service problems. This is accomplished within local, state, federal and corporate guidelines as well as fiscal restraints. All improvement plans will include: what needs to be changed, when and how corrective action will be implemented, who is responsible for the implementation of the corrective action and what time interval is set for reassessment. Improvement plans and effectiveness of actions will be documented in the committee minutes." 2. During an interview on [DATE] at 3:43 PM, the Administrator stated that he was the head of QA. The QA Committee meets once monthly on the second Tuesday of every month, the last meeting was held on [DATE]. A set agenda was followed with every department head reviewed for trends or concerns. The entire committee then looks for trends or concerns. Action plans were reviewed during the QA for compliance or quality improvements. Plant operations were also reviewed. Items such as Infection Control were reviewed as well. No concerns with labs were discussed during the July meeting. New concerns that were identified between meetings were brought to the committee in an Ad Hoc forum. The Medical Director would still be informed and would have an opportunity for input. No Ad Hoc meetings were conducted in [DATE]. No action plans related to labs were in QA. No concerns related to labs were brought to the committee for review. The Administrator stated that he was made aware of the concern regarding physician notification of lab results "this week." He stated that on [DATE] he was informed that a family had concerns that their loved one was here and went to the hospital and passed away. He stated that there "might have been an issue with labs." The Administrator stated that the Unit Manager and the Assistant Director of Nurses spoke with the family regarding their concern on [DATE]. He stated that he did not have any additional information regarding the incident and did not know the resident's name at the time. The Administrator stated that he was made aware of the severity of the concern on [DATE] when the survey started. He stated that the Unit Manager educated the nurses on [DATE] regarding notification of lab results. All nurses were educated on [DATE] and [DATE]. No audits were conducted prior to [DATE]. During an interview on [DATE] at 3:55 PM, the Assistant Director of Nurses (ADON) stated that the family of Resident #1 came to the facility on [DATE] and had some concerns related to a lab that was done on Monday ([DATE]) and the resident was not sent out until Wednesday ([DATE]). The ADON apologized to the family and said she "would do something about it." The ADON stated that education was provided on [DATE] regarding reporting labs immediately. The nurse (Employee H) received a written warning. She stated that she did not write the concerns on a grievance form since the resident was already discharged . She stated that if he was a current resident she would have done a grievance. She stated that she informed the administrator of the concerns. Review of the education provided to the nursing staff on [DATE] regarding timely reporting of lab results revealed only 16 nurses attended. No additional investigation such as audits were completed. The facility did not implement a plan of action related to laboratory results, changes in condition or physician notification. During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were supposed to be reviewed during the clinical portion of the meeting. The facility utilized a lab audit form where the nurses were responsible for documenting the lab test, date the test was to be drawn, the phlebotomist's initials and when the lab was received in the facility. The nurse was then supposed to initial the "follow up" box to indicate the physician was notified of the results and that a narrative note was documented. The DON stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident's change in condition or lab results. The DON confirmed that the facility systematic process of catching laboratory errors was not identified on ,[DATE] or [DATE] related to Resident #1. She also confirmed that on [DATE], when the family initially voiced their concerns, the facility did not fully investigate and identify potential deficient practice. The facility also did not implement a plan of action. The facility was comprised of two units, a long term care unit with a memory care hallway and a short term rehab unit. One of the hallways on the short term rehab unit was primarily used for Medicare patients recently admitted from the hospital. These residents required a higher level of care and were potentially more compromised with surgical wounds, infections and debilitation from prolonged hospital stays. Resident's #1, #3 and #10 resided on this hallway. The facility did not have routine set nursing assignments for the nurses and CNAs. During an interview on [DATE] at 4 PM, the Director of Nurses (DON) confirmed the staff assignments changed frequently. She stated that the goal was to have set assignments but due to accommodating staff's personal schedules, the nurses and CNAs were moved to different hallways to cover the staffing requirements. The DON confirmed that the nurses and the CNAs did not have an opportunity to know the residents especially on the Short Term Rehab hallway where the resident turnover was very quick. The DON also confirmed the acuity of the residents on the Short Term Hallway as being higher than other hallways in the facility. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had "really low blood levels" and did nothing about it until Wednesday ([DATE]) evening. She stated that he complained of a stomach ache for three days and staff did not assess him. They only came into the room and stood 10 feet away and asked if he was ok. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a history of urinary bleeding (hematuria). She stated that he was "fine" prior to going into the facility and he was there for rehab. She stated that, on Sunday [DATE], she and her husband were in the resident's room when he was complaining of stomach pain and the nursing supervisor, Employee A, came in the room and said he was fine. The family member stated that the nurse did not assess the resident at all. She also stated that her sister in law was in the building on Monday, [DATE], when he was still complaining of stomach pain, and again, no one assessed him. On Tuesday, the family was not able to be in the facility. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that the day after he died , she went to the facility to pick up his belongings and spoke with the "head nurse." She informed them that the nurses did not check on her father in law and it took two days for anyone to read the lab results. The family member stated that she felt the facility's treatment of [REDACTED]. She stated that he was not supposed to die the way he did, when he did. Review of the Hospital Notes, dated [DATE], revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident "may die tonight." The resident began to have worsening [MEDICAL CONDITION] that went to asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. Review of the Laboratory Data revealed labs were collected on [DATE] that noted his kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was "waiting on culture." Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses ' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident's potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident's hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(erature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor." At 6:45 PM, "resident leaving via non-emergency ambulance. No complaints of pain or distress." No narrative notes were made on [DATE]. Review of the check off assessment per organ system assessment located on the front of the Skilled Nurses' Notes revealed the nurse "checked" that the resident's abdomen was soft and he had no "bowel problems." On [DATE], Employee B documented the resident's vital signs were within acceptable parameters and his abdomen was soft. The narrative notes documented a "breathing treatment" was given with effective results. On [DATE], Employee I was the assigned nurse, she documented the resident's abdomen was soft with no bowel problems noted. No narrative notes were documented on [DATE]. On [DATE], the resident was not in any distress and denied any discomfort. Incontinent care was provided by staff. On [DATE], no narrative notes were documented. On [DATE], "(Attending Physician) updated on UA with blood. Dr. to wait on culture results." The nurses notes were reviewed from admission with no additional concerns noted. No additional documentation could be found related to the resident's abdominal pain or hematuria. Review of the Medical Record revealed a SBAR (Situation, Background, Assessment and Recommendation) Form that was not dated revealed the resident's blood pressure was ,[DATE] with a pulse of 66 and a respiratory rate of 17. He was afebrile. The nurse noted hematuria on the assessment. No additional assessment information was located. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: "soft and non-tender." He wanted the resident to go to the ER. The family was called and informed of the resident's condition by the physician. The resident was assessed by the physician on [DATE] in the morning, prior to the lab results being received at 7:12 PM. The resident "denies any ailments, denies SOB (shortness of breath), CP (Chest Pain), N/V (nausea/vomiting), or abdominal pain." His abdomen was soft and non-tender. He was "hemodynamically stable." During an interview on [DATE] at 11:48 AM, the Attending Physician stated that he knew the resident had a history of [REDACTED]. He stated that the resident was also recently diagnosed with [REDACTED]. The physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and looked in his binder (a communication tool the facility uses for the physicians to sign orders, lab results or other communications with the nurses) and noted that the resident's labs that were collected on Monday [DATE]. He stated that he had not been notified of the results prior to [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER that day. He stated that the resident's lab results were indicative of kidney failure and blood loss. The physician also stated that when he assessed the resident on [DATE], the resident did not have abdominal pain and was "hemodynamically stable" meaning his blood pressure and heart rate were normal. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or residents involved. Review of the [DATE] Physician admission orders [REDACTED]. Review of the Telephone Orders revealed on [DATE], Kayexelate 30 mg PO x1 dose now was ordered and to send to the ER for [MEDICAL CONDITION], acute [MEDICAL CONDITION] and hematuria. On [DATE] a CBC and BMP were ordered for the morning of [DATE]. On [DATE], a Urinalysis was ordered. Review of the comprehensive Care Plan dated [DATE] revealed the care plan included a history of [MEDICAL CONDITION]. However, the care plan did not include hematuria. Review of the ADL (Activities of Daily Living) Tracking Form (a form the Certified Nursing Assistants used to document what care was provided to the residents) for [DATE] revealed no documentation of bloody urine (hematuria). During an interview on [DATE] at 11:05 AM, the Nurse Consultant and Director of Nurses confirmed the resident's abnormal labs, physician progress notes [REDACTED]. They confirmed the abnormal labs were received at the facility on [DATE] at 7:12 PM. Both confirmed the physician was not informed of the abnormal labs until [DATE], when the resident was transferred to the ER. The DON stated that the fax machine was located at the nurses' station and the nurses were to notify the physician "within hours" of the receipt of the lab. During a telephone interview on [DATE] at 11:27 AM, Employee A (Weekend Supervisor) recalled the resident. She stated that Employee I was the assigned nurse that day and she was called to the resident's room on Sunday ([DATE]) to assess the resident. His skin was cold and clammy. His oxygen saturation was "ok" and his vital signs were "ok." She stated that his blood sugar was also within normal limits. She stated that the physician was notified, but by the time the physician called back the episode had subsided and the resident was back to his baseline. She stated that the physician ordered blood work for the morning. Employee A stated that the family was not in the facility during her assessment or when the resident was experienced his "episode." She stated that the resident did not report any pain. She also stated that Employee I would have completed the assessment and should have documented in the nurses ' notes her assessment findings. Employee A stated that she spoke with the family later that day and did not recall if they were upset. She informed them of the episode and that the physician had been notified. She confirmed she did not document her assessment of the resident. During an interview on [DATE] at 11:39 AM, Employee B stated that she was the assigned nurse on the 7 AM-3 PM shift on [DATE] and [DATE]. She stated that the resident did have blood in his urine and also stated that he "always had discolored urine." The nurse stated that she did not document the bloody urine or the discolored urine in the nurses' notes or report the findings to the physician. The nurse stated that during the day shift on [DATE], the resident did not report any abdominal pain. During an additional interview on [DATE] at 3:34 PM Employee B stated that on [DATE] the resident had an episode of low oxygen saturation. She stated that she administered oxygen to the resident and gave him his inhaler. She left the oxygen on just long enough for his saturations to return to normal. She then stated that she did not report the incident to the physician and confirmed she did not document on the Medication Administration Record. The nurse stated that she passed the episode on to the next shift in report. During an interview on [DATE] at 11:42 AM, Employee C stated that she was the evening shift (3PM-11PM) nurse on [DATE] and [DATE]. She stated that the resident did not have a lot of pain and was a "happy guy." She stated that sometimes he did have blood in his urine. She stated that she would see the blood in his diaper. She stated that "someone" told her that it was normal for him and he had bloody urine for "a while." She stated that that resident did not tell her that and could not recall if the family had given her the information. She stated that on [DATE], she was notified that the resident's blood work was abnormal and the physician wanted him sent to the hospital. She stated that she did not assess the resident because "he was in the process of going out." She stated that the resident was confused and was not complaining of pain, he was wearing oxygen. She also stated that she did not inform the family of his transfer because they had already been informed. She stated that she was not informed of any hematuria or abdominal pain by a CNA. During an interview on [DATE] at 11:59 AM, Employee D (CNA) confirmed she was the day shift CNA on [DATE]. The CNA stated that the resident had blood in his urine. She stated that the blood was "quite a lot" that was bright red in color and was coming out in a thick clot. She stated that she immediately notified the nurse (Employee E). She was informed by the nurse that this was common for the resident and that the family had mentioned the bloody urine. She stated that the resident did not have any abdominal pain during her shift. During an interview on [DATE] at 12:18 PM Employee E (LPN) stated that she was assigned to the resident twice. She stated that the resident had bloody urine on [DATE] and that a CNA had reported it to her. She stated that when she went and assessed the resident, she noted "one small drop of blood." The nurse stated that "when men are not circumcised, sometimes they have blood coming out of their penis." She stated that she called the doctor and was informed that hematuria was part of his history. The nurse confirmed she did not document the hematuria or the physician notification. She stated that on [DATE], when she was assigned to the resident, she was not informed of any bloody urine or blood clots in a brief. During an interview on [DATE] at 1:27 PM, Employee F (CNA) confirmed she was the evening shift aide on [DATE]. She stated that the resident had "a lot of blood in his urine" and was complaining of stomach pain. She immediately reported both concerns to the nurse (Employee C). She stated that later that day, he went to the hospital. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. She stated that the resident had "hematuria for a while." She stated that the physician was aware of the hematuria. Employee G stated that when she went down to the resident ' s room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that the resident was alert and was not complaining of any pain. She stated that he did not appear to be in any distress. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that she was not aware of any hematuria or abdominal pain. She stated that she did not recall any labs. She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 2:10 PM, Employee I (LPN) stated that she cared for the resident on [DATE] during both the day and the evening shifts. She stated that the resident was his normal self and did not have any complaints of pain or changes in condition. She stated that the Nursing Supervisor did not come into the room that she recalled. No hematuria was observed and she had not received a history of hematuria in the past. No complaints of abdominal pain. She confirmed she did not document a narrative note regarding the resident's condition. Per the interview with Employee A, the resident did have a change in condition on [DATE] and the physician was notified and ordered a CBC and BMP for [DATE]. During an interview on [DATE] at 9:55 AM, Employee J (CNA) confirmed she worked the night shift of [DATE]. She stated that she noted a small amount of blood in the resident's brief and reported it to the nurse immediately. The nurse informed her that it was normal for that resident. During an interview on [DATE] at 10:15 AM, Employee K (LPN) stated that she worked the 11 PM-7 AM shift on ,[DATE] and [DATE]. She stated that on ,[DATE] she obtained a UA and noted "a lot of blood." She stated that she asked the resident if he was having any pain and he stated no. She passed along to the day shift her findings and the day shift reported to the physician. She stated that on [DATE], she did not receive any reports of blood in the urine or abdominal pain. She stated that the resident was very quiet and did not complain much. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician's binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. During an interview on [DATE] at 3 PM, the Medical Director stated that he was just appointed Medical Director. He stated that he had been the Assistant Medical Director and oversees the Sub-Acute residents. He stated that over the past [AGE] years there had been a "few instances" of the nurses not informing the physicians of abnormal lab results. He stated that he was not aware of the incident with Resident #1. He stated that gross/frank hematuria should be reported to the physician immediately regardless if the resident had a history of [REDACTED]. He also stated that the nurses and the physician should document the resident's hematuria and should have documented the history of hematuria. The Medical Director stated that the physicians rely on the nursing assessments to be accurate. He stated that the nurses should assess the residents at least on a daily basis including vital signs. The nurses should document any deviations from normal including hematuria, pain or any other physical complaint. He stated that the physician should be notified immediately with incidents including falls and injuries. The Medical Director stated that if a CNA report

Based on record review, interviews with facility nursing staff, the Attending Physician, the Medical Director and facility Administration and review of the facility ' s policy and procedure regarding physician notification, facility staff failed to notify the attending physician of changes in condition for one (#1) of eleven sampled residents. Resident #1, a [AGE] year old resident, was noted by the nursing staff to have hematuria. Resident #1 had laboratory tests collected on [DATE] that were not indicative of [MEDICAL CONDITION] or acute blood loss. Resident #1 had abnormal labs collected on [DATE] that required physician intervention. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1). A high potassium level could lead to abnormal heart rhythms. His Creatinine was 5.2 and the Blood Urea Nitrogen (BUN) was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]), indicating the resident was losing blood. The physician was not notified of the continued hematuria and did not discover the lab results until [DATE]. On [DATE] at 7:30 PM, the resident was transferred to the hospital. His lab values had markedly worsened. Resident #1 subsequently died on [DATE] at 11:39 PM. The facility ' s current census was 113 residents. The lack of action taken by the nursing staff to notify the physician of changes in condition resulted in a delay in treatment and a transfer to higher level of care that resulted in Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: During an interview on [DATE] at 11:48 AM, the Attending Physician stated that he knew the resident had a history of [REDACTED]. He stated that he was not informed of the amount of bloody urine and stated that a resident that had " blood loss " should have a transfusion. The physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and noted that the resident ' s labs were collected on Monday [DATE]. The physician stated that he looked in his binder and found the labs in the book. He stated that he had not been notified of the results prior to him discovering them on [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER (emergency room ) that day. He stated that the resident ' s lab results were indicative of kidney failure and blood loss. The physician also stated that when he assessed the resident on [DATE], the resident did not have abdominal pain and was " hemodynamically stable " meaning his blood pressure and heart rate were normal. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or other residents involved. Review of the Laboratory Data revealed labs were collected on [DATE] that noted his kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was " waiting on culture. " Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses ' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. Review of the Hospital Notes dated [DATE] revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident " may die tonight. " The resident began to have worsening [MEDICAL CONDITION] that went to asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had " really low blood levels " and did nothing about it until Wednesday ([DATE]) evening. She stated that she was not contacted with the results of the labs until [DATE]. She stated that the resident complained of a stomach ache for three days and staff did not assess him. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a history of urinary bleeding (hematuria). She stated that he was " fine " prior to going into the facility and he was there for rehab. She stated that on Sunday [DATE], she and her husband were in the resident ' s room when he was complaining of stomach pain and the nursing supervisor; Employee A came in the room and said he was fine. The family member stated that the nurse did not assess the resident at all. She also stated that her sister in law was in the building on Monday, [DATE], when he was still complaining of stomach pain, and again, no one assessed him. On Tuesday, the family was not able to be in the facility. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that her father in law died in the ER. She also stated that he was not supposed to die the way he did, when he did. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. She stated that the resident had " hematuria for a while. " She stated that the physician was aware of the hematuria, however no documentation could be located related to hematuria. Employee G stated that when she went down to the resident ' s room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that the resident was alert and was not complaining of any pain. She stated that he did not appear to be in any distress. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. During an interview on [DATE] at 11:42 AM, Employee C stated that she was the evening shift (3 PM-11 PM) nurse on [DATE] and [DATE]. She stated that the resident did not have a lot of pain and was a " happy guy. " She stated that sometimes he did have blood in his urine. She stated that she would see the blood in his brief. She stated that " someone " told her that it was normal for him and he had bloody urine for " a while " . She stated that the resident did not tell her that and could not recall if the family had given her the information. She confirmed she did not notify the physician of the hematuria and did not document her findings. She stated that on [DATE], she was notified that the resident ' s blood work was abnormal and the physician wanted him sent to the hospital. She stated that she did not assess the resident because " he was in the process of going out. " She stated that the resident was confused and was not complaining of pain, he was wearing oxygen. She also stated that she did not inform the family of his transfer because they had already been informed. She stated that she was not informed of any hematuria or abdominal pain by a CNA on [DATE]. During an interview on [DATE] at 11:39 AM, Employee B stated that she was the assigned nurse on the 7 AM-3 PM shift on [DATE] and [DATE]. She stated that the resident did have blood in his urine and also stated that he " always had discolored urine. " The nurse stated that she did not document the bloody urine or the discolored urine in the nurses ' notes or report the findings to the physician. The nurse stated that during the day shift on [DATE], the resident did not report any abdominal pain. During an additional interview on [DATE] at 3:34 PM, Employee B stated that on [DATE] the resident had an episode of low oxygen saturation. She stated that she administered oxygen to the resident and gave him his inhaler. She left the oxygen on just long enough for his saturations to return to normal. She then stated that she did not report the incident to the physician or the responsible party and confirmed she did not document the medication on the Medication Administration Record. The nurse stated that she passed the episode on to the next shift in report. During an interview on [DATE] at 11:59 AM, Employee D (CNA) confirmed she was the day shift CNA on [DATE]. The CNA stated that the resident had blood in his urine. She stated that the blood was " quite a lot " that was bright red in color and was coming out in a thick clot. She stated that she immediately notified the nurse (Employee E). She was informed by the nurse that this was common for the resident and that the family had mentioned the bloody urine. She stated that the resident did not have any abdominal pain during her shift. During an interview on [DATE] at 12:18 PM Employee E (LPN) stated that she was assigned to the resident twice. She stated that the resident had bloody urine on [DATE] and that a CNA had reported it to her. She stated that when she went and assessed the resident, she noted " one small drop of blood. " The nurse stated that " when men are not circumcised, sometimes they have blood coming out of their penis. " She stated that she called the doctor and was informed that hematuria was part of his history. The nurse confirmed she did not document the hematuria or the physician notification. She stated that on [DATE], when she was assigned to the resident, she was not informed of any bloody urine or blood clots in a brief. During an interview on [DATE] at 1:27 PM, Employee F (CNA) confirmed she was the evening shift aide on [DATE]. She stated that the resident had " a lot of blood in his urine " and was complaining of stomach pain. She immediately reported both concerns to the nurse (Employee C). She stated that later that day, he went to the hospital. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that she was not aware of any hematuria or abdominal pain. She stated that she did not recall any labs. She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 2:10 PM, Employee I (LPN) stated that she cared for the resident on [DATE] during both the day and the evening shifts. She stated that the resident was his normal self and did not have any complaints of pain or changes in condition. She stated that the Nursing Supervisor did not come into the room that she recalled. No hematuria was observed and she had not received a history of hematuria in the past. No complaints of abdominal pain. She confirmed she did not document a narrative note regarding the resident ' s condition or notify the physician of any changes in condition. Per the interview on [DATE] at 11:27 AM with Employee A, (the Weekend Supervisor) the resident did have a change in condition on [DATE] and the physician was notified and ordered a CBC and BMP for [DATE]. During an interview on [DATE] at 9:55 AM, Employee J (CNA) confirmed she worked the night shift of [DATE]. She stated that she noted a small amount of blood in the resident ' s brief and reported it to the nurse immediately. The nurse informed her that it was normal for that resident. During an interview on [DATE] at 10:15 AM, Employee K (LPN) stated that she worked the 11 PM-7 AM shift on ,[DATE] and [DATE]. She stated that on ,[DATE] she obtained a UA (urine for a Urinalysis) and noted " a lot of blood. " She stated that she asked the resident if he was having any pain and he stated no. She passed along to the day shift her findings and the day shift reported to the physician. She stated that on [DATE], she did not receive any reports of blood in the urine or abdominal pain. She stated that the resident was very quiet and did not complain much. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician ' s binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. During an interview on [DATE] at 3 PM, the Medical Director stated that over the past [AGE] years there had been a " few instances " of the nurses not informing the physicians of abnormal lab results. He stated that he was not aware of the incident with Resident #1. He stated that gross/frank hematuria should be reported to the physician immediately regardless if the resident had a history of [REDACTED]. He also stated that the nurses and the physician should document the resident ' s hematuria and should have documented the history of hematuria. The Medical Director stated that the physicians rely on the nursing assessments to be accurate. He stated that the nurses should assess the residents at least on a daily basis including vital signs. The nurses should document any deviations from normal including hematuria, pain or any other physical complaint. He stated that the physician should be notified immediately with incidents including falls and injuries. The Medical Director stated that if a CNA reported a change in condition to the nurse, it would be the nurse ' s judgment of how quickly the assessment should be conducted. The Medical Director stated that the nurse should assess the resident regardless. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident ' s hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(temperature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor. " At 6:45 PM, " resident leaving via non-emergency ambulance. No complaints of pain or distress. " No narrative notes were made on [DATE]. Review of the check off assessment per organ system assessment located on the front of the Skilled Nurses ' Notes revealed the nurse " checked " that the resident ' s abdomen was soft and he had no " bowel problems. " On [DATE], Employee B documented the resident ' s vital signs were within acceptable parameters and his abdomen was soft. The narrative notes documented a " breathing treatment " was given with effective results. On [DATE], Employee I was the assigned nurse, she documented the resident ' s abdomen was soft with no bowel problems noted. No narrative notes were documented on [DATE]. On [DATE], the resident was not in any distress and denied any discomfort. Incontinent care was provided by staff. On [DATE], no narrative notes were documented. On [DATE], " (Attending Physician) updated on UA with blood. Dr. to wait on culture results. " The nurses notes were reviewed from admission with no additional concerns noted. No additional documentation could be found related to the resident ' s abdominal pain or hematuria. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: " soft and non-tender. " He wanted the resident to go to the ER. The family was called and informed of the resident ' s condition by the physician. The resident was assessed by the physician on [DATE] in the morning, prior to the lab results being received at 7:12 PM. The resident " denies any ailments, denies SOB (shortness of breath), CP (Chest Pain), N/V (nausea/vomiting), or abdominal pain. " His abdomen was soft and non-tender. He was " hemodynamically stable. " During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident ' s change in condition or lab results. The DON stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were reviewed during the clinical portion of the meeting. During an interview on [DATE] at 3:43 PM, the Administrator stated that he was made aware of the concern regarding physician notification of lab results " this week. " He stated that on [DATE] he was informed that a family had concerns that their loved one was here and went to the hospital and passed away. He stated that there " might have been an issue with labs. " The Administrator stated that the Unit Manager and the Assistant Director of Nurses spoke with the family regarding their concern on [DATE]. He stated that he did not have any additional information regarding the incident and did not know the resident ' s name at the time. The Administrator stated that he was made aware of the severity of the concern on [DATE] when the survey started. He stated that the Unit Manager educated the nurses on [DATE] regarding notification of lab results. All nurses were educated on [DATE] and [DATE]. No audits were conducted prior to [DATE]. Review of the facility ' s policy entitled Change in Resident Condition, revised on [DATE], revealed the policy of the facility was " the clinical nurse will recognize and appropriately intervene in the event of a change in resident condition. The physician/family/Responsible Party will be notified as soon as possible. " Under Procedure item 1. " The primary clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as soon as it occurs. This will also be documented in the 24 hour report. 2. The physician/family/responsible party will be notified as soon as possible to not limited to significant change, accident/incident, change in treatment, transfer/discharge. All physician ordered interventions will be immediately carried out by the clinical nurse overseen by nurse manager/supervisor. In the event of an emergency situation, 911 will be called and the physician/family/responsible party will be notified as soon as possible. 3. With change of resident status, the clinical nurse will gather subjective and objective assessment information, the nurse is responsible to complete an assessment of the resident ' s condition to including vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent and or physician and must document the date, time, party ' s notified, findings and details of the notification in the nurses ' notes. Notification of the physician and agent person of a significant change in status shall routinely occur during the shift in which it occurs. 4. Any contact to the attending physician regarding the resident ' s condition will be made by the nurse. 5. Document in medical record. The licensed nurse may use the SBAR for or document in the narrative form if necessary. 6. The supervisor will communicate to the MDS or case manager any significant changes in condition, which may warrant a reassessment. " Review of the facility ' s policy entitled Reporting Lab Results, revised on [DATE], revealed the policy was " to ensure timely reporting of lab results to the facility. " The procedure was " 1. Upon completion of the test, the lab will send written results to the facility ...3. The nurse will call or fax the abnormal results to the physician. 4. When the nurse has called or faxed the results to the physician, the nurse will write on the lab slip: 1. results faxed to Dr. __ at [PHONE NUMBER] on [DATE] at 3:00 PM. 2. Dr. __ called at 3:00 PM on [DATE], lab results reported to him. " Review of the Education provided to the nurses on [DATE] regarding notifying the physician of laboratory results timely revealed only 16 nurses attended. The facility implemented the following measures that resulted in the Immediate Jeopardy being removed on [DATE] at 1:45 PM. The measures included: 1. Educated 100% of all nurses educated on all three shifts. 2. Audited all in house residents for all labs since [DATE]. The results of the audit were reviewed and revealed 4 resident lab results were not in the clinical record, they were retrieved and noted to be within normal limits. The audit also revealed the nursing documentation of physician notification lacking. 3. All labs were to be documented on the 24 hour report with physician and nursing administration to follow up in the morning meeting 4. Random audits to be completed daily for all residents with lab orders. The findings were to be reported to QA for 3 months. The 4 Point Action Plan was reviewed and approved by the Medical Director on [DATE]. The facility ' s action plan was validated by the survey team on [DATE]. Seventeen nurses from all three shifts were interviewed regarding the education they received on ,[DATE] and [DATE]. All seventeen nurses were able to articulate the facility ' s lab process and physician notification procedure. The nurses stated that they were to initial the lab audit form after they notified the physician. The nurses stated that they were to document in the nurses ' notes the notification of the physician and any corresponding orders.

Based on record review, interviews with facility nursing staff, the Attending Physician, the Medical Director and facility Administration and review of the facility ' s policy and procedure regarding physician notification, facility staff failed notify the attending physician of laboratory results for two of eleven sampled residents reviewed for laboratory services. (Resident #1, and #3). Resident #1, an [AGE] year old resident, had laboratory tests collected on [DATE] that were not indicative of [MEDICAL CONDITION] or acute blood loss. Resident #1 had abnormal lab values collected on [DATE] that required physician intervention. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1). A high potassium level could lead to abnormal heart rhythms. His Creatinine was 5.2 and the Blood Urea Nitrogen (BUN) was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]), indicating the resident was losing blood. The physician was not notified of the results until [DATE]. On [DATE] at 7:30 PM, the resident was transferred to the hospital. His lab values had markedly worsened. Resident #1 subsequently died on [DATE] at 11:39 PM. Resident #3, an [AGE] year old resident, was noted to have a low hemoglobin on [DATE]; the physician was not notified of the results until [DATE]. The resident was directly admitted to the hospital for a blood transfusion. The facility ' s current census was 113 residents. All 113 residents had the potential to be affected. The lack of action by the nursing staff to notify the physician of abnormal laboratory results resulted in a delay in treatment and a transfer to higher level of care that resulted in Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: 1. Review of the Laboratory Data revealed labs were collected on [DATE] that noted his kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was " waiting on culture. " Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses ' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. Review of the Hospital Notes dated [DATE] revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident " may die tonight. " The resident began to have worsening [MEDICAL CONDITION] that went asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. The facility was comprised of two units, a long term care unit and a short term rehab unit. One of the hallways on the short term rehab unit was primarily used for Medicare patients recently admitted from the hospital. These residents required a higher level of care and were potentially more compromised with surgical wounds, infections and debilitation from prolonged hospital stays. Resident ' s #1 and #3 resided on this hallway. The facility did not have routine set nursing assignments for the nurses and CNAs. During an interview on [DATE] at 4 PM, the Director of Nurses (DON) confirmed the staff assignments changed frequently. She stated that the goal was to have set assignments but due to accommodating staff ' s personal schedules, the nurses and CNAs were moved to different hallways to cover the staffing requirements. The DON confirmed that the nurses and the CNAs did not have an opportunity to know the residents especially on the Short Term Rehab hallway where the resident turnover was very quick. The DON also confirmed the acuity of the residents on the Short Term Hallway as being higher than other hallways in the facility. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician ' s binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. Employee G stated that when she went down to the resident ' s room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: " soft and non-tender. " He wanted the resident to go to the ER. The family was called and informed of the resident ' s condition by the physician. During an interview on [DATE] at 11:48 AM, the Attending Physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and looked in his binder (a communication tool the facility uses for the physicians to sign orders, lab results or other communications with the nurses) and noted that the resident ' s labs were collected on Monday [DATE]. He stated that he had not been notified of the results prior to [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER that day. He stated that the resident ' s lab results were indicative of kidney failure and blood loss. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or other residents involved. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had " really low blood levels " and did nothing about it until Wednesday ([DATE]) evening. She stated that he complained of a stomach ache for three days and staff did not assess him. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a current history of urinary bleeding (hematuria). She stated that he was " fine " prior to going into the facility and he was there for rehab. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that the day after he died , she went to the facility to pick up his belongings and spoke with the " head nurse. " She informed them that the nurses did not check on her father in law and it took two days for anyone to read the lab results. The family member stated that she felt the facility ' s treatment of [REDACTED]. She stated that he was not supposed to die the way he did, when he did. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident ' s hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(temperature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor. " At 6:45 PM, " resident leaving via non-emergency ambulance. No complaints of pain or distress. " No additional documentation could be found related to laboratory results. During an interview on [DATE] at 11:05 AM, the Nurse Consultant and Director of Nurses (DON) confirmed the resident ' s abnormal labs, physician progress notes [REDACTED]. They confirmed the abnormal labs were received at the facility on [DATE] at 7:12 PM. Both confirmed the physician did not discover the abnormal labs until [DATE]; then the resident was transferred to the ER. The DON stated that the fax machine was located at the nurses ' station and the nurses were to notify the physician " within hours " of the receipt of the lab. During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident ' s change in condition or lab results. The DON stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were reviewed during the clinical portion of the meeting. During an interview on [DATE] at 3:43 PM, the Administrator stated that he was made aware of the concern regarding physician notification of lab results " this week. " He stated that on [DATE] he was informed that a family had concerns that their loved one was here and went to the hospital and passed away. He stated that there " might have been an issue with labs. " The Administrator stated that the Unit Manager and the Assistant Director of Nurses spoke with the family regarding their concern on [DATE]. He stated that he did not have any additional information regarding the incident and did not know the resident ' s name at the time. The Administrator stated that he was made aware of the severity of the concern on [DATE] when the survey started. He stated that the Unit Manager educated the nurses on [DATE] regarding notification of lab results. All nurses were educated on [DATE] and [DATE]. No audits were conducted prior to [DATE]. 2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Lab Data revealed a CBC was collected on [DATE]. The hemoglobin was 7.3 (low). Normal values were ,[DATE] in an adult male. The results were received in the facility on [DATE] at 7:05 PM. The physician was not notified until [DATE] at 8 PM. The resident was directly admitted to the hospital for a blood transfusion of 2 units of packed red blood cells. Review of the Nurses ' Notes revealed on [DATE], no narrative notes were documented. On [DATE] at 12:40 AM, the resident sustained [REDACTED]. No other documentation was noted related to abnormal lab values. On [DATE] the nurse documented the resident was on antibiotics for pneumonia and " will continue to monitor. " On [DATE] at 3:03 AM, " [MEDICATION NAME] added for pneumonia. " No other documentation was noted related to physician notification or lab values. On [DATE] at 12 AM, the resident was noted sitting on the floor mat, no injuries were noted. No other notes were located related to abnormal labs. Review of the physician progress notes [REDACTED]. A Foley Catheter was in place. On [DATE], the resident was noted with transient hematuria due to a possible kink in the Foley. On [DATE] the resident was noted with pneumonia and [MEDICATION NAME] was added. Review of the Progress Note documented on [DATE], revealed the resident was seen as a re-admission. The note read he (the resident) was sent to the hospital for a hemoglobin of 7.3 and was transfused with 2 units of packed red blood cells on [DATE]. He was readmitted back to the facility on [DATE]. Review of the telephone orders revealed the original CBC and BMP orders were entered directly into the computer to be collected on [DATE]. On [DATE] an order was written by the physician for " CBC, BMP done on [DATE], call in results to (attending physician). " The physician was in the building, assessed the resident and requested the labs on [DATE]. The labs were received at the facility two days prior on [DATE] at 7:05 PM and there was no documentation the physician was notified prior to [DATE] at 8 PM. During an interview on [DATE] at 2 PM, the Director of Nurses and the Nurse Consultant verified no nurses ' notes were documented that corresponded to abnormal labs or physician notification. Also, both confirmed the receipt of the lab on [DATE] at 7:05 PM and the physician was not notified until [DATE] at 8 PM. The DON confirmed the resident was directly admitted to the hospital for a blood transfusion on [DATE]. 3. Review of the facility ' s policy entitled Reporting Lab Results, revised on [DATE], revealed the policy was " to ensure timely reporting of lab results to the facility. " The procedure was " 1. Upon completion of the test, the lab will send written results to the facility ...3. The nurse will call or fax the abnormal results to the physician. 4. When the nurse has called or faxed the results to the physician, the nurse will write on the lab slip: 1. results faxed to Dr. ____ at (fax number) on [DATE] at 3:00 PM. 2. Dr. ____ called at 3:00 PM on [DATE], lab results reported to him. " 4. Review of the Education provided to the nurses on [DATE] regarding notifying the physician of laboratory results timely revealed only 16 nurses attended. The facility implemented the following measures that resulted in the Immediate Jeopardy being removed on [DATE] at 1:45 PM. The measures included: 1. Educated 100% of all nurses educated on all three shifts. 2. Audited all in house residents for all labs since [DATE]. The results of the audit were reviewed and revealed 4 resident lab results were not in the clinical record, they were retrieved and noted to be within normal limits. The audit also revealed the nursing documentation of physician notification lacking. 3. All labs were to be documented on the 24 hour report with physician and nursing administration to follow up in the morning meeting 4. Random audits to be completed daily for all residents with lab orders. The findings were to be reported to QA for 3 months. The 4 Point Action Plan was reviewed and approved by the Medical Director on [DATE]. The facility ' s action plan was validated by the survey team on [DATE]. Seventeen nurses from all three shifts were interviewed regarding the education they received on ,[DATE] and [DATE]. All seventeen nurses were able to articulate the facility ' s lab process and physician notification procedure. The nurses stated that they were to initial the lab audit form after they notified the physician. The nurses stated that they were to document in the nurses ' notes the notification of the physician and any corresponding orders.

Based on a review of the Administrator ' s and Director of Nurses Job Descriptions, review of the facility ' s policy and procedure regarding changes in condition and physician notification, record review, interviews with facility nursing staff, the Attending Physician, the Medical Director and facility Administration, the facility failed to operationalize facility policies for three of eleven sampled residents, Residents #1, #3 and #10. The Administrator failed to assure facility staff followed facility policy and procedures for physician notification of changes in condition and lab results and clinical documentation. The Administration failed to manage in a manner that enabled it to use its resources effectively to maintain the highest practicable physical & psychosocial well-being for Residents #1, #3 and #10 whose lab results were not reported timely to the physician that resulted in Resident #1 being transferred to the emergency room for treatment and he subsequently died ; Resident #3 required a blood transfusion and Resident #10 required an increase in his medications to treat pneumonia. The Administration did not assure that the direct functions and operations of the facility were in accordance with current regulations governing long term care facilities policies for resident care and services, physician notification and clinical assessments. During a review of Residents #1, #3 and #10's medical records, it was determined that the facility failed to operationalize it's " Change in Resident Condition " , " Daily Skilled Nursing Progress Notes " and " Reporting Lab Results " policies that resulted in Resident #1 ' s, an [AGE] year old resident, transfer to the hospital with abnormal lab values. He subsequently died in the emergency room . Resident #3, an [AGE] year old resident, was noted to have a low hemoglobin on [DATE]; the physician was not notified of the results until [DATE]. The resident was directly admitted to the hospital for a blood transfusion. Resident #10, an [AGE] year old resident, was ordered to have a chest x-ray on [DATE], the x-ray was not completed until [DATE] and the results were not given to the physician until [DATE] when the resident ' s antibiotic was increased to treat the pneumonia. The facility Administration ' s failure to oversee and effectively manage day to day operations placed residents at risk for more than minimal harm and resulted in Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: 1. Review of the Administrator ' s Job Description, effective ,[DATE], revealed the Position Summary was defined as: " The primary purpose of the Administrator is to oversee, manage and direct the day to day functions and overall operations of the facility in accordance with the current federal, state and local government regulations that govern long term care facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of quality care for the residents while achieving the facility's business objectives. " Under " Essential Duties and Responsibilities, Administrative Functions: " " Adopt, implement and maintain written policy and procedures that govern the operation of the facility. " Under Miscellaneous: " Ensure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status as defined by the comprehensive assessment and care plan. " The Job Description was signed and dated by the Administrator on [DATE]. Review of the Director of Clinical Services (Director of Nurses) Job Description that was not signed or dated revealed the following relevant duties: " As Director of Clinical Services, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties ...You will assume the primary role of ensuring the delivery of high quality, efficient nursing care ...In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility ... " Under Duties and Responsibilities: Item 9. " Maintain and guide implementation of current policies and procedures, which reflect adherence to corporate and external regulatory guidelines. " 2. Review of the facility's policy entitled "Change in Resident Condition" , revised on [DATE], revealed the policy of the facility was "the clinical nurse will recognize and appropriately intervene in the event of a change in resident condition. The physician/family/Responsible Party will be notified as soon as possible." Under Procedure item 1. "The primary clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as soon as it occurs. This will also be documented in the 24 hour report. 2. The physician/family/responsible party will be notified as soon as possible to significant change, accident/incident, change in treatment, transfer/discharge. All physician ordered interventions will be immediately carried out by the clinical nurse overseen by nurse manager/supervisor. In the event of an emergency situation, 911 will be called and the physician/family/responsible party will be notified as soon as possible. 3. With change of resident status, the clinical nurse will gather subjective and objective assessment information, the nurse is responsible to complete an assessment of the resident's condition to including vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent and or physician and must document the date, time, party's notified, findings and details of the notification in the nurses' notes. Notification of the physician and agent person of a significant change in status shall routinely occur during the shift in which it occurs. 4. Any contact to the attending physician regarding the resident's condition will be made by the nurse. 5. Document in medical record. The licensed nurse may use the SBAR for or document in the narrative form if necessary. 6. The supervisor will communicate to the MDS or case manager any significant changes in condition, which may warrant a reassessment." Review of the facility's policy entitled "Daily Skilled Nursing Progress Notes" , revised on [DATE], revealed the policy was "residents receiving skilled care shall have progress documented every shift (documented in 8 hour increments) in the medical record." The procedure was "1. The nurse shall utilize the Daily Skilled Nurses ' Notes to document resident's progress every shift. 2. The nurse will document on the Daily Skilled Nurses' Note legibly with blank ink. The resident's name and date of the note will be noted ...4. The nurse will document abnormal findings in a narrative note on the form. The nurse will also document in a narrative noted the indications for continued skilled care using the skilled charting guideline ...6. All narrative entries must have the date, time and the nurses' signatures with credentials." Review of the facility's policy entitled "Reporting Lab Results" , revised on [DATE], revealed the policy was "to ensure timely reporting of lab results to the facility." The procedure was "1. Upon completion of the test, the lab will send written results to the facility ...3. The nurse will call or fax the abnormal results to the physician. 4. When the nurse has called or faxed the results to the physician, the nurse will write on the lab slip: 1. results faxed to Dr. ___ at (fax number) on [DATE] at 3:00 PM. 2. Dr. ____ called at 3:00 PM on [DATE], lab results reported to him." 3. During an interview on [DATE] at 3:43 PM, the Administrator stated that he was made aware of the concern regarding physician notification of lab results " this week." He stated that, on [DATE], he was informed that a family had concerns that their loved one was here and went to the hospital and passed away. He stated that there "might have been an issue with labs." The Administrator stated that the Unit Manager and the Assistant Director of Nurses spoke with the family regarding their concern on [DATE]. He stated that he did not have any additional information regarding the incident and did not know the resident's name at the time. The Administrator stated that he was made aware of the severity of the concern on [DATE] when the survey started. He stated that the Unit Manager educated the nurses on [DATE] regarding notification of lab results. All nurses were educated on [DATE] and [DATE]. No audits were conducted prior to [DATE]. During an interview on [DATE] at 3:55 PM, the Assistant Director of Nurses (ADON) stated that the family of Resident #1 came to the facility on [DATE] and had some concerns related to a lab that was done on Monday and the resident was not sent out until Wednesday. The resident was alert at the hospital. The resident [MEDICAL CONDITION]. The ADON apologized to the family and said she "would do something about it." The ADON stated that education was provided on [DATE] regarding reporting labs immediately. The nurse (Employee H) received a written warning. She stated that she did not write the concerns on a grievance form since the resident was already discharged . She stated that if he was a current resident she would have done a grievance. She stated that she informed the administrator of the concerns. The facility was comprised of two units, a long term care unit with a memory care hallway and a short term rehab unit. One of the hallways on the short term rehab unit was primarily used for Medicare patients recently admitted from the hospital. These residents required a higher level of care and were potentially more compromised with surgical wounds, infections and debilitation from prolonged hospital stays. Resident ' s #1, #3 and #10 resided on this hallway. The facility did not have routine set nursing assignments for the nurses and CNAs. During an interview on [DATE] at 4 PM, the Director of Nurses (DON) confirmed the staff assignments changed frequently. She stated that the goal was to have set assignments but due to accommodating staff 's personal schedules, the nurses and CNAs were moved to different hallways to cover the staffing requirements. The DON confirmed that the nurses and the CNAs did not have an opportunity to know the residents especially, on the Short Term Rehab hallway where the resident turnover was very quick. The DON also confirmed the acuity of the residents on the Short Term Hallway as being higher than other hallways in the facility. Review of the Laboratory Data revealed labs were collected on [DATE] that noted Resident #1's kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was "waiting on culture." Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident's potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. Review of the Hospital Notes, dated [DATE], revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident "may die tonight." The resident began to have worsening [MEDICAL CONDITION] that went to asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had "really low blood levels" and did nothing about it until Wednesday ([DATE]) evening. She stated that he complained of a stomach ache for three days and staff did not assess him. They only came into the room and stood 10 feet away and asked if he was ok. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a history of urinary bleeding (hematuria). She stated that he was "fine" prior to going into the facility and he was there for rehab. She stated that on Sunday [DATE], she and her husband were in the resident's room when he was complaining of stomach pain and the nursing supervisor; Employee A came in the room and said he was fine. The family member stated that the nurse did not assess the resident at all. She also stated that her sister in law was in the building on Monday, [DATE], when he was still complaining of stomach pain, and again, no one assessed him. On Tuesday, the family was not able to be in the facility. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that the day after he died , she went to the facility to pick up his belongings and spoke with the "head nurse." She informed them that the nurses did not check on her father in law and it took two days for anyone to read the lab results. The family stated that she felt the facility ' s treatment of [REDACTED]. She stated that he was not supposed to die the way he did, when he did. During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident's change in condition or lab results. The DON stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were reviewed during the clinical portion of the meeting. During an interview on [DATE] at 3 PM, the Medical Director stated that he was just appointed Medical Director. He stated that he had been the Assistant Medical Director and oversees the Sub-Acute residents. He stated that over the past [AGE] years there had been a "few instances" of the nurses not informing the physicians of abnormal lab results. He stated that he was not aware of the incident with Resident #1. He stated that gross/frank hematuria should be reported to the physician immediately regardless if the resident had a history of [REDACTED]. He also stated that the nurses and the physician should document the resident's hematuria and should have documented the history of hematuria. The Medical Director stated that the physicians rely on the nursing assessments to be accurate. He stated that the nurses should assess the residents at least on a daily basis including vital signs. The nurses should document any deviations from normal including hematuria, pain or any other physical complaint. He stated that the physician should be notified immediately with incidents including falls and injuries. The Medical Director stated that if a CNA reported a change in condition to the nurse, it would be the nurse's judgment of how quickly the assessment should be conducted. The Medical Director stated that the nurse should assess the resident regardless. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident's hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(erature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor." At 6:45 PM, "resident leaving via non-emergency ambulance. No complaints of pain or distress." No narrative notes were made on [DATE]. Review of the check off assessment per organ system assessment, located on the front of the Skilled Nurses ' Notes, revealed the nurse "checked" that the resident's abdomen was soft and he had no "bowel problems." On [DATE], Employee B documented the resident's vital signs were within acceptable parameters and his abdomen was soft. The narrative notes documented a "breathing treatment" was given with effective results. On [DATE], Employee I was the assigned nurse, she documented the resident's abdomen was soft with no bowel problems noted. No narrative notes were documented on [DATE]. On [DATE], the resident was not in any distress and denied any discomfort. Incontinent care was provided by staff. On [DATE], no narrative notes were documented. On [DATE], " (Attending Physician) updated on UA with blood. Dr. to wait on culture results." The nurses notes were reviewed from admission with no additional concerns noted. No additional documentation could be found related to the resident's abdominal pain or hematuria. Review of the Medical Record revealed a SBAR (Situation, Background, Assessment and Recommendation) Form that was not dated revealed the resident's blood pressure was ,[DATE] with a pulse of 66 and a respiratory rate of 17. He was afebrile. The nurse noted hematuria on the assessment. No additional assessment information was located. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: "soft and non-tender." He wanted the resident to go to the ER. The family was called and informed of the resident's condition by the physician. The resident was assessed by the physician on [DATE] in the morning, prior to the lab results being received at 7:12 PM. The resident "denies any ailments, denies SOB (shortness of breath), CP (Chest Pain), N/V (nausea/vomiting), or abdominal pain." His abdomen was soft and non-tender. He was "hemodynamically stable." During an interview on [DATE] at 11:48 AM, the Attending Physician stated that he knew the resident had a history of [REDACTED]. He stated that the resident was also recently diagnosed with [REDACTED]. The physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and looked in his binder (a communication tool the facility uses for the physicians to sign orders, lab results or other communications with the nurses) and noted that the resident's labs were collected on Monday [DATE]. He stated that he had not been notified of the results prior to [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER that day. He stated that the resident's lab results were indicative of kidney failure and blood loss. The physician also stated that when he assessed the resident on [DATE], the resident did not have abdominal pain and was "hemodynamically stable" meaning his blood pressure and heart rate were normal. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or residents involved. During an interview on [DATE] at 11:05 AM, the Nurse Consultant and Director of Nurses confirmed the resident's abnormal labs, physician progress notes [REDACTED]. They confirmed the abnormal labs were received at the facility on [DATE] at 7:12 PM. Both confirmed the physician was not informed of the abnormal labs until [DATE], when the resident was transferred to the ER. The DON stated that the fax machine was located at the nurses' station and the nurses were to notify the physician "within hours" of the receipt of the lab. During a telephone interview on [DATE] at 11:27 AM, Employee A (Weekend Supervisor) recalled the resident. She stated that Employee I was the assigned nurse that day and she was called to room the resident's room on Sunday ([DATE]) to assess the resident. His skin was cold and clammy. His oxygen saturation was "ok" and his vital signs were "ok." She stated that his blood sugar was also within normal limits. She stated that the physician was notified, but by the time the physician called back the episode had subsided and the resident was back to his baseline. She stated that the physician ordered blood work for the morning. Employee A stated that the family was not in the facility during her assessment or when the resident was experienced his "episode." She stated that the resident did not report any pain. She also stated that Employee I would have completed the assessment and should have documented in the nurses' notes her assessment findings. Employee A stated that she spoke with the family later that day and did not recall if they were upset. She informed them of the episode and that the physician had been notified. She confirmed she did not document her assessment of the resident. During an interview on [DATE] at 11:39 AM, Employee B stated that she was the assigned nurse on the 7 AM-3 PM shift on [DATE] and [DATE]. She stated that the resident did have blood in his urine and also stated that he "always had discolored urine." The nurse stated that she did not document the bloody urine or the discolored urine in the nurses' notes or report the findings to the physician. The nurse stated that during the day shift on [DATE], the resident did not report any abdominal pain. During an additional interview on [DATE] at 3:34 PM, Employee B stated that on [DATE] the resident had an episode of low oxygen saturation. She stated that she administered oxygen to the resident and gave him his inhaler. She left the oxygen on just long enough for his saturations to return to normal. She then stated that she did not report the incident to the physician and confirmed she did not document on the Medication Administration Record. The nurse stated that she passed the episode on to the next shift in report. During an interview on [DATE] at 11:42 AM, Employee C stated that she was the evening shift (3PM-11PM) nurse on [DATE] and [DATE]. She stated that the resident did not have a lot of pain and was a "happy guy." She stated that sometimes he did have blood in his urine. She stated that she would see the blood in his diaper. She stated that "someone" told her that it was normal for him and he had bloody urine for "a while." She stated that that the resident did not tell her that and could not recall if the family had given her the information. She stated that on [DATE], she was notified that the resident's blood work was abnormal and the physician wanted him sent to the hospital. She stated that she did not assess the resident because "he was in the process of going out." She stated that the resident was confused and was not complaining of pain, he was wearing oxygen. She also stated that she did not inform the family of his transfer because they had already been informed. She stated that she was not informed of any hematuria or abdominal pain by a CNA. During an interview on [DATE] at 11:59 AM, Employee D (CNA) confirmed she was the day shift CNA on [DATE]. The CNA stated that the resident had blood in his urine. She stated that the blood was " quite a lot " that was bright red in color and was coming out in a thick clot. She stated that she immediately notified the nurse (Employee E). She was informed by the nurse that this was common for the resident and that the family had mentioned the bloody urine. She stated that the resident did not have any abdominal pain during her shift. During an interview on [DATE] at 12:18 PM Employee E (LPN) stated that she was assigned to the resident twice. She stated that the resident had bloody urine on [DATE] and that a CNA had reported it to her. She stated that when she went and assessed the resident, she noted "one small drop of blood." The nurse stated that "when men are not circumcised, sometimes they have blood coming out of their penis." She stated that she called the doctor and was informed that hematuria was part of his history. The nurse confirmed she did not document the hematuria or the physician notification. She stated that on [DATE], when she was assigned to the resident, she was not informed of any bloody urine or blood clots in a brief. During an interview on [DATE] at 1:27 PM, Employee F (CNA) confirmed she was the evening shift aide on [DATE]. She stated that the resident had "a lot of blood in his urine" and was complaining of stomach pain. She immediately reported both concerns to the nurse (Employee C). She stated that later that day, he went to the hospital. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. She stated that the resident had "hematuria for a while." She stated that the physician was aware of the hematuria. Employee G stated that when she went down to the resident's room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that the resident was alert and was not complaining of any pain. She stated that he did not appear to be in any distress. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that she was not aware of any hematuria or abdominal pain. She stated that she did not recall any labs. She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 2:10 PM, Employee I (LPN) stated that she cared for the resident on [DATE] during both the day and the evening shifts. She stated that the resident was his normal self and did not have any complaints of pain or changes in condition. She stated that the Nursing Supervisor did not come into the room that she recalled. No hematuria was observed and she had not received a history of hematuria in the past. No complaints of abdominal pain. She confirmed she did not document a narrative note regarding the resident's condition. Per the interview with Employee A, the resident did have a change in condition on [DATE] and the physician was notified and ordered a CBC and BMP for [DATE]. During an interview on [DATE] at 9:55 AM, Employee J (CNA) confirmed she worked the night shift of [DATE]. She stated that she noted a small amount of blood in the resident's brief and reported it to the nurse immediately. The nurse informed her that it was normal for that resident. During an interview on [DATE] at 10:15 AM, Employee K (LPN) stated that she worked the 11 PM-7 AM shift on ,[DATE] and [DATE]. She stated that on ,[DATE] she obtained a UA and noted "a lot of blood." She stated that she asked the resident if he was having any pain and he stated no. She passed along to the day shift her findings and the day shift reported to the physician. She stated that on [DATE], she did not receive any reports of blood in the urine or abdominal pain. She stated that the resident was very quiet and did not complain much. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician's binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. 3. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Lab Data revealed a CBC was collected on [DATE]. The hemoglobin was 7.3 (low). Normal values were ,[DATE] in an adult male. The results were received in the facility on [DATE] at 7:05 PM. The physician was not notified until [DATE] at 8 PM. The resident was directly admitted to the hospital for a blood transfusion of 2 units of packed red blood cells. Review of the Nurses' Notes revealed on [DATE], no narrative notes were documented. On [DATE] at 12:40 AM, the resident sustained [REDACTED]. No other documentation was noted related to abnormal lab values. On [DATE] the nurse documented the resident was on antibiotics for pneumonia and "will continue to monitor." On [DATE] at 3:03 AM, "[MEDICATION NAME] added for pneumonia." No other documentation was noted related to physician notification or lab values. On [DATE] at 12 AM, the resident was noted sitting on the floor mat, no injuries were noted. No other no

Based on record review, interviews with facility nursing staff, the Attending Physician, the Medical Director and facility Administration, and review of the facility ' s policy and procedure regarding changes in condition and physician notification, the facility failed to assure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing for three of eleven residents. (Residents #1, #3 and #10). Based on a review of eleven residents that had laboratory tests collected and experienced a change in condition requiring treatment, Resident #1, an [AGE] year old resident, had laboratory tests collected on [DATE] that were not indicative of [MEDICAL CONDITION] or acute blood loss. Resident #1 was reported to have hematuria (blood in the urine) since [DATE]. The nursing staff failed to assess and document the hematuria and failed to notify the physician of the continued hematuria. Resident #1 also had abnormal lab values collected on [DATE] that required physician intervention. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1). A high potassium level could lead to abnormal heart rhythms. His Creatinine was 5.2 and the Blood Urea Nitrogen (BUN) was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]), indicating the resident was losing blood. The physician did not discover the results until [DATE]. The resident was noted to have hematuria. On [DATE] at 7:30 PM, the resident was transferred to the hospital. His lab values had markedly worsened. Resident #1 subsequently died on [DATE] at 11:39 PM. Resident #3, an [AGE] year old resident, was noted to have a low hemoglobin on [DATE]; the physician was not notified of the results until [DATE]. The resident was directly admitted to the hospital for a blood transfusion. Resident #10, an [AGE] year old resident, was ordered to have a chest x-ray on [DATE], the x-ray was not completed until [DATE] and the results were not given to the physician until [DATE] when the resident ' s antibiotic was increased to treat the pneumonia. The facility ' s current census was 113 residents. All three residents (#1, #3, and #10) resided on one hallway of the Short Term Rehab/Subacute side of the facility. The lack of action by the nursing staff to assess, document and notify to the physician of abnormal laboratory results resulted in a delay in treatment and a transfer to higher level of care that resulted in Immediate Jeopardy existing in the facility as of [DATE]. The Immediate Jeopardy was removed on [DATE] at 1:45 PM and the scope and severity was reduced to a " D " . The findings included: 1. During a telephone call on [DATE] at 8:35 AM, the family member of Resident #1 stated that the facility was aware on [DATE] (Monday) that he had " really low blood levels " and did nothing about it until Wednesday ([DATE]) evening. She stated that he complained of a stomach ache for three days and staff did not assess him. They only came into the room and stood 10 feet away and asked if he was ok. During an additional interview on [DATE] at 8:45 AM, the family member stated that Resident #1 did not have a history of urinary bleeding (hematuria). She stated that he was " fine " prior to going into the facility and he was there for rehab. She stated that on Sunday [DATE], she and her husband were in the resident ' s room when he was complaining of stomach pain and the nursing supervisor, Employee A, came in the room and said he was fine. The family member stated that the nurse did not assess the resident at all. She also stated that her sister in law was in the building on Monday, [DATE], when he was still complaining of stomach pain, and again, no one assessed him. On Tuesday, the family was not able to be in the facility. On Wednesday, they received a call from the doctor at 5:30 PM stating that her father in law was going to the hospital for a blood transfusion. She stated that the day after he died , she went to the facility to pick up his belongings and spoke with the " head nurse. " She informed them that the nurses did not check on her father in law and it took two days for anyone to read the lab results. The family member stated that she felt the facility ' s treatment of [REDACTED]. She stated that he was not supposed to die the way he did, when he did. Review of the Hospital Notes dated [DATE] revealed Resident #1 arrived at the emergency roiagnom on [DATE] after 7 PM. His principal [DIAGNOSES REDACTED]. Upon his initial ER assessment on [DATE] at 9:40 PM, he was noted to have a Glasgow Coma Scale of 14 out of 15. He was weak with thready pulses. He was in 1st degree heart block. The resident was noted to have crackles throughout his lung fields. He had abdominal guarding and tenderness upon palpation. He also had hematuria with bloody urine noted in his Foley Catheter. His lab work in the ER was significant for a hemoglobin level of 7.1 (critically low). His potassium level was 7.9 (Critically high). He was noted to be in acute [MEDICAL CONDITION]. The family was consulted via telephone and gave verbal consent for a Do Not Resuscitate, no vasoactive medications, no intubations and to keep his father comfortable. The family did not want [MEDICAL TREATMENT]. The family was aware that the resident " may die tonight. " The resident began to have worsening [MEDICAL CONDITION] that went to asystole (no heart beat). He was pronounced dead at 11:39 PM with the family at the bedside. Review of the Laboratory Data revealed labs were collected on [DATE] that noted his kidney function was within acceptable parameters with a BUN of 33 and a Creatinine of 1.1. His electrolytes were normal. The resident was noted to be anemic with a hemoglobin level of 9.0. (Normal for an adult male was ,[DATE]). A UA (Urinalysis) was collected on [DATE] and the results were called to the physician on [DATE]. The resident was noted to have blood in his urine. The nurse documented on the lab result that the physician was notified and no new orders were given. The physician was " waiting on culture. " Review of the culture results received on [DATE] revealed no growth after 48 hours. There was no documentation that the physician was contacted regarding the culture results on either the lab sheet or the nurses ' notes. On [DATE] a CBC and BMP were collected and were sent via fax to the facility on [DATE] at 7:12 PM. The resident ' s potassium was 6.3 (normal-3XXX,[DATE].1), the creatinine was 5.2 and the BUN was 90 (indicating [MEDICAL CONDITION]). His Hemoglobin was 7.3 (normal was ,[DATE]). He was also noted to have increased white blood cells at 19.4 (3XXX,[DATE]). These labs indicated a marked worsening of his kidney function and electrolytes and were significant for blood loss. The labs on [DATE] referenced the lab results that were collected on [DATE] to show the comparison. The facility admitted Resident #1 on [DATE]. Per the demographic face sheet, the resident was admitted with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes for Resident #1 revealed on [DATE] at 6:30 PM, Employee C documented: " (Attending Physician) in facility, checked lab results and decided to send pt. out to hospital. Resident ' s hemoglobin was 7.3, transfusion needed as per (Attending Physician). Foley Catheter inserted. Vitals are stable ,[DATE], HR (Heart Rate) 67, RR (Respiratory Rate) 17, temp(temperature) 98.4. O2 sat (Oxygen Saturation) 96% RA (Room Air). Resident is alert with no complaints of pain. Family notified, report called to (hospital). Resident in bed will continue to monitor. " At 6:45 PM, " resident leaving via non-emergency ambulance. No complaints of pain or distress. " No narrative notes were made on [DATE]. Review of the check off assessment per organ system assessment located on the front of the Skilled Nurses ' Notes revealed the nurse " checked " that the resident ' s abdomen was soft and he had no " bowel problems. " On [DATE], Employee B documented the resident ' s vital signs were within acceptable parameters and his abdomen was soft. The narrative notes documented a " breathing treatment " was given with effective results. On [DATE], Employee I was the assigned nurse, she documented the resident ' s abdomen was soft with no bowel problems noted. No narrative notes were documented on [DATE]. On [DATE], the resident was not in any distress and denied any discomfort. Incontinent care was provided by staff. On [DATE], no narrative notes were documented. On [DATE], " (Attending Physician) updated on UA with blood. Dr. to wait on culture results. " The nurses notes were reviewed from admission with no additional concerns noted. No additional documentation could be found related to the resident ' s abdominal pain or hematuria. Review of the Medical Record revealed a SBAR (Situation, Background, Assessment and Recommendation) Form that was not dated revealed the resident ' s blood pressure was ,[DATE] with a pulse of 66 and a respiratory rate of 17. He was afebrile. The nurse noted hematuria on the assessment. No additional assessment information was located. Review of the physician progress notes [REDACTED]. He assessed the resident and documented under the abdominal section: " soft and non-tender. " He wanted the resident to go to the ER. The family was called and informed of the resident ' s condition by the physician. The resident was assessed by the physician on [DATE] in the morning, prior to the lab results being received at 7:12 PM. The resident " denies any ailments, denies SOB (shortness of breath), CP (Chest Pain), N/V (nausea/vomiting), or abdominal pain. " His abdomen was soft and non-tender. He was " hemodynamically stable. " During an interview on [DATE] at 11:48 AM, the Attending Physician stated that he knew the resident had a history of [REDACTED]. He stated that the resident was also recently diagnosed with [REDACTED]. The physician stated that on [DATE] he arrived at the facility at approximately 5:30 PM and looked in his binder (a communication tool the facility uses for the physicians to sign orders, lab results or other communications with the nurses) and noted that the resident ' s labs that were collected on Monday [DATE]. He stated that he had not been notified of the results prior to [DATE]. He stated that he went and assessed the resident and determined that he needed to be treated in the hospital. His hemoglobin was 7 and his potassium was high. He stated that he called the family and they were in agreement to send him to the hospital. The physician stated that since his vital signs were stable he could be sent to the hospital via non-emergent transfer. The physician stated that the nurses were supposed to contact him immediately with lab results especially if the results were critical. He stated that if he was contacted on Monday, [DATE], he would have sent the resident to the ER that day. He stated that the resident ' s lab results were indicative of kidney failure and blood loss. The physician also stated that when he assessed the resident on [DATE], the resident did not have abdominal pain and was " hemodynamically stable " meaning his blood pressure and heart rate were normal. The physician stated that this was not the first time the nurses failed to contact him with lab results. He stated that he had spoken with the Unit Manager and the Director of Nurses regarding the concern and the facility educated the nurses. The physician could not recall specific times or residents involved. Review of the [DATE] Physician admission orders [REDACTED]. Review of the Telephone Orders revealed on [DATE], Kayexelate 30 mg PO x1 dose now was ordered and to send to the ER for [MEDICAL CONDITION], acute [MEDICAL CONDITION] and hematuria. On [DATE] a CBC and BMP were ordered for the morning of [DATE]. On [DATE], a Urinalysis was ordered. Review of the comprehensive Care Plan dated [DATE] revealed the care plan included a history of [MEDICAL CONDITION]. However, the care plan did not include hematuria. Review of the ADL (Activities of Daily Living) Tracking Form (a form the Certified Nursing Assistants used to document what care was provided to the residents) for [DATE] revealed no documentation of bloody urine (hematuria). During an interview on [DATE] at 11:05 AM, the Nurse Consultant and Director of Nurses confirmed the resident ' s abnormal labs, physician progress notes [REDACTED]. They confirmed the abnormal labs were received at the facility on [DATE] at 7:12 PM. Both confirmed the physician was not informed of the abnormal labs until [DATE], when the resident was transferred to the ER. The DON stated that the fax machine was located at the nurses ' station and the nurses were to notify the physician " within hours " of the receipt of the lab. During a telephone interview on [DATE] at 11:27 AM, Employee A (Weekend Supervisor) recalled the resident. She stated that Employee I was the assigned nurse that day and she was called to the resident ' s room on Sunday ([DATE]) to assess the resident. His skin was cold and clammy. His oxygen saturation was " ok " and his vital signs were " ok. " She stated that his blood sugar was also within normal limits. She stated that the physician was notified, but by the time the physician called back the episode had subsided and the resident was back to his baseline. She stated that the physician ordered blood work for the morning. Employee A stated that the family was not in the facility during her assessment or when the resident was experienced his " episode. " She stated that the resident did not report any pain. She also stated that Employee I would have completed the assessment and should have documented in the nurses ' notes her assessment findings. Employee A stated that she spoke with the family later that day and did not recall if they were upset. She informed them of the episode and that the physician had been notified. She confirmed she did not document her assessment of the resident. During an interview on [DATE] at 11:39 AM, Employee B stated that she was the assigned nurse on the 7 AM-3 PM shift on [DATE] and [DATE]. She stated that the resident did have blood in his urine and also stated that he " always had discolored urine. " The nurse stated that she did not document the bloody urine or the discolored urine in the nurses ' notes or report the findings to the physician. The nurse stated that during the day shift on [DATE], the resident did not report any abdominal pain. During an additional interview on [DATE] at 3:34 PM Employee B stated that on [DATE] the resident had an episode of low oxygen saturation. She stated that she administered oxygen to the resident and gave him his inhaler. She left the oxygen on just long enough for his saturations to return to normal. She then stated that she did not report the incident to the physician and confirmed she did not document on the Medication Administration Record. The nurse stated that she passed the episode on to the next shift in report. During an interview on [DATE] at 11:42 AM, Employee C stated that she was the evening shift (3 PM-11 PM) nurse on [DATE] and [DATE]. She stated that the resident did not have a lot of pain and was a " happy guy. " She stated that sometimes he did have blood in his urine. She stated that she would see the blood in his diaper. She stated that " someone " told her that it was normal for him and he had bloody urine for " a while " . She stated that that resident did not tell her that and could not recall if the family had given her the information. She stated that on [DATE], she was notified that the resident ' s blood work was abnormal and the physician wanted him sent to the hospital. She stated that she did not assess the resident because " he was in the process of going out. " She stated that the resident was confused and was not complaining of pain, he was wearing oxygen. She also stated that she did not inform the family of his transfer because they had already been informed. She stated that she was not informed of any hematuria or abdominal pain by a CNA. During an interview on [DATE] at 11:59 AM, Employee D (CNA) confirmed she was the day shift CNA on [DATE]. The CNA stated that the resident had blood in his urine. She stated that the blood was " quite a lot " that was bright red in color and was coming out in a thick clot. She stated that she immediately notified the nurse (Employee E). She was informed by the nurse that this was common for the resident and that the family had mentioned the bloody urine. She stated that the resident did not have any abdominal pain during her shift. During an interview on [DATE] at 12:18 PM Employee E (LPN) stated that she was assigned to the resident twice. She stated that the resident had bloody urine on [DATE] and that a CNA had reported it to her. She stated that when she went and assessed the resident, she noted " one small drop of blood. " The nurse stated that " when men are not circumcised, sometimes they have blood coming out of their penis. " She stated that she called the doctor and was informed that hematuria was part of his history. The nurse confirmed she did not document the hematuria or the physician notification. She stated that on [DATE], when she was assigned to the resident, she was not informed of any bloody urine or blood clots in a brief. During an interview on [DATE] at 1:27 PM, Employee F (CNA) confirmed she was the evening shift aide on [DATE]. She stated that the resident had " a lot of blood in his urine " and was complaining of stomach pain. She immediately reported both concerns to the nurse (Employee C). She stated that later that day, he went to the hospital. During an interview on [DATE] at 3:23 PM, Employee G (LPN) stated that she was the Evening Supervisor on [DATE]. She stated that the physician informed her that Resident #1 had abnormal labs and wanted him sent to the hospital for a blood transfusion. She stated that the resident had " hematuria for a while. " She stated that the physician was aware of the hematuria. Employee G stated that when she went down to the resident ' s room that evening, the nurse (Employee C) and a CNA were inserting a Foley catheter. She stated that the resident was alert and was not complaining of any pain. She stated that he did not appear to be in any distress. She stated that she did not perform an assessment. The Supervisor stated that the assigned nurse was responsible for notifying the physician of lab results. During an interview on [DATE] at 4:20 PM, Employee H stated that she was assigned to Resident #1 on [DATE] during the evening shift (the day and shift when the abnormal lab results were received at the facility). She stated that she was not aware of any hematuria or abdominal pain. She stated that she did not recall any labs. She stated that the nurses were supposed to remove the lab results from the fax machine and call the physician with the results. She confirmed that she did not notify the physician of any lab results on [DATE]. She stated that she did not recall removing his labs from the fax machine. During an interview on [DATE] at 2:10 PM, Employee I (LPN) stated that she cared for the resident on [DATE] during both the day and the evening shifts. She stated that the resident was his normal self and did not have any complaints of pain or changes in condition. She stated that the Nursing Supervisor did not come into the room that she recalled. No hematuria was observed and she had not received a history of hematuria in the past. No complaints of abdominal pain. She confirmed she did not document a narrative note regarding the resident ' s condition. Per the interview with Employee A, the resident did have a change in condition on [DATE] and the physician was notified and ordered a CBC and BMP for [DATE]. During an interview on [DATE] at 9:55 AM, Employee J (CNA) confirmed she worked the night shift of [DATE]. She stated that she noted a small amount of blood in the resident ' s brief and reported it to the nurse immediately. The nurse informed her that it was normal for that resident. During an interview on [DATE] at 10:15 AM, Employee K (LPN) stated that she worked the 11 PM-7 AM shift on ,[DATE] and [DATE]. She stated that on ,[DATE] she obtained a UA and noted " a lot of blood. " She stated that she asked the resident if he was having any pain and he stated no. She passed along to the day shift her findings and the day shift reported to the physician. She stated that on [DATE], she did not receive any reports of blood in the urine or abdominal pain. She stated that the resident was very quiet and did not complain much. During an interview on [DATE] at 3:30 PM, the Unit Manager stated that the assigned nurses were to call the doctor with the lab results. She stated that the nurses were supposed to check the fax machine throughout their shift to check for lab results. She stated that once the physician had been notified the nurses were to file the lab in the physician ' s binder for the physician to review and sign. She stated that the nurses should make a narrative note in the chart of the physician notification. She stated that abnormal lab values were to be reported to the Unit Manager to follow up in clinical morning meeting. During an interview on [DATE] at 3 PM, the Medical Director stated that he was just appointed Medical Director. He stated that he had been the Assistant Medical Director and oversees the Sub-Acute residents. He stated that over the past [AGE] years there had been a " few instances " of the nurses not informing the physicians of abnormal lab results. He stated that he was not aware of the incident with Resident #1. He stated that gross/frank hematuria should be reported to the physician immediately regardless if the resident had a history of [REDACTED]. He also stated that the nurses and the physician should document the resident ' s hematuria and should have documented the history of hematuria. The Medical Director stated that the physicians rely on the nursing assessments to be accurate. He stated that the nurses should assess the residents at least on a daily basis including vital signs. The nurses should document any deviations from normal including hematuria, pain or any other physical complaint. He stated that the physician should be notified immediately with incidents including falls and injuries. The Medical Director stated that if a CNA reported a change in condition to the nurse, it would be the nurse ' s judgment of how quickly the assessment should be conducted. The Medical Director stated that the nurse should assess the resident regardless. During an interview on [DATE] at 3:43 PM, the Administrator stated that he was made aware of the concern regarding physician notification of lab results " this week. " He stated that on [DATE] he was informed that a family had concerns that their loved one was here and went to the hospital and passed away. He stated that there " might have been an issue with labs. " The Administrator stated that the Unit Manager and the Assistant Director of Nurses spoke with the family regarding their concern on [DATE]. He stated that he did not have any additional information regarding the incident and did not know the resident ' s name at the time. The Administrator stated that he was made aware of the severity of the concern on [DATE] when the survey started. He stated that the Unit Manager educated the nurses on [DATE] regarding notification of lab results. All nurses were educated on [DATE] and [DATE]. No audits were conducted prior to [DATE]. During an interview on [DATE] at 3:55 PM, the Assistant Director of Nurses (ADON) stated that the family of Resident #1 came to the facility on [DATE] and had some concerns related to a lab that was done on Monday and the resident was not sent out until Wednesday. The resident was alert at the hospital. The resident [MEDICAL CONDITION]. The ADON apologized to the family and said she " would do something about it. " The ADON stated that education was provided on [DATE] regarding reporting labs immediately. The nurse (Employee H) received a written warning. She stated that she did not write the concerns on a grievance from since the resident was already discharged . She stated that if he was a current resident she would have done a grievance. She stated that she informed the administrator of the concerns. During an interview on [DATE] at 4:10 PM, the Director of Nurses and Nurse Consultant stated that during the clinical meeting on [DATE], Resident #1 was not discussed. She stated that the 24 hour report did not document anything regarding the resident ' s change in condition or lab results. The DON stated that the normal facility process was to review all labs in the morning meeting Monday through Friday. She stated that residents with abnormal labs were reviewed during the clinical portion of the meeting. Review of the facility ' s policy entitled Change in Resident Condition, revised on [DATE], revealed the policy of the facility was " the clinical nurse will recognize and appropriately intervene in the event of a change in resident condition. The physician/family/Responsible Party will be notified as soon as possible. " Under Procedure item 1. " The primary clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as soon as it occurs. This will also be documented in the 24 hour report. 2. The physician/family/responsible party will be notified as soon as possible to not limited to significant change, accident/incident, change in treatment, transfer/discharge. All physician ordered interventions will be immediately carried out by the clinical nurse overseen by nurse manager/supervisor. In the event of an emergency situation, 911 will be called and the physician/family/responsible party will be notified as soon as possible. 3. With change of resident status, the clinical nurse will gather subjective and objective assessment information, the nurse is responsible to complete an assessment of the resident ' s condition to including vital signs, level of consciousness and any other symptoms related to the condition and make any judgment calls regarding the course of action to be taken, the need to contact the agent and or physician and must document the date, time, party ' s notified, findings and details of the notification in the nurses ' notes. Notification of the physician and agent person of a significant change in status shall routinely occur during the shift in which it occurs. 4. Any contact to the attending physician regarding the resident ' s condition will be made by the nurse. 5. Document in medical record. The licensed nurse may use the SBAR for or document in the narrative form if necessary. 6. The supervisor will communicate to the MDS or case manager any significant changes in condition, which may warrant a reassessment. " Review of the facility ' s policy entitled Daily Skilled Nursing Progress Notes, revised on [DATE], revealed the policy was " residents receiving skilled care shall have progress documented every shift (documented in 8 hour increments) in the medical record. " The procedure was " 1. The nurse shall utilize the Daily Skilled Nurses ' Notes to document resident ' s progress every shift. 2. The nurse will document on the Daily Skilled Nurses ' Note legibly with blank ink. The resident ' s name and date of the note will be noted ...4. The nurse will document abnormal findings in a narrative note on the form. The nurse will also document in a narrative noted the indications for continued skilled care using the skilled charting guideline ...6. All narrative entries must have the date, time and the nurses ' signatures with credentials. " Review of the facility ' s policy entitled Reporting Lab Results, revised on [DATE], revealed the policy was " to ensure timely reporting of lab results to the facility. " The procedure was " 1. Upon completion of the test, the lab will send written results to the facility ...3. The nurse will call or fax the abnormal results to the physician. 4. When the nurse has called or faxed the results to the physician, the nurse will write on the lab slip: 1. results faxed to Dr. __ at [PHONE NUMBER] on [DATE] at 3:00 PM. 2. Dr. __ called at 3:00 PM on [DATE], lab results reported to him. " Review of the facility ' s policy on Resident Concerns, effective on [DATE] and revised on [DATE], revealed the policy was " it is the policy of the company to investigate all concerns in an effort to provide and follow up of concerns expressed by resident, family members and or visitors which may affect the quality of care we deliver. On admission facility personnel inform residents and families to report concern. Advocacy phone numbers are posted for resident/family use. " The procedure was defined as " 1. Any company employee receiving a complaint from a resident, family member or visitor shall initiate a concerns form including the following information: 1. Name of person voicing the concern. 2. Date the concern was received. 3. Nature of the concern (detailed description is imperative). 4. Who received the concern including name and title. 2. All original concern forms are then submitted to the Executive Director for further action. 3. The Executive Director shall act on the concern and begin an investigation of the concern or submit it to the appropriate department for follow up. 4. The findings of the concern shall be recorded ... " The facility was comprised of two units, a long term care unit with a memory care hallway and a short term rehab unit. One of the hallways on the short term rehab unit was primarily used for Medicare patients recently admitted from the hospital. These residents required a higher level of care and were potentially more compromised with surgical wounds, infections and debilitation from prolonged hospital stays. Resident ' s #1, #3 and #10 resided on this hallway. The facility did not have routine set nursing assignments for the nurses and CNAs. During an interview on [DATE] at 4 PM, the Director of Nurses (DON) confirmed the staff assignments changed frequently. She stated that the goal was to have set assignments but due to accommodating staff ' s personal schedules, the nurses and CNAs were moved to different hallways to cover the staffing requirements. The DON confirmed that the nurses and the CNAs did not have an opportunity to know the residents especially on the Short Term Rehab hallway where the resident turnover was very quick. The DON also confirmed the acuity of the residents on the Short Term Hallway as being higher than other hallways in the facility. 2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Lab Data revealed a CBC was collected on [DATE]. The hemoglobin was 7.3 (low). Normal values were ,[DATE] in an adult male. The results were received in the facility on [DATE] at 7:05 PM. The physician was not notified until [DATE] at 8 PM. The resident was directly admitted to the hospital for a blood transfusion of 2 units of packed red blood cells. Review of the Nurses ' Notes revealed on [DATE], no narrative notes were documented. On [DATE] at 12:40 AM, the resident sustained [REDACTED]. No other documentation was noted related to abnormal lab values. On [DATE] the nurse documented the resident was on antibiotics