Every finding on record at Westchester Manor at Providence Place

Based on record review and interviews with staff and the Medical Director, facility staff failed to report a witnessed accident that resulted in an approximately 3.5 centimeters laceration over Resident #129's right eye which delayed her transfer to the hospital for evaluation and treatment. Nurse Aide #1 did not report the accident or bleeding to the nurse. The laceration was discovered by the nurse later in the night and the resident was sent to the hospital and the laceration was closed with three sutures. This deficient practice was identified for 1 of 3 residents sampled for supervision to prevent accidents (Resident #129). The findings included: Resident #129 was admitted to the facility on [DATE] with diagnoses of muscle weakness and anemia. A review of Resident #129's physician orders revealed Resident #129 was not prescribed blood thinners. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #129 was severely cognitively impaired and required substantial to maximum assistance with toileting and transfers. The MDS documented Resident #129's mobility status required supervision or touching assistance for transfer which included but not limited to sit-to-stand and chair- to-bed. A review of Resident #129's care plan dated 01/01/26 revealed the resident was at risk of falls due to cognitive impairment and decreased balance. The care plan interventions included assistance from one staff member for pivoting and transfers, and use of a wheelchair for mobility. An interview with NA #1 on 08/12/25 at 3:30 pm revealed she worked on 01/16/26 from 3:00 pm to 11:00 pm and remembered being assigned to Resident #129. At approximately 9:00 pm, NA #1 wheeled Resident #129 to her room from the nurse's station, and asked NA #2 if she would assist in getting Resident #129 ready for bed. NA #1 continued wheeling Resident #129 to her room. Once in the room, NA #1 stated she removed the pedals from the wheelchair and Resident #129 became agitated. Resident #129 and was leaning to the right side in her wheelchair. NA #1 indicated she removed Resident #129's shoes, heard a thump, but stated she did not know where or what caused the noise. NA #1 stated NA #2 came into Resident #129's room at approximately 9:10 pm and assisted her in placing Resident #129 into the bed and then NA #2 left the room. NA #1 immediately observed Resident #129 bleeding from the right-side forehead area and used paper towels to wipe the blood from Resident #129's injury. NA #1 stated she assumed Resident #129 had hit her head on the over bed table when the resident was leaning to the right because there were no other obstacles for Resident #129 to hit her head on. NA #1 stated she left the room at approximately 9:25 pm and Resident #129 was still actively bleeding. NA #1 stated she was in shock and did not let the nurse know what happened and she didn't tell anyone else before leaving after her shift at 11:00 pm. An interview with NA #2 on 08/12/26 at 3:40 pm revealed on 01/16/26, approximately between 8:00 pm to 9:00 pm, she went to Resident #129's room to assist NA #1 with putting Resident #129 to bed. NA #2 observed Resident #129 sitting in her wheelchair, leaning to the right side, and was wearing grip socks. NA #2 stated she helped NA #1 transfer Resident #129 to the bed. NA #2 stated she did not hear a thump or notice any blood on Resident #129 and was only in the room for about five minutes. NA #2 stated NA #1 did not inform her of an injury related to Resident #129 throughout the remainder of her shift (3:00 pm-11:00 pm) or before they transferred the resident. A review of a nursing progress note dated 01/17/26 at 2:01 am documented by Nurse #2 revealed the following: During rounds she observed Resident #129 lying in bed with blood on the pillow under her head. Nurse #2 assessed Resident #129 and revealed blood pressure (BP) was 177/99, pulse 75, respirations 18, and oxygen saturation rate of 96% on room air. Nurse #2 cleaned her head and observed the laceration over the right eye and notified the Nurse Supervisor. An interview with Nurse #2 on 08/12/26 at 2:46 pm revealed on 01/16/26 she worked from 7:00 pm to 7:00 am. Nurse #2 stated she received on-coming report for Resident #129 with no mention of any type of injury or increased agitation. Nurse #2 stated she went into Resident #129's room at approximately 12:00 am because Resident #129 was quieter than usual. Nurse #2 stated Resident #129 usually showed some agitation in the evening, and Nurse #2 would bring Resident #129 to the nurse's station to help watch her while the NAs completed routine resident care. Nurse #2 indicated when she went into Resident #129's room, she noticed blood, about the size of an orange, was on her pillowcase and noticed the laceration over her right eye with the blood drying. Nurse #2 called the Nurse Supervisor immediately and notified the physician. Orders were obtained to send Resident #129 to the hospital for evaluation. A review of nursing progress note dated 01/17/26 at 06:36 am documented by the Nurse Supervisor revealed he received notification by Nurse #2 that Resident #129 had a laceration above her right eyebrow and blood was on her pillow. On 8/12/26 at 11:55 am, an interview occurred with the Nurse Supervisor. The Nurse Supervisor stated on 01/17/26, shortly after midnight, Nurse #2 reported a laceration she discovered over the right eyebrow of Resident #129. After assessing Resident #129, he informed Nurse #2 to notify the physician, and orders were obtained for Resident #129 to be transported to the hospital emergency department. The Nursing Supervisor stated the amount of blood on Resident #129's pillow was a light to medium amount and was enough to cause concern. The Nurse Supervisor did not remember hearing of Resident #129's injury prior to Nurse #2 notifying him. An interview with NA #3 on 08/13/26 at 6:51 am revealed on the evening of 01/16/26, he arrived at the facility at approximately 10:45 pm to begin the 11:00 pm to 7:00 am shift and started gathering the blood pressure machine and materials to complete resident vital signs. NA #3 stated Nurse #2 informed him Resident #129's vital signs were already completed and not to wake her. NA #3 stated Resident #129 was typically not asleep when he arrived at work for the 11:00 pm to 7:00 am shift. NA #3 recalled at approximately 12:10 am on 01/17/26, NA #3 was asked by Nurse #2 to obtain Resident #129's vital signs. NA #3 stated he went to Resident #129's room minutes later and the Nurse Supervisor was in the room. NA #3 stated he observed blood on Resident #129's pillowcase about the size of the palm of a hand and was not sure if Resident #129 was actively bleeding. NA #3 stated when he began his shift, NA #1 had not reported any incidences or accidents involving Resident #129. The Nursing Supervisor stated he notified the on-call physician regarding Resident #129's laceration. A review of Resident #129's hospital records dated 01/17/26 revealed Resident #129 arrived at the hospital emergency department at approximately 12:45 am to have evaluation of the laceration. The hospital records revealed the laceration was approximately 3.5 centimeters (cm) in size and no drainage was noted. Resident #129 received three sutures above her right eyebrow and returned to the facility at 8:30 am on 01/17/26.A phone interview occurred with Medication Aide #1 (MA) on 08/13/26 at 7:51 am. MA #1 revealed she worked the 3:00 pm to 11:00 pm shift on 01/16/26 and administered medications to the residents prior to 9:00 pm. MA #1 stated she had given Resident #129's medications without incident while she was sitting in her wheelchair. MA #1and did not observe any blood or injury during her shift from 3:00 pm to 11:00 pm. After MA #1 administered Resident #129's medications, she didn't see her for the remainder of her shift. MA #1 stated she was not informed of any injury for Resident #129 during her shift. On 08/13/26 at 11:28 am a phone interview occurred with the Medical Director. The Medical Director stated on 01/17/2026, she went to the facility and learned of Resident #129's incident on 01/17/2026 at approximately 8:30 am. The Medical Director stated she assessed Resident #129 when she returned from the hospital on [DATE] and she was at baseline with no complaints. The Medical Director stated when an accident occurs, treatment should start as soon as possible. The Medical Director indicated due to Resident #129's anemia, bleeding or losing blood would be problematic for Resident #129 due to her diagnosis of anemia. The Medical Director concluded that Resident #129 could have been treated sooner if the accident had been reported at the time of occurrence An interview was conducted with the Director of Nursing (DON) on 08/13/26 at 1:28 pm. The DON stated the facility's process was broken when Resident #129's accident was not immediately reported to the nurse. The DON stated NA #1 was a new NA and became very upset and didn't know what to do. The DON stated when she interviewed NA #1 on 1/19/2026, NA #1 stated she just panicked and didn't tell anyone. The DON stated NA #1 had received training on reporting accidents upon hire in November 2025. The DON stated all staff should immediately notify the nurse when any change of condition occurs. An interview was conducted with the Administrator on 08/13/26 at 1:28 pm. The Administrator stated Resident #129's laceration above the right eyebrow should have been reported immediately to the nurse and stated staff were expected to report any change of condition to include, but not limited to, falls, and injuries. The Administrator stated NA #1 was a brand-new NA and NA #1 was scared by the accident and didn't know what to do. The Administrator indicated when she interviewed NA #1 on 01/19/2026 NA #1 stated she was worried she might get into trouble if she reported it to the nurse.

Based on staff and Registered Dietitian (RD) interviews and record review, the facility failed to have no greater than a 14 hour lapse between the provision of a substantial evening meal and breakfast the following day for residents served their meals on 6 of 6 halls (400 Hall, 500 Hall, 600 Hall, 300 Hall, 200 Hall and 100 Hall).The findings included:A schedule of the Meal Service Times (Starting January 1, 2025) was provided upon entry to the facility. A review of this schedule indicated the delivery times for each hallway allowed 14 hours and 30 minutes to elapse between the last meal of the day and first meal of the following day as follows:--The 400 Hall meals were scheduled to be delivered at 5:15 PM for dinner and at 7:45 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).--The 500 Hall meals were scheduled to be delivered at 5:30 PM for dinner and at 8:00 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).--The 600 Hall meals were scheduled to be delivered at 5:45 PM for dinner and at 8:15 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).--The 300 Hall meals were scheduled to be delivered at 6:00 PM for dinner and at 8:30 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).--The 200 Hall meals were scheduled to be delivered at 6:15 PM for dinner and at 8:45 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).--The 100 Hall meals were scheduled to be delivered at 6:30 PM for dinner and at 9:00 AM for breakfast (indicative of a 14-hour and 30-minute time span between the two meals).An interview was conducted with the facility's Dining Services Director and Chef Manager on 7/24/25 at 10:28 AM. During the interview, concerns were shared regarding the meal delivery schedule allowing a lapse of greater than 14 hours between dinner and the breakfast meal the following day. The Dining Services Director and Chef Manager confirmed the meal schedule was changed within the last several months and reported that prior to the change, the scheduled mealtimes between dinner and the next day's breakfast were within the 14-hour requirement. The Chef Manager stated, It'll be easy to change back. When asked, the Dining Services Director reported that bedtime snacks were available on the halls upon resident request. However, these snacks primarily included packaged items such as crackers, cookies, and chips. Bedtime snacks were not necessarily served or provided to all residents.An interview was conducted on 7/24/25 at 1:59 PM with the facility's Registered Dietitian (RD) to discuss concerns regarding the timing of the meal delivery schedule. During the interview, the RD stated he wasn't aware the facility failed to meet a requirement by scheduling a lapse of greater than 14 hours between the dinner meal and breakfast the following day. On 7/24/25 at 3:55 PM, an interview was conducted with the facility's Administrator in the presence of the Director of Clinical Services and Campus Executive Director. At that time, the Administrator confirmed they had been made aware there was a lapse of more than 14 hours between the meal service provided for dinner and breakfast the following day and were working to change the meal schedule.

Based on observations and interviews with the facility staff, the facility failed to: 1) Label, date, and seal opened food items stored in the Dietary Department's walk-in freezer; 2) Dispose of expired food items stored in the reach-in refrigerator; and 3) Cover facial hair for 2 of 2 Dietary staff observed with facial hair and working with food preparation in the kitchen (Dining Services Director and [NAME] #1. These practices had the potential to affect food being served to residents.The findings included:1) Accompanied by the Dining Services Director, an initial tour was conducted of the Dietary Department on 7/21/25 at 9:29 AM. Observations made at the time of the initial tour identified the following concerns in the walk-in freezer:--An opened cardboard box dated 5/6/25 was observed to contain an opened plastic bag containing 5 salmon patties. The plastic bag was not dated as to when it had been opened and was not sealed, leaving the salmon patties open to air. --An opened cardboard box dated 7/16/25 was observed to contain approximately 25 chicken tenders stored in an unsealed plastic bag. Underneath this plastic bag was another opened, unsealed plastic bag containing 2 or 3 hamburger patties. The hamburger patties were observed to have ice crystals on them, making it difficult to determine exactly how many patties were stored in the bag. Neither the plastic bag containing the chicken tenders nor the bag containing the hamburger patties were dated as to when they had been opened.The Dining Services Director was observed to discard the salmon patties, chicken tenders, and hamburger patties when these concerns were identified during the initial tour conducted on 7/21/25 at 9:29 AM.On 7/21/25 at 9:50 AM, an interview was conducted with the facility's Dining Services Director. During the interview, the Director was asked what education was provided to his staff with regards to the storage of open food products. He reported the facility's policy was to label and date food products when received, when pulled (referring to when the box was removed from the refrigerator or freezer), and when opened. He stated that the containers of all opened food products should be sealed for storage. 2) Observations made during the initial tour of the Dietary Department conducted on 7/21/25 at 9:29 AM identified the following food items were expired in the reach-in refrigerator:--A one-quart container of pork gravy was labeled with two dates. One date indicated the gravy was made on 7/17/25 while the second date reported the gravy had an expiration date of 7/20/25.--A plastic container containing approximately 16 ounces of coleslaw was labeled with two dates. One date indicated the coleslaw was made on 7/17/25 while the second date reported it had an expiration date of 7/20/25.During the initial tour conducted on 7/21/25 at 9:29 AM, the Dining Services Director was observed as he pulled the pork gravy and coleslaw containers from the refrigerator and reported they would be discarded. On 7/21/25 at 9:50 AM, an interview was conducted with the facility's Dining Services Director. When asked, the Director stated that education needed to be provided to the staff related to the facility's policy for labeling, dating, and discarding expired food items.3) Upon entry to the Dietary Department on 7/21/25 at 9:29 AM for an initial tour, the facility's Dining Services Director and [NAME] #1 were observed to have facial hair without wearing a beard restraint while working with food in the kitchen. The Dining Services Director was observed at that time to be working at the stove top dishing up eggs for a meal tray while [NAME] #1 was working on food preparation.On 7/23/25 at 10:38 AM, the Dining Services Director was observed to be working in the Dietary Department as he approached the dishwashing area. At that time, the Dining Services Director was wearing a beard restraint positioned below his mouth. The beard restraint covered his beard but did not cover his mustache.An interview was conducted with the Dining Services Director on 7/23/25 at 11:40 AM. During the interview, the observations conducted on 7/21/25 and 7/23/25 when a beard restraint was not used or was not properly positioned to cover facial hair were discussed. The Dining Services Director acknowledged the staff (including himself) knew what needed to be done but needed to consistently implement the required measures for covering facial hair.An interview was conducted on 7/24/25 at 1:59 PM with the facility's Registered Dietitian (RD). When asked, the RD reported he would agree that facial hair needed to be covered in the kitchen and stated, That's pretty standard.

Based on record review, observation, and resident and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request staff assistance. This was for 1 of 3 residents reviewed for accommodation of needs (Resident #47). The findings included:Resident #47 was admitted to the facility on [DATE] with diagnoses that included repeated falls, type 2 diabetes mellitus, and dementia. Resident #47's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was severely impaired and she had no behaviors or rejection of care. She required moderate assistance of one person for toileting hygiene, dressing, personal hygiene, transfers, and bed mobility. Resident #47 had no range of motion impairments, was frequently incontinent with bladder, and occasionally incontinent with bowel. Resident #47's active care plan indicated she was at risk for falls related to impaired cognition, impaired vision, impaired mobility, and incontinent episodes. The interventions included for staff to provide Resident #47 with reminders to use call bell when needing assistance as many times as needed and to keep call bell within reach and to answer it timely. An interview and observation were conducted with Resident #47 on 07/21/25 at 10:01 AM. A saturated brief was observed on the floor on the right side of the bed. Resident #47 stated the brief was wet and making her itch, so she took it off and threw it on the floor. The surveyor could see sheets were not wet when Resident #47 moved the sheet exposing her perineal area to show she did not have a brief on. Her perineal area was not red, and skin was intact. Resident #47 then stated she did not know where her call bell was so that she could call for assistance. A pad style call bed was observed at the head of the bed lying over the mattress with the call bell pad hanging off the mattress towards the floor. Resident #47 asked this surveyor to please hand her the call bell so she could call for assistance. The call bell was given to Resident #47, and she pressed the pad to put the call light on. This surveyor went into the hall outside of the residents' room to wait for staff. An interview and observation were conducted on 07/21/25 at 10:11 AM with Nursing Assistant (NA) # 1. She verified she was assigned to Resident #47 during the first shift on 07/21/25. NA #1 was made aware Resident #47 had thrown her saturated brief onto the floor prior to her entering her room. During the observation NA #1 entered Resident #47's room and closed the door. An interview and observation were conducted on 07/21/25 at 10:15 AM with NA #1. She verified she was assigned to Resident #47 during the first shift on 07/21/25. NA #1 stated she last checked Resident #47 after breakfast around 9:30 AM and she was dry. She stated Resident #47 would use her call light to call for assistance and she had not done that. This surveyor explained that she could not reach her call bell because it was out of reach. She stated Oh, I thought I put it where she could reach it. During an observation on 07/21/25 at 10:29 AM Resident #47's call light was observed on, and NA #2 was observed entering Resident #47's room and closing the door. An interview was conducted on 07/21/25 at 10:36 AM with NA #2. NA #2 indicated she had worked with Resident #47 at times and that Resident #47 did utilize her call bell to request assistance. She stated she had just provided Resident #47 incontinence care and put Resident #47's call bell within reach. A follow up interview was conducted on 07/23/25 at 1:32 PM with NA #1. NA #1 explained that she fed Resident #47 her breakfast on the morning of 07/21/25. However, she did not look to see where her call bell was located prior to exiting the room, she did not think about doing so. NA #1 also stated Resident #47 did utilize her call bell to request assistance. An interview was conducted on 07/21/25 at 10:40 AM with Nurse #1. She verified she was the nurse for Resident #47 on 07/21/25 and that she normally worked on the 400 hall. She stated Resident #47 did utilize her call light when she needed assistance. An interview was conducted on 07/24/25 at 1:23 PM with the Director of Nursing. She stated her expectation was for staff to ensure the call light was within the residents' reach prior to exiting the room.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) Level II status for 2 of 24 residents (Resident #3 and Resident #11) whose MDS assessments were reviewed.The findings included: 1. Resident #3 was admitted to the facility on [DATE] with cumulative diagnoses which included major depressive disorder. A PASRR Level II Determination Notification letter dated 4/28/23 for Resident #3 was reviewed. This letter noted Resident #3 had a PASRR number ending with the letter “B,” which was indicative of a PASRR Level II determination with no expiration date. The results of the evaluation, including the determination of a PASRR Level II status, are used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care. Resident #3’s annual Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The “Identification Information” section of the MDS reported the resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #3’s most recent comprehensive MDS was an annual assessment dated [DATE]. The “Identification Information” section of this MDS also reported Resident #3 was not determined to have a PASRR Level II status. An interview was conducted on 7/24/25 at 10:43 AM with MDS Nurse #1 related to the PASRR determination reported on Resident #3’s annual MDS assessments dated 10/8/24 and 6/6/25. Upon review of these two annual MDS assessments, MDS Nurse #1 confirmed the assessments indicated Resident #3 did not have a PASRR Level II status. When asked whether the MDS assessments correctly reported the resident’s PASRR status, the MDS Nurse stated the facility did not report residents with PASRR authorization codes of “H” or “B” as having a PASRR Level II status based on previous practices. She was not aware these authorization codes should be reported as a PASRR Level II on an MDS assessment. On 7/24/25 at 3:55 PM, an interview was conducted with the facility’s Administrator in the presence of the Director of Clinical Services and Campus Executive Director. At that time, the Administrator reported she had been made aware of the issues related to the incorrect reporting of PASRR Level II on residents’ MDS assessments and had no questions. 2. Resident #11 was admitted to the facility on [DATE] with cumulative diagnoses which included bipolar disorder, major depressive disorder, post-traumatic stress disorder and dementia. A PASRR Level II Determination Notification letter dated 12/10/24 for Resident #11 was reviewed. This letter noted Resident # 11 had a PASRR number that ended with the letter “H,” which was indicative of a PASRR Level II determination with no expiration date and required no additional screening. Resident #11’s annual Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The “Identification Information” section of the MDS reported the resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. An interview was conducted on 7/24/25 at 10:43 AM with MDS Nurse #1 related to the PASRR determination reported on Resident #11’s annual MDS assessment dated [DATE]. Upon review of the annual MDS assessment, MDS Nurse #1 confirmed the assessment indicated Resident #11 did not have a PASRR Level II status. When asked whether the MDS assessment correctly reported the resident’s PASRR status, the MDS Nurse stated the facility did not report residents with PASRR authorization codes of “H” or “B” as having a PASRR Level II status based on previous practices. She was not aware these authorization codes should be reported as a PASRR Level II on an MDS assessment. On 7/24/25 at 3:55 PM, an interview was conducted with the facility’s Administrator in the presence of the Director of Clinical Services and Campus Executive Director. At that time, the Administrator reported she had been made aware of the issues related to the incorrect reporting of PASRR Level II on residents’ MDS assessments and had no questions.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) Level II status for 2 of 24 residents (Resident #3 and Resident #11) whose MDS assessments were reviewed.The findings included:A PASRR Level II Determination Notification letter issued for Resident #25 (dated 9/9/24) was reviewed. The letter noted Resident #25 had a PASRR number ending with the letter F, which was indicative of a PASRR Level II determination. The letter reported that Nursing Facility placement was appropriate for a 90 day period with the provision of specialized services, which included follow-up psychiatric services and rehabilitative services. The letter also indicated if the resident's placement was expected to extend beyond the end date (90 days), further approval and screening was required. The results of the evaluation, including the determination of a PASRR Level II status, are used for formulating a determination of need, an appropriate care setting, and a set of recommendations for services to help develop an individual's plan of care.Resident #25 was admitted to the facility on [DATE] from another skilled nursing facility. Her cumulative diagnoses included recurrent major depressive disorder, generalized anxiety disorder, and vascular dementia.The resident's most recent comprehensive Minimum Data Set (MDS) was an admission assessment dated [DATE]. The Identification Information section of the MDS assessment indicated Resident #25 was determined to have a PASRR Level II status due to serious mental illness.Resident #25's electronic medical record (EMR) included a Halted PASRR Level II Determination Notification letter dated 12/4/24. The 12/4/24 letter revealed Resident #25 was determined to have a PASRR number ending with the letter H with no restrictions and no end date (due to the resident having a primary diagnosis of dementia). This Determination Notification letter included a notation that read, in part, No further Level I screening is required unless a significant change occurs with the individual's mental status which suggests a psychiatric disorder that is not dementia. The resident's current care plan dated 5/6/25 - Present was reviewed. This review revealed the Problems addressed in the care plan did not include an area of focus related to Resident #25's Halted PASRR Level II determination or include guidance for future care decisions related to her PASRR status.An interview was conducted on 7/24/25 at 12:00 PM with MDS Nurse #1 related to Resident #25's PASRR determination and care plan. When asked, the nurse stated that Resident #25's current care plan likely did not include her Halted PASRR Level II status due to her PASRR authorization code changing from an F to an H. MDS Nurse #1 further explained that the facility did not report residents with PASRR authorization codes of H or B as having a PASRR Level II status on an MDS assessment (based on the facility's previous practices). Therefore, the facility may not have incorporated a PASRR Level II finding coded with an H into Resident #25's care planUpon request, an interview was conducted on 7/24/25 at 1:37 PM with the Director of Clinical Services. During the interview, the Director reported Resident #25 was currently care-planned for the medications she received, followed by a psychiatric service, and noted as having no behaviors. She provided a copy of Resident #25's previous care plan and noted the resident's PASRR Level II had initially been included on the old care plan (documented as last reviewed on 5/25/25). However, the Halted PASRR Level II determination was no longer included in Resident #25's current care plan after her PASRR authorization code was changed to an H. On 7/24/25 at 3:55 PM, an interview was conducted with the facility's Administrator in the presence of the Director of Clinical Services and Campus Executive Director. At that time, the Administrator reported she had been made aware of the issues related to both the reporting of residents' PASRR Level II status on the MDS assessments and the failure to incorporate PASRR findings into a resident's care plan. She had no further questions.

Based on observations, record review, staff and nurse practitioner interviews the facility failed to protect a resident's right to be free from abuse (Resident #13) when another resident (Resident #44) pulled out a section of hair from Resident #13. This deficient practice occurred for 1 of 3 residents reviewed for physical abuse. The reasonable person concept was applied for Resident #13 due to a reasonable person would feel pain and emotional distress having his or her hair pulled out of their head by another person. Findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses of unspecified dementia and hallucinations. Resident #44's most recent Minimum Data Set (MDS) dated [DATE] showed her to be cognitively intact, required moderate staff assistance to complete activities of daily living, and she used a wheelchair to propel herself. Resident #44's care plan showed she had been care planned for physical behaviors on 4/23/24 which included hitting, scratching, and throwing objects at staff during care. Interventions included removing resident from triggering behavior, approach resident warmly and softly, and allow resident time to de-escalate when agitated. Resident #13 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia and orthostatic hypotension. Resident #13's quarterly MDS assessment dated [DATE] revealed she was moderately cognitively impaired, and she used a wheelchair to propel herself. A review of a facility reported incident revealed that on 4/30/24 at around 4:00 pm, Resident #44 was seen sitting in her wheelchair behind Resident #13, who was also in her wheelchair, in the common area in front of the nurse's station on the 400 hall. Resident #44 was observed to be holding a moderate amount of hair in her hand by Nurse Aide #1. The report stated that both residents were immediately separated and 1:1 supervision immediately began for Resident #44 until a psychiatric evaluation was obtained. Resident #13 was immediately assessed, and an approximately two-inch reddened area was noted to her back hairline near her neck. Resident #13 voiced no complaints at that time. The nurse practitioner was made aware of the incident and both responsible parties were notified. An interview with Resident #44 was attempted on 5/20/24 at 10:32 am. Resident #44 was noted to be oriented to self only. When asked if she had any recollection of an incident with Resident #13, she became agitated, and the interview ceased. An observation on 5/20/24 at 10:50 am of Resident #13 showed approximately 1/2 inch of new hair growth where the hair had been pulled out near her neckline. There was no redness noted. Resident #13's hair was fairly thin and most of it was curled toward the top. She had very little near the bottom and around her neckline where it was thinner. An interview with Resident #13 on 5/20/24 at 10:50 am revealed that she had no memory of the incident and denied any past or current issues with staff or other residents. During an interview with Nurse Aide #1 (NA#1) on 5/22/24 at 2:58 pm, she stated that she saw both residents sitting in the common area on the 400-hall watching television. She stated that when she came back to the common area a few minutes later, she saw Resident #44 had propelled herself over to Resident #13 and was holding some of Resident #13's hair in her hand. She stated that she did not hear Resident #13 yell out in pain. NA#1 stated that Resident #13 did not complain of any pain when asked and only stated that she wanted her hair back. NA#1 stated that Resident #13 had about a 2-inch reddened area where her hair was at her neckline. She stated that she immediately separated the two residents, and the Director of Nursing (DON) was made aware of the incident. During an interview with the Social Worker on 5/22/24 at 12:13 pm she stated that Resident #13 had no memory of the incident and was seen smiling at her within minutes of the incident occurring. The social worker stated that Resident #44 had become combative with staff and increasingly agitated since she realized she could not propel her wheelchair as easily as she could before even with rehabilitation services. The social worker stated this was the first time she had touched a resident. She added that the facility is trying new interventions with Resident #44 such as taking her on walks when it's nice outside and spending more time doing one-on-one activities. During an interview with the DON on 5/22/24 at 3:30 pm, she stated that she was made aware of the incident as soon as it occurred. She stated that Resident #44 was immediately put on 1:1 until they were able to get her to the hospital for a psychiatric evaluation. She stated that she reviewed the incident via camera footage of the 400-hall common area. She saw Resident #44 propel herself a couple feet over to Resident #13, reach out and pull out a section of Resident #13's hair. She stated she saw staff intervene within seconds of it occurring and separating the two. She stated she was immediately notified of the incident. The DON stated that Resident #44 had been displaying behaviors over the last month such as kicking and spitting on staff and throwing her food at staff members. She stated that they have done bloodwork and radiology scans to see if there is a metabolic reason for her behavior change and they have not found one. The DON did state that she was recently treated for a urinary tract infection, and she also had COVID infection. Per psychiatry recommendation, they are keeping her on 1:1 supervision for the foreseeable future. Camera footage of the 400-hall common area for the incident was not downloaded and saved by the facility. It was not available for review during the investigation. During an interview with the psychiatric Nurse Practitioner on 5/23/24 at 3:20 pm, she stated that she has spent a lot of time with both residents. She stated that Resident #44 has become very agitated over the last month or two and had recently started exhibiting behaviors such as kicking and spitting on staff, including her. She stated she has seen her twice since the incident, changing medication dosages each time. She added that she feels like this is a progression of her dementia following two significant infections and that the staff are doing all they can to redirect her when she becomes agitated and keeping her on 1:1 supervision while they are adjusting her medications so that no further incidents occur. During an interview with the Administrator on 5/23/24 at 3:45 pm, she stated she has reached out to both responsible parties to discuss the incident. She stated that she has spoken with Resident #44's daughter at length regarding her change in behavior and the possibility of her having to eventually have constant 1:1 supervision to keep others safe. She stated that Resident #44's daughter is open to any help the facility can provide.

Based on observations, staff interviews, and maintenance audit and repair review the facility failed to maintain walls (Rooms 501 A, 509, and 601 B) and red plastic electrical outlet plate (room [ROOM NUMBER] B) in good repair for 4 of 20 rooms (Rooms 501, 509, 601, and 603) on the 500 and 600 halls reviewed for environment. Findings included: a. Observations of room [ROOM NUMBER] A on 05/20/24 at 3:48 PM and on 05/21/24 at 10:56 AM revealed horizontal areas of gouged drywall behind the head of the bed and 10 reddish-brown spots on the ceiling near the doorway. b. Observations of room [ROOM NUMBER] on 05/20/24 at 4:00 PM and on 05/21/24 at 10:33 AM revealed gouged drywall behind the visitors' chairs on the left side of the room. c. Observations of room [ROOM NUMBER] B on 05/20/24 at 4:15 PM and on 05/23/24 at 3:00 PM revealed black marks around the perimeter of the room approximately 3 feet from the floor. d. Observations of room [ROOM NUMBER] B on 05/20/24 at 4:15 PM and on 05/21/24 at 11:19 AM revealed a broken red plastic electrical outlet plate on the wall behind the head of the bed. During an interview and room observations with the Maintenance Director on 05/23/24 at 3:00 PM he stated he had been the Maintenance Director for [AGE] years for the entire facility complex. He further stated facility staff notified him of repairs that were needed in residents' rooms. He explained staff could enter work orders into an online system and he could access the orders from a database. The Maintenance Director shared he was aware that there were many areas in the facility that needed repairs, and they are prioritizing the areas as they identify concerns. He explained he prioritized repairs by working on those which impacted resident safety first. He added two maintenance employees recently quit and he was working with a recruiting agency to find skilled maintenance assistants. During the observation round with the Maintenance Director, he stated he had repaired many of the concerns found during the survey and the others were on a list to be completed within the week. He displayed a list of the rooms he had audited and the repairs that had been completed. On 05/23/24 at 5:20 PM an interview was conducted with the Administrator, and she stated she expected the Maintenance Director to complete repairs that impacted resident safety first and then attend to cosmetic repairs. She stated the Maintenance Director had completed an audit of needed room repairs and had initiated or completed many of the repairs. She stated a process will be put in place for department leaders to make rounds on a consistent basis to identify areas of concern. The Administrator added nurses on the hall should submit work orders in the online system. She said training on entering work orders will be part of process that will be put in place. She stated staff are expected to report identified needs in the electronic system or to report concerns directly to her or the Maintenance Director.

Based on observations, record review, and staff interviews, the facility failed to transcribe an ordered dietary supplement for 1 of 5 residents (Resident #74) reviewed for nutrition. The findings included: Resident #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74 weight on 8/4/2021 was 190.2 pounds. Resident #74 was discharged to the hospital on 8/26/2021 and readmitted to the facility on [DATE] with a weight of 146.4 pounds. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively impaired for making decisions of daily living and required one staff member assistance with eating. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #74 had greater than 5% weight loss that was not intentional. The Care Area Assessment (CAA) identified Resident #74 to be at risk for Malnutrition and documented nutrition was to be updated on the care plan and it was noted that the Resident was to receive a dietary supplement two times per day, as ordered. A review of the care plan updated 9/21/2021 revealed a focused area for nutrition and malnutrition with recent weight loss and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was to have no significant weight loss through the next review. Interventions included dietary supplements, monitor labs as ordered, Registered dietician consults as indicated, and serve diet as ordered. A review was conducted of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietary supplement was not ordered. A review of the electronic medical record revealed weekly weights for Resident #74 for the dates of: 9/17/2021 145.4 pounds 9/21/2021 161 pounds 10/5/2021 161.8 pounds 10/12/2021 155.6 pounds 10/20/2021 151.2 pounds An observation was conducted on 10/17/2021 at 1:03 PM during the lunch meal of Resident #74. A staff member assisted the Resident to eat. The meal ticket was observed, and a dietary supplement was not listed on the meal ticket and was not available on the tray. The meal ticket stated puree consistency with thin liquids. An observation was conducted on 10/20/2021 at 8:48 AM during breakfast of Resident #74. A staff member assisted the Resident to eat. The meal ticket was observed, and a dietary supplement was not listed on the meal ticket and was not available on the tray. The meal ticket stated puree consistency with thin liquids. The meal included ½ cup cereal, French toast, sausage link, syrup, margarine, coffee, whole milk, juice and assorted fruit. The Resident was observed to eat 100% of the meal. An interview was conducted with the Unit Supervisor for the 300 hall on 10/20/2021 at 9:17 AM and she revealed Resident #74 had significant weight loss due to a recent hospitalization . She stated she did not see an intervention in the computer ordered upon readmission except for weekly weights that were added on 9/17/2021. She revealed that on 10/18/2021 an order was placed for a speech therapy consult because the Resident was observed to be pocketing food. She stated the resident had been on Speech therapy from admission until 10/14/2021. She added that Resident #74 had not been placed on a dietary supplement and she was not sure why this intervention was not added. An interview was conducted with the Registered Dietician (RD) on 10/20/2021 at 9:50 AM and she revealed that Resident #74 had 25% weight loss over 6 months from 4/7/2021, with a weight of 195.2 through 10/12/2021, with a weight of 155.6 pounds. She added this was due to a recent hospitalization in September. She stated she had thought she added an intervention. She reviewed her documentation and clarified that she made a recommendation for Resident #74 on 9/21/2021 for Med pass 2.0 120 ml twice a day but did not enter the order into the electronic medical system. She stated it was her expectation that recommended supplements be added into the system and the resident maintain their weight without further weight loss. The RD revealed she would enter the order immediately. An interview was conducted with the Nurse Practitioner (NP) for Resident #74 on 10/20/2021 at 11:39 AM and she revealed that it was her expectation that orders be transcribed as recommended by a physician, NP, physician assistant or RD. She revealed in this case the Resident did not suffer further weight loss and his serum [MEDICATION(S)] levels were within normal limits.

Based on observation, staff interviews and record review the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines requiring staff to wear a facemask covering their nose in long term care settings for 1 of 4 staff reviewed for infection control. This failure occurred during a COVID-19 pandemic. Findings Included: According to the CDC guidelines dated June 2, 2020 titled how to wear a facemask recommended a facemask must cover the nose and mouth. A review of the facility's Novel Coronavirus Prevention and Response dated 3/17/2020 reads in part, wear masks upon entering room and when caring for resident. An observation was made on 12/30/2020 at 12:21 PM on the 600 hallway which was a general population hallway of Nurse #1 at the medication cart, wearing her mask below her nose. Nurse #1 was asked if she had time for a few questions and Nurse #1 stated she needed to give a medication first before answering questions. Nurse #1 proceeded to resident #1's room to give the medication and exited resident #1's room and walked back to the medication cart with her mask below her nose. An interview was completed with Nurse #1 on 12/20/2020 at 12:33 PM who stated her mask must have slipped down below her nose and she wasn't paying attention. Nurse #1 grabbed the front of her mask and pulled it away from her face and stated, that she was used to pulling her mask away from her face when talking to her residents, even though they were taught not to, but stated most of her residents were hard of hearing and could not hear her. During the interview Nurse #1 again pulled her mask away from her face two additional times. An interview was completed with the nurse supervisor (NS) on 12/30/2020 at 12:42 PM who stated mask are to be worn over the nose and mouth. A phone interview was completed with the Administrator on 12/31/2020 at 3:44 PM who stated that masks were to be worn anytime in the building and should cover the nose and mouth. A phone interview completed with the Director of Nursing (DON) on 12/31/2020 at 4:55 PM revealed staff should have a mask on per CDC guidelines covering the nose and mouth. The DON stated they should not pull the mask away to talk.

Based on observations, staff interviews, medical record review, and review of the facility's screening tool, entitled, Prevent COVID-19 Start of Shift Employee Screening Log, the facility failed to ensure that staff were screened immediately upon entry into the facility for one (1) of three (3) screenings. The facility also failed to ensure that staff followed the facility's policy, entitled, Glucometer Cleaning & Disinfecting, for cleaning and disinfecting glucometers (used to measure blood glucose), in a manner to prevent the potential transmission of infectious disease for one (1) of three (3) nurses observed. The failures occurred during a COVID-19 (coronavirus) pandemic. The findings include: 1. During an observation on 05/15/2020 at 9:07 a.m., the Chef Manager (CM), after exiting his vehicle, entered the facility through a door (behind the building), where the waste dumpster was located. At 10:25 a.m., accompanied by the administrator, the CM confirmed, that no one immediately screened him at the point he entered the facility. He stated that he had been to another facility, and this was the first time he entered the facility for the day. The CM demonstrated via tour that he entered the facility through the aforementioned area. He demonstrated that he proceeded through areas of the facility, upon entry, wherein there was a potential for close contact with residents and staff. Areas included close proximity or walking through the dining room, common area (100/200/300 halls), elevator, conference room, and the physical therapy room, then to the main lobby. The administrator confirmed there was no one present to screen the CM, when he entered through the back of the building. She stated if no one was present, staff are to exit the facility, and enter through the main entrance, to complete screening, prior to proceeding through the facility. Review of the facility's screening tool, revealed, numerous questions were to be asked upon entering the facility, that include the following: Check temperature .cough .sore throat .new shortness of breath or difficulty breathing .chills and/or repeated shaking with chills .muscle pain .headache .new loss of taste or smell .worked a another facility in past 14 days . etc. 2. During an observation on 05/15/2020 at 9:53 a.m., accompanied by the administrator, Licensed Practical Nurse (LPN) #1 confirmed that she had five (5) residents under her care that required glucose monitoring. She further stated that she had not performed a glucose check on any of the residents yet. LPN #1 demonstrated that the procedure for cleaning and disinfecting the glucometer, included wiping the device with a 70% alcohol pad (allow to dry one (1) minute), then repeat the cleaning process as aforementioned, after used on each resident. LPN #1 stated that she would repeat the cleaning procedure aforementioned, as she moved from resident-to-resident. LPN #1 confirmed that she was an agency nurse. During an interview on 05/15/2020 at 10:00 a.m., the Nursing Supervisor stated that glucometers were not to be cleaned and disinfected with a 70% pad. She stated that staff was expected to use the micro-kill cleaning wipe. During an interview on 05/15/2020 at 10:52 p.m., the Director of Nursing accompanied by the administrator, stated that glucometers were to the cleaned before and after use with the mirco-kill wipes. Review of Residents' 1, 2, 3, 4 and 5 who required a glucose monitoring, medical record, revealed, no active [DIAGNOSES REDACTED]. The facility had no residents that tested positive of showed signs and symptoms of exposure to COVID-19. Review of the facility policy, undated, provided by the provider, revealed the glucometer was to be cleaned and disinfected after each patient use, in between patients, and after contact with blood or bodily fluids. The policy further read, .Wipe down with Sani-cloths (purple tops) - contact time for purple wipes is 2 minutes .

Based on observations, record review, and staff interviews the facility failed to follow a physician order [REDACTED]. Findings included: Resident #53 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognition, needed one to two-person extensive to total assistance for activities of daily living (ADLs), and required one-person supervision while eating meals. During an observation of Resident #53 on 8/26/19 12:40 PM Nurse #10 was setting up Resident #53's meal and this surveyor saw a straw in his drink cup. The resident took a sip from the straw. At the time of the observation, this surveyor had not reviewed his record and did not know that the resident had orders to not use straws. All other meal observations of the resident revealed no straws were used. Review of Resident #53's Care Plan revealed a plan in place last updated on 7/3/19 for risk for aspiration related to dysphagia with history of aspiration pneumonia. It stated that he required a soft textured diet with thin liquids with no use of straws. Resident #53's Physician order [REDACTED]. Review of the Resident #53's Speech Therapy Discharge Summary dated for 10/31/18 revealed that the resident had an aspiration risk with straws due to overly large sip size and bolus propulsion to base of tongue at a quick rate. It stated that Resident #53 was not safe to use straws with thin liquids. During an interview with Nurse Assistant (NA) #10 on 8/29/19 at 12:03 PM she stated that Resident #53 did not get straws during meals because he was an aspiration risk. She stated that this information was located on his care plan and on the diet slip on his meal tray when it was delivered. During an interview with Nurse #10 on 8/29/19 1:47 PM she stated that she knew the resident was an aspiration risk, remembered setting his meal tray up on 8/26/19, but that she could not remember if he had used a straw or not. During an interview with the speech therapist on 8/29/19 at 1:32 PM she stated that it was recommended that Resident #53 did not use straws due to his large sip size and that this increased his risk for aspiration pneumonia. During an interview with the Director of Nursing on 8/29/19 at 2:18 PM she stated that it was her expectation that staff follow physician orders [REDACTED]. She stated that she would expect that straws were not used by Resident #53 to ensure his safety and to prevent aspiration.

Based on record review and staff interview, the facility failed to indicate code status in the medical record for 1 of 23 residents (Resident #90) reviewed for advanced directives. The findings included: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #90 had severely impaired cognition. A review of the electronic health record was conducted on 8/26/19. There was not a code status addressed for Resident #90. An interview was conducted on 8/27/19 at 3:37 PM with Nurse #2. She was asked where code status was found for residents. Nurse #2 stated code status is available in the electronic health record and on the report sheet. Surveyor asked Nurse #2 what Resident #90 ' s code status was, Nurse #2 went to the computer and pulled up Resident #90 ' s electronic health record. Nurse #2 stated she didn ' t see Resident #90 ' s code status addressed on the profile. Nurse #2 then looked at the physician orders [REDACTED].#2 then looked on her report sheet; no code status information for Resident #90 was observed on the report sheet. She stated the admission nurse would take the code status information from the discharge summary, but this did not get done for this resident. An interview was conducted on 8/29/19 at 4:56 PM with the Director of Nursing. She stated the admission nurse puts the order in for code status. She did not know why it did not get done for this resident.

Based on observations, record review and staff interviews, the facility failed to follow a physician ordered intervention for pressure reduction for 1 of 3 (Resident #168) reviewed for pressure ulcers. The findings included: Resident #168 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set assessment had not been completed however, a review of the admission nursing assessment revealed Resident #168 required extensive assistance with bed mobility and transfers and was incontinent of bowel and bladder. The care plan dated 8/22/19 revealed a problem of presence of skin breakdown on left heel. The goal was for Resident #168 to not develop additional areas of skin breakdown through the next review and the wound would be free from signs and symptoms of infection. Interventions included treatments as ordered, monitor for signs and symptoms of infection and assess characteristics of wound daily and document findings weekly. A physician's order [REDACTED]. An observation on 8/28/19 at 8:23 AM revealed Resident #168 lying in bed without her heels floated. There was no device observed near Resident #168 ' s feet used to float heels. An observation on 8/29/19 at 8:24 AM revealed Resident #168 lying in bed on her back without her heels floated. There was no device observed near Resident #168 ' s feet used to float heels. An interview was conducted on 8/29/19 at 2:29 PM with NA #1. She stated she gets the information for what each resident needs from the report sheet which is kept at the desk in a binder. She stated she was not aware Resident #168 required her heels to be floated. She stated the assistant director of nursing fills out the sheets. An interview was conducted on 8/29/19 at 2:31 PM with Nurse #1. She revealed she didn ' t recall their being an order to float Resident #168 ' s heels. She stated she does go around and make sure interventions are put into place when she does her medication pass. An interview was conducted on 8/29/19 at 2:36 PM with the assistant director of nursing. She stated she does update the report sheets for the residents. She stated she gets the information from the nurses ' , the physician orders [REDACTED].#168 ' s heels did not get put onto the report sheet. An observation of Resident #168 ' s wound was completed on 8/29/19 at 2:45 PM. Resident #168 had a darkened area to her left heel that was unopened. An interview was conducted on 8/29/19 at approximately 3:15 PM with the director of nursing revealed Resident #168 should have her heels floated per the physician's order [REDACTED].

Based on observations, record review and staff interviews, the facility failed to use a method to maintain cold food temperatures of protein-based sandwiches prepared with mayonnaise for bagged lunches provided to residents on [MEDICAL TREATMENT]. This was evident for 1 of 1 resident (Resident #168) reviewed for [MEDICAL TREATMENT]. The findings included: Resident #168 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment had not yet been completed. A review of the care plan dated 8/22/19 revealed a problem of [MEDICAL TREATMENT]. The goal was to maintain stability within constraints of disease process through next review. Interventions included sending scheduled meal with resident to [MEDICAL TREATMENT] using a cooler bag with ice pack. An observation on 8/27/19 at 10:02 AM revealed Resident #168 sitting in her wheelchair at the front door of the facility. Resident #168 was observed with a lunch meat sandwich, applesauce, drink and graham crackers in a zip lock bag. There was no cooler bag observed for the lunch. An observation on 8/29/19 at 9:36 AM revealed Resident #168 being wheeled by transportation driver to the van for transport to [MEDICAL TREATMENT]. Nurse #1 brought Resident #168's lunch to her in a zip lock bag. The lunch consisted of a chicken salad sandwich, juice, applesauce and graham crackers. An observation on 8/29/19 of Resident #168's room revealed she did not have a cooler bag in her room. An interview on 8/29/19 at 2:43 PM with the dietary manager revealed the dietary staff prepare the bagged lunches for the residents on [MEDICAL TREATMENT] and leave them in the refrigerator. The nursing staff is responsible for picking up the bagged lunch before the resident leaves for [MEDICAL TREATMENT] and putting the lunch into the cooler bag. She stated the cooler bags are kept in the resident's room. An interview on 8/29/19 at 3:03 PM with Nurse #1 revealed she didn't put the lunch in the cooler bag because the trip from [MEDICAL TREATMENT] to facility is so short. She stated central supply keeps the cooler bags. An interview on 8/29/19 at 3:06 PM with the supply clerk revealed when a resident is admitted that requires [MEDICAL TREATMENT], she puts a cooler bag in their room. She stated she was unaware that this resident didn't have one.

Based on observations, record reviews, and staff interviews, the facility failed to provide treatment and services to increase range of motion and prevent the right handed contracture of 1 of 1 sampled resident reviewed for limited range of motion. Resident #60. Findings included: Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly minimum (MDS) data set [DATE] indicated Resident #60 was severely, cognitively impaired; required extensive assistance of two staff with bed mobility; was totally dependent of two staff with transfers; and had no range of motion impairments. Review of the Care Plan dated 7/31/18 documented Resident #60's [DIAGNOSES REDACTED]. Interventions included: referral to occupational, physical, and/or speech therapy, as necessary. Review of the Progress Notes from Resident #60's admitted to 9/14/18 revealed no documentation of the resident's contracted right hand and/or range of motion issues. During an observation on 9/11/18 at 12:11 p.m., Resident #60 was awake, alert and verbal with some confusion. The resident's right hand was observed lying atop of the bed blanket in a fisted position. When asked if he could open his hand, the resident was unable to fully extend his fingers of his right hand. Upon further inspection of the resident's room, there was no splinting device observed in the room. During an interview on 9/13/18 at 11:29 a.m., NA#5 (nursing assistant) indicated Resident #60 was alert and verbal but had some confusion. She stated that she had frequently worked with the resident since his admission. NA#5 stated that because the resident's right hand was contracted she would place a rolled cloth in the hand, but the resident continuously dropped it. NA#5 revealed the resident did not have a splinting device and was not currently receiving therapy. During an interview on 9/13/18 at 2:00 p.m., the Rehabilitative Director revealed Resident #60 was not currently receiving therapy and the rehabilitative department had not received a therapy referral from the nursing department. On 9/18/18 at 9:15 a.m., Resident #60 was observed sitting upright in bed, slowly feeding himself using a fork in his right, fisted hand. During an interview on 9/18/18 at 1:46 p.m., the Rehabilitative Director stated if/when a functional change was noticed in a resident, the facility nurses were to complete a Rehabilitative/Therapy Referral form. She indicated the Rehabilitative department had received several referrals of residents from the nurses, but had not received any referrals concerning Resident #60. The Rehabilitative Director revealed that as a result of the prior interview on 9/13/18, the resident was assessed and added to the therapy caseload on 9/17/18 by the OT (occupational therapist) for ROM (range of motion) of his right hand. She stated that the resident's right hand had a partial contracture; but the resident was at risk for contractures and the length of time the hand had been contracted could not be determined due to his [DIAGNOSES REDACTED].#60 would also be fitted for a splint for his partially, contracted right hand.

Based on observation, staff interviews and resident interviews the facility failed to provide a non-institutional dining experience by not offering residents the option for their food to be removed from their tray for 3 of 4 dining areas (Hall 400, Hall 600 and second floor dining room). Findings included: 1a. An observation was made on 9-11-18 between 12:00pm and 12:30pm in the dining area of hall 400. There was noted to be 4 residents sitting at the dining room table and a nursing assistant placing a tray of food in front of each resident removing the cover on the plate. The nursing assistant was noted not to ask the residents if they would like their food taken off the tray. 1b. During an observation on 9-11-18 between 12:00pm and 12:30pm in the dining area of hall 600 it was noted that there were 3 residents siting at the dining room table and a nursing assistant was passing out the lunch trays. The nursing assistant was noted to leave the residents food on the tray without giving the option for the resident to not eat their food on the tray. During an observation on 9-11-18 at 6:15pm in the dining area of hall 600 there were 3 residents sitting at the dining room table receiving their dinner meal on trays and were not being given the option to have their meal taken off the tray. 1c. An observation was made on 9-11-18 at 5:25pm in the second-floor dining room. There were approximately 5 residents noted to be receiving their dinner on a tray without the option being given not to have their food on a tray. An observation was made on 9-13-18 at 12:20pm in the second-floor dining room where lunch was being served on trays and the residents were not being given the option to not have their meal left on the tray. During an interview with Resident #97, who was eating in the second-floor dining room on 9-13-18 at 12:22pm, he stated the nursing assistant had never asked me if I didn't want to eat on my tray. We just always get our food like this. Resident also stated he would like to not have his food off the tray so we have more room at the table. An interview with the nursing assistant(NA) #3 occurred on 9-13-18 at 12:23pm. NA #1 stated she was the nursing assistant that served the meals in the dining room on the second floor and that she had never given the residents a choice to not eat on their trays this is just how we have always done it. During an interview with the Assistant Director of Nursing (ADON) on 9-18-18 at 9:37am she stated she trains the nursing assistance in nutrition upon hire and that she was aware that the residents should be given an option not to have their plates left on the tray but that she did not teach this practice to the nursing assistance during new hire orientation. She also stated she expected the nursing assistant who was training the new hire assigned to them to teach the new nursing assistant the practice of giving the resident an option not to have their plates left on their tray. An interview with the Director of Nursing (DON) occurred on 9-19-18 at 10:16am. The DON stated she expected the nursing assistant to offer for the meal to be removed from the tray and if the resident was not cognitive enough to answer the question then the nursing assistant was expected to remove the meal from the tray.

Based on observations, record review, and staff interviews, the facility failed to provide assistance with meals for 2 of 4 sampled residents (Resident # 69, Resident #63) who were dependent on staff for ADL care (Activities of Daily Living). Findings include: 1. Resident #69 was admitted to the facility on [DATE] with [MEDICAL CONDITION], pseudobulbar affect, and depression. A review of Resident #69's most recent MDS (Minimum Data Set) dated 8/2/18 was coded as a quarterly assessment. Resident #69 was coded as cognitively impaired and as needing extensive one-person assistance with eating. Active [DIAGNOSES REDACTED]. A review of Resident #69's most recent care plan dated 8/2/18 revealed the resident was care planned to help as needed with meals, cue/redirect resident to finish meals, and monitor food consumption. Resident #69 was care planned to need extensive assistance with ADLs. An observation was made on 9/11/18 at 12:30pm of Resident #69 at lunch in the dining area on the memory care unit. Nurse #2 placed Resident #69's tray on the table in front of the resident. Observations of the meal tray revealed the tray had 4 covered bowls on it. Nurse #2 opened one of the bowls and handed it to the resident with a spoon. Resident #69 ate all the food in the bowl and kept scraping the sides. When Resident #69 had cleaned the bowl, she sat with the bowl in her hands. It was observed that no staff came over during the meal. At 12:55pm, the aides picked up Resident #69's tray after placing the empty bowl on it and the aides did not offer the resident any of the other unserved foods on her meal tray. The other 3 bowls of food on the resident's meal tray remained unopened. An observation was made on 9/12/18 at 12:30pm of Resident #69 at lunch in the dining area on the memory care unit. It was observed that staff placed the resident's 4 covered bowls in front of her. Nurse #2 opened the pinto bean bowl and the rice bowl and combined the food and placed the mixed food on the table in front of Resident #69. Resident #69 was observed to eat one bite of food with the spoon then dropped the spoon on the table. Resident #69 then started picking up the food with her fingers. She kept moving the bowl closer to the edge of the table as she ate. Nurse #2 was observed to come over to the table Resident #69 was seated at and she assisted a couple other residents with their meal, but she did not provide any meal assistance to Resident #69. Resident #69 proceeded to spill bowl of food into lap/floor during meal while attempting to feed herself the meal. An interview was conducted with Nurse #2 on 9/12/18 at 12:59pm. She reported Resident #69 could not open her own bowls to eat so staff had to open them for her and hand them to her. An interview was conducted with NA #4 (Nursing Assistant) on 9/19/18 at 9:35am. He reported there were only 2 residents on the memory care unit that needed assistance with feeding and both usually were fed in their rooms. He reported the residents that ate in the dining room including Resident #69 could feed themselves once the tray was set up. 2. Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #63's most recent MDS dated [DATE] was coded as a quarterly assessment. The MDS coded the resident as cognitively impaired. Active [DIAGNOSES REDACTED]. Resident #63's functional status was coded as resident needed extensive one-person assistance with eating. A review of Resident #63's care plan dated 8/8/18 revealed the resident was care planned for ADL self-care deficits which included assisting and encouraging resident throughout meals. An observation was made on 9/11/18 at 12:32pm of Resident #63 during a meal in the dining area of the memory care unit. Observed that Resident #63 had difficulty using her spoon to obtain food off her plate. Resident #63 would attempt to get food off plate but unable to perform the task, so she would eat her brownie that she picked up with her fingers. Throughout the meal, Resident #63 was observed attempting to unsuccessfully eat food off her plate. No staff were observed to assist the resident during the meal. Observations at 1:00pm revealed an aide picked up the resident's tray without asking the resident if she was finished with her meal or to provide encouragement to eat more. An observation was made on 9/12/18 at 12:55 pm of Resident #63 during a meal in the dining area of the memory care unit. Observed Resident #63 having difficulty with using fork for food. Nurse #2 came over and stood over the resident and assisted her with using her fork for a couple bites then left to take care of another resident. After Nurse #2 left Resident #63, she continued to struggle to eat her meal. An interview was conducted with Nurse #2 on 9/12/18 at 1:10pm. Nurse #2 reported Resident #63 needed to be encouraged to eat. Reported the resident sometimes did need some assistance with meals. An interview was conducted with NA #4 (Nursing Assistant) on 9/19/18 at 9:35am. He reported there were only 2 residents on the memory care unit that needed assistance with feeding and both usually were fed in their rooms. He reported the residents that ate in the dining room including Resident #63 could feed themselves once the tray was set up. An interview was conducted with the DON (Director of Nursing) on 9/13/18 at 2:00pm. She reported it was her expectation that all residents care planned as needing assistance with meals be aided throughout the meals. She reported it was the responsibility of the nurse and the aides on the memory care unit to assist and be present in the dining area during the meals.

Based on observations, record reviews, and staff interviews, the facility failed to develop and implement a comprehensive person centered care plan on 1 out of 1 resident (Resident #33) reviewed for smoking at the facility. Findings include: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #33's most recent MDS (Minimum Data Set) was dated 7/9/2018 and was coded as an annual assessment. Resident #33 was coded as cognitively impaired. Active [DIAGNOSES REDACTED]. Resident #33's functional status was coded as limited one-person assistance with transferring and personal hygiene, and supervision with eating and locomotion on/off the unit. A review of Resident #33's care plan dated 7/9/18 revealed the resident was not care planned for smoking precautions at the facility or any previous care plans dating back to (YEAR). An observation was made on 9/11/18 at 12:45pm of Resident #33. Resident #33 asked Nurse #2 for a cigarette so she could go smoke. The nurse retrieved a cigarette from the medication cart and the resident rolled in her wheelchair out on the porch off the dining area of the 300 hall with Nurse #2. Nurse #2 lit the resident's cigarette then came back inside. Observed the resident smoking her cigarette unsupervised. An interview was conducted with Nurse #2 on 9/13/18 at 12:29pm. Nurse #2 reported when she first started working on the memory care unit, she was told Resident #33 didn't need supervision with smoking but just recently she was told that Resident #33 did need assistance with smoking. She reported she had never seen that a smoking assessment had been done on the resident and there was nothing in her care plan. An interview was conducted with the DON (Director of Nursing) on 9/18/18 at 10:11am. She reported it was her expectation that any resident who could smoke at the facility should be care planned for smoking precautions. She confirmed Resident #33's care plan did not include smoking precautions. An interview was conducted on 9/18/18 at 3:30pm with the MDS coordinator. She reported she only updated a care plan if told of a change with the resident's condition.

Based on observations, record reviews, and staff interviews, the facility failed to update the Care Plan of 1 of 1 sampled resident requiring treatment and services for a contracture of the right hand. Resident #60. Findings included: Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly minimum (MDS) data set [DATE] indicated Resident #60 was severely,cognitively impaired; required extensive assistance of two staff with bed mobility; was totally dependent of two staff with transfers; and had no range of motion impairments. Review of the Care Plan dated 7/31/18 documented Resident #60's [DIAGNOSES REDACTED]. Interventions included: referral to occupational, physical, and/or speech therapy, as necessary. The Care Plan was not updated to include range of motion services and Resident #60 ' s hand contracture. During an observation on 9/11/18 at 12:11 p.m., Resident #60 was awake, alert and verbal with some confusion. The resident's right hand was observed lying atop of the bed blanket in a fisted position. When asked if he could open his hand, the resident was unable to fully extend his fingers of his right hand. Upon further inspection of the resident's room, there was no splinting device observed in the room. During an interview on 9/13/18 at 11:29 a.m., NA#5 (nursing assistant) indicated Resident #60 was alert and verbal but had some confusion. She stated that she had frequently worked with the resident since his admission. NA#5 stated that because the resident's right hand was contracted she would place a rolled cloth in the hand, but the resident continuously dropped it. NA#5 revealed the resident did not have a splinting device and was not currently receiving therapy. During an interview on 9/13/18 at 2:00 p.m., the Rehabilitative Director revealed Resident #60 was not currently receiving therapy and the rehabilitative department had not received a therapy referral from the nursing department. On 9/18/18 at 9:15 a.m., Resident #60 was observed sitting upright in bed, slowly feeding himself using a fork in his right, fisted hand. During an interview on 9/18/18 at 1:46 p.m., the Rehabilitative Director stated if/when a functional change was noticed in a resident, the facility nurses were to complete a Rehabilitative/Therapy Referral form. She indicated the Rehabilitative department had received several referrals of residents from the nurses, but had not received any referrals concerning Resident #60. The Rehabilitative Director revealed that as a result of the prior interview on 9/13/18, the resident was assessed and added to the therapy caseload on 9/17/18 by the OT (occupational therapist) for ROM (range of motion) of his right hand. She stated that the resident's right hand had a partial contracture; but the resident was at risk for contractures and the length of time the hand had been contracted could not be determined due to his [DIAGNOSES REDACTED].#60 would also be fitted for a splinting device for his partially, contracted right hand. During an interview on 9/18/18 at 3:52 p.m., the MDS (minimum data set) Manager stated she was not aware Resident #60 had any ROM changes. She revealed the nurses were to inform the MDS staff when there was a change in a resident's functional ability via a direct message in the facility's software system or documenting the change in function on the 24-hour report. The MDS Manager stated that Resident #60's Care Plan would be immediately updated to include his contracted right hand.

Based on staff interviews and record review, the pharmacist failed to identify and report bradycardia (low heart rate) as a clinically significant adverse consequence of duplicate medication therapy for 1 of 3 sampled residents (Resident #1) reviewed for unnecessary medications. The findings included: Resident #3 was admitted to the facility on [DATE]. The resident was readmitted to the facility from the hospital on [DATE]. The resident ' s cumulative [DIAGNOSES REDACTED]. A review of Resident #3 ' s medical record revealed that the following antihypertensive medications were reinitiated upon readmission to the facility on [DATE]: 200 milligrams (mg) labetalol (a medication classified as a beta-adrenergic blocking agents or beta-blocker) given as one tablet by mouth twice daily; 50 mg atenolol (a medication classified as a beta-adrenergic blocking agents) given as one tablet by mouth twice daily; and 5 mg amlodipine (a medication classified as a calcium channel blocker) given as two tablets by mouth once daily. According to Lexi-Drug, a comprehensive drug database of Lexi-Comp, bradycardia may be observed more frequently in elderly patients (>[AGE] years of age) receiving beta-adrenergic blocking agents (or beta-blockers); dosage reductions may be necessary. A review of the resident ' s Medication Administration Records (MARs) from June 2013 through October 2013 revealed the resident continued to receive the antihypertensive medication regimen initiated on 5/21/12, which included: 200 mg labetalol given as one tablet by mouth twice daily; 50 mg atenolol given as one tablet by mouth twice daily; and 5 mg amlodipine given as two tablets by mouth once daily. A review of the resident ' s November 2013 MAR indicated [REDACTED]. Further review of the November 2013 MAR indicated [REDACTED]. The vital signs included measurements of blood pressure (the normal blood pressure (BP) is 120/80) and pulse rate (a normal resting pulse or heart rate (HR) for adults may range from 60 to 100 beats per minute). Resident #3 ' s vital signs for November 2013 included: 11/6/13 BP (lying) = 131/70; Pulse (radial or wrist) = 57 beats per minute (bpm) 11/13/13 BP (lying) = 112/56; Pulse (radial or wrist) = 58 bpm 11/20/13 BP (sitting) = 144/70; Pulse (radial or wrist) = 54 bpm 11/27/13 BP (lying) = 166/84; Pulse (radial or wrist) = 64 bpm A review of the resident ' s December 2013 MAR indicated [REDACTED]. Further review of the December 2013 MAR indicated [REDACTED]. Resident #3 ' s vital signs for December 2013 included: 12/4/13 BP (lying) = 150/84; Pulse (radial or wrist) = 62 bpm 12/11/13 BP (lying) = 134/72; Pulse (radial or wrist) = 61 bpm 12/18/13 BP (lying) = 140/73; Pulse (radial or wrist) = 55 bpm 12/25/13 BP (lying) = 134/60; Pulse (radial or wrist) = 89 bpm A review of the resident ' s January 2014 MAR indicated [REDACTED]. Further review of the January 2014 MAR indicated [REDACTED]. Resident #3 ' s vital signs for January 2014 included: 1/1/14 BP (lying) = 122/65; Pulse (radial or wrist) = 57 bpm 1/8/14 BP (lying) = 150/76; Pulse (radial or wrist) = 58 bpm 1/15/14 BP (lying) = 172/81; Pulse (radial or wrist) = 55 bpm 1/22/14 BP (lying) = 119/64; Pulse (radial or wrist) = 52 bpm 1/29/14 BP (lying) = 128/65; Pulse (radial or wrist) = 58 bpm A review of the resident ' s February 2014 MAR indicated [REDACTED]. Further review of the February 2014 MAR indicated [REDACTED]. Resident #3 ' s vital signs for February 2014 included: 2/5/14 BP (sitting) = 145/72; Pulse (radial or wrist) = 69 bpm 2/12/14 BP (sitting) = 130/62; Pulse (radial or wrist) = 56 bpm 2/19/14 BP (sitting) = 138/60; Pulse (radial or wrist) = 62 bpm A review was completed of the consultant pharmacist ' s monthly progress notes from June 2013 through February 2014. No concerns were documented in regards to the use of two beta-blockers or the low HR recorded for Resident #3. A review of the Nursing Progress notes dated 2/22/14 at 3:45 PM revealed the resident ' s family member came into the facility and requested Resident #3 be sent to the emergency room (ER) due to complaints of abdominal pain during recent weeks. The nurse reported she contacted the on-call NP and received an order to send her to the ER. A second Nursing Progress note dated 2/22/14 indicated the resident ' s vital signs were taken at the facility prior to sending her out and included a report of BP 100/58 and heart rate 48 bpm. The Nursing Progress note also reported, " but when the EMS (Emergency Medical Service) got here P (pulse or heart rate was) 38 but resident was still alert and oriented propelling herself in her wheelchair without any difficulties noted. " A review of the hospital records revealed Resident #3 was transported by ambulance and arrived at theER on [DATE] at 4:07 PM. The resident ' s chief complaints upon arrival to the ER were noted as: abdominal pain and bradycardia. The History and Physical dictated by the Medical Doctor (MD) at the ER read in part, " Per EMS report from nursing home, patient ' s heart rate usually runs in the 60 ' s ...Per EMS, upon arrival vitals were taken and HR was noted to be in the 30s and patient was pale and diaphoretic (perspiring profusely). " Additional notes from the 2/22/14 hospital admission records read, in part: " She goes on to say that she spent, ' the whole day telling the people at the nursing home to send me to the hospital, ' and eventually she called her son and at some point, it was realized that her heart rate was very low and so she was brought to the Emergency Department. In the ED, her vital signs have been stable, however. Her heart rate has been in the 30s all throughout her stay, between 33 and 38 beats per minute. On review of her medication, she is both on atenolol as well as labetalol and also on Aricept, all of which lead to bradycardia. " Further review of the hospital records dated 2/22/14 included the MD ' s Assessment and Plan which read, in part: " An [AGE] year-old female with a past medical history of [REDACTED]. " 1. Symptomatic bradycardia: -- " I believe that we can attribute several of her symptoms to bradycardia. She has maintained an acceptable blood pressure throughout this stay. We would like, however, to administer glucagon (an intravenous medication which may be used to reverse beta-blocker-induced HR depression) and see if we can place her heart rate in at least the 40s. This may also improve her overall wellbeing. I am holding Aricept and we should monitor heart rate once it is re-introduced. " -- " Of note, the patient had been admitted in 2012 by (MD name) and during that admission, he discontinued the atenolol and mentioned that he was doing so because she was already on labetalol. Obviously, the patient was at some point placed back on both of them. " Resident #3 was discharged from the hospital on [DATE] to another nursing home facility. Hospital records indicated the resident ' s discharge [DIAGNOSES REDACTED]. Symptomatic bradycardia secondary to medications. " The History of Present Illness and Hospital Course reported in the 2/26/14 discharge records read, in part: " The patient admitted with bradycardia with heart rate of between 33 and 38, the patient was found to be (on beta-) blockers (atenolol and labetalol). Both medications were discontinued. The patient ' s heart rate came up to the 60s-70s. Started atenolol at a low dose of 25 mg. " Discharge instructions from the hospital included discontinuation of labetalol and a decreased dose of atenolol (25 mg once daily) secondary to symptomatic bradycardia. Resident #3 was discharged from the hospital on [DATE] to another nursing home facility. Hospital records indicated the resident ' s primary discharge [DIAGNOSES REDACTED]. The History of Present Illness and Hospital Course included in the 2/26/14 discharge records read, in part: " The patient admitted with bradycardia with heart rate of between 33 and 38, the patient was found to be (on beta-) blockers (atenolol and labetalol). Both medications were discontinued. The patient ' s heart rate came up to the 60s-70s. Started atenolol at a low dose of 25 mg. " A telephone interview was conducted with the facility ' s consultant pharmacist on 4/3/14 at 11:32 AM. Inquiry was made regarding Resident #3 ' s medication profile and inclusion of two beta-blockers to treat her blood pressure. The pharmacist stated she, " may have missed " this duplication. Upon further inquiry, the pharmacist stated that she typically would have contacted the prescriber when a therapeutic duplication was identified. During the interview, the pharmacist was asked if she had noted when the resident ' s heart rates were reported to be in the 50 ' s (bpm). The pharmacist stated, " I did not watch the HR as closely as the BP. " Upon review of her records, the pharmacist indicated she did not see where a concern or written recommendation was made to Resident #3 ' s physician/NP in regards to the therapeutic duplication of the beta-blockers prescribed or the low heart rates recorded. An interview was conducted on 4/3/13 at 12:15 PM with the Director of Nursing (DON). Upon review of the vital sign records for 12/13, 1/14, and 2/14, the DON stated, " I would have wanted to contact the physician and let him/her know the resident was having bradycardic episodes and ask does he need to do a medication review. " When asked about the therapeutic duplication and use of two beta-blockers for Resident #3, the DON also stated, " I would have thought the pharmacist would have picked up on that. "

Based on staff interviews and record review, the facility failed to identify a resident ' s low heart rate as a significant adverse consequence of the medication regimen for 1 of 3 sampled residents (Resident #3) reviewed for unnecessary medications. The findings included: Resident #3 was admitted to the facility on [DATE]. The resident was readmitted to the facility from the hospital on [DATE]. The resident ' s cumulative [DIAGNOSES REDACTED]. A review of Resident #3 ' s medical record revealed that the following antihypertensive medications were reinitiated upon readmission to the facility on [DATE]: 200 milligrams (mg) [MEDICATION NAME] (a medication classified as a beta-adrenergic blocking agents or beta-blocker) given as one tablet by mouth twice daily; 50 mg [MEDICATION NAME] (a medication classified as a beta-adrenergic blocking agents) given as one tablet by mouth twice daily; and 5 mg [MEDICATION NAME] (a medication classified as a calcium channel blocker) given as two tablets by mouth once daily. According to Lexi-Drug, a comprehensive drug database of Lexi-Comp, [MEDICAL CONDITION] (slowness of the heartbeat, usually a rate less than 60 beats per minute) may be observed more frequently in elderly patients (>[AGE] years of age) receiving beta-adrenergic blocking agents (or beta-blockers); dosage reductions may be necessary. A review of the resident ' s Medication Administration Records (MARs) from June 2013 through October 2013 revealed the resident continued to receive the antihypertensive medication regimen initiated on 5/21/12, which included: 200 mg [MEDICATION NAME] given as one tablet by mouth twice daily; 50 mg [MEDICATION NAME] given as one tablet by mouth twice daily; and 5 mg [MEDICATION NAME] given as two tablets by mouth once daily. A review of the resident ' s November 2013 MAR indicated [REDACTED]. Further review of the November 2013 MAR indicated [REDACTED]. The vital signs included measurements of blood pressure (the normal blood pressure (BP) is 120/80) and pulse rate (a normal resting pulse or heart rate (HR) for adults may range from 60 to 100 beats per minute). Resident #3 ' s vital signs for November 2013 included: 11/6/13 BP (lying) = 131/70; Pulse (radial or wrist) = 57 beats per minute (bpm) 11/13/13 BP (lying) = 112/56; Pulse (radial or wrist) = 58 bpm 11/20/13 BP (sitting) = 144/70; Pulse (radial or wrist) = 54 bpm 11/27/13 BP (lying) = 166/84; Pulse (radial or wrist) = 64 bpm There was no documentation indicating a concern was identified regarding the resident ' s low heart rate (HR) or that the physician/Nurse Practitioner (NP) was notified of a low HR. A review of the resident ' s December 2013 MAR indicated [REDACTED]. Further review of the December 2013 MAR indicated [REDACTED]. Resident #3 ' s vital signs for December 2013 included: 12/4/13 BP (lying) = 150/84; Pulse (radial or wrist) = 62 bpm 12/11/13 BP (lying) = 134/72; Pulse (radial or wrist) = 61 bpm 12/18/13 BP (lying) = 140/73; Pulse (radial or wrist) = 55 bpm 12/25/13 BP (lying) = 134/60; Pulse (radial or wrist) = 89 bpm There was no documentation indicating a concern was identified regarding the resident ' s low HR or that the physician/NP was notified of a low HR. A review of the resident ' s January 2014 MAR indicated [REDACTED]. Further review of the January 2014 MAR indicated [REDACTED]. Resident #3 ' s vital signs for January 2014 included: 1/1/14 BP (lying) = 122/65; Pulse (radial or wrist) = 57 bpm 1/8/14 BP (lying) = 150/76; Pulse (radial or wrist) = 58 bpm 1/15/14 BP (lying) = 172/81; Pulse (radial or wrist) = 55 bpm 1/22/14 BP (lying) = 119/64; Pulse (radial or wrist) = 52 bpm 1/29/14 BP (lying) = 128/65; Pulse (radial or wrist) = 58 bpm There was no documentation indicating a concern was identified regarding the resident ' s low HR or that the physician/NP was notified of a low HR. A review of the resident ' s February 2014 MAR indicated [REDACTED]. Further review of the February 2014 MAR indicated [REDACTED]. Resident #3 ' s vital signs for February 2014 included: 2/5/14 BP (sitting) = 145/72; Pulse (radial or wrist) = 69 bpm 2/12/14 BP (sitting) = 130/62; Pulse (radial or wrist) = 56 bpm 2/19/14 BP (sitting) = 138/60; Pulse (radial or wrist) = 62 bpm There was no documentation indicating a concern was identified regarding the resident ' s low HR or that the physician/NP was notified of a low HR. A review of the Nursing Progress notes dated 2/22/14 at 3:45 PM revealed the resident ' s family member came into the facility and requested Resident #3 be sent to the emergency room (ER) due to complaints of abdominal pain during recent weeks. The nurse reported she contacted the on-call NP and received an order to send her to the ER. A second Nursing Progress note dated 2/22/14 indicated the resident ' s vital signs were taken at the facility prior to sending her out and included a report of BP 100/58 and HR 48 bpm. The Nursing Progress note also reported, " but when the EMS (Emergency Medical Service) got here P (pulse or heart rate was) 38 but resident was still alert and oriented propelling herself in her wheelchair without any difficulties noted. " A review of the hospital records revealed Resident #3 was transported by ambulance and arrived at theER on [DATE] at 4:07 PM. The resident ' s chief complaints upon arrival to the ER were noted as: abdominal pain and [MEDICAL CONDITION]. The History and Physical dictated by the Medical Doctor (MD) at the ER read in part, " Per EMS report from nursing home, patient ' s heart rate usually runs in the 60 ' s ...Per EMS, upon arrival vitals were taken and HR was noted to be in the 30s and patient was pale and diaphoretic (perspiring profusely). " Additional notes from the 2/22/14 hospital admission records read, in part: " She goes on to say that she spent, ' the whole day telling the people at the nursing home to send me to the hospital, ' and eventually she called her son and at some point, it was realized that her heart rate was very low and so she was brought to the Emergency Department. In the ED, her vital signs have been stable, however. Her heart rate has been in the 30s all throughout her stay, between 33 and 38 beats per minute. On review of her medication, she is both on [MEDICATION NAME] as well as [MEDICATION NAME] and also on [MEDICATION NAME], all of which lead to [MEDICAL CONDITION]. " Further review of the hospital records dated 2/22/14 included the MD ' s Assessment and Plan which read, in part: " An [AGE] year-old female with a past medical history of [REDACTED]. " 1. Symptomatic [MEDICAL CONDITION]: -- " I believe that we can attribute several of her symptoms to [MEDICAL CONDITION]. She has maintained an acceptable blood pressure throughout this stay. We would like, however, to administer [MEDICATION NAME] (an intravenous medication which may be used to reverse beta-blocker-induced HR depression) and see if we can place her heart rate in at least the 40s. This may also improve her overall wellbeing. I am holding [MEDICATION NAME] and we should monitor heart rate once it is re-introduced. " -- " Of note, the patient had been admitted in 2012 by (MD name) and during that admission, he discontinued the [MEDICATION NAME] and mentioned that he was doing so because she was already on [MEDICATION NAME]. Obviously, the patient was at some point placed back on both of them. " Resident #3 was discharged from the hospital on [DATE] to another nursing home facility. Hospital records indicated the resident ' s discharge [DIAGNOSES REDACTED]. Symptomatic [MEDICAL CONDITION] secondary to medications. " The History of Present Illness and Hospital Course reported in the 2/26/14 discharge records read, in part: " The patient admitted with [MEDICAL CONDITION] with heart rate of between 33 and 38, the patient was found to be (on beta-) blockers ([MEDICATION NAME] and [MEDICATION NAME]). Both medications were discontinued. The patient ' s heart rate came up to the 60s-70s. Started [MEDICATION NAME] at a low dose of 25 mg. " Discharge instructions from the hospital included discontinuation of [MEDICATION NAME] and a decreased dose of [MEDICATION NAME] (25 mg once daily) secondary to symptomatic [MEDICAL CONDITION]. An interview was conducted on 4/3/14 at 9:35 AM with Nurse #1. Nurse #1 worked on Resident #3 ' s hall during her stay at the facility. Upon inquiry, Nurse #1 indicated that routine vital signs were taken once a week for each resident and on an as needed basis. She stated that if the BP or HR was out of that resident ' s normal range, she would contact the physician. Nurse #1 was not aware of a facility policy which provided guidelines or parameters used to indicate when the resident ' s physician or NP would need to be alerted for a high or low reading. A telephone interview was conducted on 4/3/13 at 10:50 AM with the NP who had provided care for Resident #3. Upon inquiry, the NP did remember Resident #3. However, she did not have access to the facility ' s records at the time of the telephone interview so did not wish to comment on the specifics of Resident #3 ' s medication regimen. When asked in general terms whether having a resident on two beta-blockers was a typical or usual practice, she stated that the only time two beta blockers would be used was if one of them was an as needed (PRN) medication. Upon further inquiry, the NP reported she would expect to be contacted by nursing staff if a resident ' s HR was less than 60 or greater than 100 bpm. However, she added the some residents " run in the 50 ' s, " and in those cases, she would expect to be notified if the resident ' s HR was less than 50 bpm. A telephone interview was conducted with the facility ' s consultant pharmacist on 4/3/14 at 11:32 AM. Inquiry was made regarding Resident #3 ' s medication profile and inclusion of two beta-blockers to treat her blood pressure. The pharmacist stated she, " may have missed " this duplication. Upon further inquiry, the pharmacist stated that she typically would have contacted the prescriber when a therapeutic duplication was identified. During the interview, the pharmacist was asked if she had noted when the resident ' s heart rates were reported to be in the 50 ' s (bpm). The pharmacist stated, " I did not watch the HR as closely as the BP. " An interview was conducted on 4/3/13 at 12:15 PM with the Director of Nursing (DON). Upon review of the vital sign records for 12/13, 1/14, and 2/14, the DON stated, " I would have wanted to contact the physician and let him/her know the resident was having bradycardic episodes and ask does he need to do a medication review. " When asked about the therapeutic duplication and use of two beta-blockers for Resident #3, the DON also stated, " I would have thought the pharmacist would have picked up on that. "

Based on record review, staff interview, nurse practitioner interview and physician interview the facility failed to notify the physician of a fall with head injury and increased pain for 1 of 1 (Resident #25) resident who sustained a head injury. Resident #25 developed a subdural hematoma with a brain shift to the left placing pressure on the [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for evaluation and expired [DATE]. Immediate jeopardy began on [DATE] and was identified on [DATE] at 5:30 PM. Validation of the facility's credible allegation was conducted on [DATE]-[DATE]. Residents on all halls (100, 200, 300, 400, 500 and 600 halls) in the facility records were reviewed and observations were conducted on residents who had changes in conditions. The observations included interventions associated with falls, skin conditions, staff reporting/communication process from shift to shift, staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools ([DATE]). The SBAR(Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from [DATE]-[DATE] was reviewed. Record reviews were completed to verify the implementation of the assessment tools and the functional process of staff communication regarding resident change of condition between shifts and medical staff/responsible parties. Staff interviews were conducted with all three shift to verify the implementation of the newly developed SBAR(Situation, Background, Assessment, Recommendation/Request) form, Guidelines for Change in Condition form (falls, skin condition neurological checks), Nursing Assistant Reporting Changes in Resident Condition to Nurse Guideline/Tool and Physician signature on the SBAR form indicating review of the assessment and knowledge of the resident change of condition had been completed by [DATE] per the Credible Allegation. Direct Care, Physical Therapy Staff and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The completion date for all in-services for nursing and nursing assistant became effective [DATE]. The Quality Assurance Audit reports since [DATE] through [DATE] were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of Notification of physician (157) on [DATE]. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. Findings included: The record review indicated that the resident was admitted on [DATE] at 2:13 PM for rehabilitation following an ischemic [MEDICAL CONDITION] (a lack of blood supply in the brain). Admission [DIAGNOSES REDACTED]. Resident #25's admission medications included: Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. The record review revealed that the Minimum Data Set ((MDS) dated [DATE] indicated Resident #25 was severely cognitively impaired. There were no mood disorders noted and there were no behaviors noted. There were no pain problems noted. The resident required extensive assistance with activities of daily living (ADL) with at least one person assistance at all times. Resident #25 had an unsteady gait and required one person assistance for transfer and for toileting. Upon review of Resident #25's medical chart and electronic chart, there was no information noted that the resident had a chronic pain issue or that the resident was constantly anxious. From admission date of [DATE] to [DATE] the resident had no behavior problems charted and had no pain problems charted. On [DATE] [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for agitation was ordered. The resident was medicated on [DATE], [DATE], and [DATE] with [MEDICATION NAME] for agitation prior to her fall on [DATE]. The record review indicated the medical physician saw and evaluated the resident on [DATE]. The evaluation stated that the resident denied pain. The record review indicated that the care plan dated [DATE] did include interventions for falls related to use of [MEDICAL CONDITION] medications for dementia, recent stroke and hospitalization . The resident was not care planned for pain, mood disorder, or behavior problems. The record review stated that the resident fell on [DATE] at 4:14 AM. The resident was found on the floor in her room by Nurse #2. A Nurses note by Nurse #1 stated " fall with head injury. Attempted to go to bathroom unassisted. Hit back of her head. Neuro (neurological) checks WNL (within normal limits). " Neurological checks compare a person's baseline to a current assessment of level of consciousness (alertness/behavior), vital signs, pupil response to light, eye response to stimuli, level of consciousness, speech pattern, and motor response. An interview on [DATE] at 11:20 AM with Nurse #1 revealed that Nurse #2 found the resident on the floor in her room. Nurse #1 came to the resident's room to assess the resident for injury and determined Resident #25 was without major injury. Nurse #1 stated that the resident had equal grips, no more than normal confusion, no lacerations, and did not appear to be harmed other than the " bump " to the back of her head. The nurse's notes by Nurse #2 indicated that on [DATE] at 6:25 AM the neuro checks were still in progress and within normal limits. The resident complained of pain around her head area where her head had hit the floor. No swelling was noted at that time. According to Nurse #2's notes, the physician was notified of the resident's fall via the facilities communication board. During record review of the communication notes on [DATE] at 11:00 AM the note for [DATE] could not be located for Resident #25. At that time the Director of Nursing (DON) was asked if she had a copy of that communication sheet, she stated that she did not. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM the DON indicated that the protocol for falls was to have the charge nurse evaluate the resident for injury, after that, they assisted with getting the resident back to bed or bathroom. The DON stated the physician would be called if there were serious injuries to the resident. The DON indicated that a serious injury would be a skin tear that kept bleeding, abnormal neuro checks, deviation from the resident's baseline, dislocation or odd positioning of the extremities. If there were no serious injuries then the resident's fall would be placed on the communication board which was seen by the physician or NP on a daily basis. The facility was unable to show any communication regarding Resident #25 on the communication board sheets from February through [DATE] about Resident #25's fall. The record review revealed no other notes in Resident #25's chart from a physician or NP for the dates following the fall. The DON stated her expectation would be the nurse would have contacted the physician per the facilities recognized protocol. The ADON indicated that the MD or the NP would see the communication board on a daily basis while doing rounds. On [DATE] at 9:32 AM the record review of the MAR indicated [REDACTED]. During an interview on [DATE] at 11:12 AM, Nurse #2 indicated that the resident's neuro checks were normal during her time with the resident immediately following the fall. Nurse #2 stated that the medical physician would not be called unless neuro checks deviated from normal or if the resident showed signs of injury at the time of the fall that required immediate evaluation. On [DATE] at 9:35 PM the record review of the MAR indicated [REDACTED]. A nursing note dated [DATE] at 10:42 PM included, " Resident alert, oriented, and verbally responsive. " The note also indicated the resident received Tylenol 650 mg (milligram) and [MEDICATION NAME] (anxiety medication) given for back pain and anxiety respectively. The nurse's note indicated that neuro checks continued. A nurse's note entry by Nurse #2 on [DATE] at 6:21 AM stated that the neuro checks were still in progress and Resident #25 was within normal limits. There were no delayed injuries noted. The nurse's note also stated Resident #25 woke up at 4:00 AM yelling out and complaining of back pain. Nurse #2 gave Resident #25 Tylenol 650 mg. Nurse #2 indicated Resident #25 started yelling out again in pain after 15 minutes and stated she wanted to lie down again. Resident #25 was then transferred back to bed. The nursing notes stated Resident #25 began yelling out again at 5:00 AM requesting to get out of bed because of her back pain. Resident #25 was placed in a wheelchair but continued to yell out when approached. Nurse #2 stated " resident unsure of what help she needs, not easily redirected. " The record review of Resident #25's medication record indicated that she was medicated with Tylenol at 4:10 AM. Nurse #2 indicated Resident #25 Resident didn't yell and call out that she was in pain prior to her falling. An interview with Nurse #3 and Nurse #4 on [DATE] at 3:00 PM revealed that they would use the facial recognition system to evaluate pain on a resident who was severely cognitively impaired. Nurse #3 and Nurse #4 both indicated a ,[DATE] pain scale would not be reliable on a resident who is cognitively impaired because the resident would not be able to use the scale. They stated that it would be better to judge the resident by his/her normal baseline and compare it to how have they changed since an incident. Record review revealed that on [DATE] at 3:29 PM a nurse's note written by Nurse #3 indicated that the resident was alert and oriented to herself and place with no complaints noted. The resident's level of care or ADLs did not change per the nurse's note. On [DATE] at 7:18 PM the MAR indicated [REDACTED]. Record review revealed that on [DATE] 10:20 PM Nurse #4 wrote " Resident alert, oriented, and verbally responsive. PRN (as needed for) pain med (medication) Tylenol 650 mg and [MEDICATION NAME] given for back pain and anxiety respectively. F/U (follow up) fall day 1 with neuro checks continuing. Ate supper at substation, extensive assistance with ADL's and tranfers. Family visits often, in bed with call light in reach. " Record review revealed that on [DATE] 05:45 AM Nurse #2 wrote " S/P (status [REDACTED]. " The record review of Resident #25's therapy notes indicated that on [DATE] Occupational Therapist #1 charted a note that stated Resident #25 continued to " c/o (complain of) back and head pain which is effecting her performance. " In an interview on [DATE] at 10:31 AM Occupational Therapist #1 revealed she remembered Resident #25 as having had severe head pain during her session on [DATE]. Occupational Therapist #1 (OT #1) told a Physical Therapist Assistant (PTA) that Resident #25 was complaining and that they should tell the nurse. The OT #1 stated that she couldn't remember who the nurse was or if the nurse had been told of the resident's increased pain. . The record review revealed a note on [DATE] from physical therapy that read " Pt (Patient) with c/o lower back pain today with difficulty performing sit to stand and unable to tolerate standing. " The physical therapy note also indicated that the physical therapist had spoken with nursing staff and included, " No documentation seen regarding x-rays to rule out injury. Discussed with nursing possibility of x-rays if pain does not improve. " The Physical Therapist was called on [DATE] at 4:00 PM. A message was left to return the phone call, by [DATE] at 5:00 PM the Physical Therapist had not returned the phone call. On [DATE] at 5:40 PM the MAR indicated [REDACTED]. The record review revealed a nurses note dated [DATE] at 05:48 AM included that on the 3rd day after her fall Resident #25 had no delayed injuries noted, no acute distress noted, and that monitoring would continue. On [DATE] at 1:41 PM the MAR indicated [REDACTED]. On [DATE] Occupational therapist #2 charted " Pt crying out and stating ' my back hurts worse than ever! My back! ' Pt. performed 2 standing trials with minimal assist to reach forward to grasp parallel bar. 1 minute 1st trial, 30 seconds 2nd trial. " please let me sit down. " OT #2 ' s notes indicated that a back massage was done but the resident stated " ' it helps but it still hurts so bad. ' " During an interview on [DATE] at 9:55 AM Occupational Therapist #2 (OT #2) said she found Resident #25 crying out in the hallway that day. Occupational Therapist #2 indicated that what she wrote was a true assessment of the residents back pain as being severe on those specific dates and that she did seem more in pain after her fall. On [DATE], the Nurse Practitioner ordered " [MEDICATION NAME] 800 mg tablet give 1 tablet (800 mg) by oral route once daily as needed only to be given after resident has eaten /1st dose asap (as soon as possible). " On [DATE] at12:40 PM the MAR indicated [REDACTED]. A nurse's note entry by Nurse #3 stated the Nurse Practitioner (NP) saw Resident #25 concerning an order for [REDACTED]. On [DATE] at10:05 AM an interview with the Nurse Practitioner (NP) was obtained. The NP didn't remember the resident and stated " if there is no note in the chart or progress notes then I didn't see her. " During the survey there were no physician notes or nurse practitioner notes found in Resident #25's chart to indicate the resident was seen by either the MD or NP following her fall and head trauma. The facility could not provide any further documentation that showed the NP or the MD saw Resident #25 following her fall. According to the resident's medical record, Resident #25 was not seen by occupational therapy or physical therapy on [DATE] but did return to occupational therapy on [DATE] and complained of severe pain. On [DATE] Resident #25 returned to physical therapy. There was no pain noted during physical therapy on that day. Resident #25 was considered on [DATE] for discharge from physical therapy related to resident meeting her maximum level of functional capability. According to nurse's notes on [DATE] at 11:53 AM Resident #25 was medicated with [MEDICATION NAME] 800 mg for a complaint of pain. A nurses noted charted by Nurse #3 stated " No change in level of care, ADL's or behavior. " The note also included that the resident " Continues to yells and screams for attention " and made frequent requests to go from the bathroom to her recliner. On [DATE] at 3:51 PM the MAR indicated [REDACTED]. During record review of the physician's orders [REDACTED]. During the NP's interview [DATE] at 10:05 AM she stated that she did not remember Resident #25 and did not recall writing any orders for this resident. On [DATE] at 9:37 am the MAR indicated [REDACTED]. No nurse's note was written. On [DATE] at 1:54 PM a nurse note stated " Alert and oriented to self. No acute complaints nor in any apparent acute compromising condition. " According to the MD's communication board, on [DATE] a note was left on the communication board about the family wanting to have the [MEDICATION NAME] discontinued because of the resident ' s history of an ulcer and pain whenever she uses it. This was observed on [DATE] at 11:00 AM. On [DATE] at 8:56 am the record review indicated that the resident was medicated with 800 mg of [MEDICATION NAME] PO for pain. No nurse's note were written on [DATE]. On [DATE] the social worker saw Resident #25 on [DATE] and wrote a note. The social worker noted the resident " continues to exhibit behaviors of yelling and crying per nurses notes ,[DATE] - [DATE] per nurses notes ,[DATE] and ,[DATE] resident was medicated with [MEDICATION NAME] for " anxiety. " During an interview on [DATE] at 9:25 AM the social worker indicated the resident was always looking for her family but didn't have any behaviors other than calling for her family that she was aware of. On [DATE] at 1:45 PM nurses note entry read " alert and verbal. No signs and symptoms of any apparent acute compromising condition. Continue to yells but soon as staff talk to her she stop then yell later on again. No change in level of care or ADL's (activities of daily living). " On [DATE] at 1:13 PM a nurse's note entry read " Resident continues to yell and scream of back pain. No change in level of care or ADL's. " A new order written on [DATE] and signed by the Nurse Practitioner stated " [MEDICATION NAME] (narcotic like pain medication) 25 mg PO (by mouth) BID (twice a day) and every 6 hours as needed for pain. Hold for sedation. X-ray of lumbar and [MEDICATION NAME] spine. " Results from portable x-ray done on Resident #25 were sent to the facility on [DATE] with negative results for any acute findings. On [DATE] at 3:20 PM a telephone order was written for Tylenol for arthritis every 8 hours and Tylenol 325 mg, 2 tablets orally every 6 hours PRN for break through pain. The order for [MEDICATION NAME] was discontinued. This order was taken by the assistant director of nursing from the NP. The order was then signed by the MD. On [DATE] at 7:32 AM nurse #7 charted " At 5:45 AM NA noted resident was lethargic and was assessed by this writer. " " Resident c/o neck pain and scheduled Tylenol was given. " At 7:56 AM nurse #1 charted that the resident was more alert and was able to recall friends and family names. The communication board had a note to the medical physician dated [DATE] was observed on [DATE] at 11:00AM. At 10:12 AM Nurse # 7 obtained a urine sample per standing orders because of the resident ' s new lethargy. Nurse #7 ' s note included, " Resident complained of headache this morning and was given pain medication that was effective. " At 1:56 PM nurse #7 charted " resident in bed finishing eating lunch, ate 25%. Alert and verbally responsive, able to make needs known. Writer assisted resident in drinking juice, resident had difficulty swallowing and juice dripping to her mouth. Writer observed slurred speech and left sided weakness. Notified supervisor, RP, and MD. " An interview with nurse #7 on [DATE] at 11:00 am revealed the resident was in bed in the morning which wasn ' t normal and heard that the resident had a rough night. She noted that the resident didn ' t seem " right. " The urine sample was collected per standing orders and sent out because of resident's frequent urinary tract infections. By 1:00 PM the resident wasn't able to eat lunch without dribbling fluid down mouth and was still lethargic. The on call medical physician was called and orders taken for the resident to be transferred to the hospital for further evaluation. At 1:15 PM Resident #25 was transferred to emergency department for evaluation. According to the admission history and physical report dated [DATE], once at the hospital the resident was sent for a CT (Computed Tomography) scan (which created a 3-dimentional image of the brain/skull) where it was noted Resident #25 had a 14 millimeter thick subdural hematoma that had caused a shift of Resident #25's brain 8 millimeters to the left place pressure on the [DIAGNOSES REDACTED]. The resident was also found to be anemic with a hemoglobin of 5.8. There was black stool noted but was not tarry in nature. The family reported to the ER physician that they were unaware of any bowel problems related to dark stool having been occurring at the facility. The resident was transfused with 1 unit of packed red blood cells. The resident was seen by a Neuro Surgeon and discussed with the family the prognosis for the resident if she underwent surgery. The decision was made to place the resident in Hospice care with comfort measures only. Resident #25 died on [DATE]. An interview with the facilities medical physician (MD) was conducted on [DATE] at 2:45 PM. The MD stated that he did not remember being told about this residents fall. He stated that his expectation following a resident fall was that the nurses would assess the resident, determine if there were any injuries and start neuro checks if the fall involved head trauma. He stated that the only time a nurse would directly call him or the on call doctor would be when the resident started to have neurological changes showing during the neuro checks. The doctor stated that he expected the nurses to contact him or the on call MD directly if a cognitively impaired resident started complaining of more pain following a fall or had behavior changes such as more agitation and anxiety following a fall. The MD stated that according to the resident's chart that the resident was not seen by himself or the Nurse Practitioner following the residents fall. He stated " If I lay eyes on them (resident) or put my hands on them (resident) I leave a note in the chart. " He stated that his expectation was that the NP did the same. When asked directly if the resident was seen by himself or the NP following the fall he stated " no, based on what is in this chart. " The MD stated that if the nurses had called him or the on call MD and reported that the resident was experiencing more pain and more anxiety following the fall that he would have been able to pick up on pupil changes or focal defects of the resident's arms and legs. If these changes were picked up by him or his NP, then the resident would have been sent to the emergency room (ER) for a CT scan of the head at that time. The CT report from the hospital was read and shown to the MD. The MD stated that based on the CT report from the hospital that " her fall (the residents) could be a cause of her subdural hematoma and subsequent death. It is most likely the cause and I ' m sure the fall contributed to her death. " An interview with the Nurse practitioner on [DATE] at 2:30 PM revealed that she does not remember this resident, did not remember writing orders on the resident and that it is possible that she was called for orders and never physically saw the resident. She stated that if there are no notes in the chart that state she assessed the resident, then she didn't visually assess the resident prior to giving orders for the resident. The NP stated that she doesn't normally write orders on residents she doesn't evaluate but it could happen if she was not in the building. On [DATE] at 5:00 PM the MD stated that the resident received 4 doses of [MEDICATION NAME] after her fall and before she was sent to the hospital for evaluation. The MD stated it could have been a contributing factor in an increase of a slow bleed from a traumatic injury such as a subdural hematoma. The death certificate dated [DATE] stated the immediate cause of death was a subdural hematoma due to (or as a consequence of) a fall.

Based on record review, staff interview, nurse practitioner interview and physician interview the facility failed to notify the physician of a fall with head injury and increased pain for 1 of 1 (Resident #25) resident who sustained a head injury. Resident #25 developed a subdural hematoma with a brain shift to the left placing pressure on the [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for evaluation and expired [DATE]. Immediate jeopardy began on [DATE] and was identified on [DATE] at 5:30 PM. The immediate jeopardy is present and ongoing. Validation of the facility's credible allegation was conducted on [DATE]-[DATE]. The facility records were reviewed and observations were conducted on residents who had changes in conditions on all halls (100, 200, 300, 400, 500 and 600 halls). The observations included interventions associated with falls, skin conditions, staff reporting/communication process from shift to shift; staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools ([DATE]). The SBAR (Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from [DATE]-[DATE] were reviewed. Record reviews were completed to verify the implementation of the assessment tools and the functional process of staff communication regarding resident change of condition between shifts and medical staff/responsible parties. Staff interviews were conducted with all three shift to verify the implementation of the newly developed SBAR(Situation, Background, Assessment, Recommendation/Request) form, Guidelines for Change in Condition form (falls, skin condition neurological checks), Nursing Assistant Reporting Changes in Resident Condition to Nurse Guideline/Tool and Physician signature on the SBAR form indicating review of the assessment and knowledge of the resident change of condition had been completed by [DATE] per the Credible Allegation. Direct Care, Physical Therapy Staff and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The completion date for all in-services for nursing and nursing assistant became effective [DATE]. The Quality Assurance Audit reports since [DATE] through [DATE] were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of Notification of physician as a result of a fall on [DATE]. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. Findings included: The record review indicated that the resident was admitted on [DATE] at 2:13 PM for rehabilitation following an ischemic [MEDICAL CONDITION] (a lack of blood supply in the brain). Admission [DIAGNOSES REDACTED]. Resident #25's admission medications included: Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. The record review revealed that the Minimum Data Set ((MDS) dated [DATE] indicated Resident #25 was severely cognitively impaired. There were no mood disorders noted and there were no behaviors noted. There were no pain problems noted. The resident required extensive assistance with activities of daily living (ADL) with at least one person assistance at all times. Resident #25 had an unsteady gait and required one person assistance for transfer and for toileting. Upon review of Resident #25's medical chart and electronic chart, there was no information noted that the resident had a chronic pain issue or that the resident was constantly anxious. From admission date of [DATE] to [DATE] the resident had no behavior problems charted and had no pain problems charted. On [DATE] [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for agitation was ordered. The resident was medicated on [DATE], [DATE], and [DATE] with [MEDICATION NAME] for agitation prior to her fall on [DATE]. The record review indicated the medical physician saw and evaluated the resident on [DATE]. The evaluation stated that the resident denied pain. The record review indicated that the care plan dated [DATE] did include interventions for falls related to use of [MEDICAL CONDITION] medications for dementia, recent stroke and hospitalization . The resident was not care planned for pain, mood disorder, or behavior problems. The record review stated that the resident fell on [DATE] at 4:14 AM. The resident was found on the floor in her room by Nurse #2. A Nurses note by Nurse #1 stated " fall with head injury. Attempted to go to bathroom unassisted. Hit back of her head. Neuro (neurological) checks WNL (within normal limits). " Neurological checks compare a person's baseline to a current assessment of level of consciousness (alertness/behavior), vital signs, pupil response to light, eye response to stimuli, level of consciousness, speech pattern, and motor response. An interview on [DATE] at 11:20 AM with Nurse #1 revealed that Nurse #2 found the resident on the floor in her room. Nurse #1 came to the resident's room to assess the resident for injury and determined Resident #25 was without major injury. Nurse #1 stated that the resident had equal grips, no more than normal confusion, no lacerations, and did not appear to be harmed other than the " bump " to the back of her head. The nurse's notes by Nurse #2 indicated that on [DATE] at 6:25 AM the neuro checks were still in progress and within normal limits. The resident complained of pain around her head area where her head had hit the floor. No swelling was noted at that time. According to Nurse #2's notes, the physician was notified of the resident's fall via the facilities communication board. During record review of the communication notes on [DATE] at 11:00 AM the note for [DATE] could not be located for Resident #25. At that time the Director of Nursing (DON) was asked if she had a copy of that communication sheet, she stated that she did not. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM the DON indicated that the protocol for falls was to have the charge nurse evaluate the resident for injury, after that, they assisted with getting the resident back to bed or bathroom. The DON stated the physician would be called if there were serious injuries to the resident. The DON indicated that a serious injury would be a skin tear that kept bleeding, abnormal neuro checks, deviation from the resident's baseline, dislocation or odd positioning of the extremities. If there were no serious injuries then the resident's fall would be placed on the communication board which was seen by the physician or NP on a daily basis. The facility was unable to show any communication regarding Resident #25 on the communication board sheets from February through [DATE] about Resident #25's fall. The record review revealed no other notes in Resident #25's chart from a physician or NP for the dates following the fall. The DON stated her expectation would be the nurse would have contacted the physician per the facilities recognized protocol. The ADON indicated that the MD or the NP would see the communication board on a daily basis while doing rounds. On [DATE] at 9:32 AM the record review of the MAR indicated [REDACTED]. During an interview on [DATE] at 11:12 AM, Nurse #2 indicated that the resident's neuro checks were normal during her time with the resident immediately following the fall. Nurse #2 stated that the medical physician would not be called unless neuro checks deviated from normal or if the resident showed signs of injury at the time of the fall that required immediate evaluation. On [DATE] at 9:35 PM the record review of the MAR indicated [REDACTED]. A nursing note dated [DATE] at 10:42 PM included, " Resident alert, oriented, and verbally responsive. " The note also indicated the resident received Tylenol 650 mg (milligram) and [MEDICATION NAME] (anxiety medication) given for back pain and anxiety respectively. The nurse's note indicated that neuro checks continued. A nurse's note entry by Nurse #2 on [DATE] at 6:21 AM stated that the neuro checks were still in progress and Resident #25 was within normal limits. There were no delayed injuries noted. The nurse's note also stated Resident #25 woke up at 4:00 AM yelling out and complaining of back pain. Nurse #2 gave Resident #25 Tylenol 650 mg. Nurse #2 indicated Resident #25 started yelling out again in pain after 15 minutes and stated she wanted to lie down again. Resident #25 was then transferred back to bed. The nursing notes stated Resident #25 began yelling out again at 5:00 AM requesting to get out of bed because of her back pain. Resident #25 was placed in a wheelchair but continued to yell out when approached. Nurse #2 stated " resident unsure of what help she needs, not easily redirected. " The record review of Resident #25's medication record indicated that she was medicated with Tylenol at 4:10 AM. Nurse #2 indicated Resident #25 Resident didn't yell and call out that she was in pain prior to her falling. An interview with Nurse #3 and Nurse #4 on [DATE] at 3:00 PM revealed that they would use the facial recognition system to evaluate pain on a resident who was severely cognitively impaired. Nurse #3 and Nurse #4 both indicated a ,[DATE] pain scale would not be reliable on a resident who is cognitively impaired because the resident would not be able to use the scale. They stated that it would be better to judge the resident by his/her normal baseline and compare it to how have they changed since an incident. Record review revealed that on [DATE] at 3:29 PM a nurse's note written by Nurse #3 indicated that the resident was alert and oriented to herself and place with no complaints noted. The resident's level of care or ADLs did not change per the nurse's note. On [DATE] at 7:18 PM the MAR indicated [REDACTED]. Record review revealed that on [DATE] 10:20 PM Nurse #4 wrote " Resident alert, oriented, and verbally responsive. PRN (as needed for) pain med (medication) Tylenol 650 mg and [MEDICATION NAME] given for back pain and anxiety respectively. F/U (follow up) fall day 1 with neuro checks continuing. Ate supper at substation, extensive assistance with ADL's and tranfers. Family visits often, in bed with call light in reach. " Record review revealed that on [DATE] 05:45 AM Nurse #2 wrote " S/P (status [REDACTED]. " The record review of Resident #25's therapy notes indicated that on [DATE] Occupational Therapist #1 charted a note that stated Resident #25 continued to " c/o (complain of) back and head pain which is effecting her performance. " In an interview on [DATE] at 10:31 AM Occupational Therapist #1 revealed she remembered Resident #25 as having had severe head pain during her session on [DATE]. Occupational Therapist #1 (OT #1) told a Physical Therapist Assistant (PTA) that Resident #25 was complaining and that they should tell the nurse. The OT #1 stated that she couldn't remember who the nurse was or if the nurse had been told of the resident's increased pain. . The record review revealed a note on [DATE] from physical therapy that read " Pt (Patient) with c/o lower back pain today with difficulty performing sit to stand and unable to tolerate standing. " The physical therapy note also indicated that the physical therapist had spoken with nursing staff and included, " No documentation seen regarding x-rays to rule out injury. Discussed with nursing possibility of x-rays if pain does not improve. " The Physical Therapist was called on [DATE] at 4:00 PM. A message was left to return the phone call, by [DATE] at 5:00 PM the Physical Therapist had not returned the phone call. On [DATE] at 5:40 PM the MAR indicated [REDACTED]. The record review revealed a nurses note dated [DATE] at 05:48 AM included that on the 3rd day after her fall Resident #25 had no delayed injuries noted, no acute distress noted, and that monitoring would continue. On [DATE] at 1:41 PM the MAR indicated [REDACTED]. On [DATE] Occupational therapist #2 charted " Pt crying out and stating ' my back hurts worse than ever! My back! ' Pt. performed 2 standing trials with minimal assist to reach forward to grasp parallel bar. 1 minute 1st trial, 30 seconds 2nd trial. " please let me sit down. " OT #2 ' s notes indicated that a back massage was done but the resident stated " ' it helps but it still hurts so bad. ' " During an interview on [DATE] at 9:55 AM Occupational Therapist #2 (OT #2) said she found Resident #25 crying out in the hallway that day. Occupational Therapist #2 indicated that what she wrote was a true assessment of the residents back pain as being severe on those specific dates and that she did seem more in pain after her fall. On [DATE], the Nurse Practitioner ordered " [MEDICATION NAME] 800 mg tablet give 1 tablet (800 mg) by oral route once daily as needed only to be given after resident has eaten /1st dose asap (as soon as possible). " On [DATE] at12:40 PM the MAR indicated [REDACTED]. A nurse's note entry by Nurse #3 stated the Nurse Practitioner (NP) saw Resident #25 concerning an order for [REDACTED]. " On [DATE] at10:05 AM an interview with the Nurse Practitioner (NP) was obtained. The NP didn't remember the resident and stated " if there is no note in the chart or progress notes then I didn't see her. " During the survey there were no physician notes or nurse practitioner notes found in Resident #25's chart to indicate the resident was seen by either the MD or NP following her fall and head trauma. The facility could not provide any further documentation that showed the NP or the MD saw Resident #25 following her fall. According to the resident's medical record, Resident #25 was not seen by occupational therapy or physical therapy on [DATE] but did return to occupational therapy on [DATE] and complained of severe pain. On [DATE] Resident #25 returned to physical therapy. There was no pain noted during physical therapy on that day. Resident #25 was considered on [DATE] for discharge from physical therapy related to resident meeting her maximum level of functional capability. According to nurse's notes on [DATE] at 11:53 AM Resident #25 was medicated with [MEDICATION NAME] 800 mg for a complaint of pain. A nurses noted charted by Nurse #3 stated " No change in level of care, ADL's or behavior. " The note also included that the resident " Continues to yells and screams for attention " and made frequent requests to go from the bathroom to her recliner. On [DATE] at 3:51 PM the MAR indicated [REDACTED]. During record review of the physician's orders [REDACTED]. During the NP's interview [DATE] at 10:05 AM she stated that she did not remember Resident #25 and did not recall writing any orders for this resident. On [DATE] at 9:37 am the MAR indicated [REDACTED]. No nurse's note was written. On [DATE] at 1:54 PM a nurse note stated " Alert and oriented to self. No acute complaints nor in any apparent acute compromising condition. " According to the MD's communication board, on [DATE] a note was left on the communication board about the family wanting to have the [MEDICATION NAME] discontinued because of the resident ' s history of an ulcer and pain whenever she uses it. This was observed on [DATE] at 11:00 AM. On [DATE] at 8:56 am the record review indicated that the resident was medicated with 800 mg of [MEDICATION NAME] PO for pain. No nurse's note were written on [DATE]. On [DATE] the social worker saw Resident #25 on [DATE] and wrote a note. The social worker noted the resident " continues to exhibit behaviors of yelling and crying per nurses notes ,[DATE] - [DATE] per nurses notes ,[DATE] and ,[DATE] resident was medicated with [MEDICATION NAME] for " anxiety. " During an interview on [DATE] at 9:25 AM the social worker indicated the resident was always looking for her family but didn't have any behaviors other than calling for her family that she was aware of. On [DATE] at 1:45 PM nurses note entry read " alert and verbal. No signs and symptoms of any apparent acute compromising condition. Continue to yells but soon as staff talk to her she stop then yell later on again. No change in level of care or ADL's (activities of daily living). " On [DATE] at 1:13 PM a nurse's note entry read " Resident continues to yell and scream of back pain. No change in level of care or ADL's. " A new order written on [DATE] and signed by the Nurse Practitioner stated " [MEDICATION NAME] (narcotic like pain medication) 25 mg PO (by mouth) BID (twice a day) and every 6 hours as needed for pain. Hold for sedation. X-ray of lumbar and [MEDICATION NAME] spine. " Results from portable x-ray done on Resident #25 were sent to the facility on [DATE] with negative results for any acute findings. On [DATE] at 3:20 PM a telephone order was written for Tylenol for arthritis every 8 hours and Tylenol 325 mg, 2 tablets orally every 6 hours PRN for break through pain. The order for [MEDICATION NAME] was discontinued. This order was taken by the assistant director of nursing from the NP. The order was then signed by the MD. On [DATE] at 7:32 AM nurse #7 charted " At 5:45 AM NA noted resident was lethargic and was assessed by this writer. " " Resident c/o neck pain and scheduled Tylenol was given. " At 7:56 AM nurse #1 charted that the resident was more alert and was able to recall friends and family names. The communication board had a note to the medical physician dated [DATE] was observed on [DATE] at 11:00AM. At 10:12 AM Nurse # 7 obtained a urine sample per standing orders because of the resident ' s new lethargy. Nurse #7 ' s note included, " Resident complained of headache this morning and was given pain medication that was effective. " At 1:56 PM nurse #7 charted " resident in bed finishing eating lunch, ate 25%. Alert and verbally responsive, able to make needs known. Writer assisted resident in drinking juice, resident had difficulty swallowing and juice dripping to her mouth. Writer observed slurred speech and left sided weakness. Notified supervisor, RP, and MD. " An interview with nurse #7 on [DATE] at 11:00 am revealed the resident was in bed in the morning which wasn ' t normal and heard that the resident had a rough night. She noted that the resident didn ' t seem " right. " The urine sample was collected per standing orders and sent out because of resident's frequent urinary tract infections. By 1:00 PM the resident wasn't able to eat lunch without dribbling fluid down mouth and was still lethargic. The on call medical physician was called and orders taken for the resident to be transferred to the hospital for further evaluation. At 1:15 PM Resident #25 was transferred to emergency department for evaluation. According to the admission history and physical report dated [DATE], once at the hospital the resident was sent for a CT (Computed Tomography) scan (which created a 3-dimentional image of the brain/skull) where it was noted Resident #25 had a 14 millimeter thick subdural hematoma that had caused a shift of Resident #25's brain 8 millimeters to the left place pressure on the [DIAGNOSES REDACTED]. The resident was also found to be anemic with a hemoglobin of 5.8. There was black stool noted but was not tarry in nature. The family reported to the ER physician that they were unaware of any bowel problems related to dark stool having been occurring at the facility. The resident was transfused with 1 unit of packed red blood cells. The resident was seen by a Neuro Surgeon and discussed with the family the prognosis for the resident if she underwent surgery. The decision was made to place the resident in Hospice care with comfort measures only. Resident #25 died on [DATE]. An interview with the facilities medical physician (MD) was conducted on [DATE] at 2:45 PM. The MD stated that he did not remember being told about this residents fall. He stated that his expectation following a resident fall was that the nurses would assess the resident, determine if there were any injuries and start neuro checks if the fall involved head trauma. He stated that the only time a nurse would directly call him or the on call doctor would be when the resident started to have neurological changes showing during the neuro checks. The doctor stated that he expected the nurses to contact him or the on call MD directly if a cognitively impaired resident started complaining of more pain following a fall or had behavior changes such as more agitation and anxiety following a fall. The MD stated that according to the resident's chart that the resident was not seen by himself or the Nurse Practitioner following the residents fall. He stated " If I lay eyes on them (resident) or put my hands on them (resident) I leave a note in the chart. " He stated that his expectation was that the NP did the same. When asked directly if the resident was seen by himself or the NP following the fall he stated " no, based on what is in this chart. " The MD stated that if the nurses had called him or the on call MD and reported that the resident was experiencing more pain and more anxiety following the fall that he would have been able to pick up on pupil changes or focal defects of the resident's arms and legs. If these changes were picked up by him or his NP, then the resident would have been sent to the emergency room (ER) for a CT scan of the head at that time. The CT report from the hospital was read and shown to the MD. The MD stated that based on the CT report from the hospital that " her fall (the residents) could be a cause of her subdural hematoma and subsequent death. It is most likely the cause and I ' m sure the fall contributed to her death. " An interview with the Nurse practitioner on [DATE] at 2:30 PM revealed that she does not remember this resident, did not remember writing orders on the resident and that it is possible that she was called for orders and never physically saw the resident. She stated that if there are no notes in the chart that state she assessed the resident, then she didn't visually assess the resident prior to giving orders for the resident. The NP stated that she doesn't normally write orders on residents she doesn't evaluate but it could happen if she was not in the building. On [DATE] at 5:00 PM the MD stated that the resident received 4 doses of [MEDICATION NAME] after her fall and before she was sent to the hospital for evaluation. The MD stated it could have been a contributing factor in an increase of a slow bleed from a traumatic injury such as a subdural hematoma. The death certificate dated [DATE] stated the immediate cause of death was a subdural hematoma due to (or as a consequence of) a fall.

Based on record review, staff interview, nurse practitioner interview and physician interview the facility failed to recognize a significant change in condition for 1 of 1 (Resident #25) resident who sustained a head injury during a fall and failed to assess a resident post fall for 1 of 6 Residents (Resident #5). Resident #25 developed a subdural hematoma with a brain shift to the left placing pressure on the [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for evaluation and expired on [DATE]. Immediate jeopardy began on [DATE] and was identified on [DATE] at 5:30 PM. Validation of the facility's credible allegation was conducted on [DATE]-[DATE]. Residents on all halls (100, 200, 300, 400, 500 and 600 halls) in the facility records were reviewed and observations were conducted on residents who had changes in conditions. The observations included interventions associated with falls, skin conditions, staff reporting/communication process from shift to shift, staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools([DATE]). The SBAR(Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from [DATE]-[DATE] was reviewed. Record reviews were completed to verify the implementation of the assessment tools and the functional process of staff communication regarding resident change of condition between shifts and medical staff/responsible parties. Staff interviews were conducted with all three shift to verify the implementation of the newly developed SBAR(Situation, Background, Assessment, Recommendation/Request) form, Guidelines for Change in Condition form (falls, skin condition neurological checks), Nursing Assistant Reporting Changes in Resident Condition to Nurse Guideline/Tool and Physician signature on the SBAR form indicating review of the assessment and knowledge of the resident change of condition had been completed by [DATE] per the Credible Allegation. Direct Care, Physical Therapy Staff and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The completion date for all in-services for nursing and nursing assistant became effective [DATE]. The Quality Assurance Audit reports since [DATE] through [DATE] were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of Assessment of Resident Change of Condition as a result of a fall (F309) on [DATE]. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. Findings included: The record review indicated that the resident was admitted on [DATE] at 2:13 PM for rehabilitation following an ischemic [MEDICAL CONDITION] (a lack of blood supply in the brain). Admission [DIAGNOSES REDACTED]. Resident #25's admission medications included: Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain The record review revealed that the Minimum Data Set ((MDS) dated [DATE] indicated Resident #25 was severely cognitively impaired. There were no mood disorders noted and there were no behaviors noted. There were no pain problems noted. The resident required extensive assistance with activities of daily living (ADL) with at least one person assistance at all times. Resident #25 had an unsteady gait and required one person assistance for transfer and for toileting. Upon review of Resident #25's medical chart and electronic chart, there was no information noted that the resident had a chronic pain issue or that the resident was constantly anxious. From admission date of [DATE] to [DATE] the resident had no behavior problems charted and had no pain problems charted. The nurse's notes indicated Resident #25 would call for her family because of her dementia and new surroundings. The family was involved with the resident care on a daily basis. On [DATE] [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for agitation was ordered. The resident was medicated on [DATE], [DATE], and [DATE] with [MEDICATION NAME] for agitation prior to her fall on [DATE]. The record review indicated the medical physician saw and evaluated the resident on [DATE]. The evaluation stated that the resident denied pain. The record review indicated that the care plan dated [DATE] did include interventions for falls related to use of [MEDICAL CONDITION] medications for dementia, recent stroke and hospitalization . The resident was not care planned for pain, mood disorder, or behavior problems. The record review stated that the resident fell on [DATE] at 4:14 AM. The resident was found on the floor in her room by Nurse #2. A Nurses note by Nurse #1 stated " fall with head injury. Attempted to go to bathroom unassisted. Hit back of her head. Neuro (neurological) checks WNL (within normal limits). " The nurse's note also indicated the resident's range of motions was within normal limits. Neurological checks compare a person's baseline to a current assessment of level of consciousness (alertness/behavior), vital signs, pupil response to light, eye response to stimuli, level of consciousness, speech pattern, and motor response. An interview on [DATE] at 11:20 AM with Nurse #1 revealed that nurse #2 found the resident on the floor in her room. Nurse #1 came to the resident's room to assess the resident for injury and determined Resident #25 was without major injury. Nurse #1 stated that the resident had equal grips, no more than normal confusion, no lacerations, and did not appear to be harmed other than the " bump " to the back of her head. The nurse's notes by Nurse #2 indicated that on [DATE] at 6:25 AM the neuro checks were still in progress and within normal limits. The resident complained of pain around her head area where her head had hit the floor. No swelling was noted at that time. According to Nurse #2's notes, the resident's responsible party was notified and the medical physician was notified of the resident's fall via the facilities communication board. During record review of the communication notes on [DATE] at 11:00 AM the note for [DATE] could not be located for Resident #25. At that time the Director of Nursing (DON) was asked if she had a copy of that communication sheet, she stated that she did not. The resident was not medicated for pain at this time according the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM the DON indicated that the protocol for falls was to have the charge nurse evaluate the resident for injury, after that, they assisted with getting the resident back to bed or bathroom. The DON stated they were to look at interventions that could be put in place to help the resident to be safe, the family should be notified and the physician would be called if there were serious injuries to the resident. The DON indicated that a serious injury would be a skin tear that keeps bleeding, a resident has neuro checks that are abnormal, abnormal pain from the resident, dislocation or odd positioning of the extremities. If there were no serious injuries then the residents fall would be placed on the communication board which was seen by the physician or NP on a daily basis. The facility was unable to show any communication regarding Resident #25 on the communication board sheets from February through [DATE] that indicated a fall by Resident #25. The record review revealed no other notes in Resident #25's chart from a physician or NP for the dates following the fall. The DON stated her expectation would be the nurse would have contacted the physician per the facilities recognized protocol. The ADON indicated that the MD or the NP would see the communication board on a daily basis while doing rounds. On [DATE] at 9:32 AM the record review of the MAR indicated [REDACTED]. During an interview on [DATE] at 11:12 AM, Nurse #2 indicated that the resident's neuro checks were normal during her time with the resident immediately following the fall. Nurse #2 stated that the medical physician would not be called unless neuro checks deviated from normal or if the resident showed signs of injury at the time of the fall that required immediate evaluation. During an interview on [DATE] at 11:12 AM, Nursing Assistant #1 indicated Resident #25 yelled out often. Nursing Assitant #1 who worked the 7 AM to 3 PM shift stated that the resident was no different to her following her fall. A nurse's note entry by Nurse #3 on [DATE] at 1:18 PM included that there had been no change in the resident's level of care or behaviors. The nurse's note indicated the resident yelled and cried out but would settle down once others talked to her or while she was eating her meals. The nurse's note also included, " Family visited earlier and resident was calmer." The record review indicated that a family member stated " oh mother you always have headache and back pain. " During an interview on [DATE] at 9:00 AM with Nurse #3 she stated that she remembered Resident #25 would call out often for her family. When asked if she called out all the time before and after her fall she stated yes. Stated that the resident was " very verbal and always calling for her family " Stated she couldn't remember if the resident was complaining of back pain or head pain after her fall, just remembered her yelling out and being verbal. On [DATE] at 9:35 PM the record review of the MAR indicated [REDACTED]. The record review stated a nursing note dated [DATE] at 10:42 PM that " Resident alert, oriented, and verbally responsive. " The note also indicated the resident received Tylenol 650 mg (milligram) and [MEDICATION NAME] (anxiety medication) given for back pain and anxiety respectively. The nurse's note indicated that neuro checks continued. A nurse's note entry by Nurse #2 on [DATE] at 6:21 AM stated that the neuro checks were still in progress and Resident #25 was within normal limits. There were no delayed injuries noted. The nurse's note also stated Resident #25 woke up at 4:00 AM yelling out and complaining of back pain. Nurse #2 gave Resident #25 Tylenol 650 mg. Nurse #2 indicated Resident #25 started yelling out again in pain after 15 minutes and stated she wanted to lie down again. Resident #25 was then transferred back to bed. The nursing notes stated Resident #25 began yelling out again at 5:00 AM requesting to get out of bed because of her back pain. Resident #25 was placed in a wheelchair but continued to yell out when approached. Nurse #2 stated " resident unsure of what help she needs, not easily redirected. " The record review of Resident #25's medication record indicated that she was medicated with Tylenol at 4:10 AM using the ,[DATE] pain scale, with 10 being the most severe pain. Resident #25 was assessed as having back pain rating a 3 with a reassessment pain level of a 1. Nurse #2 indicated Resident #25 Resident didn ' t yell and call out that she was in pain prior to her falling. An interview with Nurse #3 and Nurse #4 on [DATE] at 3:00 PM revealed that they would use the facial recognition system to evaluate pain on a resident who was severely cognitively impaired. Nurse #3 and Nurse #4 both indicated a ,[DATE] pain scale would not be reliable on a resident who is cognitively impaired because the resident would not be able to use the scale. They stated that it would be better to judge the resident by his/her normal baseline and compare it to how have they changed since an incident. Record review revealed that on [DATE] at 3:29 PM a nurse's note written by Nurse #3 indicated that the resident was alert and oriented to her self and place with no complaints noted. The resident's level of care or ADL change per the nurse's note. On [DATE] at 7:18 PM the MAR indicated [REDACTED]. Record review revealed that on [DATE] 10:20 PM Nurse #4 wrote " Resident alert, oriented, and verbally responsive. PRN (as needed for) pain med Tylenol 650 mg and [MEDICATION NAME] given for back pain and anxiety respectively. F/U (follow up) fall day 1 with neuro checks continuing. Ate supper at substation, extensive assistance with ADL's and tranfers. Family visits often, in bed with call light in reach. " Record review revealed that on [DATE] 05:45 AM Nurse #2 wrote " S/P (status [REDACTED]. " The record review of Resident #25's therapy notes indicated that on [DATE] Occupational therapist #1 charted a note that stated Resident #25 continued to " c/o (complain of) back and head pain which is effecting her performance. " In an interview on [DATE] at 10:31 AM Occupational Therapist #1 revealed she remembered Resident #25 having severe head pain during her session on [DATE]. Occupational Therapist #1 (OT #1) told a Physical Therapist Assistant (PTA) that Resident #25 was complaining and that they should tell the nurse. The OT #1 stated that she couldn't remember who the nurse was or if the nurse had been told of the resident's increased pain. The record review revealed a note on [DATE] from physical therapy that read " Pt (Patient) with c/o lower back pain today with difficulty performing sit to stand and unable to tolerate standing. " The physical therapy note also indicated that the physical therapist had spoken with nursing staff and included, " No documentation seen regarding x-rays to rule out injury. Discussed with nursing possibility of x-rays if pain does not improve. " The Physical Therapist was called on [DATE] at 4:00 PM. A message was left to return the phone call, by [DATE] at 5:00 PM the Physical Therapist had not returned the phone call. On [DATE] at 5:40 PM the MAR indicated [REDACTED]. The record review revealed a nurses note dated [DATE] at 05:48 AM included that on the 3rd day after her fall Resident #25 had no delayed injuries noted, no acute distress noted, will c/t (continue to) monitor. On [DATE] at 1:41 PM the MAR indicated [REDACTED]. On [DATE] Occupational therapist #2 charted " Pt crying out and stating " my back hurts worse than ever! My back! " Pt. performed 2 standing trials with minimal assist to reach forward to grasp parallel bar. 1 minute 1st trial, 30 seconds 2nd trial. " please let me sit down. " The OT #2 ' s notes indicated that a back massage was done but the resident stated " it helps but it still hurts so bad. " During an interview on [DATE] at 9:55 AM Occupational Therapist #2 (OT #2) said she found Resident #25 crying out in the hallway that day. Occupational therapist #2 indicated that what she wrote was a true assessment of the residents back pain as being severe on those specific dates and that she did seem more in pain after her fall. On [DATE], the Nurse Practitioner ordered " [MEDICATION NAME] 800 mg tablet give 1 tablet (800 mg) by oral route once daily as needed only to be given after resident has eaten /1st dose asap. " On [DATE] at12:40 PM the MAR indicated [REDACTED]. A nurse's note entry by Nurse #3 stated the Nurse Practitioner (NP) saw Resident #25 concerning an order for [REDACTED]. " On [DATE] at10:05 AM an interview with the Nurse Practitioner (NP) was obtained. The NP didn't remember the resident and stated " if there is no note in the chart or progress notes then I didn't see her. " During the survey there were no physician notes or nurse practitioner notes found in Resident #25's chart that indicated that the resident was seen by either the MD or NP following her fall and head trauma. The facility could not provide any further documentation that showed the NP or the MD saw Resident #25 following her fall. According to the resident's medical record, Resident #25 was not seen by occupational therapy or physical therapy on [DATE] but did return to occupational therapy on [DATE] and complained of severe pain. On [DATE] Resident #25 returned to physical therapy. There was no pain noted during physical therapy on that day. Resident #25 was considered on [DATE] for discharge from physical therapy related to resident meeting her max functional capability. According to nurse's notes on [DATE] at 11:53 AM Resident #25 was medicated with [MEDICATION NAME] 800 mg for a complaint of pain. A nurses noted charted by Nurse #3 stated " No change in level of care, ADL's or behavior. " The note also included that the resident " continues to yells and screams for attention " and made frequent requests to go from the bathroom to her recliner. During record review of the physician's orders [REDACTED]. On [DATE] at 3:51 PM the MAR indicated [REDACTED]. During the NP's interview [DATE] at 10:05 AM she stated that she did not remember Resident #25 and did not recall writing any orders for this resident. On [DATE] at 9:37 am the MAR indicated [REDACTED]. No nurse ' s note written. On [DATE] at 1:54 PM a nurse note stated " Alert and oriented to self. No acute complaints nor in any apparent acute compromising condition. " According to the MD's communication board, on [DATE] a note was left on the communication board about the family wanting to have the [MEDICATION NAME] discontinued because of the resident's history of an ulcer and pain whenever she uses it. This was observed on [DATE] at 11:00 AM. On [DATE] at 8:56 am the record review indicated that the resident was medicated with 800 mg of [MEDICATION NAME] PO for pain. No nurse ' s note were written on [DATE]. On [DATE] the social worker saw Resident #25 on [DATE] and wrote a note. The social worker noted the resident " continues to exhibit behaviors of yelling and crying per nurses notes ,[DATE] - [DATE] per nurses notes ,[DATE] and ,[DATE] resident was medicated with [MEDICATION NAME] for " anxiety. " During an interview on [DATE] at 9:25 AM the social worker indicated the resident was always looking for her family but didn't have any behaviors other than calling for her family that she was aware of. On [DATE] at 1:45 PM nurses note entry read " alert and verbal. No signs and symptoms of any apparent acute compromising condition. Continue to yells but soon as staff talk to her she stop then yell later on again. No change in level of care or ADL's (activities of daily living). " On [DATE] at 1:13 PM a nurse's note entry read " Resident continues to yell and scream of back pain. No change in level of care or ADL's. A new order written on [DATE] and signed by the Nurse Practitioner stated " [MEDICATION NAME] (narcotic like pain medication) 25 mg PO (by mouth) BID (twice a day) and every 6 hours as needed for pain. Hold for sedation. X-ray of lumbar and [MEDICATION NAME] spine. " Results from portable x-ray done on Resident #25 were sent to the facility on [DATE] with negative results for any acute findings. On [DATE] at 3:20 PM a telephone order was written for Tylenol arthritis every 8 hours and Tylenol 325 mg, 2 tabs = 650 mg PO every 6 hours PRN break through pain. The order for [MEDICATION NAME] was discontinued. This order was taken by the assistant director of nursing from the NP. The order was then signed by the MD. On [DATE] at 7:32 AM nurse #7 charted " At 5:45 AM NA noted resident was lethargic and was assessed by this writer. " " Resident c/o neck pain and scheduled Tylenol was given. " At 7:56 AM nurse #1 charted that the resident was more alert and was able to recall friends and family names. Note to MD/NP communication board. The communication board had a note to the medical physician dated [DATE] that was observed on [DATE]. This note on the communication board was observed on [DATE] at 11:00AM. At 10:12 AM Nurse # 7 obtained a urine sample per standing orders because of the resident ' s new lethargy. Resident complained of headache this morning and was given pain medication that was effective. At 1:56 PM nurse #7 charted " resident in bed finishing eating lunch, ate 25%. Alert and verbally responsive, able to make needs known. Writer assisted resident in drinking juice, resident had difficulty swallowing and juice dripping to her mouth. Writer observed slurred speech and left sided weakness. Notified supervisor, RP, and MD. " An interview with nurse #7 on [DATE] at 11:00 am revealed that the resident was in bed in the AM which wasn't normal and heard that the resident had a rough night. She noted that the resident didn't seem " right. " The urine sample was collected per standing orders and sent out because of resident's frequent urinary tract infections. By 1:00 PM the resident wasn't able to eat lunch without dribbling fluid down mouth and was still lethargic. The on call medical physician was called and orders taken for the resident to be transferred to the hospital for further evaluation. At 1:15 PM Resident #25 was transferred to emergency department for evaluation. According to the admission history and physical report dated [DATE], once at the hospital the resident was sent for a CT (Computed Tomography) scan (which created a 3-dimentional image of the brain/skull) where it was noted Resident #25 had a 14 millimeter thick subdural hematoma that had caused a shift of Resident #25's brain 8 millimeters to the left place pressure on the [DIAGNOSES REDACTED]. The resident was also found to be anemic with a hemoglobin of 5.8. There was black stool noted but was not tarry in nature. The family reported to the ER physician that they were unaware of any bowel problems related to dark stool having been occurring at the facility. The resident was transfused with 1 unit of packed red blood cells. The resident was seen by a Neuro Surgeon and discussed with the family the prognosis for the resident if she underwent surgery. The decision was made to place the resident in Hospice care with comfort measures only. Resident #25 died on [DATE]. An interview with the facilities medical physician (MD) was conducted on [DATE] at 2:45 PM. The MD stated that he did not remember being told about this residents fall. He stated that his expectation following a resident fall was that the nurses would assess the resident, determine if there were any injuries and start neuro checks if the fall involved head trauma. He stated that the only time a nurse would directly call him or the on call doctor would be when the resident started to have neurological changes showing during the neuro checks. The doctor stated that he expected the nurses to contact him or the on call MD directly if a cognitively impaired resident started complaining of more pain following a fall or had behavior changes such as more agitation and anxiety following a fall. The MD stated that according to the resident's chart that the resident was not seen by himself or the Nurse Practitioner following the residents fall. He stated " If I lay eyes on them (resident) or put my hands on them (resident) I leave a note in the chart. " He stated that his expectation was that the NP did the same. When asked directly if the resident was seen by himself or the NP following the fall he stated " no, based on what is in this chart. " The MD stated that if the nurses had called him or the on call MD and reported that the resident was experiencing more pain and more anxiety following the fall that he would have been able to pick up on pupil changes or focal defects of the resident's arms and legs. If these changes were picked up by him or his NP, then the resident would have been sent to the emergency room (ER) for a CT scan of the head at that time. The CT report from the hospital was read and shown to the MD. The MD stated that based on the CT report from the hospital that " her fall (the residents) could be a cause of her subdural hematoma and subsequent death. It is most likely the cause and I'm sure the fall contributed to her death. " An interview with the Nurse practitioner on [DATE] at 2:30 PM revealed that she did not remember this resident, did not remember writing orders on the resident and that it is possible that she was called for orders and never physically saw the resident. She stated that if there are no notes in the chart that state she assessed the resident, then she didn't visually assess the resident prior to giving orders for the resident. The NP stated that she doesn't normally write orders on residents she doesn't evaluate but it could happen if she was not in the building. On [DATE] at 5:00 PM the MD stated that the resident received 4 doses of [MEDICATION NAME] after her fall and before she was sent to the hospital for evaluation. The MD stated it could have been a contributing factor in an increase of a slow bleed from a traumatic injury such as a subdural hematoma. The death certificate dated [DATE] stated the immediate cause of death was a subdural hematoma due to (or as a consequence of) a fall. 2. Review of the policy titled, Fall Protocol and Guideline undated dated, revealed in part, Response: ? Initiate neuro (neurological) checks per protocol if head involvement or unwitnessed fall ? Notify MD/ NP (physician /nurse practioner) of the fall and injuries, transcribe all orders received ? Complete COC (change of condition) and ensure that all nursing documentation (including new orders) are place in resident medical record ? Document q (every) shift x (for) 72 hours. Review of the electronic record revealed Resident #5 was admitted on [DATE] at 4:06 PM, for rehabilitation. His [DIAGNOSES REDACTED]. He was readmitted from the hospital on [DATE] due to [MEDICAL CONDITION]. Review of the discharge summary dated [DATE] revealed due fall risk, [MEDICATION NAME] (a blood thinning agent) 2 mg (milligram) a day by mouth except Tuesday and 1 mg on Tuesday was discontinued and aspirin 81 mg every day was started. Review of current physician orders [REDACTED]. The Minimum (MDS) data set [DATE], revealed cognition was intact and he was able to make decisions about his daily care. He required extensive assistance with two people to perform bed mobility, to transfer, to use the toilet, to dress and for personal hygiene. He was totally dependent on staff for bathing. He was not steady and only able to stabilize with staff assistance when moving on and off the toilet, turning around, walking moving from a seated to a standing position and surface to surface transfer. He had left lower extremity impairment, requiring a walker or wheelchair. Resident #5 was frequently incontinent of bowel or bladder, and currently was not managed on toileting program. Review of the fall risk assessment dated [DATE] indicated Resident #5 was at high risk for falls. Review of the nursing note dated [DATE] at 4:50 AM, Nurse #1 revealed " Resident got up and went to the bathroom. On his way back when he got to his bed as he reached for the bed he stated he lost his balance and dropped to his knees on the safety matt at his bedside. No injury noted. Vital signs stable. Will continue to monitor. " Review of the nursing notes for [DATE] and [DATE] revealed no follow up documentation regarding the fall. During an interview on [DATE] at 11:44 AM the DON (Director of Nursing) indicated Resident #5 had not sustained a fall on [DATE], there was no documented accident report or SBAR (Situation, Background, Assessment and Recommendation). The DON was then asked to read the nurse ' s note dated [DATE] at 4:50 AM. She had no further comment. During an interview on [DATE] at 2:19 pm Nurse # 2 indicated he was assigned to Resident # 5 on [DATE] beginning at 7:00 AM until 3:00 PM. Nurse #1 did not report that Resident #5 had sustained an unwitnessed fall during the 11:00pm-7:00 am shift. The fall was not recorded on the 24 hour communication log. The DON informed him on [DATE] at 1:00 PM. During an interview on [DATE] at 2: 25 PM, Nurse #1 indicated she heard the alarm going off in Resident #5 room. She arrived to the room to see Resident #5 kneeling on the matt next to his bed. She and Aide #1 assisted him back into bed. She did not report the unwitnessed fall to Nurse #2, and did not write it in the 24 hour communication log. She indicated she was trained on the fall protocol and did not follow it. When asked why she did not follow the protocol she indicated it was all new and she was trying to get used to it. During an interview on [DATE]at 5:00 PM, DON indicated the expectation was for Nurse #1 to follow the fall protocol training given on [DATE]. During an interview on [DATE] at 5:15 PM, Administrator indicated the nurses had relied on verbal report and the 24 hour log for information and had read the nursing notes. The expectation was for the nurses to read the off going nursing notes from the previous shift.

Based on record review, staff interview, nurse practitioner interview and physician interview the facility failed to recognize a significant change in condition for 1 of 1 (Resident #25) resident who sustained a head injury during a fall and failed to assess a resident post fall for 1 of 6 Residents (Resident #5). Resident #25 developed a subdural hematoma with a brain shift to the left placing pressure on the [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] for evaluation and expired on [DATE]. Immediate jeopardy began on [DATE] and was identified on [DATE] at 5:30 PM. The immediate jeopardy is present and ongoing. Validation of the facility's credible allegation was conducted on [DATE]-[DATE]. The facility records were reviewed and observations were conducted on residents who had changes in conditions on all halls (100, 200, 300, 400, 500 and 600 halls). The observations included interventions associated with falls, skin conditions, staff reporting/communication process from shift to shift; staff documentation of observed changes in condition in accordance with the facility newly developed guidelines/tools ([DATE]). The SBAR (Situation, Background, Assessment and Recommendation/Request)/Change in Condition Review Audit form for all residents from [DATE]-[DATE] were reviewed. Record reviews were completed to verify the implementation of the assessment tools and the functional process of staff communication regarding resident change of condition between shifts and medical staff/responsible parties. Staff interviews were conducted with all three shift to verify the implementation of the newly developed SBAR(Situation, Background, Assessment, Recommendation/Request) form, Guidelines for Change in Condition form (falls, skin condition neurological checks), Nursing Assistant Reporting Changes in Resident Condition to Nurse Guideline/Tool and Physician signature on the SBAR form indicating review of the assessment and knowledge of the resident change of condition had been completed by [DATE] per the Credible Allegation. Direct Care, Physical Therapy Staff and Management Staff interviews were conducted to verify current staff and agency staff had been in-serviced in the new systemic changes and protocols. The completion date for all in-services for nursing and nursing assistant became effective [DATE]. The Quality Assurance Audit reports since [DATE] through [DATE] were reviewed along with all the supportive documentation of the Credible Allegation of Compliance, to verify the implementation of the facility's Credible Allegation of Compliance. The survey found that immediate jeopardy was removed for the area of Assessment of Resident Change of Condition as a result of a fall on [DATE]. The facility remains out of compliance at the D level (No Actual Harm with Potential for More than Minimal Harm that is not Immediate Jeopardy), in order to continue implementation of the process and monitor systems. Findings included: The record review indicated that the resident was admitted on [DATE] at 2:13 PM for rehabilitation following an ischemic [MEDICAL CONDITION] (a lack of blood supply in the brain). Admission [DIAGNOSES REDACTED]. Resident #25's admission medications included: Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain The record review revealed that the Minimum Data Set ((MDS) dated [DATE] indicated Resident #25 was severely cognitively impaired. There were no mood disorders noted and there were no behaviors noted. There were no pain problems noted. The resident required extensive assistance with activities of daily living (ADL) with at least one person assistance at all times. Resident #25 had an unsteady gait and required one person assistance for transfer and for toileting. Upon review of Resident #25's medical chart and electronic chart, there was no information noted that the resident had a chronic pain issue or that the resident was constantly anxious. From admission date of [DATE] to [DATE] the resident had no behavior problems charted and had no pain problems charted. The nurse's notes indicated Resident #25 would call for her family because of her dementia and new surroundings. The family was involved with the resident care on a daily basis. On [DATE] [MEDICATION NAME] 0.5 mg by mouth every 6 hours as needed for agitation was ordered. The resident was medicated on [DATE], [DATE], and [DATE] with [MEDICATION NAME] for agitation prior to her fall on [DATE]. The record review indicated the medical physician saw and evaluated the resident on [DATE]. The evaluation stated that the resident denied pain. The record review indicated that the care plan dated [DATE] did include interventions for falls related to use of [MEDICAL CONDITION] medications for dementia, recent stroke and hospitalization . The resident was not care planned for pain, mood disorder, or behavior problems. The record review stated that the resident fell on [DATE] at 4:14 AM. The resident was found on the floor in her room by Nurse #2. A Nurses note by Nurse #1 stated " fall with head injury. Attempted to go to bathroom unassisted. Hit back of her head. Neuro (neurological) checks WNL (within normal limits). " The nurse's note also indicated the resident's range of motions was within normal limits. Neurological checks compare a person's baseline to a current assessment of level of consciousness (alertness/behavior), vital signs, pupil response to light, eye response to stimuli, level of consciousness, speech pattern, and motor response. An interview on [DATE] at 11:20 AM with Nurse #1 revealed that nurse #2 found the resident on the floor in her room. Nurse #1 came to the resident ' s room to assess the resident for injury and determined Resident #25 was without major injury. Nurse #1 stated that the resident had equal grips, no more than normal confusion, no lacerations, and did not appear to be harmed other than the " bump " to the back of her head. The nurse's notes by Nurse #2 indicated that on [DATE] at 6:25 AM the neuro checks were still in progress and within normal limits. The resident complained of pain around her head area where her head had hit the floor. No swelling was noted at that time. According to Nurse #2's notes, the resident's responsible party was notified and the medical physician was notified of the resident's fall via the facilities communication board. During record review of the communication notes on [DATE] at 11:00 AM the note for [DATE] could not be located for Resident #25. At that time the Director of Nursing (DON) was asked if she had a copy of that communication sheet, she stated that she did not. The resident was not medicated for pain at this time according the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 12:30 PM the DON indicated that the protocol for falls was to have the charge nurse evaluate the resident for injury, after that, they assisted with getting the resident back to bed or bathroom. The DON stated they were to look at interventions that could be put in place to help the resident to be safe, the family should be notified and the physician would be called if there were serious injuries to the resident. The DON indicated that a serious injury would be a skin tear that keeps bleeding, a resident has neuro checks that are abnormal, abnormal pain from the resident, dislocation or odd positioning of the extremities. If there were no serious injuries then the residents fall would be placed on the communication board which was seen by the physician or NP on a daily basis. The facility was unable to show any communication regarding Resident #25 on the communication board sheets from February through [DATE] that indicated a fall by Resident #25. The record review revealed no other notes in Resident #25's chart from a physician or NP for the dates following the fall. The DON stated her expectation would be the nurse would have contacted the physician per the facilities recognized protocol. The ADON indicated that the MD or the NP would see the communication board on a daily basis while doing rounds. On [DATE] at 9:32 AM the record review of the MAR indicated [REDACTED]. During an interview on [DATE] at 11:12 AM, Nurse #2 indicated that the resident's neuro checks were normal during her time with the resident immediately following the fall. Nurse #2 stated that the medical physician would not be called unless neuro checks deviated from normal or if the resident showed signs of injury at the time of the fall that required immediate evaluation. During an interview on [DATE] at 11:12 AM, Nursing Assistant #1 indicated Resident #25 yelled out often. Nursing Assitant #1 who worked the 7 AM to 3 PM shift stated that the resident was no different to her following her fall. A nurse's note entry by Nurse #3 on [DATE] at 1:18 PM included that there had been no change in the resident's level of care or behaviors. The nurse's note indicated the resident yelled and cried out but would settle down once others talked to her or while she was eating her meals. The nurse's note also included, " Family visited earlier and resident was calmer. " The record review indicated that a family member stated " oh mother you always have headache and back pain. " During an interview on [DATE] at 9:00 AM with Nurse #3 she stated that she remembered Resident #25 would call out often for her family. When asked if she called out all the time before and after her fall she stated yes. Stated that the resident was " very verbal and always calling for her family " Stated she couldn't remember if the resident was complaining of back pain or head pain after her fall, just remembered her yelling out and being verbal. On [DATE] at 9:35 PM the record review of the MAR indicated [REDACTED]. The record review stated a nursing note dated [DATE] at 10:42 PM that " Resident alert, oriented, and verbally responsive. " The note also indicated the resident received Tylenol 650 mg (milligram) and [MEDICATION NAME] (anxiety medication) given for back pain and anxiety respectively. The nurse's note indicated that neuro checks continued. A nurse's note entry by Nurse #2 on [DATE] at 6:21 AM stated that the neuro checks were still in progress and Resident #25 was within normal limits. There were no delayed injuries noted. The nurse's note also stated Resident #25 woke up at 4:00 AM yelling out and complaining of back pain. Nurse #2 gave Resident #25 Tylenol 650 mg. Nurse #2 indicated Resident #25 started yelling out again in pain after 15 minutes and stated she wanted to lie down again. Resident #25 was then transferred back to bed. The nursing notes stated Resident #25 began yelling out again at 5:00 AM requesting to get out of bed because of her back pain. Resident #25 was placed in a wheelchair but continued to yell out when approached. Nurse #2 stated " resident unsure of what help she needs, not easily redirected. " The record review of Resident #25's medication record indicated that she was medicated with Tylenol at 4:10 AM using the ,[DATE] pain scale, with 10 being the most severe pain. Resident #25 was assessed as having back pain rating a 3 with a reassessment pain level of a 1. Nurse #2 indicated Resident #25 Resident didn ' t yell and call out that she was in pain prior to her falling. An interview with Nurse #3 and Nurse #4 on [DATE] at 3:00 PM revealed that they would use the facial recognition system to evaluate pain on a resident who was severely cognitively impaired. Nurse #3 and Nurse #4 both indicated a ,[DATE] pain scale would not be reliable on a resident who is cognitively impaired because the resident would not be able to use the scale. They stated that it would be better to judge the resident by his/her normal baseline and compare it to how have they changed since an incident. Record review revealed that on [DATE] at 3:29 PM a nurse's note written by Nurse #3 indicated that the resident was alert and oriented to her self and place with no complaints noted. The resident's level of care or ADL change per the nurse's note. On [DATE] at 7:18 PM the MAR indicated [REDACTED]. Record review revealed that on [DATE] 10:20 PM Nurse #4 wrote " Resident alert, oriented, and verbally responsive. PRN (as needed for) pain med Tylenol 650 mg and [MEDICATION NAME] given for back pain and anxiety respectively. F/U (follow up) fall day 1 with neuro checks continuing. Ate supper at substation, extensive assistance with ADL's and tranfers. Family visits often, in bed with call light in reach. " Record review revealed that on [DATE] 05:45 AM Nurse #2 wrote " S/P (status [REDACTED]. " The record review of Resident #25's therapy notes indicated that on [DATE] Occupational therapist #1 charted a note that stated Resident #25 continued to " c/o (complain of) back and head pain which is effecting her performance. " In an interview on [DATE] at 10:31 AM Occupational Therapist #1 revealed she remembered Resident #25 having severe head pain during her session on [DATE]. Occupational Therapist #1 (OT #1) told a Physical Therapist Assistant (PTA) that Resident #25 was complaining and that they should tell the nurse. The OT #1 stated that she couldn't remember who the nurse was or if the nurse had been told of the resident's increased pain. The record review revealed a note on [DATE] from physical therapy that read " Pt (Patient) with c/o lower back pain today with difficulty performing sit to stand and unable to tolerate standing. " The physical therapy note also indicated that the physical therapist had spoken with nursing staff and included, " No documentation seen regarding x-rays to rule out injury. Discussed with nursing possibility of x-rays if pain does not improve. " The Physical Therapist was called on [DATE] at 4:00 PM. A message was left to return the phone call, by [DATE] at 5:00 PM the Physical Therapist had not returned the phone call. On [DATE] at 5:40 PM the MAR indicated [REDACTED]. The record review revealed a nurses note dated [DATE] at 05:48 AM included that on the 3rd day after her fall Resident #25 had no delayed injuries noted, no acute distress noted, will c/t (continue to) monitor. On [DATE] at 1:41 PM the MAR indicated [REDACTED]. On [DATE] Occupational therapist #2 charted " Pt crying out and stating " my back hurts worse than ever! My back! " Pt. performed 2 standing trials with minimal assist to reach forward to grasp parallel bar. 1 minute 1st trial, 30 seconds 2nd trial. " please let me sit down. " The OT #2 ' s notes indicated that a back massage was done but the resident stated " it helps but it still hurts so bad. " During an interview on [DATE] at 9:55 AM Occupational Therapist #2 (OT #2) said she found Resident #25 crying out in the hallway that day. Occupational therapist #2 indicated that what she wrote was a true assessment of the residents back pain as being severe on those specific dates and that she did seem more in pain after her fall. On [DATE], the Nurse Practitioner ordered " [MEDICATION NAME] 800 mg tablet give 1 tablet (800 mg) by oral route once daily as needed only to be given after resident has eaten /1st dose asap. " On [DATE] at12:40 PM the MAR indicated [REDACTED]. A nurse's note entry by Nurse #3 stated the Nurse Practitioner (NP) saw Resident #25 concerning an order for [REDACTED]. " On [DATE] at10:05 AM an interview with the Nurse Practitioner (NP) was obtained. The NP didn't remember the resident and stated " if there is no note in the chart or progress notes then I didn't see her. " During the survey there were no physician notes or nurse practitioner notes found in Resident #25's chart that indicated that the resident was seen by either the MD or NP following her fall and head trauma. The facility could not provide any further documentation that showed the NP or the MD saw Resident #25 following her fall. According to the resident's medical record, Resident #25 was not seen by occupational therapy or physical therapy on [DATE] but did return to occupational therapy on [DATE] and complained of severe pain. On [DATE] Resident #25 returned to physical therapy. There was no pain noted during physical therapy on that day. Resident #25 was considered on [DATE] for discharge from physical therapy related to resident meeting her max functional capability. According to nurse's notes on [DATE] at 11:53 AM Resident #25 was medicated with [MEDICATION NAME] 800 mg for a complaint of pain. A nurses noted charted by Nurse #3 stated " No change in level of care, ADL's or behavior. " The note also included that the resident " continues to yells and screams for attention " and made frequent requests to go from the bathroom to her recliner. During record review of the physician's orders [REDACTED]. On [DATE] at 3:51 PM the MAR indicated [REDACTED]. During the NP's interview [DATE] at 10:05 AM she stated that she did not remember Resident #25 and did not recall writing any orders for this resident. On [DATE] at 9:37 am the MAR indicated [REDACTED]. No nurse ' s note written. On [DATE] at 1:54 PM a nurse note stated " Alert and oriented to self. No acute complaints nor in any apparent acute compromising condition. " According to the MD's communication board, on [DATE] a note was left on the communication board about the family wanting to have the [MEDICATION NAME] discontinued because of the resident's history of an ulcer and pain whenever she uses it. This was observed on [DATE] at 11:00 AM. On [DATE] at 8:56 am the record review indicated that the resident was medicated with 800 mg of [MEDICATION NAME] PO for pain. No nurse ' s note were written on [DATE]. On [DATE] the social worker saw Resident #25 on [DATE] and wrote a note. The social worker noted the resident " continues to exhibit behaviors of yelling and crying per nurses notes ,[DATE] - [DATE] per nurses notes ,[DATE] and ,[DATE] resident was medicated with [MEDICATION NAME] for " anxiety. " During an interview on [DATE] at 9:25 AM the social worker indicated the resident was always looking for her family but didn't have any behaviors other than calling for her family that she was aware of. On [DATE] at 1:45 PM nurses note entry read " alert and verbal. No signs and symptoms of any apparent acute compromising condition. Continue to yells but soon as staff talk to her she stop then yell later on again. No change in level of care or ADL's (activities of daily living). " On [DATE] at 1:13 PM a nurse's note entry read " Resident continues to yell and scream of back pain. No change in level of care or ADL's. A new order written on [DATE] and signed by the Nurse Practitioner stated " [MEDICATION NAME] (narcotic like pain medication) 25 mg PO (by mouth) BID (twice a day) and every 6 hours as needed for pain. Hold for sedation. X-ray of lumbar and [MEDICATION NAME] spine. " Results from portable x-ray done on Resident #25 were sent to the facility on [DATE] with negative results for any acute findings. On [DATE] at 3:20 PM a telephone order was written for Tylenol arthritis every 8 hours and Tylenol 325 mg, 2 tabs = 650 mg PO every 6 hours PRN break through pain. The order for [MEDICATION NAME] was discontinued. This order was taken by the assistant director of nursing from the NP. The order was then signed by the MD. On [DATE] at 7:32 AM nurse #7 charted " At 5:45 AM NA noted resident was lethargic and was assessed by this writer. " " Resident c/o neck pain and scheduled Tylenol was given. " At 7:56 AM nurse #1 charted that the resident was more alert and was able to recall friends and family names. Note to MD/NP communication board. The communication board had a note to the medical physician dated [DATE] that was observed on [DATE]. This note on the communication board was observed on [DATE] at 11:00AM. At 10:12 AM Nurse # 7 obtained a urine sample per standing orders because of the resident ' s new lethargy. Resident complained of headache this morning and was given pain medication that was effective. At 1:56 PM nurse #7 charted " resident in bed finishing eating lunch, ate 25%. Alert and verbally responsive, able to make needs known. Writer assisted resident in drinking juice, resident had difficulty swallowing and juice dripping to her mouth. Writer observed slurred speech and left sided weakness. Notified supervisor, RP, and MD. " An interview with nurse #7 on [DATE] at 11:00 am revealed that the resident was in bed in the AM which wasn't normal and heard that the resident had a rough night. She noted that the resident didn't seem " right. " The urine sample was collected per standing orders and sent out because of resident's frequent urinary tract infections. By 1:00 PM the resident wasn't able to eat lunch without dribbling fluid down mouth and was still lethargic. The on call medical physician was called and orders taken for the resident to be transferred to the hospital for further evaluation. At 1:15 PM Resident #25 was transferred to emergency department for evaluation. According to the admission history and physical report dated [DATE], once at the hospital the resident was sent for a CT (Computed Tomography) scan (which created a 3-dimentional image of the brain/skull) where it was noted Resident #25 had a 14 millimeter thick subdural hematoma that had caused a shift of Resident #25's brain 8 millimeters to the left place pressure on the [DIAGNOSES REDACTED]. The resident was also found to be anemic with a hemoglobin of 5.8. There was black stool noted but was not tarry in nature. The family reported to the ER physician that they were unaware of any bowel problems related to dark stool having been occurring at the facility. The resident was transfused with 1 unit of packed red blood cells. The resident was seen by a Neuro Surgeon and discussed with the family the prognosis for the resident if she underwent surgery. The decision was made to place the resident in Hospice care with comfort measures only. Resident #25 died on [DATE]. An interview with the facilities medical physician (MD) was conducted on [DATE] at 2:45 PM. The MD stated that he did not remember being told about this residents fall. He stated that his expectation following a resident fall was that the nurses would assess the resident, determine if there were any injuries and start neuro checks if the fall involved head trauma. He stated that the only time a nurse would directly call him or the on call doctor would be when the resident started to have neurological changes showing during the neuro checks. The doctor stated that he expected the nurses to contact him or the on call MD directly if a cognitively impaired resident started complaining of more pain following a fall or had behavior changes such as more agitation and anxiety following a fall. The MD stated that according to the resident's chart that the resident was not seen by himself or the Nurse Practitioner following the residents fall. He stated " If I lay eyes on them (resident) or put my hands on them (resident) I leave a note in the chart. " He stated that his expectation was that the NP did the same. When asked directly if the resident was seen by himself or the NP following the fall he stated " no, based on what is in this chart. " The MD stated that if the nurses had called him or the on call MD and reported that the resident was experiencing more pain and more anxiety following the fall that he would have been able to pick up on pupil changes or focal defects of the resident's arms and legs. If these changes were picked up by him or his NP, then the resident would have been sent to the emergency room (ER) for a CT scan of the head at that time. The CT report from the hospital was read and shown to the MD. The MD stated that based on the CT report from the hospital that " her fall (the residents) could be a cause of her subdural hematoma and subsequent death. It is most likely the cause and I'm sure the fall contributed to her death. " An interview with the Nurse practitioner on [DATE] at 2:30 PM revealed that she did not remember this resident, did not remember writing orders on the resident and that it is possible that she was called for orders and never physically saw the resident. She stated that if there are no notes in the chart that state she assessed the resident, then she didn't visually assess the resident prior to giving orders for the resident. The NP stated that she doesn't normally write orders on residents she doesn't evaluate but it could happen if she was not in the building. On [DATE] at 5:00 PM the MD stated that the resident received 4 doses of [MEDICATION NAME] after her fall and before she was sent to the hospital for evaluation. The MD stated it could have been a contributing factor in an increase of a slow bleed from a traumatic injury such as a subdural hematoma. The death certificate dated [DATE] stated the immediate cause of death was a subdural hematoma due to (or as a consequence of) a fall. 2. Review of the policy titled, Fall Protocol and Guideline undated dated, revealed in part, Response: ? Initiate neuro (neurological) checks per protocol if head involvement or unwitnessed fall ? Notify MD/ NP ( physician /nurse practioner) of the fall and injuries , transcribe all orders received ? Complete COC (change of condition) and ensure that all nursing documentation (including new orders) are place in resident medical record ? Document q (every) shift x (for) 72 hours. Review of the electronic record revealed Resident #5 was admitted on [DATE] at 4:06 PM, for rehabilitation. His [DIAGNOSES REDACTED]. He was readmitted from the hospital on [DATE] due to [MEDICAL CONDITION]. Review of the discharge summary dated [DATE] revealed due fall risk, [MEDICATION NAME] (a blood thinning agent) 2 mg (milligram) a day by mouth except Tuesday and 1 mg on Tuesday was discontinued and aspirin 81 mg every day was started. Review of current physician orders [REDACTED]. The Minimum (MDS) data set [DATE], revealed cognition was intact and he was able to make decisions about his daily care. He required extensive assistance with two people to perform bed mobility, to transfer, to use the toilet, to dress and for personal hygiene. He was totally dependent on staff for bathing. He was not steady and only able to stabilize with staff assistance when moving on and off the toilet, turning around, walking moving from a seated to a standing position and surface to surface transfer. He had left lower extremity impairment, requiring a walker or wheelchair. Resident #5 was frequently incontinent of bowel or bladder, and currently was not managed on toileting program. Review of the fall risk assessment dated [DATE] indicated Resident #5 was at high risk for falls. Review of the nursing note dated [DATE] at 4:50 AM , Nurse #1 revealed " Resident got up and went to the bathroom. On his way back when he got to his bed as he reached for the bed he stated he lost his balance and dropped to his knees on the safety matt at his bedside. No injury noted. Vital signs stable. Will continue to monitor. " Review of the nursing notes for [DATE] and [DATE] revealed no follow up documentation regarding the fall. During an interview on [DATE] at 11:44 AM the DON (Director of Nursing) indicated Resident #5 had not sustained a fall on [DATE], there was no documented accident report or SBAR (Situation, Background, Assessment and Recommendation). The DON was then asked to read the nurse ' s note dated [DATE] at 4:50 AM. She had no further comment. During an interview on [DATE] at 2:19 pm Nurse # 2 indicated he was assigned to Resident # 5 on [DATE] beginning at 7:00 AM until 3:00 PM. Nurse #1 did not report that Resident #5 had sustained an unwitnessed fall during the 11:00pm-7:00 am shift. The fall was not recorded on the 24 hour communication log. The DON informed him on [DATE] at 1:00 PM. During an interview on [DATE] at 2: 25 PM, Nurse #1 indicated she heard the alarm going off in Resident #5 room. She arrived to the room to see Resident #5 kneeling on the matt next to his bed. She and Aide #1 assisted him back into bed. She did not report the unwitnessed fall to Nurse #2, and did not write it in the 24 hour communication log. She indicated she was trained on the fall protocol and did not follow it. When asked why she did not follow the protocol she indicated it was all new and she was trying to get used to it. During an interview on [DATE]at 5:00 PM, DON indicated the expectation was for Nurse #1 to follow the fall protocol training given on [DATE]. During an interview on [DATE] at 5:15 PM, Administrator indicated the nurses had relied on verbal report and the 24 hour log for information and had read the nursing notes. The expectation was for the nurses to read the off going nursing notes from the previous shift.