Every finding on record at Willow Creek Lodge

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. On 11/12/25, the facility failed to ensure the Direct Care Daily Staffing Numbers were posted. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include:An observation on 11/19/25 at 07:40 AM revealed, there was no posting of the facility Direct Care Staffing Numbers. The placard that held the posting at the front entrance was empty. An observation on 11/19/25 at 08:15 AM revealed, there was no posting of the facility Direct Care Staffing Numbers. The placard that held the posting at the front entrance was empty. In an interview on 11/19/25 at 11:52 AM, the Staffing Coordinator said he took over the position recently and he was still in training. He said while he was responsible for ensuring the facility was adequately staffed, he was not responsible for the daily direct care posting. The Staffing Coordinator said he was never trained to complete the posting. He stated the DON normally posted them at the front entrance, and he did not know who was responsible for the posting in her absence. In an interview on 11/19/25 at 11:57 AM, the Administrator said he did not know the regulations surrounding the nursing posting, and it was the responsibility of the DON. He said he did not know why the posting was not completed today when the surveyor entered the building. He stated the DON was on leave since Monday, 11/17/25, and he did not know if the posting had or had not been updated since her leave began. He said, to his understanding, the posting must be up daily, but he did not know when. The Administrator said the posting served to notify consumers of the staffing level in the building, and failure to update the posting would leave them unaware of the facility staffing if they did not ask staff for it. He said the facility had multiple shifts with 12-hour shifts (6-6) for nurses and 8 hour shifts (6 AM- 2 PM, 2PM- 10PM and 10 PM- 6 AM) for CNAs/CMAs. In an interview on 11/19/25 at 01:53 PM, the ADON said the Staffing Coordinator was supposed to be responsible for the direct care posting, but he was new, so the DON had completed the task while he was training. She said the DON went out on leave on Monday, 11/17/25, so she completed the task in her place. The ADON said today, she asked the Staffing Coordinator to update posting, but she was not aware that he had not been trained on the task yet, so it was not completed. She said the posting's purpose was to inform visitors of the available staff types and hours, and it included the facility name, date, census, the staff types and total hours worked. The ADON said failure to have a direct care staff posting could result in visitors being unaware of the facility census, as well as the type and number of staff available in the building. In an interview on 11/19/25 at 01:58 PM, the Administrator said the facility did not have a specific policy on Posting Direct Care Daily Staffing Numbers. In an interview on 11/19/25 at 02:48 PM, the ADON said she had updated the Direct Care Daily Staffing Numbers posting daily since the DON went on leave, and she usually arrived at the facility between 07:45 AM and 08:00 AM. Record review of the facility's policy Staffing, Sufficient and Competent Nursing revised August 2022 revealed, 6. Direct care daily staffing numbers (the number of personnel responsible for provide direct care to residents) are posted in the facility for every shift by 10 am daily. Related Documents Posting Direct Care Daily Staffing Numbers.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 3 of 5 residents (Resident #2, Resident #67, and Resident #83) reviewed for accuracy of assessments .- The facility failed to accurately assess Resident #2's use of antipsychotics on her Quarterly MDS dated [DATE].- The facility failed to accurately assess Resident #67's dialysis status and use of antiplatelets on her Admissions MDS dated [DATE].- The facility failed to accurately assess Resident #83's hospice status on her Quarterly MDS dated [DATE].Findings include:Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: high blood pressure, unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's Order Summary Report dated 07/15/25 revealed, Resident #2 had orders for antipsychotic medication monitoring since 02/26/25. She was ordered Quetiapine (antipsychotic medication) 25 mg every 12 hours on admission on [DATE] and the medication was gradually increased to Quetiapine 100 mg ever morning and at bedtime on 06/17/25.Record review of Resident #2's July 2025 Medication Administration Record revealed, Resident #2 received Quetiapine 100 mg twice daily at 09:00 AM and 09:00 PM.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia. The MDS did not indicate Resident #67 was taking antipsychotic medications.Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift.Resident #67Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD ( a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, CAD (disease were fats and cholesterol build up in blood vessels), low blood pressure and acid reflux.Record review of Resident #67's Progress Note dated 06/21/25 at 04:36 PM revealed, Resident #67 arrived in the facility with a previous medical history of CKD, CAD, DM, COPD, she had orthostatic hypotension (a drop in pressure after a change in position) and a dialysis port to her right upper chest.Record review of Resident #67's Progress Notes dated 06/21/25 at 04:36 PM revealed, resident goes to dialysis every Monday, Wednesday, and Friday.Record review of Resident #67's Order Summary Report dated 07/15/25 revealed,- Resident #67 had varied dialysis related orders since 06/22/25.- Clopidogrel 75 mg- give 1 tablet by mouth one time a day r/t coronary heart disease.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15. The MDS indicated Resident #67 did not receive dialysis on admission, while a resident at the facility and that she was not taking antiplatelet medications.Record review of Resident #67's undated Care Plan revealed, Special Instructions: Resident #83 received dialysis every Monday, Wednesday and Friday, her chair time was 3:30 PM and the EMS would pick her up at 02:30 PM. Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. An observation on 07/15/25 at 09:12 AM revealed, Resident #67 in bed. There was a visible dressing on her right chest and Resident #67 said the dressing was over her dialysis port.Resident #83Record review of Resident #83's Face Sheet dated 07/15/25 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: COPD (a lung disease that makes it difficult to breath), dysphagia (difficulty swallowing), hypertension (high blood pressure), anxiety disorder and skin cancer.Record review of Resident #83's Quarterly MDS dated [DATE] revealed, minimal difficulty hearing, moderately impaired cognition as indicated by a BIMS score of 08 out of 15. The MDS did not indicate Resident #83 received Hospice Care while at the facility.Record review of Resident #83's undated Care Plan revealed; Special Instruction: Contact hospice provider with questions/concerns/change in condition, falls and death. Focus- terminal prognosis r/t COPD; the residents dignity and autonomy will be maintained at the highest level; intervention- consult with physician and social services to have hospice care for the resident in the facility, revised on 06/04/26.Record review of Resident #83's Order Summary Report dated 07/15/25 revealed,- Admit to hospice under the care of Dr. for a diagnosis of COPD, order date 04/30/25.- Contact Hospice with questions/concerns/change in condition/falls/death, order date 04/30/25.- No ER/Labs/Hospital visits without notifying hospice first, order date 04/30/25.In an interview on 07/16/25 at 02:39 PM, the MDS Nurse said she was responsible for completing resident MDSs and care plans and the MDS assessed the resident's functional abilities within a 7-day window. The MDS nurse said a resident's status of hospice, dialysis and other diagnosis/treatments should be accurately documented in their MDS because it triggered CAAs that were used to develop the care plan. She said an inaccurate MDS could result in a hinderance in a resident's plan of care, resulting in missed opportunity for treatment, untreated conditions and worsening of health conditions.In an interview on 07/17/25 at 08:08 AM, the DON said a resident's MDS told staff about patient needs and what would be done for them. She said the MDS triggered the CAAs and moved into the care plan so an incorrect MDS could place a resident at risk of not getting appropriate care. The MDS nurse said after review Resident #67's and Resident #83's care plans were inaccurate, and they should have included the residents' dialysis and hospice status. She said she did not know why they were not included and that they must have been missed.Record review of the facility policy titled Resident Assessment Instrument Process (RAI/MDS) with no revision date revealed, purpose: Gather data in order to develop comprehensive, individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required. Care Area Assessments (CAAs) will be processed based on clinical analysis of the triggered MDS items. Individualized resident-centered care plans will be developed and updated as needed according to the data and resulting analysis utilizing CAA documentation.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 Residents (Resident #2 and Resident #67) reviewed for care plans.- The facility failed to include Resident #2's diagnosis of MDD in her care plan.- The facilitate failed to include Resident #67's diagnosis of hypotension (low blood pressure), CAD (buildup of fats & cholesterol on the walls of blood vessel), hyperlipidemia (high cholesterol) , COPD (disease that makes it hard to breath), GERD (acid reflux) and her use of antiplatelet (clopidogrel) on her care plan.This failure could place residents at risk for inadequate care.Findings include:Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: high blood pressure, unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia. Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift. Focus- impaired cognitive function related to dementia; intervention- administer medications as ordered. Monitor/document for side effects and effectiveness. There was no focus area addressing Resident #2's diagnosis of MDD.Record review of Resident #2's Order Summary dated 07/15/25 revealed, - Mirtazapine (antidepressant) 7.5 mg- Give 2 tablet by mouth at bedtime r/t MDDResident #67Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD (a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, hypotension, CAD, and GERD.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, active diagnoses of orthostatic hypotension, CAD, GERD, Asthma/COPD/Chronic Lung Disease, and high cholesterol.Record review of Resident #67's undated Care Plan revealed, Special Instructions: Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. There were no Focus areas for hypotension, CAD, COPD, hyperlipidemia, and her use of antiplatelets. Record review of Resident #67's Progress Note dated 06/21/25 at 04:36 PM revealed, Resident #67 arrived in the facility with a previous medical history of CKD[VT1] , CAD, DM[VT2] , COPD, she had orthostatic hypotension and a dialysis port to her right upper chest.Record review of Resident #67's Order Summary Report dated 07/15/25 revealed.- Midodrine 10 mg- give 1 tablet by mouth three times a day related to hypotension. - Clopidogrel 75 mg- give 1 tablet by mouth one time a day r/t coronary heart disease.An observation and interview on 07/15/25 at 09:12 AM revealed, Resident #67 in bed with a dressing on her right lower arm that read 07/10. There was a [NAME] sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened. There was a visible dressing on her right chest and Resident #67 said the dressing was over her dialysis port.In an interview on 07/16/25 at 02:39 PM, the MDS Nurse said she was responsible for resident MDSs and Care Plans. She said resident care plans should paint a full picture of the resident and document a plan of care for the patient. The MDS nurse said Resident #67's care plan was inaccurate because it should have had her diagnosis such as hypotension and COPD, but it did not. She said inaccurate care plans place residents at risk of an omission of assistance and not having a plan of care for an area of concern.In an interview on 07/17/25 at 08:08 AM, the DON said the care plan represents a plan of care that is personalized to the resident, and it should address, everything including diagnosis, dietary; wounds; supportive devices. She said an inaccurate care plan could place residents at risk of not receiving the care they need, and the resident's necessary interventions and goals would be possibly unknown.Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; c. trauma informed.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 5 residents (Resident #83) reviewed for dignity.- The facility failed to change Resident #83's sheets after an episode of urinary incontinence in the early morning on Saturday 07/12/25 leaving her lying on the soiled sheets.- The facility failed to launder Resident #83's bed sheets after an episode of urinary incontinence on Saturday 07/12/25 leaving the soiled sheets in a bag on a chair in her room until Tuesday 07/15/25.This failure could place residents at risk of feeling uncomfortable and disrespected.Findings included:Record review of Resident #83's Face Sheet dated 07/15/25 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: COPD (a lung disease that makes it difficult to breath), dysphagia (difficulty swallowing), hypertension (high blood pressure), anxiety disorder and skin cancer.Record review of Resident #83's Quarterly MDS dated [DATE] revealed, minimal difficulty hearing, moderately impaired cognition as indicated by a BIMS score of 08 out of 15; moderate severity of depression as indicated by a PHQ-9 (patient depression questionnaire) score of 15 out of 27 reporting: feelings of little interest or pleasure in doing things nearly every day; feeling tired or having little energy nearly every day; and no feelings of being down depressed/hopeless and no feeling bad about herself. She was always incontinent of both bladder and bowel.Record review of Resident #83's undated Care Plan revealed: Focus- resident has stress, bladder incontinence r/t disease process and impaired mobility; Goal- the resident will remain free of skin breakdown due to incontinence and brief use through the review date; Interventions- Brief use: the resident uses disposable briefs. Incontinent: check and as required for incontinence, was rinse and dry perineum (area between the genitals and anus), change clothing PRN after incontinence episodes. Focus- terminal prognosis r/t COPD; Goal- the resident's dignity and autonomy will be maintained at the highest level.An observation and interview on 07/15/25, at 09:15 AM revealed Resident #83 was sitting in bed playing with a deck of cards on her bedside table as she received oxygen via nasal canula at 4 L/min. He bed had patterned bed sheets that did not appear to be facility provided. She said on Saturday (07/12/25) she woke up in the early morning wet and the staff on duty provided her incontinence care including changing her brief and clothing, but they did not change her sheets, so she had to sleep on the wet mattress. Resident #83 said later on in the day, facility staff changed her sheets and placed the soiled sheets in a bag on the chair in her room and it had been sitting there ever since. The surveyor observed a bag on a chair in the resident's room that contained bed linens wadded up. Resident #83 said facility staff said her linens could not be laundered because they did not have her name on them, but no one would help her do it. She said she was able and willing to write her name on her sheets herself, but she needed help due to her limited mobility.An observation on 07/16/25 at 07:25 AM revealed Resident #83 was asleep in bed. A new stack of cleanly folded bed linens were observed on the chair in the resident's room where the bag of soiled linens sat the previous day.An observation and interview on 07/16/25 at 02:43 PM revealed, Resident #83 was lying on her right side on her dressed with patterned white sheets with folded clean white patterned bed linens in a chair across from her bed. Resident #83 said she woke up that night just soaked, and she felt disgusted that the staff did not take the time to change her sheets when they changed her brief. Resident #83 said her family member usually did her laundry, but the family member had been so sick that the facility needed to wash them. She said facility staff told her name had to be written on all her items, but no one would help her. In an interview on 07/17/25 at 08:00 AM, the DON said when a resident had an episode of incontinence where the bedding become soiled, nursing staff were expected to change the bedding and sanitize the mattress along with incontinence care. She said there was no point in changing the resident and leaving them in bodily waste. The DON said some residents had instructions that only their family did their laundry, and a sign would be visibly displaced in the resident's room, but she said she was unsure if Resident #83's family did her laundry. The DON said failure to change soiled bed linens after an episode of incontinence could place a resident at risk of skin breakdown, infections, and psychosocial harm (social and environmental influences on a person's mind and behavior. The DON said she was unaware of any issues Resident #83 had with her sheets not being changed or laundered.An observation and interview on 07/17/25 at 03:25 PM revealed Resident #83 was in bed talking to a family member on her phone. The resident and family member said the facility provided all laundry services for Resident #83 and the family did not do her laundry. There were no signs that reflected family does laundry observed in Resident #83's room. Resident #83 said the episode of incontinence occurred on Saturday at approximately 2-3 AM so she knew the staff were not too busy to change her linens, the staff were lazy and left her lying in her wet sheets. She said being left in wet sheets bothered her and made her feel cranky, but she did not have any redness, irritation, or wounds due to inappropriate incontinent care. Resident #83 said no one should be left to lay in soiled sheets and an unknown nurse helped her get her sheets washed yesterday (07/16/25).In an interview on 07/17/25 at 03:45 PM, LVN E said she worked with Resident #83 on 07/16/25 but she did not know Resident #83 had an issue with her sheets not being changed after incontinence care or being laundered all she saw was a stack of folded clean bedding on the chair in the resident's room.In an interview on 07/17/25 at 03:55 PM, the Laundry Director said all personal laundry was labeled when brought into the facility and personal sheets were washed with facility sheets daily to maintain the proper sanitizing temperatures and stacked in the residents room. He was unaware of any delay in resident laundry and said in cases such as Resident #83's sheets, the delay was most likely due to a CNA not moving the linens from the resident room to the soiled laundry area.Record review of Resident #83's Progress Notes from admission dated 07/17/25 revealed, no documentation of the resident's episode of incontinence on 07/12/25 and the need to launder her sheets.Record review of the facility's Grievance Log for July 2025 revealed, no grievances listed for Resident #83.Record review of the facility policy titled Perineal Care revised 02/2018 revealed, no instructions on changing clothing and linens after an episode of incontinence.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to immediately consult with the resident's physician; when there wis an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #67 ) reviewed for change of condition. - The facility failed to notify Resident #67's physician after she sustained a nickel sized skin tear on 07/10/25.This failure could place residents at risk for not receiving appropriate care and interventions.Finding include:Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD (a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, low blood pressure and acid reflux.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, she had no current or healed pressure injuries, no venous and arterial ulcers, and no other ulcers, wounds, or skin problems.Record review of Resident #67's undated Care Plan revealed, Focus- needs dialysis r/t kidney failure; intervention- monitor for dry skin and apply lotion as needed. There was no reference to any skin tears documented in Resident #67's care plan.An observation on 07/15/25 at 09:12 AM revealed Resident #67 was in bed with a dressing on her right lower arm that reflected 07/10. There was a nickel sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened.Record review of Resident #67's Progress Notes from 06/15/25 to 07/14/25 printed on 07/15/25 at 01:42 PM revealed no documentation of Resident #67's skin tear on 07/10/25 or notification to the physician.Record review of Resident #67's EMR on 07/15/25 revealed, no documented CIC, SBAR or skin note completed on 07/10/25.Record review of the facility Accident & Incident Report dated 07/15/25 with date range of 02/15/25 to 07/15/25 revealed, no documented accidents or incidents for Resident #67In an observation and interview with Resident #67 on 07/16/25 at 12:50 PM, revealed the Wound Care Nurse removed the dressing from Resident #67's lower right arm dated 07/10 and a circle of dried blood was observed on the dressing. There was a skin tear, and the resident said the wound did not hurt and an unknown staff put a dressing on it because it would not stop bleeding. The Wound Care Nurse said a skin tear was considered a CIC, and it should have been documented in the resident's chart as such. She said the staff member who identified the tear should have completed a CIC, Risk Management assessment, notified the Wound Care Nurse and sent notifications to the MD, nursing administration and family. The Wound Care Nurse said she was not notified of Resident #67's skin tear that occurred on 07/10/25 and that kind of injury warranted she received notification.In an observation and interview with Resident #67 on 07/16/25 at 01:40 PM revealed Resident #67 had a wound on her lower arm that appeared to be a superficial skin tear with the skin folded over itself in the corner and measured approximately 1' X 1.5. The Wound Care Nurse cleansed the area with wound cleanser and applied a new dressing dated 07/16/25. Resident #67 denied any pain associated with the skin tear.In an interview on 07/16/25 at 02:09 PM, the Wound Care Nurse said a skin CIC were any changes in color, break in skin, swelling and anything out of the norm. She said when a nurse observed a skin tear, they should immediately notify the wound care nurse, then the wound care doctor, complete a skin check and an SBAR. The Wound Care Nurse said if she was working at the time the orders were received, she would perform the initial care and if she was no, then the nurse would. She said neither she nor the Wound Care Doctor were notified of Resident #67's new skin tear and she did not see any documentation about the injury on the resident's medical record.In an interview on 07/17/25 at 08:00 AM, the DON said any newly identified skin tear was a change of condition, and the identifying nurse immediately notified the wound care nurse who then received orders to perform treatment from the wound care doctor. She said nursing staff were expected to ask the resident how it occurred, then complete a skin check, pain assessment, CIC/SBAR documentation and complete an incident report. She said after investigation, she identified RN C as the nurse who placed the dressing on Resident #67. The DON said in an interview RN C said he was notified by an unknown therapy staff that the Resident #67 had a new skin tear, and he performed treatment on the wound but he got caught up and forgot to document it[BR1] . She said the PT staff should have completed stop and watch documentation and submitted it to the nurse, but there was no documentation of the injury from what she had seen. The DON said to her knowledge RN C did not notify anyone or document the incident and no action was taken following his initial care on 07/10/25. The DON said failure to notify the physician, document the incident or provide follow up care could result in the wound worsening and/or infection. On 07/17/25 at 12:33 PM, an attempt was made to contact RN C via telephone. The surveyor left a message on RN C voicemail and sent a text message requesting the staff return the call. RN C did not return the call or reply to the text message.In an interview on 07/17/25 at 01:57 PM, the Wound Care Doctor said she was not notified of a new skin tear for Resident #67 on 07/10/25 and the first time she was heard of it was on 07/16/25 when she was notified by the Wound Care Nurse, but she had standing orders that could be followed. She said her expectation was that the wound care nurse notified her of the incident, and the standing orders be followed. She said if a resident received inappropriate treatment for a wound at a minimum the wound could worsen and in a worst-case scenario they could suffer from infection.Record review of the facility's In-service/Education Sheet dated 06/26/25 revealed, subject: Wound Care, Skin Assessments, Reporting Skin Issues. During your shift if a new skin issue is identified, you are required to notify the wound care nurse and complete the following: Braden Assessment (used to predict the risk of a pressure ulcer), Risk Management which includes skin note under progress notes and skin check assessment; SBAR and notify the wound care nurse. Noncompliance with these procedures may result in disciplinary action. RN C signed the in-service documentation indicating he received the training. Record review of the facility's undated Wound Care Standing Orders revealed, -Standing Order #2: Skin Tear Management. Indication: Skin tears (open skin) . Order: Cleanse skin tear with wound cleanser. Apply xeroform to wound bed, cover with dry dressing. Frequency: Dressing change three times per week. (Monday, Wednesday, Thursday) or as needed if soiled or non-adherent. Duration: until healed or per Wound MD guidance. Record review of the facility policy titled Acute Condition Changes- Clinical Protocol revised March 2018 revealed, 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse.4. Nursing assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison.a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 10. The nurse and physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Cause Identification: 1. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. Treatment/Management:1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up: 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.2. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. 3. At the next visit, the physician will review the status of the condition change and document his/her evaluation, including the anticipated impact on the individual's function, prognosis, and quality of life. a. The physician will make interim visits as needed to assess the situation (especially if the individual is not stable or is not improving as anticipated).Record review of the facility policy titled Change in a Resident's Condition or Status revised 02/2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source. 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #2 and #77) reviewed for PASRR.- The facility failed to ensure Resident #2's diagnosis of Dementia and Mental Illness ( MDD and psychosis) were accurately documented in her PL1.- The facility failed to ensure Resident #77's diagnosis of Mental Illness (MDD) was accurately documented in his PL1.This failure could place residents who had a mental illness at risk of not receiving needed assessments (PASRR Evaluation), and individualized specialized services to meet their needs.Findings included: Resident #2Record review of Resident #2's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified psychosis, anxiety disorder, major depressive disorder, and unspecified dementia without behavioral disturbance.Record review of Resident #2's PL 1 completed 02/07/25 revealed, C0090 Primary diagnosis of dementia: the answer was NO for is there evidence that dementia is the primary diagnosis for this individual. C0100 Mental Illness: the answer was NO for is there evidence or an indicator this is an individual that has a mental illness.Record review of Resident #2's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, delusions, verbal behavioral symptoms and other behavioral symptoms not directed towards others, active diagnoses of: anxiety disorder, depression and psychotic disorder, resident was taking antianxiety medications and the indication for use was noted, and the resident had non-Alzheimer's Dementia.Record review of Resident #2's undated Care Plan revealed, Focus- use of antipsychotic medications r/t fluctuating mood initiated on 02/24/25; intervention: Administer antipsychotic medication as ordered by a physician, monitor for side effects and effectiveness every shift. Focus- impaired cognitive function related to dementia; intervention- administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #2's Order Summary Report dated 07/15/25 revealed, Resident #2 had orders for antipsychotic medication monitoring since 02/26/25. She was ordered Quetiapine (antipsychotic medication) 25 mg every 12 hours on admission on [DATE] and the medication was gradually increased to Quetiapine 100 mg ever morning and at bedtime on 06/17/25.Record review of Resident #2's July 2025 Medication Administration Record revealed, Resident #2 received Quetiapine 100 mg twice daily at 09:00 AM and 09:00 PM.Resident #77Record review of Resident #77's Face Sheet dated 07/15/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: adjustment disorder with mixed anxiety and depressed mood, MDD, anxiety disorder and dementia without behavioral disturbance.Record review of Resident #77's PL 1 dated 05/01/2023 revealed, C0090 Primary diagnosis of dementia: the answer was YES for is there evidence that dementia is the primary diagnosis for this individual. C0100 Mental Illness: the answer was NO for is there evidence or an indicator this is an individual that has a mental illness.Record review of Resident #77's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 08 out of 15, active diagnoses of: non-Alzheimer's Dementia anxiety disorder, depression, and psychotic disorder.Record review of Resident #77's undated Care Plan revealed, Focus- trauma screen performed which indicated trauma related to his stroke related loss of independence and the loss of his partner; Intervention- consult with social and psych services. Focus- impaired cognitive function and impaired though process r/t dementia; Intervention- administer medications as ordered. Monitor/document side effects and effectiveness. Focus: use of antidepressant medication r/t MDD, recurrent, severe with psychotic symptoms; Intervention: administer antidepressant medications as ordered by physician. Focus: use of psychotropic medications r/t behavior management; Intervention administer medications as ordered and monitor for side effects and effectiveness every shift. Focus: depression r/t dementia; intervention- administer medications as ordered and monitor for side effects and effectiveness. In an interview on 07/17/25 at 10:51 AM, the MDS nurse said when a resident admitted they should have a PASRR, she reviewed the information for completion and accuracy and enters it into the portal. She said if a resident had a positive PL 1 the appropriate behavioral health organization contacted the facility to initiate a meeting to determine if services were appropriate. She said regardless of whether a resident had a diagnosis of dementia or not if they had a diagnosis of mental illness such as Schizophrenia, mood disorder or MDD, mental illness should be indicated as yes in their PL1. She said an incorrect PASRR could place residents at risk of not being assessed for services and ultimately, they may not receive the services for which they are qualified. The MDS Nurse said based on what she saw in the system Resident #2's PASARR was inaccurate because she had dementia and a mental illness and Resident #77's was inaccurate because he also had a mental illness. She did not have a reason for why she did not identify the incorrect admitting PL1. Record review of the facility provided untiled document with no revision date revealed, 1 Purpose : This policy establishes procedures for complying with the federal Preadmission Screening and Resident Review (PASRR) program, as mandated by the Code of Federal Regulations, Title 42, Part 483, Subpart C, and Texas Administrative Code, Title 26, Part 1, Chapter 303. The PASRR process ensures that individuals seeking admission to or residing in [Nursing Facility Name], a Medicaid-certified nursing facility, are appropriately screened for mental illness (MI), intellectual disability (ID), or developmental disability (DD), also known as a related condition (RC), to determine the appropriateness of nursing facility placement and the need for specialized services. 2 Scope: This policy applies to all staff involved in the admission, assessment, and care planning processes at [Nursing Facility Name], including MDS coordinators, nursing staff, administrators, and billing personnel. It covers all individuals seeking admission, regardless of funding source (Medicaid, Medicare, private pay), and residents requiring ongoing reviews. 3 Definitions: PASRR Level I (PL1) Screening: A preliminary assessment to identify individuals with suspected MI, ID, or DD, completed prior to admission. [Nursing Facility Name] is committed to ensuring compliance with federal and Texas PASRR regulations by screening all applicants for MI, ID, or DD, facilitating appropriate placement, and providing required specialized services. The facility will collaborate with referring entities, local authorities, and the Texas Medicaid Healthcare Partnership (TMHP) to complete PASRR processes accurately and timely.

Based on interview, observation, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 of 6 residents (Resident #96) reviewed for baseline care plan. - The facility failed to ensure Resident #96's baseline care plan addressed the resident's diagnoses of anxiety disorder and depression which were treated with medications, the presence of a pacemaker, his orders for the opioid pain medication morphine.This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, and services provided with could cause a physical or psychosocial decline in health. Findings includeRecord review of Resident #96's Face Sheet dated 07/15/25 revealed, Resident #86 admitted to facility on 07/11/25 with diagnoses which included: anxiety disorder, depression, irregular heartbeat, and the presence of a cardiac pacemaker. The resident was receiving hospice services.Record review of Resident #96's EMR on 07/15/25 revealed, the resident's MDS was not completed yet due to his recent admissionRecord review of Resident #96's baseline care plan signed 07/11/25 revealed, Initial discharge goals- receive hospice care/coordination; Medications- Opioids and Black box medications (medications with life threatening risks such as opioid pain medications, benzodiazepines such as lorazepam used to treat anxiety, antidepressants like sertraline) and black box medications were not selected. There was no reference to his diagnosis of anxiety disorder, depression, or the presence of a pacemaker.Record review of Resident #96's Order Summary Report dated 07/17/25 revealed:- Pacemaker: continuous monitoring at bedside with home transmitter.- Lorazepam 0.5 mg- 1 tabled every 2 hours as needed for anxiety and SOB for 14 days - Morphine Sulfate 100 mg/5 mL- give 0.5 ml by mouth every 2 hours as needed for pain and/or SOB.- Sertraline 100 mg - give 1 tablet by mouth one time a day for depression/anxiety.An observation and interview on 07/15/25 at 11:43 AM revealed Resident #93 was well dressed and in no immediate distress sitting in a wheelchair with his legs cross watching TV in the activities room. He said he was doing well, on hospice and had no issues or concerns.In an interview on 07/17/25 at 08:08 AM, the DON said the care plan represented a plan of care that is personalized to the resident, and it should address, everything including diagnoses, dietary; wounds; and supportive devices. She said an inaccurate care plan could place residents at risk of not receiving the care they need, and the resident's necessary interventions and goals would be possibly unknown. In an interview on 07/17/25 at 02:31 PM, the MDS Nurse said the baseline care plan was developed by nursing staff within the first 48 hours after admission in order to provide immediate care for the resident. She said failure to have an accurate baseline care plan could place residents at risk of not receiving the care they requiredRecord review of the facility policy titled admission of Resident with no revision date revealed, The Baseline Care Plan will be developed within 48 hours of the resident's admission to the facility. The resident or resident representative will be given a summary of the Baseline Care Plan by completion of the comprehensive care plan. The resident's medical record will reflect the provision of the written Baseline Care Plan summary. 13. The Licensed Nurse and IDT members will develop a baseline plan of care detailing the resident's care needs that will be utilized by all staff members until the admission MDS has been completed and the resulting comprehensive care plan has been developed.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 5 residents (Resident #67) reviewed for quality of care.- The facility failed to provide care to Resident #67 for 4 days after she suffered from a skin tear on 07/10/25. These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, infection and hospitalizationFindings included:Record review of Resident #67's Face Sheet dated 07/15/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection), COPD ( a lung disease that makes it difficult to breathe), high cholesterol, vitamin d deficiency, low blood pressure and acid reflux.Record review of Resident #67's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, she had no current or healed pressure injuries, no venous and arterial ulcers, an no other ulcers, wounds, and skin problems.Record review of Resident #67's undated Care Plan revealed, Focus- needs dialysis r/t renal failure; intervention- monitor for dry skin and apply lotion as needed. There was no reference to any skin tears documented in Resident #67's care plan.An observation and interview on 07/15/25 at 09:12 AM revealed, Resident #67 in bed with a dressing on her right lower arm that read 07/10. There was a [NAME] sized circle of dry blood visible through the dressing and the dressing appeared slightly dingy. Resident #67 said the dressing was old and she did not know how it happened.In an observation and interview with Resident #67 on 07/16/25 at 12:50 PM, the Wound Care Nurse removed the dressing from Resident #67's lower right arm dated 07/10 and a circle of dried blood was observed on the dressing. There was a skin tear, and the resident said the wound did not hurt and an unknown staff put a dressing on it because it would not stop bleeding. In an observation and interview with Resident #67 on 07/16/25 at 01:40 PM revealed, Resident #67's lower arm had a superficial skin tear with the skin folded over itself in the corner and measured approximately 1' X 1.5. The Wound Care nurse cleansed the area with wound cleanser and applied a new dressing dated 07/16/25. Resident #67 denied any pain associated with the skin tear.In an interview on 07/16/25 at 02:09 PM, the Wound Care Nurse said when a nurse observed a skin tear, they should immediately notify the wound care nurse, then the wound care doctor, complete a skin note with a skin check and an SBAR. The Wound Care Nurse said if she was working at the time the orders were received, she would perform the initial care and if she was not working, the nurse would. She said neither she nor the Wound Care Doctor were notified of Resident #67's new skin tear and she did not see any documentation about the injury on the resident's medical record. She said from what she saw Resident #67 had not received any treatment to the skin tear on her right arm since 07/10/25In an interview on 07/17/25 at 08:00 AM, the DON said a newly identified skin tear was a change of condition, and the identifying nurse must immediately notify the provider, wound care nurse who then received orders to perform treatment. She said after investigation she identified RN C as the nurse who placed the dressing on Resident #67 but there was no documentation of the injury, or care provided to the site from what she had seen. The DON said failure to provide follow up care could result in the wound worsening and/or infection. On 07/17/25 at 12:33 PM, an attempt was made to contact RN C via telephone. Surveyor left a message on RN C voicemail and sent a text message requesting the staff return the call; RN C did not return the call or reply to the text message.In an interview on 07/17/25 at 01:57 PM, the Wound Care Doctor said she was not notified of a new skin tear for Resident #67 on 07/10/25 and the first time she heard of it was on 07/16/25 when she was notified by the Wound Care Nurse, but she had standing orders that could be followed. The Wound Care Doctor said she was unaware of any care provided to the site since she was not notified. She said the expectation was that the wound care nurse notify her of the incident, and the standing orders be followed. She said if a resident received inappropriate treatment for a wound at a minimum the wound could worsen and in a worst-case scenario they could suffer from infection.Record review of Resident #67's Skilled Evaluation dated 07/10/25 revealed, no documentation of any skin tears. Only skin discoloration that was present upon admission was documented.Record review of Resident #67's Progress Notes from 06/15/25 to 07/14/25 printed on 07/15/25 at 01:42 PM revealed no documentation of Resident #67's skin tear on 07/10/25 or documentation of wound care to the tear of Resident #67's right lower arm.Record review of Resident #67's Skin Assessment completed on 07/14/25 revealed, no documentation of Resident #67's skin tear from 07/10/25.Record review of Resident #67's Active Order Summary dated 07/15/25 at 01:48 PM revealed, no orders for care to Resident #67's skin tear on her lower right arm.Record review of the facility's undated Wound Care Standing Orders revealed, -Standing Order #2: Skin Tear Management Indication: Skin tears (open skin) . Order: Cleanse skin tear with wound cleanser. Apply xeroform to wound bed, cover with dry dressing. Frequency: Dressing change three times per week. (Monday, Wednesday, Thursday) or as needed if soiled or non-adherent. Duration: until healed or per Wound MD guidance. Record review of the facility policy titled Acute Condition Changes- Clinical Protocol revised March 2018 revealed, 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. The nursing staff will contact the physician based on the urgency of the situation 10. The nurse and physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Cause Identification: 1. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. Treatment/Management:1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up: 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. 2. The physician will help the staff monitor a resident/patient with a recent acute change of condition until the problem or condition has resolved or stabilized. 3. At the next visit, the physician will review the status of the condition change and document his/her evaluation, including the anticipated impact on the individual's function, prognosis, and quality of life. a. The physician will make interim visits as needed to assess the situation (especially if the individual is not stable or is not improving as anticipated).

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 Resident (Resident #4)reviewed for enteral nutrition. - The facility failed to administer medications safely to Resident #4 via G-tube (a feeding tube inserted into the stomach through the abdomen) by not checking for placement and forcefully pushing fluids into the residents G-tube with a syringe. These failures could place residents at risk of injuries, and hospitalization. Findings include: Record review of Resident #4's Face Sheet dated 07/17/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure, MDD, dysphagia (difficulty swallowing), type 2 diabetes with kidney disease, dementia, and anxiety. Record review of Resident #4's Significant Change in Status MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, active diagnosis of dysphagia and use of a feeding tube while a resident. Record review of Resident #4's undated Care Plan revealed, Focus- resident requires tube feeding r/t weight loss and lack of appetite; intervention- check placement of enteral tube before and after administering medications Record review of Resident #4's Order Summary Report revealed,- Omeprazole 20 mg DR- t daily for GERD.- Sennosides 8.6 mg- give 1 tablet via PEG-tube every morning and at bedtime for constipation.- Polyethylene Glycol 3350 Powder (MiraLAX) Give 1 packet via G-Tube two times a day for constipation mix with 4-8 oz beverage of choice. An observation and interview on 07/16/25 at 09:00 AM revealed, LVN D preparing for administration of medication via G-tube to Resident #4 with a Jug of cold water on the top of her medication cart. She retrieved 1 tablet of Omeprazole 20 mg (antacid for acid reflux) oral disintegrating tablets and placed it in a medication cup and then retrieved and crushed 1 Sennosides 8.6 mg (laxative) tablet and 17 grams of MiraLAX (stool softener) mixed in approximately 6 ml of water. LVN D then poured cold water into a cups and entered into the residents room. She then mixed and administered the disintegrating omeprazole to Resident #4 placing it on his tongue, mixed the crushed Sennosides 8.6 mg in cold water, mixed it with the syringe and paused the resident's continuous feed. LVN D withdrew approximately 10 cc of cold water into the syringe, attached it to the side port since the main port still had the paused continuous feed connected and pushed with force through the syringe 10 cc of water. She did not check for placement with osculation (listening for sounds) or check for residual by pulling volume from the syringe attached to the side port. LVN D withdrew the entire volume of mixed MiraLAX and attached the syringe to the side port and attempted to push the medication into the tube but there was resistance, and she was unable to administer the medication with force through the g-tube side port. LVN D said she could not administer medication through Resident #4's g-tube via gravity because the port was too small. She said she had administered medication via syringe to Resident #4 successfully in the past. LVN D attempted to disconnect the continuous feed from the other port to use but it was stuck so she stopped medication administration and said she would get one of the male staff to help her to disconnect the continuous feed. Resident #4 was chatty throughout the observation and did not show or verbalize any pain or discomfort. In an interview with on 07/16/25 at 09:14 AM, the ADON said when administrating medication via G-tube staff must first dissolve the medications in warm water. The nurse must then check for placement by checking the residual feed and if acceptable they can begin administration of a warm water flush followed by the medications with 5-10 ml warm water flushes in between and a flush after the last medication. She said cold water should not be used because it could lead to residents having spasms and flushes/feeds must be done through gravity not by force of a syringe because the syringe can cause spasms if the medication is pushed too fast. In an interview on 07/17/25 at 08:08 AM, the DON said prior to administering medication via g-tube nursing staff must check for placement by injecting air and listening for bowel sounds and check for residual. She said they should not push the fluid with a syringe through the g-tube. The DON said medication must be administered via gravity because if force is used it could result in in internal injury to the resident or damage to the port. The DON said cold water should not be used to dissolve medication for g-tube administration because the medication would not dissolve which could cause the g-tube to become clogged, and the use of cold water could also cause cramping to the resident. The DON said nursing staff are not supposed to use the g-tube side port for medication administration because it was smaller . In an interview on 07/17/25 at 03:39 PM, LVN D said prior to medication administration nursing staff are expected to check for residual to make sure the feeding tube is in the right place and the resident is not full. She said if the residual is more than 30 mL nursing staff are expected to hold off on medication administration and failure to check placement could place residents at risk of the feed going into the wrong place if the tube was displaced which could lead to peritonitis (redness and swelling of the lining of your belly or abdomen). LVN D said g-tube medications should be administered via gravity because using force with a syringe could blow the tube or cause the resident injury. She said she attempted to administer medication to Resident #4 through the wrong port and she was not sure why, she said she should have used gravity, she had a brain fart and should have known better[VT3] . Record review of LVN D is undated Competency Assessment G Tube Medication Administration revealed, 4- dissolve crush medications in lukewarm water; 12- check for placement ; 13. Check for residual; 14. Flush tube with warm water. The assessment did not specify that medications were to be administered via gravity and LVN D was deemed competent in all tasks by the ADON.A request was made on 07/16/25 at 09:14 AM to the ADON for a policy on G-tube medication administration. The policy was not provided prior to exit, but a policy addressing the care of G-tubes was provided.Record review of the facility undated policy titled Enteral Feeding Tube, Care of revealed, no instructions on how to safely administer medications to resident's via G-tube.

Number of residents sampled: Number of residents cited: Based on observations, interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 5 residents (Resident #11) reviewed for treatment and services for mental and psychosocial concerns.- The facility failed to provide mental health services to Resident #11 who was diagnosed with MDD resulting in the resident feeling sad, lonely and crying.These failures could place residents at risk of minor and major injuries, suicide threats, attempted suicide, hospitalization, and death.Findings included:Record review of Resident #11's Face Sheet dated [DATE] revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of: difficulty walking, lack of coordination, breast cancer in left breast, PVD ( circulatory disease where there is reduced flow to the limbs and other parts of the body), and MDD. Record review of Resident #11's admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, her resident mood interview indicated mild depression with a score of 08 out of 27; the resident reported she felt down, depressed and hopeless nearly every day, but she did not feel bad about herself or have thoughts she would be better off dead or of hurting herself in any way. Resident #11 had no signs of psychosis and no behavioral symptoms, with an active diagnosis of depression.Record review of Resident #11's undated Care Plan revealed, Focus- MDD, single episode with severe psychotic features; Goal- resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date; monitor/document/report any s/sx of depression including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness.An interview and observation on [DATE] at 09:30 AM revealed, Resident #11 was well groomed and in no immediate distress propelling herself down out of the therapy room and down the hall in a wheelchair. When she entered her room Resident #11 said she was doing pretty good, but she was sad because she was lonely. She said she missed her grandchildren, missed a birthday and her brother died since she admitted to the facility. As she transferred herself from her wheelchair to her bed, she cried stating that she could not go to her brother's funeral because she was in the facility. Record review of Resident #11's Initial Social Services Assessment & History dated [DATE] signed by the Social Worker revealed, psychological wellbeing: adjusts well to change, psychiatric diagnosis of MDD, single episode with severe psychotic features; Social Services Summary: referral to psych/psychological services.Record review of Resident #11's entire EMR on [DATE] revealed, no documentation of a psychological referral or evaluation. There were no practitioner notes for psych services or reference of any type of psychiatric evaluation. In an interview on [DATE] at 12:42 PM, the DON said when a resident arrived at the facility with a diagnosis of mental health issues or orders for psych medication, they automatically receive a referral for psychiatric services. She said a psychiatry referral is required for residents with mental health diagnosis to ensure that the residents are being followed. The DON said if a resident had a diagnosis of MDD and did not receive a psych evaluation then the resident would not receive care for their diagnosis which could place residents at risk for self-isolation and self-harm. She said if a resident with MDD refused psych services the MD would talk to them to understand the significance. The DON said Resident #11 was generally calm, participated in the facility and goes to therapy, she said she had not observed any signs of depression in the resident. The DON was not sure if Resident #11 received any psychiatric services.[VT3] In an interview on [DATE] at 12:50 PM, Resident #11 said her mood was down because she wanted to go home. She said she did not want to die and would not try to harm herself. Resident #11 said no one from the facility had talked to her about her mood and she had not denied any offers for mental health services. In an interview on [DATE] at 01:13 PM, the Activities Director said Resident #11 liked to do word searches, plays bingo and exercises. She said the resident was sometimes withdrawn; the resident never told her she did not want to be at the facility, but she was excited about going home. The Activities Director said Resident #11 never showed or expressed signs of depression and suicidal ideation. In an interview on [DATE] at 01:20 PM, the Social Worker said Resident #11 lived with her son when she fell and was discovered hours later and due to this her son has concerns for her discharging home. She said Resident #11 wanted to discharge and live with her son, so her goal was to go home. The Social Worker said she assessed Resident #11's mood at the beginning of her stay and it was mild, so she asked if the resident wanted to talk to someone and she said no, so Resident #11 never received psychiatric services. She said residents with a diagnosis of MDD should be continuously evaluated because failure could result in a worsening of condition, but she had not observed any signs or symptoms of depression, sadness, or the resident crying. Record review of the facility provided list on [DATE] of residents who received behavioral health services with a licensed social worker revealed, Resident #11 was not being followed and had not received any psychological services. Record review of the facility Psychological Services Policy with no revision date revealed, Purpose & Context: As requested, the facility will provide or arrange for psychological services to meet the mental health needs of the residents. These services will support diagnosis, treatments and monitoring of psychiatric conditions and promote the quality of life for residents. Procedure: 1 Identification and referral. Residents may be referred for psychological services by physicians, nursing staff, social worker or upon admission screening. 2 Assessment: A licensed medical professional will assess the resident's mental health status, including cognitive, emotional, and behavioral functioning. 3 Treatment Planning: An individual treatment plan will be developed in coordination with the resident, their RP (when appropriate, and the interdisciplinary team. 4.Documentation: All assessments, interventions, progress notes and treatment plans will be part of the resident's medical record.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #84) reviewed for infection control.- The facility failed to practice proper infection control when providing perineal care to Resident #84 following a bowel movement.These failures could place residents at risk of exposure to infection, decline in health and hospitalization.Findings included:Record review of Resident #84's Face Sheet dated 07/17/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right side paralysis, difficulty swallowing, anxiety disorder, dementia and need for assistance with personal care.Record review of Resident #83's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, and the resident was always incontinent of both bladder and bowel.Record review of Resident #84's undated Care Plan revealed, Focus: The resident has bowel incontinence r/t immobility; Goal: The resident will remain free from skin breakdown due to incontinence and brief use; Intervention: Check resident every two hours and assist with toileting as needed. In an observation and interview on 07/16/25 at 08:45 AM, CNA A provided incontinence care for Resident #84. The resident required EBP (a set of IC measures to reduce the spread of MDRO in healthcare settings), and CNA A wore the appropriate PPE. Resident #84 was observed to have stool inside his brief and on body; CNA A first used cleaned the black stool located around his testicles with wipes, then she wiped his groin, lower abdomen and then the resident's penis wearing the same gloves. She did not clean the tip of the penis, then turned the resident to his right side and wiped stool from the rectum and butt. CNA A then used a separate wipe to wipe Resident #84 down from front to back. After cleaning the dirty part CNA A changed gloves and did not sanitize or wash her hands. CNA A said she was supposed to clean the penis first and from tip on down; but she did not because she saw all the stool and wanted to clean that first. She said she should have started with penis first to prevent infection control; and should have washed her hands at the sink between changing gloves to prevent bacteria from spreading and transferring to clean items. She said she should not touch anything clean with dirty gloves.In an interview on 07/17/25 at 07:00 AM, the DON said during incontinence care nursing staff must begin at the top just like a sterile field. They must not use the same wipe and must pull back skin because elderly residents cannot perform self-care. She said staff must clean off the bowel movement and not go back and forth to prevent infection. The DON said the staff performing incontinence care must tuck the brief so as not to contaminate the front, then turn the resident and clean the backside of the resident from front to back, then clean and wipe again with new wipes until the wipes comes back clean; then remove gloves and perform hand hygiene. She said CNA A should not have cleaned from dirty to clean to prevent contamination and should not touch anything with dirty gloves. The DON said CNA A was nervous during the surveyor observed incontinence care and that partly attributed to her errors.Record review of CNA A's Competency Assessment for Perineal Care dared 04/29/24 revealed, she was assessed as competent for: Purpose: To clean the male perineum without contaminating the urethral area with germs from the rectal area. Emphasizing clean to dirty. 1 a- wash hands. Wear gloves and follow standard precautions.Record review of the facility provided undated Handwashing/Hand Hygiene policy revealed, no reference to washing from dirty to clean areas and no instructions to wash their hands between glove changes.Record review of the facility provided undated Infection Prevention and Control Guidelines revealed, Always wash your hands before and after procedures. Follow your facility's hand hygiene protocols. Always wash your hands before and after resident contact. Follow your facility's hand hygiene protocols. Use alcohol-based hand rub (ABHR) for hand hygiene, except when hands are visibly soiled. Follow your facility's hand hygiene protocols. Wear sterile or clean gloves when appropriate. Always wear gloves when working with or expecting to encounter body fluids.Record review of the facility policy titled Perineal Care revised 02/2018 revealed, For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perinea! area starting with urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and inner thighs. g. Thoroughly rinse perinea! area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. 1. Rinse washcloth and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. D1y area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 (Resident #1 and #2) residents reviewed for comprehensive assessments. The facility failed to develop and implement a care plan (dated 07/01/2025) that addressed Resident #1’s new diagnosis of chronic kidney disease after return from hospital on [DATE]. The facility failed to develop and implement a care plan (dated 07/02/2025) that addressed Resident #2’s allergy to lactose and a fall with injury on 06/02/2025. This deficient practice could place residents at risk of not receiving interventions individualized to their health care needs. The findings included: Record review of Resident #1's face sheet, dated 01/01/2025, reflected a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #1 had diagnoses which included: Chronic kidney disease, stage 4 (severe, damage to the kidneys occur when the kidneys are unable to filter waste products from the blood. This is the last stage before kidney failure), disorder of kidney and ureter, cognitive communication deficit, dementia, diabetes, hypertension (elevated blood pressures), muscle wasting and Alzheimer’s disease. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 8 out of 15 indicating moderate impaired cognition. Resident #1 was always incontinent of bowel and bladder. The active diagnoses section included disorder of kidney and ureter. Record review of Resident #1’s hospital records, under the Nephrology Progress Notes, with the date of service as 06/10/2025 revealed an assessment to include CKD stage 3. Record review of Resident #1’s hospital discharge summary notes with the admit date of 06/03/2025 and discharge date of 06/12/2025 revealed AKI (acute kidney injury) on CKD stage 4 (meaning AKI occurs in CKD patients and is known to be more severe and difficult to recover). Record review of Resident #1’s care plan printed on 07/01/2025 revealed CKD was not addressed; no goals or interventions were put into place on the care plan. Record review of Resident #1’s active physician orders as of 07/01/2025 revealed an order for Furosemide 40mg tablet by mouth daily for diuretic (a drug that promotes the increased production of urine), start date was 06/13/2025. Record review of Resident #2’s face sheet dated 07/02/2025 reflected an [AGE] year-old admitted to the facility on [DATE]. Resident #2 had an allergy to Lactose. Resident #2’s diagnoses included Hemiplegia (severe loss of strength on one side of the body), Aphasia (language disorder caused by damage in a specific area of the brain), GERD Gastroesophageal Reflux Disease (a condition where stomach acid flows back into the throat causing symptoms like heartburn), obesity, Dysphagia (swallowing disorder); Dysarthria and Anarthria (speech disorders caused by brain damage). Record review of Resident #2's quarterly MDS, dated [DATE], revealed she had short term and long-term memory problems. Resident #2 made consistent independent decisions regarding tasks of daily life and had no evidence of acute changes in mental status. Further review revealed the resident had no fall history. Record review of Resident #2’s active physician order for food allergies dated 6/20/2024 revealed she had a mild intolerance to lactose. Record review of Resident #2’s active physician orders as of 07/02/2025 revealed an order for regular diet, mechanical soft texture and thin consistency. Further review revealed dietary supplement orders for health shake daily with lunch r/t weight trend, start date was 06/26/2025. Continued review revealed no orders for lactase (an enzyme that breaks down lactose, preventing symptoms like gas, bloating and diarrhea associated with lactose intolerance). Record review of Resident #2’s change in condition evaluation dated 06/02/2025 revealed the resident had a fall and had a wound to the side of the right thigh and contusion to the right side of the head. Record review of Resident #2’s incident note dated 06/02/2025 at 8:55 PM, the resident had an unwitnessed fall and was found on the floor next to the bed. Further review revealed the physician was notified and the resident was sent to hospital for further evaluation. Record review of Resident #2’s nurse note dated 06/03/2025 at 1:50 AM, the resident returned from the hospital, alert and oriented and had no complaints. Record review of Resident #2’s care plan printed on 07/02/2025 revealed the allergy to lactose was not addressed. No goals and interventions were in place to prevent risk of complications. Further review revealed the fall that took place on 6/2/2025 was not addressed in the care plan. No goals or interventions were in place on the care plan to prevent injuries from falls. In an observation and interview on 07/02/2025 at 2:00 PM revealed, Resident #2 was in the tv room sitting in a wheelchair that had a special large arm rest for her left arm. Resident #2 stated she recalled the fall, and she fell because she was practicing rolling from side to side in bed for when they clean her up. Resident #2 stated she hit her forehead on the wheel of the rolling table and hit her right cheek on the bar of the rolling table. She stated she had a bruise on the side of her face and had also hit her right thigh on the bar of the table. She stated it happened at night and she was sent to the hospital. She stated they did a CT scan, and nothing was broken. She stated that she had not fallen since then and that the nursing staff did remind her about safety. She stated she was lactose intolerant, and the kitchen knew but they keep sending her dairy products. She stated she can take lactase herself and it helped with preventing upset stomach. In an interview on 7/02/2025 at 3:00 PM, the MDS nurse who stated the purpose of the care plan was to meet with the IDT (interdisciplinary team), to educate staff and family members on the resident specific plan of care. The MDS nurse stated the care plan was based on resident needs, any changes in the resident’s status, significant change of condition, falls and behaviors. The MDS nurse stated if a resident had a fall, it would be discussed in the IDT meeting, added to the care plan because it must be represented in the care plan. The MDS nurse stated the team would place certain interventions to the care plan to help prevent injury or serious injury from occurring. The MDS nurse stated Resident #2’s fall was discussed on 06/03/2025 during risk management meeting and addressing it in the care plan was missed. The MDS nurse said she was responsible, and that not adding the fall to the care plan was an oversight. The MDS nurse stated Resident #2’s intolerance to lactose should be in the care plan was not and that it was also an oversight. The MDS nurse stated moving forward she would conduct chart audits so not to miss anything. The MDS nurse stated Resident #1’s CKD diagnosis should be in the care plan. The MDS nurse stated generally the admitting nurse and was responsible for adding information into PCC when a resident was admitted or readmitted and the information would be auto added to the 24-hour report. The MDS nurse stated during morning meetings, residents who were readmitted would be discussed including the rationale for readmission. The MDS nurse was asked how this could affect Resident #1 if CKD was not in the care plan: the MDS nurse stated the resident could be affected if there were any ongoing orders related to CKD that were not transferred over from the hospital. In an interview on 7/02/2025 at 4:16 PM, the DON who stated the purpose of the care plan was to provide a plan on how the resident will be cared for and modified to that specific resident. The DON stated if a resident had an active, new diagnosis that it would be addressed in the care plan. The DON stated Resident #1 was being followed by a kidney specialist therefore the CKD should be in the care plan. The DON stated she did not know why it was not added to the care plan. The DON stated allergies should also be addressed in the care plan and when Resident #2 had a fall, it was discussed during meetings and should have been added to the care plan as well. The DON stated with the fall not being addressed in the care plan we would not be able to implement interventions to prevent injury from falls. The DON stated it should have been added upon Resident #2’s return from the hospital on [DATE].). Record review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised on March 2022, read in part: “…A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident….3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment…11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents’ condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident’s condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay…” Record review of the undated facility policy and procedure titled Condition Change of the Resident read in part: “…Basic Responsibility: licensed nurse, other…Purpose: Observe record and report any condition change to the physician so proper treatment can be implemented…Care Plan Documentation Guidelines: 1. Identify underlying problem causing the condition change. 2. Record measurable goal for resolution of the condition. 3. Develop a plan to treat the condition. Observe and monitor resident’s response to treatment. Record preventative measures, safety measures and resident education provided…” Record review of the facility’s policy titled Falls and Fall Risk, Managing, revised March 2018, read in part: “Based on previous evaluations and current data, the staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling…1. The staff will monitor and document each resident’s response to interventions intended to reduce falling or the risks of falling…”

Based on observation, interview, and record review, the facility failed to maintain correct chemical concentration , based on periodic testing, at least once per shift during the dishwasher's wash cycle in one of one kitchen. The facility failed to test and maintain proper concentration level of sanitizer solution during the dishwasher's wash cycle. This failure could affect all residents by placing them at risk for food-born illness. Findings included: Observation of the kitchen on 06/11/2024 at 9:08 am revealed the facility's only dishwasher in use at the time, was a low-temp dishwasher. Staff A was observed performing a strip test after a load of dishes had been washed. The strip did not change color after 5 attempts; indicating lower than minimum PPM levels of sanitizer solution. Interview on 06/11/24 at 9:20 am with Staff A, the Dietary Supervisor revealed she arrived to work after her morning kitchen staff who was responsible of logging test results each morning, which she then verified. When asked about the entry for that morning and the two mornings prior, she stated she made staff aware of the logging requirement but did not ask staff to perform the test. She also stated she did not perform random strip tests herself and relied solely on what is logged by her staff. When asked what the risks were when there was a malfunction in the dishwasher, she stated the residents would be at risk for cross-contamination and diseases. Interview on 6/11/24 at 9:31 am with Staff B revealed he did not log testing results prior to the observation because he was in a hurry that morning and did not test sanitation levels during the wash. Interview on 6/13/24 at 3:10 pm with the Administrator revealed he was unaware of the dishwasher's malfunction. He stated he was made aware after the observation made by surveyor on 06/11/2024 and was also made aware of the repairs that occurred the next later that afternoon. He confirmed the facility's policy required kitchen staff to log concentration levels of sanitizing solution with the use of testing trips each shift during wash cycles.

Based on observation, interview, and record review, the facility failed to develop the comprehensive person-centered care plan with services furnished to maintain the resident's highest practicable physical well-being for 1 of 5 residents, (Resident #71), in that: -The facility failed to ensure Resident #71's care plan was not updated to reflect the resident's need for a urinary catheter care. -This failure placed residents at risk of not receiving adequate care. Findings Include: Record review of Resident #71 face sheet, dated 06/11/2024, reflected a [AGE] year old male admitted to the facility on [DATE] with diagnosis of infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #71 Minimum Data Set (MDS) dated [DATE] reflected BIMS score of 04, which indicated severe impaired cognition. Record review of Resident #71 comprehensive care plan dated 05/25/2024 revealed no plan of care for urethral catheter care. Observed Resident #71 on 06/11/2024 lying in bed with head of bed at approximately 30 , urinary catheter noted with light yellow urine. In an interview with CNA A on 06/13/20/24 at 3:38 PM, CNA A stated nurses start care plans when the resident arrives to facility. All the care residents needs should be in the care plan., CNA A stated she is able to see planned for resident in the Plan of care (POC) tab in Point Click Care (PCC) (an electronic charting application). CNA A stated the reason for care plans is so everybody is knowledgeable of care that is needed by the resident and what to monitor for and report up the chain of command. She states the care plan is updated daily in the morning meeting. CNA A stated the risk of not having a care plan is the resident won't get the care they need and a possible lawsuit may occur. In an interview with RN A on 06/13/2024 at 3:53 PM, RN A stated when the resident is admitted to the facility the nurse starts the baseline care plan in Point Click Care (PCC) (an electronic charting application). RN A stated safety, nutrition, activities of daily living, disease process should be in the care plan so the resident can get proper care. RN A stated the care plan is updated during daily rounds and as changes are noted during the shift. RN A stated information from the care plan is given to the CNA verbally and also through the plan of care tab in PCC. RN A stated the risk of not having a care plan is resident won't get proper care and is at risk for harm. In an interview with CNA B 6/13/2024 at 4:10 PM, CNA B stated nurses start the care plan when the resident arrives to facility. CNA B stated all residents' needs like mobility, and diet, should be in the care plan., stated she is able to see the plan in the Plan of care (POC) tab in Point Click Care (PCC). CNA B stated the reason for care plans is so everybody is knowledgeable of care that is needed by the resident and what to monitor for and report up the chain of command. She states the care plan is updated daily in the morning meeting either by the nurse or social worker. CNA B stated the risk of not having a care plan is the resident won't get the care they need and a possible harm to resident may occur. In an interview with LVN A on 6/13/2024 at 4:19 PM LVN A stated when the resident is admitted to the facility, the nurse starts the baseline care plan in Point Click Care (PCC) (an electronic charting application). LVN A stated safety, nutrition, mobility, activities of daily living, disease process should be in the care plan so the resident can get proper care. LVN A stated the care plan is updated during daily rounds and as changes are noted during the shift. LVN A stated, information from the care plan is given to the CNA verbally and also through the plan of care tab in PCC. LVN A stated the risk of not having a care plan is resident won't get proper care and is at risk for harm. In an interview with the DON on 6/13/2024 at 4:32 PM, the DON stated when the resident is admitted to the facility the admitting nurse begins the baseline care plan in Point Click Care (PCC). DON stated all diagnosis, mobility status, medications and treatments should be in the care plan so the resident can get proper care. DON stated the care plan is updated during Interdisciplinary Team meetings (IDT), daily rounds and as changes are noted during the shift, information from the care plan is given to the CNA verbally and also through the plan of care tab in PCC. DON stated the risk of not having a care plan is a failure to care for the resident, resident won't get proper care and is at risk for harm. In an interview with the Administrator on 6/13/20/24 at 4:43 PM, the Administrator stated when the resident is admitted to the facility, the admitting nurse begins the baseline care plan in Point Click Care (PCC). Administrator stated all of the residents needs should be in the care plan so the resident can get proper care. Administrator stated the care plan is updated by nurses as changes are noted during the shift. Administrator stated the risk of not having a care plan is unacceptable and is a potential failure to care for the resident, and resident is at risk for harm. Record review of facilities policy titled, Care Plans, Comprehensive Person-Centered 2001 Med-Pass, Inc. (Revised July 2016) read in part . A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the psychosocial and functional needs The comprehensive person-centered care plan should be developed within 7 days of the completion of the required MDS assessment and should be completed within 21 days of admission describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental and psychosocial wellbeing that the resident desires or that is possible .interventions should address the underlying sources of the problem.

Based on observation, interview, and record review, the facility failed to ensure a physician supervised the care of a resident for one (Resident #71) of five residents reviewed for physician services in that: The facility failed to ensure the physician supervised and monitored Resident #71's indwelling urethral catheter since Resident #71 was diagnosed with infection and inflammatory reaction due to indwelling urethral catheter. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition, or illness up to and including death. Findings included: Record review of Resident #71's face sheet, dated 06/11/2024, reflected a 85 -year -old male admitted to the facility on [DATE] with diagnosis of Infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #71's Minimum Data Set (MDS) dated [DATE] reflected BIMS score of 04, which indicated severe impaired cognition. Record review Resident #71's physician orders indicated Resident #71 didoes not have any orders from the physician to care for indwelling urethral catheter. Observed Resident #71 on 06/11/2024 lying in bed with head of bed at approximately 30 , urinary catheter noted with light yellow urine. In an interview with CNA A on 06/13/20/24 at 3:30 PM, CNA A stated that she did not review MD orders and gets her instruction for care from the nurse that observes the physician orders. CNA A stated she doesn't look for the orders but knows they are in Point Click Care (PCC) (an electronic charting application). CNA A stated MD orders are needed because of chain of command., they know what is best for the resident and she must not do any care that is not ordered by MD. CNA A stated the risk of not having a doctor or nurse practitioner order is that the wrong care could be given and a lawsuit might occur. In an interview with RN A on 06/13/2024 at 3:46 PM, RN A stated physician orders should be reviewed before performing care with a resident and before informing the CNA of care needed. MD orders are found in Point Click Care (PCC) under the order tab. Nurses give verbal instructions to CNA's for the care needed from the MD orders. RN A stated orders come from physician, hospital orders, and hospital orders will be verified with the primary care doctor during initial admit process. RN A stated if there are no orders for a particular treatment, one must call that doctor and have a discussion about what is needed. Physician orders are needed because nurses are not allowed to prescribe and the doctor is higher in the chain of command and is knowledgeable about resident needs. RN #1 stated the risk of not having MD orders is possible harm to resident and/or lawsuit can occur. In an interview with CNA B 6/13/2024 at 4:02 PM CNA B stated that she did not review MD orders and gets her instruction for care from the nurse that observes the physician orders. CNA B stated she doesn't look for the orders but knows they are in Point Click Care (PCC). CNA B stated MD orders are needed to be able to perform care for the resident. CNA B stated the risk of not having a doctor order is no care or wrong care could be given to resident with harmful effects and a lawsuit might occur. In an interview with LVN A on 6/13/2024 at 4:11 PM LVN A stated physician orders should be reviewed when seeing resident for the first time, before performing care and when informing the CNA of care needed. MD orders are found in Point Click Care (PCC) under the order tab. Nurses give verbal instructions to CNA's for the care needed from the MD orders. LVN A stated if there are no orders for a particular treatment one must call that doctor and ask for orders. Physician orders are needed for safety of resident, continuity of care. LVN#1 stated the risk of not having MD orders is possible harm to resident. In an interview with the DON on 6/13/2024 at 4:24 PM, the DON stated physician orders should be reviewed daily before performing care and before informing the CNA of care needed. MD orders are found in Point Click Care (PCC) under the order tab. Nurses give verbal instructions to CNA's for the care needed from the MD orders. DON stated if there are no orders for a particular treatment one must call that doctor and request orders. Physician orders are needed because nurses are not allowed to prescribe. DON stated the risk of not having MD orders is possible harm to resident. DON stated the expectation going forward is all residents will have orders for all treatments and she will begin a review process to identify any residents without proper orders regarding care. In an interview with the Administrator on 6/13/20/24 at 4:36 PM, Administrator stated physician orders should be reviewed quickly. MD orders are found in Point Click Care (PCC) under the order tab. Administrator stated if there are no orders for a particular treatment the nurse should call that doctor and request orders. Physician orders are needed because they have a medical degree and that is how we operate. Administrator stated the risk of not having MD orders is not acceptable and possible harm could occur to resident. Administrator stated the expectation going forward is all residents will have orders for all treatments, and he will follow up with DON and ensure all residents have orders for treatments. Record review of facility's policy titled Medication and Treatment Orders, 2001 Med-Pass, Inc. (Revised July 2016) read in part Policy Statement Orders for medications and treatments will be consistent with principle of safe and effective order writing.

Based on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record of one (Resident #1) out of four residents reviewed for discharge requirements. The facility failed to ensure that Resident #1's medical record had physician documentation to address why the resident was being discharged and what needs of the resident the facility could not meet. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm. The findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] and was discharged on [DATE]. Her diagnoses included: metabolic encephalopathy (a problem with the brain d/t an underlying condition), altered mental status, muscle wasting, hypothyroidism (a condition in which the thyroid gland produces an insufficient amount of thyroid hormone, common symptoms include memory problems), dementia, depression, anxiety, HTN, heart disease, brain stroke, fracture of bones in the neck and cystitis (inflammation of the bladder). Record review of Resident #1's Admission MDS, dated [DATE] revealed the resident's speech was unclear, was rarely/never understood and rarely/never understood others. She did not wear hearing aids and her vision was adequate. She had short term and long-term memory problems. Her cognitive skills for daily decision making were severely impaired. She did not have behavioral symptoms. Functional status under Section G revealed ADL activities occurred only once or twice and the resident required one-person physical assist. Section GG, prior functioning: Everyday Activities revealed the resident was dependent on a helper to complete self-care and functional cognition. Section N, Medications revealed the resident received antipsychotic and antianxiety medications during the last two days. Record review of Resident #1's Discharge MDS, dated [DATE] revealed she had continuous inattention behavior. Record review of Resident #1's undated comprehensive care plan revealed, Focus - the resident had delirium or an acute confusion episode r/t Acute disease process, acute cystitis with metabolic encephalopathy, date initiated 05/19/2023. Goal - the resident will be free of s/sx of delirium (change in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Interventions included - reduce distractions. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate the resident/family/caregivers to observe for and report any s/sx of delirium. Focus - the resident uses anti-anxiety medications r/t anxiety disorder. Interventions included - administer anti-anxiety medications as ordered by the physician. Monitor/document/report PRN any adverse reactions: confusion, disorientation, impaired thinking, unexpected side effects: mania, hostility, rage, aggression, hallucinations. Monitor/record occurrence of target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) Focus - the resident used psychotropic medications r/t behavior management. Interventions included - administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness. Discuss with MD, family regarding ongoing need for use of medications. Review interventions and alternate therapies attempted. Record review of Resident #1's active orders as of 05/18/2023 revealed a verbal order dated 05/18/2023 to admit the resident to the facility under the care of the physician. Further review revealed the following orders: Hydromorphone HCL oral liquid 1mg/ml, give 1 ml by mouth every 4 hours as needed for pain; Lorazepam 1mg tablet, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days; Quetiapine Fumarate 100 mg, give 1 tablet by mouth at bedtime for antipsychotics; Risperidone 0.5 mg tablet, give 1 tablet by mouth two times a day for antipsychotics. Record review of Resident #1's Behavior Note dated 5/20/2023 at 6:48 AM created by LVN A read, Resident had been awake and screaming all night, PRN meds given but not effective. Resident attempted to get out of bed so was put on a wheelchair and [NAME] to the nursing station to be safe, did one on one the whole night. Record review of Resident #1's Communication with Physician note dated 05/20/2023 at 12:11 PM, created by the DON read in part: Situation: Increase agitation, insomnia, hallucination/delusion, banging of head at the nurses' station counter, screaming Get me out of the shower, mama! Background: Resident was admitted ,d+[DATE] with no behaviors noted as the resident was asleep from time of admission till 0715 .Had breakfast .During that time resident has been showing behaviors of agitation and anxiety and to trying to get out of bed. A noted increase in agitation and hallucination at sundown Assessment (RN)/Appearance (LPN): Day shift staff noted no changes in resident behavior Recommendations: Per PCP on call send resident to ER for psych evaluation . Record review of Resident #1's physician verbal order dated 05/20/2023 at 11:48 AM, revealed the description: Send to ER for psych evaluation and treat for Medication management, with no appropriate dx with behavior of insomnia, psychosis, hallucinations/delusions. Record review of Resident #1's Behavior Note dated 5/20/2023 at 12:21 PM, created by LVN B read, Patient was found on morning rounds at 0630 at nurses' desk with outgoing nurse in w/c 1:1 ongoing. Patient is agitated at this time with multiple attempts to stand from w/c. Patient also attempting to tilt w/c backwards, was medicated x1 per PRN orders and assisted to bed. Patient slept for a few minutes before waking up. All morning medications given. VS 114/76-65-18-97.8. Record review of Resident #1's Health Status note dated 5/20/2023 at 1:06 PM created by LVN B read, Patient transferred to Hospital ER for evaluation and treatment. Dx of AMS, delusional behavior and agitation. Report called to ER department. Patient departed on stretcher with two EMTs. Patient calling out and crying continuously in low voice and unable to console. Will answer to name only. F/C patent, respirations even and nonlabored. Record review of Resident #1's Communication with Family note dated 5/20/2023 at 2:31 PM created by the DON revealed the RP returned the call from DON. The RP was notified of Resident #1's behavior and the physician's order to send the resident to the ER. Record review of Resident #1's progress notes dated 05/18/2023 at 9:40 PM to 5/20/2023 at 4:05 PM revealed no evidence documented by the Physician to address the reason the resident was discharged , the needs of the resident the facility could not meet, the danger that failure to discharge would pose for the resident and the services available at the receiving facility to meet the needs of the resident. Further review of the electronic health records revealed no Physician Progress notes, no Transfer Summary and no Discharge Summary. During an interview with the Administrator and the DON on 9/19/2023 at 12:45 PM, the Administrator stated prior to Resident #1's admission the facility received the clinical paperwork and financial review. The Administrator stated yes, we were able to meet her needs. The Administrator stated the RP made promises to come and sign the admission paperwork but never showed up. The Administrator stated Resident #1 was psychiatric evaluation and we needed the right dx and pain management before accepting back. The Administrator stated the facility would have accepted the resident back only if the RP completed the paperwork and be available when needed. The Administrated stated technically Resident #1 was admitted to the facility and the RP gave a verbal OK to treat the resident. The Administrator stated the concern was the resident needed 1:1 sitter and the facility could not provide this. The DON stated the resident was no longer safe, she was banging her head. During an interview on 09/19/2023 at 3:35 PM, the DON stated the nurse in charge of the resident would be responsible to send a Discharge Summary. The DON stated for a transfer to hospital, the nurse would send the resident's face sheet, medication list, recent labs if any, history, and physical and physician orders to transfer. Resident #1 was sent to the hospital because the hospital had a psychiatric unit. During an interview on 09/19/2023 at 4:25 PM, the Administrator stated she did not notify the Ombudsman regarding Resident's emergency transfer/discharge to the hospital. The Administrator stated Ombudsman would be notified for a 30-day notice situation only. During a telephone interview on 9/20/2023 at 9:40 AM, LVN A who worked night shift stated Resident #1 was screaming out a family name, trying to get out of bed, banging her head. LVN A stated she was unsure exactly what [NAME] as banging her head on in her room. LVN A stated the bed was low. LVN A stated, we tried educating and redirecting her, but she did not understand. LVN A stated, she was really out of it, so we had to bring her to the nursing station. LVN A stated Resident #1 was banging her head at the nursing station counter. On 9/20/2023 at 10:45 AM, the Surveyor requested the following from the Administrator: Resident #1's Transfer Summary, Discharge Summary and the Physician letter/notes regarding the reason for Resident #1's discharge. During an interview on 9/20/2023 at 1:35 PM, the DON stated the RP called her the same day Resident #1 was transferred to the hospital and told her the resident was ready to return to the facility. The DON stated she contacted the ER and was told by the ER staff the resident was calm and asleep. The DON stated the following day the hospital case manager called and told the DON that Resident #1 was calm, not exhibiting behaviors and ready to return. The DON stated if the hospital sent clinicals containing information about what the hospital provided for Resident #1, the facility would have been able to determine if services could be provided and the resident would be accepted back. The DON stated there were no physician notes for Resident #1, only the Physician orders to send her to the ER and there was no Transfer Summary or Discharge Summary. During an interview on 09/20/2023 at 1:55 PM, the Administrator stated Resident #1 would have been permitted to return to the facility under the condition there was communication with the RP and part of not accepting her back was the resident's behavior also that 24 hours under psych care was not enough time to see changes. The Administrator stated if the resident was in Psych management for 3-5 days, then things would be different. During an interview on 09/21/2023 at 5:30 PM, Resident #1's RP stated Resident #1 was currently at another nursing facility. Record review of the facility policy titled Transfer or Discharge Notice, revised March 2021 read in part: Policy Statement - Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation .2. Residents are permitted to stay in the facility and not be transferred or discharged unless a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: .d. An immediate transfer or discharge is required by the resident's urgent medical needs .6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 7. Residents have the right to appeal a discharge, the facility will not discharge residents while the appeal is pending .8. The reasons for the transfer or discharge are documented in the resident's medical record 7. This policy applies to facility-initiated transfers, and not resident-initiated transfers. Further review of the policy revealed no physician required documentation in Resident #1's medical records. Record review of the facility policy titled Bed-Holds and Returns, revised March 2022, read in part: Policy Statement - Residents and /or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy Interpretation and Implementation .6. If the resident is transferred with the expectation that he or she will return, but it is determined that the resident cannot return, that the resident will be formally discharged . Record review of the facility policy titled Discharging the Resident, revised December 2016 read in part: Purpose - The purpose of this procedure is to provide guidelines for the discharge process. Preparation .6. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 3 residents (Resident #1) reviewed for pharmaceutical services. -The facility failed to accurately document the administration of the medication Hydromorphone solution 1mg, a medication used for pain, to Resident #1. This failure could place residents receiving medications at risk of inadequate therapeutic outcomes, uncontrolled pain, and uncontrolled anxiety. Findings included: Review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] and was discharged on [DATE]. Her diagnoses included: metabolic encephalopathy (a problem with the brain d/t an underlying condition), altered mental status, muscle wasting, hypothyroidism (a condition in which the thyroid gland produces an insufficient amount of thyroid hormone, common symptoms include memory problems), dementia, depression, anxiety, HTN, heart disease, brain stroke, fracture of bones in the neck and cystitis (inflammation of the bladder). Record review of Resident #1's Admission MDS, dated [DATE] revealed the resident's speech was unclear, was rarely/never understood and rarely/never understood others. She did not wear hearing aids and her vision was adequate. She had short term and long-term memory problems. Her cognitive skills for daily decision making were severely impaired. She did not have behavioral symptoms. Functional status under Section G revealed ADL activities occurred only once or twice and the resident required one-person physical assist. Section GG, prior functioning: Everyday Activities revealed the resident was dependent on a helper to complete self-care and functional cognition. Section N, Medications revealed the resident received antipsychotic, and antianxiety medications during the last two days since admission. The resident received opioid medications (used for pain) during the last day since admission. Record review of Resident #1's undated comprehensive care plan revealed, Focus - the resident had delirium or an acute confusional episode r/t Acute disease process, acute cystitis with metabolic encephalopathy, date initiated 05/19/2023. Goal - the resident will be free of s/sx of delirium (change in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Interventions included - reduce distractions. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated. Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Educate the resident/family/caregivers to observe for and report any s/sx of delirium. Focus - the resident uses anti-anxiety medications r/t anxiety disorder. Interventions included - administer anti-anxiety medications as ordered by the physician. Monitor/document/report PRN any adverse reactions: confusion, disorientation, impaired thinking, unexpected side effects: mania, hostility, rage, aggression, hallucinations. Monitor/record occurrence of target behavior symptoms (pacing, wandering, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) Focus - the resident used psychotropic medications r/t behavior management. Interventions included - administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness. Discuss with MD, family regarding ongoing need for use of medications. Review interventions and alternate therapies attempted. Record review of Resident #1's active orders as of 05/18/2023 revealed the following orders: Hydromorphone HCL oral liquid 1mg/ml, give 1 ml by mouth every 4 hours as needed for pain; Lorazepam 1mg tablet, give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days; Quetiapine Fumarate 100 mg, give 1 tablet by mouth at bedtime for antipsychotics; Risperidone 0.5 mg tablet, give 1 tablet by mouth two times a day for antipsychotics. Further review revealed the following orders: Anti-anxiety side effects monitoring: 0) No side effects noted 1) Hypotension 2) Sedation 3) Dizziness 4) Dry mouth 5) Blurred vision, 6) Urinary retention 7) Drowsiness 8) Slurred speech 9) Confusion 10) Fatigue 11) Nightmares 12) Appetite changes, every shift for Lorazepam. Anti-Psychotic Behavior monitoring: 0) No behaviors noted 1) Agitated 2) Angry 3) Compulsive 4) Pacing 5) Yelling 6) Danger to self or others 7) Fighting 8) Hallucinations 9) Insomnia 10) Nervousness 11) Mood changes 12) Uncooperative 13) Wandering 14) Refusal of care 15) Suicidal Ideation. Interventions: 0) None 1) Redirect 2) Change positions 3) Ambulate 4) 1 on 1 5) back rub. Outcome Codes: Improved (I) Same (S) Worsened (W): every shift for Quetiapine and Risperdal. Further review revealed no order to monitor for pain. Record review of Resident #1's May 2023 MAR revealed on 09/20/2023 at 7:05 AM, LVN B documented the administration of Hydromorphone HCL 1 ml, for a pain level of 10. LVN B documented the letter I for ineffective. On 09/20/2023 at 11:49 AM, LVN B documented the administration of Hydromorphone HCL 1 ml, for a pain level of 10. LVN B documented the letter I for ineffective. On 09/20/2023 at 7:06 AM, LVN B documented the administration of Lorazepam 1mg and documented the letter I for ineffective. On 09/20/2023 at 11:49 AM, LVN B documented the administration of Lorazepam 1mg and documented the letter I for ineffective. Further review revealed no documented administration of Hydromorphone on 09/19/2023 and no doses were documented as administered prior to 7:05 AM on 09/20/2023. Record review of the Controlled Drug Receipt/Record/Disposition Form for Resident #1 revealed LVN A signed out Hydromorphone solution 1ml, on 5/19/2023 at 11:00 PM and 5/20/2023 at 3:00AM. Record review of Resident #1's Behavior Note dated 5/20/2023 at 6:48 AM created by LVN A read, Resident had been awake and screaming all night, PRN meds given but not effective. Resident attempted to get out of bed so was put on a wheelchair and brought to the nursing station to be safe, did one on one the whole night. During a telephone interview on 9/20/2023 at 9:40 AM, LVN A who worked night shift stated Resident #1 was screaming out a family name, trying to get out of bed, banging her head. LVN A stated she was unsure exactly what she was banging her head on in her room. LVN A stated the bed was low. LVN A stated, we tried educating and redirecting her, but she did not understand. LVN A stated, she was really out of it, so we had to bring her to the nursing station. LVN A stated Resident #1 was banging her head at the nursing station counter. LVN A stated she did not remember if she gave any medications and that if she could see the chart she might remember. During an interview on 09/20/2023 at 4:45 PM, the DON stated the rule of thumb when administering narcotics is to check the PRN medication order and document the administration right away in the MAR. The DON stated this is what she expected the nurses to always do. The DON stated if the medication was given and documented, the system will have a red alert for the nurse to do a follow up on the effectiveness. The DON stated the nurse on night shift told her she was administering PRN medications at night for Resident #1. The DON stated the resident was screaming out in pain and needed the pain medication and not the Lorazepam. The DON stated PRN medications are given at the nurse's discretion. The DON stated, going forward she will conduct inservice again for proper documentation of PRN medications and that her expectation was that documentation on the narcotic sheet should be the right count and should match up with the MAR because when the physician looks at the medications for the resident, the physician would not review the narcotic sheet but would instead be reviewing the MAR. The DON stated if a PRN medication was not documented as administered, then the resident did not receive it and the physician may possibly discontinue the medication since the resident was no longer needing it. The DON stated if the PRN medication was discontinued and the resident was still needing it, the behaviors will start up again. During an interview on 09/20/2023 at 6:00 PM, the DON stated she was told by the night nurse that PRN medications were given to Resident #1. The DON did not state which PRN medications. The DON stated even with the medications that were given on 9/20/2023 on day shift, they were ineffective and Resident #1's behaviors remained unchanged. The DON stated, moving forward she would conduct a 2-week plan inservice. The DON stated she would check the narcotic sheets against the PRN medications to make sure the nursing staff do things correctly and this would be a verbal warning to the nursing staff. Record review of the facility staff inservice dated 05/08/2023 for Proper Medication Pass Procedure and Infection Control was conducted by the Pharmacist. Nursing staff signed the sheet. Further review revealed no signature by LVN A. Record review of the facility policy and procedure titled Administering Oral Medications, revised October 2010 read in part: Purpose - the purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation - 1. Verify that there is a physician's medication order for this procedure General Guidelines - Follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .9. b. For narcotics. Check the narcotic record for the previous drug count and compare with the supply on hand .Documentation - Follow documentation guidelines in the procedure entitled Documentation of Medications Administration .

Based on observations, interviews, and records reviewed, the facility failed to establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply for 1 of 1 facility. -The facility's emergency water supply consisted of 225 gallons (45, 5-gallon jugs) of water on hand for a census of 76 residents and 104 employees stored in a shed behind the building. This failure could place residents at serious risk for complications from dehydration and sanitation. Findings included: Observation of the emergency water supply on 03/23/2023 at 4:15 p.m. revealed there were 45, 5-gallons jugs of water for the emergency supply stored in the facility's shed located behind the building. During an interview on 03/24/2023 at 8:52 a.m., the Director of Food Services Manager (DFSM) said she had been the DFSM for about a year. She said they should have 1 gallon of water per person for 3 days (1 gallon of water x 3 days x (76 residents + 104 staff members=180 persons) = 540 gallons gallon of water) and currently had 45, 5-gallon jugs of water (225 gallons) on the premises. She said the facility probably needed about 679 total gallons of water for residents and staff. She said there was not an emergency water supply when she became the DFSM. She said due to budget constraints she could not order all the water at once. She said if there was a disaster, residents and staff would not get enough water. She said not having the required amount of water supply on hand could cause residents to get sick, become malnourished, and/or pass away. During an interview on 03/24/2023 at 3:40 p.m., the Administrator said she was responsible for ensuring the facility had the required amount of water as per regulation, and she had delegated the task to the DFSM. She said the facility should have 3 gallons of water per resident per day. She said she did not know how many gallons of water was on hand. She said if the facility needed more water, she would go to the store and buy more. She said residents would not be able to take their medications and/or stay hydrated if they did not have the required emergency water supply. Record review of the undated Emergency Preparedness Guidance from their local food vendor, read in part: 7. An emergency source of water needs to be identified. One gallon per person, per day, is essential and a minimum three-day supply should be on hand at all times. This includes residents, staff, families of residents, and families of staff who will be at the facility. Record review of the facility's Emergency Supplies Planning policy, revised August 2018, read in part: Supplies Assessment: 2. An adequate supply of emergency water .is maintained in appropriate quantities and in accordance with all applicable regulations to accommodate the needs of residents, staff members, and their family members for emergency situations requiring evacuation or sheltering in place. Sealed Emergency Water Supply: 1. The facility maintains a minimum of 1 gallon of sealed emergency water per person for three days. This is the minimum amount designated for personal use/consumption and not for the essential functions of the facility. 2. The emergency water needs for personal consumption are calculated using the following equation: Calculation: (gallons) x (days) x (people) = gallons needed Gallons of water per person = 1 (recommended) Numbers of days = 3 recommended Number of people (staff + residents) = ____ Example: 1 (gallons) x 3 (days) x 200 (people) = 600 gallons needed.

Based on interviews and records reviewed, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 (Director of Food Services Manager, Housekeeping Manager, Certified Nurse Assistant M (CNA M), and Certified Nurse Assistant O (CNA O)) of 17 employees reviewed for employee misconduct registry (EMR)/nurse aide registry (NAR). -The facility failed to check the EMR/NAR annually for 4 of 17 employees. This failure could place residents at an increased risk of abuse, neglect, exploitation, and/or misappropriation of property. The findings included: Record review of facility's undated Employee Chart Check revealed a hire date of 01/18/2021 and an EMR/NAR check date of 01/08/2021 for the Director of Food Services Manager. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 01/08/2021. Record review of facility's undated Employee Chart Check revealed a hire date of 10/01/2020 and an EMR/NAR check date of 04/15/2020 for the Housekeeping Director. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 04/15/2020. Record review of facility's undated Employee Chart Check revealed a hire date of 10/01/2020 and an EMR/NAR check date of 02/27/2020 for CNA M. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 02/27/2020. Record review of facility's undated Employee Chart Check revealed a hire date of 12/24/2021 and an EMR/NAR check date of 12/23/2021 for CNA O. Further record review of staff's personnel file revealed an EMR/NAR printout with a run date of 12/23/2021. During an interview on 03/24/2023 at 2:25 p.m., the Human Resources Manager (HRM) said she had been working at the facility since June 2013. She said she was responsible for running the EMR/NAR checks. She said per Federal and state regulations they were only required to be checked before hire. She said she did not run them at any other time. She said she received regulation training on when to run EMR/NAR checks from her corporate human resources office. She said she was instructed by the facility to run them annually. During an interview on 03/24/2023 at 3:40 p.m., the Administrator said the HRM was responsible for running the EMR/NAR checks. She said per regulations, the checks should be run before hire and upon the employee's anniversary date. She said the facility has an audit tool they utilize to ensure the EMR/NAR are being checked annually. She said she was not aware that all employees' checks had not been run annually. She said the facility's corporate human resources director sent out a memo, around November or December 2022, informing the facility that it was time to run annual background checks. She said not running the EMR/NAR checks annually could place residents at risk for abuse, neglect, and/or misappropriation of property. Record review of Annual Background Checks memo dated 11/28/2022 from the facility's corporate human resources director, read in part: It's that time of the year where we need to run our annual background checks for staff to stay in compliance. Record review of the facility's Abuse Policy dated 10/01/202, read in part: Policy It is the policy of [facility name] to prohibit resident or patient abuse or neglect in any form . The Executive Director is designated the Abuse Coordinator for [facility name]. Procedure 1. Screening: a. Pre-employment screening will be completed on all employees, to include: Professional licensure, certification, or registry check as applicable (pre-hire and annually) Employee Misconduct Registry (EMR)- pre-hire and annually.

Based on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #22) reviewed for beneficiary notices. The facility failed to give Resident #22 a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when she was discharged from skilled services at the facility before her covered days were exhausted. This failure could place residents at risk of not being fully informed about services covered by Medicare. Findings included: Record review of Resident #22's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's disease with late onset, heart disease, chronic kidney disease, and anxiety. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed she started occupational therapy on 11/22/22 and ended it on 12/21/22. Record review of Resident #22's Order Summary Report for March 2023 revealed an order to discontinue skilled OT on 12/21/22, order date 12/22/22. Record review of Resident #22's SNF Beneficiary Protection Notification completed by the facility revealed she started Medicare Part A skilled services on 12/1/22 and the last covered day of part A service was on 12/21/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted and noted that a SNF ABN, Form CMS-10055 was not issued to the resident when it should have been. In an interview on 3/23/23 at 4:04 p.m. the Business Office Manager said she was new to the facility and was not aware that issuing ABNs was her responsibility unit 1/11/23. She said the purpose of the ABN was to notify the residents of charges they could be responsible for once they went past their Medicare stay. She said the ABN provided the resident with estimated cost of services after the last covered day. She said Resident #22 was supposed to receive an ABN because she remained in the facility for long term care. In an interview on 3/24/23 at 2:14 p.m. the Administrator said the Business Office Manager became responsible for issuing the ABNs around November or December of 2022. She said she expected the BOM to issue the ABN to the resident. Record review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated September 2022 read in part, .Residents are informed in advance when changes will occur to their bills . Skilled Nursing Facility Advance Beneficiary Notice (CMSS form 10055) 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service, the resident (or representative) is notified in writing why the service may not be covered and of the resident's potential liability for payment of the non-covered service. 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice for the following triggering events: .b. Reduction . C. Termination . 4. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility .

Based on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for oxygen therapy for 6 of 18 residents (Residents CR#1, #71, #51, #34, #81, and #64 reviewed for respiratory care. -The facility provided CR#1 oxygen therapy without a physician's order; failed to regularly assess CR #1's condition; CR #1 went to the hospital and immediately required [MEDICAL CONDITION] (bilevel positive airway pressure). -The facility failed to administer Resident #71, #51, #34, and #64 oxygen as ordered by the Physician. - The facility administered oxygen to Resident #81 without a physician's order. This deficient practice could affect residents requiring oxygen therapy. Findings include: CR #1 Record review of CR #1 face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. CR#1's face sheet photo revealed she had nasal cannula prongs positioned in her nose. Record review of CR #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed her Brief Interview for Mental Status (BIMS) was scored 12 out of 15 indicating she had moderately impaired cognitive skills. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She was always incontinent of bowel and bladder. CR #1 had an active [DIAGNOSES REDACTED]. Record review of CR #1's Care Plan with a start date of 01/09/2020 revealed: Care Plan Description: CR#1 was receiving oxygen therapy. Interventions included: Provide with humidification, ensure that supply is available at all times and administer oxygen therapy as ordered. Record review of CR #1's consolidated Physician Orders for (MONTH) 2020 revealed no orders for Oxygen administration, Oxygen concentrator or orders to wean off Oxygen. Record review of CR #1's Nursing Departmental Notes revealed the following entries in part: -01/02/2020 at 3:16 p.m. documented by LVN T. CR #1 had 2L/m of oxygen via nasal cannula; oxygen saturation rate (O2 Sat) 97%. There were no nursing notes regarding contacting the resident's primary care physician to verify admitting orders. -01/05/2020 at 10:37 a.m. documented by LVN S. CR #1 had 2L/m of oxygen via nasal cannula. -01/07/2020 at 10:24 a.m., documented by LVN T. CR #1 had 2L/m oxygen via nasal cannula, O2 Sat 94%. -01/09/2020 at 4:37 p.m., documented by LVN M. CR #1 was currently weaning off of oxygen, with oxygen sats 86-88%, with O2 sats 93-94%, no signs of distress. -01/11/2020 at 2:24 a.m. documented by LVN KS. CR #1 had Oxygen on at this time. -01/11/2020 at 9:31 a.m. documented by LVN T. CR #1, resident was on 2L/m, nasal cannula, O2 sat 92%. -01/11/2020 at 10:47 p.m., documented by LVN [MI] CR #1 was complaining of not feeling well. Resident's O2 Sat was 41% with 2L/m of oxygen via nasal cannula. A second O2 Sat monitor read 43%. 911 was called and resident was transported to hospital. Record review of a National Institutes of Health article dated (MONTH) (YEAR) revealed: .There is no clear cut-off point for abnormal oxygen saturation, but (oxygen saturation) of <=95% is used in most adult studies in [MEDICAL CONDITIONS] patients (oxygen saturation) cut-off value of <=92% is used when screening for [MEDICAL CONDITION] in [MEDICAL CONDITION] patients. In emergency medicine, low (oxygen saturation) has been shown to be associated with increased mortality . Record review of CR #1's History and Physical Report dated 01/03/2020, office visit with MD #1 revealed in part .Impression still on 3L/m nasal cannula (NC) O2, will wean off Oxygen in time. Medication history list did not include orders for Oxygen. Record review of Physician Consult notes dated 01/07/2020 titled Evaluation and Management Form revealed in part .O2 Sat 95%, 2L nasal cannula. Record review of CR #1's, History and Physical Report dated 01/08/2020, office visit with MD#1 revealed in part .impression: off oxygen for past 20 hours. Medication History reconciliation does not include orders for Oxygen. Record review of CR #1's, facility written statement from LVN L dated 01/15/2020 revealed in part the O2 concentrator was beeping in the Resident's room. Went into room and turned O2 concentrator off and was wondering why resident was on O2 Record review CR #1's, facility written statement from CNA #4, not dated, revealed in part .at 7:15 p.m. I heard a peep in room [ROOM NUMBER]. I went into the room it was the oxygen concentrator beeping. I went and notified LVN L at this time. Record review of CR #1's Hospital Medical Records with admitted [DATE] at 10:22 p.m., revealed in part XXX[AGE] year old female .presents to the emergency department via EMS from the facility for evaluation of sudden respiratory distress. She required [MEDICAL CONDITION] when she presented to the hospital. Per EMS personnel, the facility staff called 911 when patient complained of shortness of breath and Sp O2 was 70% or room air Admission [DIAGNOSES REDACTED]. 01/1/2020 Arterial blood gas labs revealed p O2, arterial value 69 (low). Reference Range 83-108 mmHg. Chest X-ray revealed no evidence of acute [MEDICAL CONDITION] embolism, extensive infiltrates and pneumonia and small pleural effusions. Resident was discharged on [DATE] to a different nursing facility. In an interview on 01/31/2020 at 10:52 a.m., CR #1's Primary Physician said he saw her on 01/03/2020, I don't have to answer any of your questions, it is the law, unless I have written permission from CR #1. In a telephone interview on 01/31/2020 at 1:28 p.m., LVN T said she did not remember CR #1. She said if she wrote that she gave Oxygen 2L/m in her notes then that was what happened. She said when she received an admitting resident, she usually reviewed the discharge orders with the physician by calling. If physician was in the facility she would verify the orders in person. She said she would document that she did this in the nurse notes. In an interview on 01/31/2020 at 4:49 p.m., the DON said she never met CR #1, but she did speak with the family member about not having an order for [REDACTED].#1 was doing well without the Oxygen. The DON said she told the family member that CR #1 left the facility not in distress. The DON said she expected the admitting nurse to complete the admission packet and the unit manager to do an admission audit the next day after admission. She said it was ok for a nurse to put resident on Oxygen if the resident experienced Respiratory distress. Then to contact the doctor immediately to get an order. She asked another staff to see if they had CR #1's admission packet. No admission packet was received by exit on 01/31/2020. Resident #71 Record review of Resident #71's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #71's Quarterly MDS assessment dated [DATE] revealed her BIMS was scored 7 of 15 to indicate severe cognitive impairment. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. She was occasionally incontinent of bowel and bladder and was on a toileting program. She had an active [DIAGNOSES REDACTED]. Record review of Resident #71's care plan dated 11/16/2019 revealed a care plan description: Resident #71 had breathing patterns ineffective related to [MEDICAL CONDITION], shortness of breath or trouble breathing with exertion. Interventions included: Monitor oxygen saturation levels and administer oxygen therapy as ordered. Care plan description: Resident #71 required oxygen therapy via NC and was capable of removing the nasal cannula, Interventions included: Ensure that supply was available at all times. Administer oxygen therapy as ordered. Record review of Resident #71's consolidated Physician Orders for (MONTH) 2020 revealed Oxygen at 2L/m via nasal cannula continuous with a start date of 11/08/2016. Record review of Resident #71's Nurse Administration Record for the month of (MONTH) 2020 revealed on 01/28/2020 at 1:00 p.m. it was documented she was receiving continuous oxygen at 2L/m via NC. In an observation on 01/28/2020 at 11:00 AM, Resident #71 was asleep in her wheel chair (w/c). There was a small O2 tank on back of w/c. Oxygen was set at 1.5 L/m via nasal cannula prongs positioned in her nose. In an observation and interview on 01/28/2020 at 12:40 PM Resident #71 was in hallway seated in w/c. The NC tubing was on the seat of the w/c. Resident #71 said she did not know how it got there. The Oxygen was set at 1.5 L/m. In an observation on 01/28/2020 at 1:00 PM Resident #71 was in her room with a female aide. The nasal cannula was not positioned in her nose. In an observation and interview on 01/28/2020 at 1:35 PM, CNA#3 assisted Resident #71 from the bathroom. Resident #71 had NC positioned in her nose. CNA #3 said she had just put it on her. She said the setting was on 2 L/m. Surveyor observed the dial was at 1.5 L/m. CNA moved the dial from 1.5 L to 2L. She said CNAs could put the oxygen tubing on and set the oxygen tank. In an interview on 01/28/2020 at 1:45 PM, LVN SK said Resident #71's oxygen was supposed to be set at 2 L/m and was supposed to be continuous. He said nurses were responsible to put the oxygen cannula on the resident and set the meter. He said CNAs were not supposed to set the meter. Resident #51 Record review of Resident #51's face sheet revealed a [AGE] year old female admitted to the facility on [DATE], no initial admitted on face sheet. Her [DIAGNOSES REDACTED]. Record review of Resident #51's quarterly MDS dated [DATE] revealed she had a BIMS scored 3 out of 15 indicating severe cognitive impairment. She required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. She was frequently incontinent of urine and bowel. She had active [DIAGNOSES REDACTED]. She received respiratory treatments of Oxygen therapy. Record review of Resident #51's Care Plan with a start date of 09/24/2019 revealed a care plan description of Resident #51 was receiving oxygen therapy as ordered by her physician for shortness of breath/decreased oxygen saturation. Interventions included ensure supply is available at all times and administer oxygen therapy as ordered. Record review of Resident #51's consolidated Physician Orders for the month of (MONTH) 2020 revealed an order to administer oxygen at 2 L/m via nasal cannula (NC) continuously for [MEDICAL CONDITION]. Record review of Resident #51's Nurse Administration Record for (MONTH) 2020 revealed documentation that Oxygen 2 L/m via NC continuously had a start date of 10/19/19. In an observation and interview on 01/29/2020 at 11:50 AM in the dining room, Resident #51 had Oxygen via NC. The tank dial was set at 2.5 L/m, she said she could feel the Oxygen in her nose. She said she needed O2 because for wheezing. Resident #51 said she had a concentrator in her room that she used at night. In an observation on 01/29/2020 at 12:40 PM, two Surveyors confirmed that the oxygen dial for Resident #51's tank was pointing closer to 2.5 L/m and not 2 L/m. Record review of Resident #51's Nurse Administration Record for the month of (MONTH) 2020 revealed on 01/29/2020 at 1:00 PM Resident #51 was receiving Oxygen 2 L/m via NC continuously. The administration was documented by LVN [NAME] In an observation and interview on 01/29/2020 at 4:17 PM, Resident #51 was in bed with O2 concentrator set at 2 L/m. The Oxygen tank on the back of wheel chair was still on and dial was set at 2.5 L/m. LVN A said she came in today at 6 AM and put Resident #51 on the portable O2. She said she checked it at noon to make sure the tank had Oxygen and said it was at 2 [MI] She said Resident #51 was supposed to receive 2 L/m. She said she did not know why it would have been set at 2.5 L/m and not 2L/m, it could have been moved by accident. In an interview on 01/29/2020 at 2:53 PM, the DON said the nurses were responsible to make sure NC was properly positioned and Oxygen was set correctly according to the physician orders. She said Oxygen settings should be checked once each 12-hour shift; this order was verified by the doctors today. Resident #34 Record review of Resident #34's face sheet revealed she was admitted to the facility on [DATE]. The resident was [AGE] years old. Her admission [DIAGNOSES REDACTED]. Record review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) that was not able to be scored. Resident #34 was totally dependent on two staff for her bed mobility and transfer. The resident required extensive assistance of one staff for her toilet use and extensive assistance of two staff for her dressing and personal hygiene. She was frequently incontinent of bowel and bladder. Resident #34's had active [DIAGNOSES REDACTED]. She received oxygen therapy. Record review of Resident #34's care plans start dated 09/16/2019 revealed the care plan: Titled: Resident receiving oxygen therapy Goal: Resident will not exhibit shortness of breath Interventions: Administer oxygen therapy as ordered Record review of Resident #34's physician's orders dated (MONTH) 2020 revealed, Administer oxygen at 2 liters/minute via nasal cannula continuously. Order start date 5/18/19 In an observation on 01/28/2020 at 9:20 AM revealed Resident #34 in her room sitting in her wheelchair. Resident #34 had an oxygen nasal cannula in position in her nose. There was a portable oxygen tank on the back of her wheelchair. The oxygen dial was pointed in the off position. The oxygen power light was not light. An attempt to interview the resident at this time revealed she was not able to be interviewed. The resident only smiled and said okay when spoke too. In an observation on 01/28/2020 at 9:35 AM revealed Resident #34's oxygen was in the off position. The resident had a nasal cannula positioned in her nose. In an interview and record review on 01/28/2020 at 9:39 AM LVN R reviewed Resident #34's physician's orders and stated her oxygen was ordered for 2 liters continually. In an observation and interview on 01/28/2020 at 9:43 AM, LVN R observed the resident's oxygen tank and stated it was turned off. LVN R stated he did not know why it was off or for how long. He stated perhaps when she was put in her chair, facility staff forgot to turn on the portable tank. LVN R assessed the resident's oxygen saturation level immediately after starting the oxygen it was 94%, 96% than 97%. In an interview on 01/28/20 at 2:02 PM, the DON stated the nurses made rounds at least every 2 hours and as needed the nurses need to check the oxygen liters to make sure they were as ordered. The nurses were responsible for the oxygen administration. In an observation on 01/29/2020 at 9:40 AM revealed Resident #34 sitting in her wheelchair in her room with her oxygen nasal cannula in her nose. There was a portable oxygen tank on the back of her wheelchair with the dial in the off position. The oxygen power light was off. The resident was unable to be interviewed. In an observation on 01/29/20 at 9:50 AM Resident #34's oxygen tank was in the off position. In an observation and interview on 01/29/2020 at 9:57 AM LVN K came to Resident #34's room. LVN K observed the oxygen tank and stated the oxygen was turned off and she did not know why or for how long. LVN K stated perhaps when the resident was put in her chair the dial was accidentally turned off. In an observation and interview on 1/29/2020 at 9:58 AM the DON entered Resident 34's room and observed the oxygen. The DON stated the oxygen was off. She did not know how because she looked at it earlier this morning and it was on. The DON said it was not an acceptable practice for the oxygen to be in the off position. In an interview with the DON on 1/29/2020 at 2:48 PM, the DON stated she has been checking with the physicians on how often they expect the nurses to check the residents' oxygen. The physicians were telling her that the nurses were to check once every 12-hour shift. Resident #81 Record review of Resident #81's face sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #81's hospital discharge summary dated 1/6/20 revealed she used oxygen set at 2 LPM at home. Record review of Resident #81's admission MDS (Minimum Data Set) assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 12 of 15, indicating moderately impaired cognitive functioning. She was able to make herself understood and understand others. She required extensive assistance with bed mobility from two staff members. She required extensive assistance with one staff member in transferring, dressing, toileting, and personal hygiene. She used a walker and wheelchair. Resident #81 had active [DIAGNOSES REDACTED]. She required oxygen therapy. Record review of Resident #81's baseline care plan dated 1/7/20 revealed she required oxygen via nasal cannula at 2 LPM (Liters Per Minute). Record review of Resident #81's comprehensive care plan with a start date of 1/16/20 revealed a care plan for oxygen therapy. Record review of Resident #81's physician orders for (MONTH) 2020 revealed she did not have orders for oxygen. In an observation and interview of Resident #81 on 1/28/20 at 10:09 a.m., revealed she was sitting upright in a wheelchair. She was wearing a nasal cannula that was connected to an oxygen concentrator that was set at 3.5 LPM. She said she was doing okay but felt tired and uncomfortable. In an interview and observation on 1/29/20 at 10:13 a.m., LVN S said Resident #81 used oxygen continuously at 2 LPM. When asked to check physician orders for oxygen, LVN S went into her electronic medical records and said Resident #81 did not have orders for oxygen. In an interview with the DON on 1/29/20 at 12:50 p.m., the surveyor asked the DON if Resident #81 had orders for oxygen. She went into her electronic medical records. The DON said Resident #81 did not have orders for oxygen. She said admitting nurses were responsible for contacting the doctor, consolidating, and ensuring admitting residents have all the orders entered in the computer. She said if a resident was transferred from a hospital, the admitting nurse would read the hospital discharge summary; contact the doctor to verify the orders; and enter the orders in the computer. In an interview on 1/29/20 at 2:28 p.m., the DON said nurses were responsible for setting and checking oxygen levels. Resident #64 Record review of Resident #64's face sheet revealed a [AGE] year-old male re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #64's admission MDS (Minimum Data Set) assessment dated [DATE] revealed his BIMS (Brief Interview for Mental Status) was unscored. He had severely impaired cognitive skills for daily decision making. He rarely made himself understood and at times he could understand others. He required extensive assistance from two staff members in bed mobility, transferring, dressing, and toileting. He required extensive assistance from one staff member in eating and personal hygiene. He had impairment to his upper and lower extremity on one side. Resident #64 required oxygen therapy, suctioning, and [MEDICAL CONDITION] care. Record review of Resident #64's comprehensive care plan with a start date of 1/13/20 revealed a care plan for oxygen therapy at 3 LPM [MEDICAL CONDITION]. Record review of Resident #64's consolidated physician orders for (MONTH) 2020 revealed an order for [REDACTED]. In an observation and attempted interview with Resident #64 on 1/29/20 at 11:20 a.m., he was lying in bed. He was nonverbal and periodically responded by nodding or shaking his head. He had [MEDICAL CONDITION] with a tube that was connected to the oxygen concentrator. His oxygen was set to 4 LPM. In an interview and observation on 1/29/20 at 11:20 a.m., LVN S said Resident #64 was on continuous oxygen at 3 LPM. LVN S went into Resident #64's electronic medical record. He said Resident #64 had orders for oxygen at 3 LPM. The Surveyor and LVN S went into the Resident #64's room. The Surveyor asked LVN S to look at the resident's oxygen concentrator. He said Resident #64's oxygen was set at 4 LPM. He turned down the setting to 3 LPM. He said he did not know why it was at 4 LPM. He said he does not know who last checked Resident #64's oxygen settings. In an interview on 1/29/20 at 2:28 p.m., the DON said nurses were responsible for setting and checking oxygen levels. Record review of facility policy titled Oxygen Administration, 2001 MED-PASS, Inc.(Revised (MONTH) 2010) revealed in part .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . Steps in the Procedure .5. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute .

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #1) reviewed for abuse, in that: CNA A was observed on video forcefully turning and repositioning Resident #1 while in bed despite the resident telling her to stop. This resulted in Resident #1 crying out in pain and telling CNA A she was being rough and hurting. CNA A was not provided supervision and staff to assist with ADL care when she provided one person ADL care to Resident #1 who required two person ADL care. CNA A verbally threatened Resident #1. These failures affected one resident and placed her at risk of abuse that could cause a decline in her quality of life, diminished self-esteem, pain, and injury. Findings Include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to to the hospital on [DATE] for chest pain. Record review of Resident #1's care plan dated 8/1/19 revealed: -Title: Resident #1 requires assistance for all Activities of Daily Living (ADLs'). -Interventions: Resident #1 requires two person assist for all ADLs' Record review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated , 9/5/19 revealed Section B identified the resident usually makes herself understood and sometimes understands others. She had a Brief Interview for Mental Status (BIMS) score of 99, indicating her cognitive skills were unable to be assessed due to she could not answer the questions. The staff assessment of Resident #1's cognitive skills for daily decision making were moderately impaired which indicated decisions poor; cues/supervision required. Resident #1 required extensive assist of two persons for bed mobility and extensive assistance from one person for dressing, eating, toilet use, and personal hygiene. Resident #1 had functional limitations in range of motion to her bilateral upper extremities. The resident was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 10/3/19 revealed: -Titled: Resident #1 was at risk for psychosocial decline secondary to allegation of verbal and physical abuse. - Goal: Resident #1 will feel safe in current environment with any changes in psychosocial mood being identified and addressed by facility staff. -Interventions: Evaluate Resident #1 for changes in psychosocial mood and address as indicated; -Initiate 1:1 sitter for resident to provide emotional support and continuous supervision; -Implement video surveillance in resident room for 24-hour supervision. Observation of video dated 10/1/19 starting at approximately 9:35 PM revealed CNA A in Resident #1's room to provide incontinent care. CNA A was alone providing care and was observed to push the resident on to her side. The resident cried out to stop snatching on her like that it hurt her. During the observation of the incontinent care Resident #1's leg was seen to fly up in the air toward the ceiling. The resident was heard crying out for the aide to stop because she was being too rough. Resident #1 was heard telling CNA A to stop digging her nails into her. Resident #1 had a bowel movement. The aide told the resident if she spit on her again she was going to put this in her mouth. The resident asked, did you stick that in my mouth? CNA A said she did, Resident #1 was heard telling the CNA you put that mess in my mouth and the CNA replied she sure did. The observation of the video was completed on 10/4/19 at 5 p.m. Record review of the facility's interview of CNA A dated 10/3/19 revealed it read, On 10/1/19 CNA A worked with Resident #1. Around 7:30 and 8:30 PM, went to do rounds. Resident #1 was awake. Resident #1 had a large BM (bowel movement). CNA A began to change her brief; Resident #1 was ok with CNA A changing her brief. CNA A said that Resident #1 was pleasantly confused, but began to get combative and verbally aggressive. CNA A told Resident #1, you should be ashamed of yourself, I'm just here to help you. CNA A understood that she was unprofessional in saying this. CNA A said she never lifted Resident #1's leg toward the ceiling and she did not stop to get help. CNA A said that Resident #1 never complained about pain and she never put anything in Resident #1's mouth. She told Resident #1 that she would report Resident #1 for hitting her. CNA A said she never cursed at the resident. CNA A said she never reported the incident to a nurse. Around 9:30 p.m., she checked on Resident #1 and she was asleep; she did not check her brief at that time. In an interview on 10/5/19 at 8:34 AM, CNA C said that she would report if she heard or thought there was something going on with a resident to the Administrator. She is the abuse (prevention) coordinator. They told us if a resident has a change in her normal mood-like crying, yelling, marks or anything different, for the resident, report it. In an interview on 10/5/19 at 8:45 AM, LVN A said that they are told if they experience or even suspect abuse, then they must report it immediately to the Administrator. Observation and interview on 10/5/19 at 11:40 AM revealed Resident #1 on her side. She had a contracture to her right hand. The resident stated there were some good people and some bad people. The resident did not recall anyone abusing her, but she stated there was an evil black girl. The resident did not state why she felt she was evil. In an interview on 10/5/19 at 12:40 PM the Administrator stated she was called at approximately 3:30 AM on 10/3/19 regarding Resident #1's family member coming to the facility because she saw a video of her mother being abused by a CN[NAME] She stated during the interview with the resident on 10/3/19 the resident remembered an aide in her room and put something in her mouth. She stated the aide was black, had braids, and glasses. The Administrator said, this is really bad. She said CNA A gave a statement prior to knowing we saw the video and she denied it. The police went in the room to talk to the resident we began our investigation and report for the state. Record review of the facility investigation report dated 10/3/19 revealed the findings were confirmed and CNA A was no longer employed with the facility. In a telephone interview on 10/6/19 at 10:30 AM with local law enforcement she stated she visited the resident when the call came in and the resident did not know anything happened. She said the resident did not remember anything. The Adult Crimes Unit was completing the investigation. In an interview on 10/10/19 at 3:45 PM the DON stated she only saw a clip of the video. The DON stated she saw CNA A providing care to Resident #1. She said Resident #1 was yelling when being repositioned, and saying you are hurting me, you are being rough with me. She said CNA A said if you spit on me again I am going to put this in your mouth. She said the resident stated, did you stick that in my mouth? CNA A said she did. The DON said no one knew what was put in Resident #1's mouth but, the assumption was, it was feces. She said they often told staff this (the facility) was the resident's home and to explain to the resident what they were going to do. The staff were to notify the charge nurse if the resident was refusing. Staff were to stop care if a resident was hurting or in pain, and ask them where the pain was, stop, and slow down. If that was still unsuccessful, stop care, ensure they were safe, notify charge nurse, and attempt at a later time. In a telephone interview on 10/10/19 at 4:55 PM CNA A stated she was not to talk to anyone. She stated she was advised not to discuss it. She stated she did write a statement and she did not put anything in the resident's mouth and she was just being sarcastic. Record review of the facility policy titled Abuse Prevention Policy dated (MONTH) (YEAR) read in part, .Policy . The facility will do all that it can within its control to prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all resident through the implementation of seven components: Screening, Training, Prevention, Indentation, Investigation, Protection and Reporting. Abuse is the willful infliction of injury, reasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Purpose . To ensure that the facility was doing all that was within its control to prevent occurrences of abuse, neglect, involuntary seclusion and misappropriation of property for all customer. To treat all residents at the facility with dignity and respect at all times.

Based on observation, interviews and record reviews. the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive plan of care for 1 of 12 residents reviewed, (CR #1) for quality of care. The facility failed to ensure that CR#1 was assessed after demonstrating a change in condition resulting in CR #1 being sent to the local hospital emergency room with [DIAGNOSES REDACTED]. This failure affected 1 discharged resident and placed her at risk of harm due to not receiving appropriate care and treatment. Findings include: Record review of the clinical chart for CR #1 revealed the [AGE] year-old resident was admitted to the facility on [DATE]. Her history included a total hip arthroplasty that became infected and required removal, persistent fevers, drainage and chills. Additional [DIAGNOSES REDACTED]. CR #1 was sent to the local hospital on [DATE]. Record review of the sign in sheet for Saturday 6/8/19 revealed the following staff were assigned to CR #1's hall: RN A 6:30 AM to 6:30 PM, CNA C from 6:30 AM to 2:30 PM, LVN B from 6:30 PM to 6:30 AM, (overnight), CNA G 2:30 PM to 10:30 PM. Record review of nursing notes for CR#1 revealed the only entry for 6/8/19 at 2:21 AM read, Resident continues on IV ABT [MEDICATION NAME] without incident. No adverse reactions noted at this time. IV site CDI Will continue to monitor. There was no name by the note indicating the author of the nursing entry. There was no documentation that CR #1 had been assessed on 6/8/19. There was no documentation to indicate if CR #1 had voided that day. Record review of the facility's 24 hour report for 6/8/19 revealed no mention of the change in condition experienced by CR #1 on 6/8/19. Record Review of the hospital records from where CR #1 was transferred on 6/8/19 read in part, .Pt is an 82 y/o female with pmhx of DM presenting to the ED via EMS due to AMS that started earlier today. EMS states that nursing home states that pt was altered at around 1700 (5:00pm) but family states they saw that pt was altered around 1500 (3:00pm) .EMS states that they don't think pt was receivng the necessary antibiotics at the nursing home she was at because they noticed that the IV was dripping antibiotics on her skin .tpa not indicated as onset of symptoms likely 12 hours ago or more. Record Review of CR #1's labs from the hospital where the resident was transferred on 6/8/19 revealed CR #1 had a BUN of 70 High. The normal value read, BUN 7-18 mg/dl. The review also revealed CR #1 had a [MEDICATION NAME] level of 3.73 High. The normal value was listed as 0.60-1.30mg/dl. The review also revealed the urine WBC count was >100 H and the normal range listed as 0-3/HPF. Record Review of CR #1's hospital records dated 6/8/19 entitled, admitting [DIAGNOSES REDACTED]. 2. New-onset acut kidney injury, possibly contributing or causing the acute [MEDICAL CONDITION]. 3. Dislocated left hip prosthesis. 3. Severe urinary bladder distention/retention with moderate bilateral hydro[DIAGNOSES REDACTED]. Record Review of CR #1's hospital records entitled, History of Present Illness: read in part, Nurse Practitioner was rounding last night and found the patient to be encephalopathic. This is a new finding for her. She was transferred emergently to the hospital where she was found to be in acute [MEDICAL CONDITION], which is a new finding for her an also had evidence of hip prosthesis dislocation. The patient is very confused, was evaluated by orthopedics and they took her this morning to the operating room to fix the hip. She also has broad-spectrum antibiotics. She has been pancultured. We will follow up on those and provide supportive care. She was initially found to have a urinary tract infection and severe [MEDICAL CONDITION] causing bilateral [DIAGNOSES REDACTED] Record Review of CR #1's hospital records dated 6/9/19 from a consultant physician read in part, History of Present Illness: The patient is an [AGE] year-old female, who was admitted last night from a rehab facility due to swelling in her lower pelvic area .Pain is localized to the bladder area as well as the hip area .family is unsure for how long the hip has been in pain for. She was not able to ambulate in the rehabilitation from what was relayed to me from the family Record review of hospital records for CR #1 stated the resident arrived at 2052 (8:52pm) on 6/8/19. The section of the hospital records entitled, Clinical Impression read in part, Primary Impression: Acute [MEDICAL CONDITION] Secondary Impressions: Acute [MEDICAL CONDITION], altered mental status, [MEDICAL CONDITION], Left heel pressure wound, Urinary Tract Infection, Weakness .tpa not indicated as onset of symptoms likely 12 hours ago or more ASSESSMENT AND PLAN: 1. Acute encephalapothy, unclear etiology, possibly toxic metabolic, may be related to kidney failure plus urinary tract infection. Treat both and monitor her progress. Consult nephrology.2. Acute kidney injury. New for her. Avoid nephrotoxic medications. Hydrate the patient. Treat the urinary tract infection. Relieve the hydro[DIAGNOSES REDACTED] with a foley catheter and consult nephrology. (MONTH) need a urinary consult. 3. Acute left prothesis dislocation. The patient taken to the operating room by orthopedic surgery for [REDACTED]. Acute [MEDICAL CONDITION] with bilateral hydronephross. The patient has a Foley catheter and intravenous antibiotics on board. Follow up on culture results. 6. Diabetes. Continue home medications, Accu-cheks, (sic), and sling scale insulin. 7. [MEDICAL CONDITION]. Continue antidepressants. Record review of CR#1's nursing entry dated 6/9/19 01:41 AM read, Resident was sent to local Hospital via emergency transport The review revealed the Nurse Practicioner had sent the resident to the hospital for Having trouble following commands andshe wants the resident to be sent to the hospital for further examination. Family of resident RP present and NP present. Telephone interview with family member on 6/17/19 at 10:50 AM, revealed he went to the facility on Saturday 6/8/19 at noon . He stated CR #1 was very drowsy and CR #1 would not wake up. He stated about 2:00 PM he tried shaking her and got no response. He stated that he kept asking staff to come into CR #1's room to assess her and they had told him they would get the nurse but no one ever came into the room to assess her that afternoon. He further stated her eyes were up in her eyeballs. He stated the nurse on duty informed him they could not admit CR#1 to the hospital until 7:00 PM when the other staff come on duty. He stated that he requested staff assess her at 7:00 PM but no one came to see her and examine her until 8:30 PM when the doctor came and called 911. He further stated he believed her IV had been put in wrong as it was leaking.The family member stated the doctor informed him she believed CR#1 was having a stroke. Interview on 6/17/19 at 10:45 AM with the Nurse Practicioner revealed that she received a text from RN [NAME] at about 5:30 PM informing her that the family wanted her to speak to them regarding the CR #1 not eating. The Nurse Practicioner stated that when she arrived at the facility that evening she found the resident to be quite lethargic and not at all like she was when she saw her when admitted . She stated she felt the resident was having a stroke and the family informed her the resident was not speaking from around 3:15 PM that afternoon. She stated that had she been informed about the resident's condition, she would have immediately ordered her admitted to the hospital. She stated no one informed her of the CR #1's change in condition until she went to the facility and saw for herself. The Nurse Practicioner further stated that when she saw the resident she was non-responsive and nonverbal. She further stated the resident went to the hospital about 8:30 PM. She stated she did not observe any leakage from the IV nor bladder distension. An interview was conducted with the ADON on 6/17/19 at 11:30 AM . She was asked to locate documentation of CR #1's change in conditions which would include assessment and vitals. She was not able to locate an entry or document in the clinical chart regarding CR#1 experiencing a change in condition on 6/8/19 and stated I guess it's not there. Telephone interview with EMS technician on 6/17/19 at 7:00 PM revealed that he was dispatched to transfer CR #1 to the hospital. He stated she was in extremely poor condition was unresponsive and her bladder area of her abdomen was extremely hard and distended. He also mentioned that the IV was leaking. Telephone interview with RN [NAME] on 7/15/19 at 1:30 PM revealed she was the weekend supervisor on all the halls on Saturday 6/8/19. She stated that she was present on 6/8/19 and left the facility about 6:45 to 7:00 PM. She believes RN A might have mentioned CR #1 being less alert but can't really recall. She stated that RN A informed her the family wanted to discuss feeding tube options. She further stated that RN A was the nurse assigned to CR #1 that day. Telephone interview with RN A on 7/16/19 at 5:30 PM revealed that RN A was not really clear on who CR #1 was. She stated she might have taken care of CR #1 on 1 day. She recalled CR #1 was not eating good and due to language barrier she had to ask for interpreter. She stated that the family member was always there and always visited. She stated she does not recall CR#1 having a change in condition. She would have informed the Nurse Practicioner or doctor if this had been the case. Telephone interview on 7/16/19 at 5:27 PM with CNA C revealed she could not recall if CR#1 exhibited any changes. She stated the resident was always in and out regarding being alert. CNA C stated she works PRN at the facility. Telephone interview with LVN B on 7/17/19 at 10:30 AM revealed that he received an oral report from RN A at 6:30 PM on 6/8/19 when he came on duty. He stated that RN A informed him that CR #1 had been lethargic and not herself. He stated he did not put anything in the 24 hour report but realizes he should have done so. He stated that no aides brought the condition of CR #1 to his attention. Surveyor attempted to contact CNA G by phone on 7/16/19 at 6:00 PM and 7/17/19 at 10:00 AM at the number provided. No one answered the phone and there was no voice mail with which to leave a message. Record review was conducted of the facility's written policies and procedures regarding residents experiencing a change in condition. The document entitled, Acute Condition Changes-Clinical Protocol revised (MONTH) (YEAR) read in part, Assessment and Recognition 1. The physician will help identify individuals with a significant risk for having acute changes in condition during their stay . 2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications. 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. 4. Nursing Assistants are encouraged to use the Stop and Watch Early Warning Tool to communicat subtle changes in the resident to the nurse.5. The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of hving additional complications; Review of the facility's written policies and procedures regarding change in condition and notification of the physician was reviewed. The document entitled, Change in Resident's Condition and Status Policy Statement revised in (MONTH) (YEAR), read in part, Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing payments, resident rights, etc.).Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment sigificantly; f. refusal of treatment of [REDACTED]. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and revision to the care plan; and d. Ultimately is based on the judgement of the clinical staff and the outlinesin the Resident Assessment Instrument. 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (fr example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition condition or status . A record review was conducted of the facility's written policies and procedures regarding notification of physician when a resident is experiencing a change in condition. The document entitled, Acute Changes-Clinical Protocol revised (MONTH) (YEAR) read in part, .7. Before contacting a physician about someone with an acute change in condition, the nursing staff will collect pertinent details to report to the physician, for example the history of present illness and previous and recent tests for comparison. a. Phone calls to attending on -call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practicioner providing backup coverage will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical dirctor for additional guidance and consultation if they do not receive a timely or appropriate response. 10. The nurse and pjysician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms .

Based on interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 6 residents (CR#1) reviewed for accidents in that. -CR # 1 fell from a mechanical Hoyer lift to the floor during a transfer and incurred a right femur fracture. This failure placed CR#1 at risk for unwanted trauma, pain, hospitalization , and surgery. Intake: # 9 Findings included: Record review of CR #1 face sheet revealed a [AGE] year old female admitted to the facility on [DATE] with following diagnoses; [MEDICAL CONDITION], chronic pain, hypertension, [MEDICAL CONDITION] bowel, [MEDICAL CONDITION] with out pathological fracture, neuromuscular dysfunction of bladder, urinary tract infections, [MEDICAL CONDITIONS], and dementia. CR #1 was discharged on [DATE]. Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating she was moderately impaired and required extensive assistance with activities of daily living. CR #1 had functional limitation in range of motion to both sides of lower extremities and required the mobile device of a wheelchair. Further record review revealed that CR #1 was frequently incontinent of bowel and bladder. Record review of CR #1 care plan dated 02/04/19 revealed that CR #1 was being care planned for total dependent transfers via Hoyer with 2 (two) staff assistance. Record review of CR #1 Nursing note dated 04/23/19 revealed in part: .9:30a.m. CNA called LVN-B went inside room [ROOM NUMBER]-A. LVN-B found CR#1 on the floor with her back on top of the Hoyer stand. CNA said that as they were transferring CR #1, CR #1 slid out of the Hoyer sling and fell on the carpet floor. A head to toe assessment was done to CR #1. CR #1 was alert and oriented x 4. LVN-B made aware the ADON and UM. EMS was called, the MD was notified, and CR #1 family . Record review of CR #1 Physician order [REDACTED].#1 to hospital due to fall. Record review of CR #1 hospital record dated 04/23/19 revealed diagnostic test x-ray knee complete 4 views right, impression: comminuted distal right femur fracture. Interview on 05/22/19 at 12:20 p.m. with the DON, she said she had started working at the Nursing facility on 04/22/19 and was in training. The DON said CR #1 fell on [DATE] during a transfer. The DON said she believed that CR #1 was not connected properly to the Hoyer lift and ended of falling. The DON said CR #1 was sent out to the hospital and it was later found out that CR #1 had incurred a fracture to the hip. The DON said the 2 (two) CNA's involved were placed on suspension pending the investigation and since then had been allowed to come back to the Nursing facility to work. Interview on 05/22/19 at 12:50 p.m. with the Administrator said she had been working at the facility for 2 weeks. The previous administrator had called in the self-report regarding CR #1 fall. The Administrator said it was LVN-A that assisted the previous Administrator with the self-report on CR #1. Interview on 05/22/19 at 1:15 p.m. with LVN-A, she said CNA-C and CNA-D was working the morning shift when CR #1 had a fall during transfer. LVN-A said corporate assisted in the investigation of CR #1 fall and it was determined that CR #1 was not placed correctly on the Hoyer lift due to CNA-C not crossing the straps on the Hoyer sling to secure CR #1. Further interview with LVN-A said when herself and other staff members entered CR #1 room, CR #1 was found on the floor sitting on her bottom and believed CR #1 legs were crossed. LVN-A said CR #1 was quiet. LVN -A said she asked CR #1 was she in pain and CR #1 said she was in pain all over. LVN-A said CR #1 was not moved until the EMS came to transport to hospital. Interview on 05/22/19 at 1:50 p.m. with CNA-C, she said she worked the morning shift and had been a CNA for [AGE] years. CNA-C said she had gone to CR #1 room to get her ready for her shower. CNA-C said she initially went into CR #1 room alone and began to place the Hoyer sling underneath CR #1. CNA-C said she criss-crossed the sling at the bottom of CR #1 lower body torso to secure CR # 1 from slipping out of the sling and hooked the straps to the Hoyer lift machine. CNA-C said she began to lift CR # 1 off the bed a little to see if she was comfortable. CNA-C said CR #1 began to complain of discomfort and said the sling was cutting in between her upper thighs. Further interview with CNA-C said she lowered CR #1 back down on the bed and went out of the room to get some towels to place in between CR #1 upper thigh and groin area so that the sling would not irritate CR #1 because she was heavy weight. CNA-C she reconnected the Hoyer sling back to the Hoyer lift and proceeded to lift CR #1 up off the bed a little. CNA-C said CR #1 began to yell that she was in discomfort. CNA-C she lowered CR #1 back down on the bed again and went to go and get help. CNA-C said she saw CNA-D who came to assist her with CR #1. CNA-C said when she lifted CR #1 off the bed for the 3rd time in the Hoyer lift, the Hoyer lift was not criss-crossed but she did support both of CR #1 legs and CR # 1 did not complain and said she felt better. CNA-C said she began to move CR #1 away from the bed toward the wheelchair with the Hoyer lift. CNA-C said then the Hoyer lift stop as if something was blocking it. CNA-C said she could not see anything that was obstructing the machine. CNA-C said she did not know if it was CR #1 weight but did know there was not anything blocking machine like cords or something else on the floor. CNA-C said CR #1 began to have a bowel movement while in the Hoyer lift therefore she started move CR #1 back toward the bed. CNA-C said she yanked the Hoyer lift toward the bed trying to get the machine to move. CNA-C said CR #1 came out of the Hoyer lift sling fast and hit the floor. CNA-C said she did not have time to try and break the force of CR #1 fall. CNA-C said CR #1 hit the floor butt first and then her legs followed. CNA-C said at first CR #1 was quiet for a minute. CNA-C said she started to apologize to CR #1. CNA-C said when LVN-A entered CR #1 room along with other staff members, CR# 1 started to complain of pain. CNA-C said she had experience with Hoyer lift machines and transfers. CNA-C said residents that are heavy weight, the Hoyer lift machine was not easy to move, and one would have to use their own weight to move the resident. CNA-C said all the straps on the Hoyer sling was connected to the Hoyer lift machine. CNA-C said she had been working at the facility for 2-1/2 months and had never been trained at the Nursing facility on Hoyer lift transfer until after the incident with CR #1. Interview on 05/22/19 at 2:37 p.m. with CNA-D, she said she was on the hallway passing out ice to the residents when CNA-C called her saying she needed some assistance with CR #1. CNA-D said when she entered in CR #1 room, CR #1 was already in the Hoyer lift sling and connected to the Hoyer lift machine. CNA-D said she did not check CR # 1 to see if she was connected properly to the Hoyer machine. CNA-D said CR #1 head was supported in the sling. CNA-D said she went and stood behind the wheelchair and CNA-C began to raise CR #1 up off the bed in the Hoyer lift. While moving CR#1 toward the wheelchair, the machine stopped. CNA-D said she could not see anything that could have been blocking the machine and thought maybe it was the carpet on the floor. CNA-D said CNA-C yanked on the machine. CNA-D said she noticed CR#1 was having a bowel movement and then realized that the Hoyer lift sling was not properly underneath CR # 1 because she could see CR #1 buttocks exposed and feces was falling on the floor instead of inside the sling. CNA-D said CNA-C yanked on the Hoyer lift machine for the second time and CR #1 came out of the sling and hit both legs and back on the Hoyer machine and then hit the floor. Further interview with CNA-D said CR #1 did not say anything and believed CR #1 was in shock. CNA-D said about 4 minutes later, CR #1 began to complain of pain. CNA-D said she had been a CNA for 5 years. CNA-D said she started working at the Nursing facility at the end of (MONTH) 2019. CNA-D said she had not been trained on Hoyer lift transfers until CR #1 fall. Interview on 05/23/19 at 11:20 a.m. with the DON said after CR #1 fall, the staff CNA's had been trained on Hoyer lift transfers. The DON said moving forward, she would ensure all new hires would get the training as well. The DON said there were two types of Hoyer lift slings in the facility and they came in different sizes and were color coded according to the size. The DON said the facility had a sling that criss-crossed on the resident and one that did not. The slings are placed underneath the resident upper body torso starting at the upper back extending down to the resident lower extremities just above the knee area. The DON said she did not know why the Hoyer lift machine stopped on CNA-C and CNA-D s during CR#1 Hoyer lift transfer unless, CNA-C did not hook the sling to the machine properly or positioned the sling underneath CR #1 unproperly. Interview on 05/23/19 at 12:45 p.m. with the Central Supply Manager said the Nursing facility used 2 types of Hoyer lift slings to transfer a resident. One was the Quickfit Deluxe that consisted of a 6 (six) point hook up, 2 at the top on each side, 2 at the bottom on each side, and 2 in the middle one on each side. The Quickfit deluxe sling came in a small, medium, large, and extra-large. The Quickfit came in sizes small, medium, and large with a 4 point hook up. The Central Supply Manager said the Quikfit sling did not criss-crossed but the Quikfit Deluxe did. The Central Supply Manager said the Quikfit Deluxe sling provided more security and should not pinch the skin. The Central Supply Manager said the only things that she could think of too not cause the Hoyer lift machine to not move smoothly would be not having the resident positioned correctly in the sling causing the machine to be unbalanced with the resident weight or an object blocking on the floor. The Manager said the resident legs needed to be slightly apart. The Supply Manager said when transferring a resident from one point to the other, one staff member needed to be in front of the resident and the other behind the resident to help guide the machine just to ensure everything is moving smoothly as it should. Interview on 05/23/19 at 1:25 p.m. with CNA-C she said she placed CR #1 in a large sling to transfer on the Hoyer lift machine. CNA-C was asked how did she know it was a large sling? CNA-C did not answer the question but said it was hard to tell exactly what size the sling was because when she went to get a sling they were all in one barrel and she just grabbed one. Interview on 05/23/19 at 2:15 p.m. with the Administrator and the DON said could not find a skills check off list for CNA-C and CNA-D for Hoyer Lift transfer. Record review of the Quikfit Deluxe Hoyer Sling revealed that the sling came in a size extra small (brown color) for weight ranging (35-100 pounds), small (red color) weight (75-170lbs), medium (yellow) weight (125-200 pounds), large (green) weight (175-350), and extra-large (blue) weight (275-500). Record review of CR #1 face sheet revealed a weight of 215 pounds. Record review of Nursing facility policy on Lifting Machine, Using a Mechanical revised (MONTH) (YEAR) revealed in part: .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Measure the resident for proper sling size and purpose, according to the manufacturer's instructions. Select a sling size bar that is appropriate for the resident's size and the task. Make sure that all necessary equipment (sling, hooks, chains and supports) is on hand and in good condition. Double check the sling and machine's weight limits against the resident weights. Place the sling under the resident. Visually check the size to ensure it is not too large or too small.

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of seven residents (CR#1) reviewed for medications, in that; LVN T electronically transcribed [MEDICATION NAME] 15mg QID (four times a day) instead of [MEDICATION NAME] 15mg Q HS(every hour of sleep). MAs Administered [MEDICATION NAME] QID for a total of 12 doses resulting in CR#1 to be oversedated and AMS requiring transportation to the local hospital. These failures affected 1 resident and placed him at risk of a decline in health status and for adverse consequences. Findings included: Intake # 9 Record Review of CR #1's Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE] and readmitted [DATE]. His [DIAGNOSES REDACTED]. CR#1 was discharged on [DATE]. Record review of Resident#1's MDS ( 5 day scheduled assessment) with ARD 11/6/18 revealed: - understood and usually understands others and had clear speech - short and long-term memory problems, moderately impaired cognitively for decision making, BIMS Score of 99 - medications received 4 days of Antidepressant - Drug regimen review identify potential clinically significant medication issue, Yes found during review - Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/ recommended actions in response to the identified potential clinically significant medication issues? Yes - Did the facility contact and complete physician (or physician-designee) prescribed/ recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission? Yes Record Review of CR #1's baseline Care Plan with a start date of 10/31/18 and updated on 11/1/18 revealed the resident was care planned for poor intake at risk weight-loss restorative dining/ Speech Therapy as indicated snacks between meals. There was no intervention listed regarding [MEDICATION NAME] for appetite. Record Review of CR#1's telephone physician's orders [REDACTED]. Record review of CR#1's Physician History and Physical dated 11/1/18 revealed documentation of poor appetite [MEDICATION NAME] 15mg QHS and Resource 60ml BID. Record Review of CR#1's Telephone order dated 11/6/18 read Send patient to hospital for further eval and treat. Record review of CR#1's MA Administration Record dated (MONTH) (YEAR) revealed, [MEDICATION NAME] 15mg give one tablet by mouth four times daily, [DIAGNOSES REDACTED]. 11/02/18 at 8am, 12pm and 8pm 11/3/18 at 8am, 12pm, 4pm and 8pm 11/4/18 at 8am, 12pm, 4pm and 8pm 11/5/18 at 8am Record Review of CR#1's Nurse Progress Notes dated 11/2/18 read MD in facility and wrote orders for [MEDICATION NAME] 15mg PO QID, Resource 2.0 60ml BID [MEDICATION NAME] gel to left elbow QID X1 week for bursitis and eMAR updated. Record Review of CR#1's Nurse Progress Notes dated 11/5/18 indicated resident was increasingly drowsy and lethargic. CN assessed resident vitals, CN review resident medication and notes [MEDICATION NAME] 15mg 1 tab po QID. CN contacts NP who states that the [MEDICATION NAME] order should be 1 tablet po HS. NP states to hold the med X3 days, start a peripheral line and infuse 2 liters of Sodium Chloride @ 125cc/hr. Record Review of CR#1's Nurse Progress Notes dated 11/6/18 read, Resident will not open his eye and not swallow. CN calls MD asks has the condition of the resident changed. CN states no the resident is the same MD states she needs to make a call and would call me back. MD calls CN back and states to call 911 and get the resident sent to hospital. Record review of Facility Medication Error report dated 11/5/18 revealed: CR#1, date of error 11/2/18. Medication order [MEDICATION NAME] 15mg, Description of error- MD wrote for [MEDICATION NAME] 15mg po QHS - nurse transcribed as [MEDICATION NAME] 15 mg QID on 11/2/18, Care provided and outcomes to resident- 11/6 MD gave order to send to ER for further evaluation. Type of Error- wrong time, Reason for Error- Transcription error, Misread order. Record Review of Hospital records for CR#1 admitted on [DATE] revealed HPI (History of Present Illness)- Presentation Chief Complaint Drug overdose, Modifying Factors Accidental Hx (History) Obtained from Nursing Home, Paramedic Unable to Obtain Hx Altered Mental Status Severity Onset Moderate Severity Current Moderate, Free Text HPI Notes: Brought in for altered mental status and overdose on medications. Apparently, patient is supposed to get [MEDICATION NAME] once a day instead been getting it 4 times a day for 1 week. Free Text MDM (Medical Decision Making) Notes DDX (Differential Diagnosis, Potential cause of a patient's illness via process of elimination): ACCIDENTAL OVERDOSE, UTI, ELECTROLYTE ABNORMALITY. Clinical Impression Primary Impression Altered mental status, Secondary Impression Accidental overdose. Surveyor called LVN H on 11/8/18 at 4:20pm and 11/9/18 at 11:00am but was unsuccessful. Record review of facility acquired signed statement form LVN H dated 11/8/18 revealed that on 11/5/18 she was told CR#1 was lethargic, not waking up and called his Primary Physician and was reviewing the medication while on the phone LVN H stated to Primary Physician that he was on [MEDICATION NAME] 15mg PO QID and Primary Physician then asked why he was getting that medication that many times a day and she grabbed the chart and saw that the actual order stated [MEDICATION NAME] 15mg PO QHS. LVN H stated that when she came back to work on 11/6/18 CR #1 was still lethargic and his condition had not improved so she called Primary Physician again. Surveyor called LVN T on 11/8/18 at 4:25pm and 11/9/18 at 11:05am but was unsuccessful. Record review of facility acquired signed statement from LVN H dated 11/8/18 revealed that on 11/5/18 CR#1 had telephone orders written the night before 11/1/18 for [MEDICATION NAME] and another nurse had been too busy to transcribe the orders but had clarified the [MEDICATION NAME] order with the Doctor 2-3 times and verified the order was correct for [MEDICATION NAME] 15mg PO QID, and she entered the order into the MAR, LVN T assumed it was for an appetite stimulant. Record Review of Employee Record of Conversation signed dated 11/8/18 for UM J revealed: Subject, Processing MD orders, Details of the Conversation: As the unit Manager, one of your assigned duties is to follow-up on all physician orders [REDACTED]. This process includes ensuring that order has been followed through completely: On 11/1/18, a physician ordered [MEDICATION NAME] 15mg Q HS. The charge nurse who transcribed the order entered the order as [MEDICATION NAME] 15 mg PO QID. When you followed up on the order the next day 11/2/18 you did not notice that this order was transcribed incorrectly, and the patient received unnecessary medications that could have caused potential harm. Moving forward, you must ensure that you are correctly following up on all physician orders [REDACTED]. Interview with MA R on 11/8/18 at 1:30pm she said, she had administered [MEDICATION NAME] 15mg to CR#1 on 11/2/18 at 8am and 12pm and 11/5/18 at 8am she did not give it but did sign out for the medication. She stated that she did not give it on 11/5/18 because CR #1 was very sleepy and that she had notified LVN H. MA R stated that she did not know the charge nurse was to give the initial dose of [MEDICATION NAME] on 11/2/18 at 8am. MA R said that she gave the initial dose of the new medication [MEDICATION NAME] to CR#1. MA R further stated that she has not had a in-service, 1:1 training/discussion or write-up about this incident and did not know about the medication error until the surveyor mentioned it during interview. MA R stated that the UM and the Charge nurse were responsible for transcribing orders, and she followed the Medication Administration Record [REDACTED]. Interview on 11/8/18 at 5:00pm with MA D, she said she had administered [MEDICATION NAME] 15mg to CR #1 on 11/2 at 8pm, 11/3 and 11/4 at 4pm and 8pm. She stated she would not know to question the order for four times a day because she is a new Medication Aide and did not have the experience to know it should be given only once a day for appetite stimulant. MA D stated she has not had an in-service, 1:1 training/discussion or write-up about this incident and did not know about the medication error until the surveyor mentioned it during interview. Interview on 11/8/18 at 5:30pm with MA O, she said she had administered [MEDICATION NAME] 15mg to CR#1 on 11/3 at 8am and 4pm. MA O stated she gave what was scheduled, I feel it was supposed to be given that way I don't know, they need to work on the system, we just follow what is in the system, I don't know that I'm not supposed to give it .I think it's right if in the system if it's not right then it's not supposed to be there. MA O stated, Nobody talked to me, she has not had an in-service, 1:1 training/discussion or write-up about this incident and did not know about the medication error until the surveyor mentioned it during interview. Interview with UM J on 11/8/18 at 4:00pm she said she was, responsible for reviewing the yellow copy of the telephone order checking for transcription correctly, dose time, med, duration, route and if the med is on the cart. She stated the check/review is done the next day after the order is written and CR#1 [MEDICATION NAME] order would have been reviewed on Friday 11/2/18 after the facility 9am meeting. UM J revealed that she was aware that [MEDICATION NAME] 15mg was given 1X a day at night for appetite stimulant, she stated I can't tell you how this slipped thru me, I'm so good at my job but doing 50 million things and being pulled, it was missed. She further stated that when LVN H brought it to her attention on Monday 11/5/18 she completed a Medication Error form, notified the DON at approximately 9:00am and the Physician wanted CR#1 sent out 911 to have stomach pumped.this is not true this happened the next day UM J stated that In-servicing was started last night (11/7/18) because of your visit I guess. UM J revealed no one has spoken or counseled LVN T who transcribed the order and that LVN T has worked since the incident, and no one has spoken or counseled the MAs who gave the [MEDICATION NAME]. UM J further stated that the DON has not 1:1 training/discussion or write-up, counseled her regarding this incident. Interview on 11/8/18 at 3:38pm with DON, she said she was notified about CR#1 [MEDICATION NAME] Medication Error on 11/6/18 and UM J reported it to her about 9:00am. DON stated, we called the Dr. to clarify and immediately stopped the medication and the next day the doctor called poison control and then called us to say maybe he needs to go to the ER to get stomach pumped, that's my knowledge of the situation, he came in with AMS. DON stated her expectation of reviewing orders are for medical records to get the white copy, yellow to Unit Managers so next morning managers check it with the Medication Administration Record [REDACTED]. DON stated she would question if this was a system failure that led to neglect, but that it was questionable Nursing judgement that led to a Medication Error. DON stated they were In the process of getting in-services completed and started in-servicing 11/7/18 on use your Nursing judgement. DON stated that she was waiting to find out from CR #1's Physician the outcome of the Resident, did it do harm to the patient before I do my final disciplinary action. DON also stated I can't answer that why it was not called in. We have 2 hours to report to y'all I just thought it was past that time and just didn't call it in I don't know why. Interview with CR#1's Primary Physician on 11/9/18 at 11:00 am, she said she was notified on 11/5/18 approximately at 8:00am that CR #1 was having some altered mental status issues, so she asked what med were recently started and when I was told [MEDICATION NAME] 15mg QID(four times a day) I said no, It's only once a day at night and not four times a day. Primary Physician stated [MEDICATION NAME] is a common medication given for appetite and questioned how did it pass the hands without someone questioning the order of four times a day. If handwriting is poor I get calls, but this time nothing, this surprised me. Primary Physician also stated she did not receive a call from anyone to clarify her order except when she was called on 11/5/18 about CR#1's AMS, she further stated no one from the facility has reached out to her Not the DON or Administrator. Interview on 11/9/18 at 10:35am with the Medical Director for the Facility revealed he read CR#1's 11/1/18 [MEDICATION NAME] order and stated Yes a Medication Error, CR#1 was to get 15mg HS(night) and not going to get into Primary Physician handwriting, but it should have been clarified with the Primary Physician. Medical Director stated if CR #1 was already lethargic it would increase the effect of drowsiness and sedation and we should have an action plan in place. Interview on 11/9/18 with Consultant Pharmacist at 11:45am, he said he was not aware CR #1's medication error until the Administrator called him last night (11/8/18) to discuss the Medication Error. He further stated that the pharmacist who completed CR #1's [MEDICATION NAME] order is on vacation and their company is conducting a QA investigation starting today 11/9/18. He stated he saw the order and the medication card that read [MEDICATION NAME] 15mg QID(four times a day) and the Error should have been caught by the pharmacist filling the order. Consultant Pharmacist stated that a safe dose for [MEDICATION NAME] as a appetite stimulant is 15-30mg once a day, QID is an unusual dose and the side effect is primarily sedation. He stated that he was in-servicing, Conducting Med Pass and Medication Cart Audits checking for correct dosing. Interview on 11/9/18 at 12:30pm with DON (Administrator and UM J present) revealed CR#1 had never been on [MEDICATION NAME] before and 11/2/18 at 8:00am was his first dose administration of the new medication. DON further stated her expectation is that the nurse gives the first dose of a new medication to a resident because the nurse to make sure it is correct, monitor for s/s, tolerated well, get consent and it would not be the MA it would be a licensed nurse. After looking at the MAR, initials the DON stated that MA R gave the first dose of [MEDICATION NAME] at 8am on 11/2/18 to CR#1 and the nurse should have and it could have been possibly caught once she read the MAR indicated [REDACTED] During an interview on 11/9/18 at 1:00 p.m., Administrator was asked Do you think this incident (Medication Error) is an area of neglect related to Significant Medication Errors? She stated, that's a tricky question it's a transcription error that lead to him not getting meds, yes since it lead to him not getting meds correctly Administrator said I know where this is going. When asked should this incident (Medication Error) be reported to the state agency, the Administrator stated No, because it was a Medication Error Report, unless Diversion you don't Report it. Administrator said there was no system failure and that she thinks the nurse wrote the order from the other nurse and she didn't know what to say about that. Review of the facility's policy and procedure titled Adverse Consequences and Medication Errors (revised date 4/2014), reflected the following including: Policy Statement; The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions and side effects. Adverse consequences shall be reported to the attending Physician and Pharmacist, and to federal agencies as appropriate. Policy Interpretation and Implementation 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. 2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition of functional or psychosocial status. An adverse consequence may include: B. Side effect 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED]. of the professional(s) providing services: 6. Examples of mediation errors include; c. Wrong dose g. Wrong time 8. When a resident receives a new medication, the medication order is evaluated for the following: a. The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. 12. In the event of a significant medication-related error ar adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare Significant is defined as: a. Requiring medication discontinuation or dose modification b. Requiring hospitalization , or extending a hospitalization : e. Resulting in cognitive deterioration or impairment Review of the facility's policy and procedure titled Administering Medications (revised date 12/2012), reflected the following including: Policy statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent an accident which caused injury to 1 of 5 residents(CR# 1) reviewed for adequate supervision. CR#1 sustained a left knee fracture and was sent to the ER due to CNA T transferring resident by herself instead of two staff. This failure affected one discharged resident and placed 95 additional residents who require staff assistance with transferring at risk of unnecessary pain, harm or decreased quality of life. Intake # 6 CR #1 Record review of CR# 1's face sheet revealed a [AGE] year old female that was admitted to the facility on [DATE] initially. She was discharged on [DATE]. She had a [DIAGNOSES REDACTED]. Record review of CR#1 MDS with ARD 7/18/18 revealed she had: - memory problems - moderately impaired cognitively for decision making BIMS= 99 - extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing - limited assistance for eating - occasionally incontinent of bladder and frequently incontinent of bowel Record review of CR#1's Baseline Care Plan dated 7/14/18 revealed in part: ADL: Bed Mobility and Transfers, assist times 2 extensive Additional Comments/Changes for Baseline care: Left hip revision(6/28/18) history of AMS after surgery Record review of CR #1's Incident report dated 7/18/18 revealed in part: Date/Time; 7/18/18 8:31am .Type of injury . fracture .Activity at time . from bed with assist .Narrative of incident and description of injuries .Patient reported that she twist her knee during transfer this a.m .and was having increased pain. X-ray ordered to r/o injury pain continued and x-ray showed spiral fracture to distal femur .Patient sent to ER NP and RP notified . Record Review of CR#1's Nursing Departmental Notes dated 7/18/18 at 10:44am revealed in part: .Patient reported to her caregiver that during a transfer this morning her knee was twisted and was causing her a lot of pain. Nurse assessed, and patient reported increased pain to left knee. Due to patient's complaint of increased pain and complaint of twisted knee during transfer x-ray was ordered to r/o injury. CNA confirmed that patient did have difficulty with transfer this am. Nurse re-educated CNA that patient is to be a 2-person transfer. CNA verbalized understanding . Record Review of CR#1's Nursing Departmental Notes dated 7/18/18 at 12:01pm revealed in part . Left knee x-ray complete .Left femur appears misplaced . Record Review of CR#1's Nursing Departmental Notes dated 7/18/18 at 12:59pm revealed in part, .EMS transferred patient at 12:45pm to . X-ray report in and showed spiral [MEDICAL CONDITION] aspect of the distal femur with angulation . Record Review of CR#1's telephone orders revealed an order dated 7/18/18 for Portable x-ray to left knee. Another telephone order dated 7/18/18 read in part, Send to .for left femur fracture at 12:45pm Record Review of CR#1's Radiology Report dated 7/18/18 and electronically signed 7/18/18 at 12:33pm revealed in part .Impression: 2. Spiral [MEDICAL CONDITION] aspect of the distal femur with angulation . In an Interview with CNA T on 7/31/18 at 2:05pm, she said she was the CNA taking care of CR#1. She said that she did not get help from another Nursing staff for transferring the resident from the bed to wheelchair or toileting the resident. CNA T said she had worked with the resident before and CR#1 was able to assist with standing and pivoting. CNA T said that during the transfer the resident did not have any complaints. CNA T said that she was told by RN J that CR #1 was a two-person transfer prior to transferring but she felt because of the resident's weight she could do it by herself. CNA said that she had been in-serviced on how to properly transfer residents and the use of the Care Guide. In an Interview with ADON on 7/31/18 at 5:30pm regarding the incident dated 7/18/18 with CR #1 she said that when she found out about the incident she reported it to the administrator. ADON said she found out from RN J at about approximately 10:45am when the resident started requesting a pain pill. ADON said she interviewed the Resident and did an assessment, CR #1 voiced that CNA T transferred her alone from the bed to her wheelchair and that's when she felt her left knee twist and it continued to hurt. CR#1 told her she did not say anything because she thought it would go away. ADON said that the resident was a two- person transfer because she had left hip surgery prior to admission. ADON said she made the resident comfortable while the RN J called the MD and got orders to transfer to Hospital. ADON said that the CNAs were expected to use the CNA Care guide on the computer to find information on how to provide care for their assigned resident. ADON also stated that a yearly in-service was done on transfers with return demonstration and reporting to Administration RN J was not available for interview and did not return surveyor calls, on 7/31/18 at 1:00pm or 2:30pm. In an Interview on 7/31/18 at 6:00pm with Administrator, he said he was the facility Abuse Coordinator. Administrator said that he first learned of the incident around lunch time he remember it because during that time another HHSC worker was in the building conducting investigations. Administrator stated CNA T was interviewed, counseled and was suspended pending investigation. Administrator stated that CNA T admitted that she transferred CR #1. Record Review of Facility Policy and Procedure Care Plans, Comprehensive Person-Centered revised 12/16 revealed in part: 8. The comphehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being According to the Facility's form 672 there were 95 residents requing staff assistance with transfer.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one of seven residents (CR#5) reviewed for neglect. -- The facility neglected to evaluate, promptly address, provide adequate assessments, closely monitor and provide adequate treatment for [REDACTED]. --The facility neglected to consult with the MD in a timely manner. This failure affected one former resident (CR#5) and has the potential to affect the 123 residents residing at the facility at risk of not having their medical needs addressed timely which could cause extended durations of pain and a delay in medical treatments. Findings included: Intake # 7 Record review of the facility face sheet revealed CR #5 was an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was admitted to a local hospital on [DATE] with a left humeral neck fracture and a left pelvic fracture. Record review of CR#5 annual MDS assessment dated [DATE] revealed that CR#5 had severe cognitive impairment with a BIMS score of 1 out of a total possible of 15. She usually understood others and usually made self understood. CR#5 required limited assistance with bed mobility, transfers, locomotion on and off unit, eating, toilet use and personal hygiene. CR#5 required extensive assistance for dressing and bathing. She was identified as always incontinent of bowel and bladder. Record review of CR#5's care plan dated 1/11/2016 revealed in part: .Problem:At risk for trauma related to poor bone density. Goal: CR#5 will not develop an unidentified fracture occurence during facility stay with interventions in place through 4/11/2016. Approaches: Notify MD and responsible party as indicated for changes identified in CR#5's status indicating possible injury occurence or for an actual fracture occurence . Record review of CR#5's departmental notes revealed in part: -3/23/2016 at 2:00 p.m. CR#5 in front of the facility stating she needs to leave to meet her family. CR#5 very insistent and verbally aggressive. Family made aware. Will continue to monitor Record review of Telephone orders dated 3/23/2016 revealed orders in part: - [DIAGNOSES REDACTED]. Discontinue [MEDICATION NAME] 2.5 mg three times a day and give [MEDICATION NAME] 5 mg by mouth three times a day for anxiety. Hold for lethargy. Get urinalysis with culture and sensitivity to rule out urinary tract infection Further record review of CR#5's departmental notes in revealed: -3/23/2016 at 7:12 p.m. MD in the facility and new orders obtained. Start [MEDICATION NAME] 5mg by mouth three times a day for anxiety, hold for lethargy and obtain urinalysis for culture to rule out urinary tract infection -3/25/2016 at 8:08 p.m. new orders for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for 7 days for urinary tract infection . Notes at 8:19 p.m. new order for [MEDICATION NAME] (anti-nausea) 4 mg every 6 hours as needed for nausea and vomiting -3/26/2016 at 8:07 a.m. Reported that CR#5 was 'out of it'. CR#5 complained of nausea. Positive bowel sounds. [MEDICATION NAME] prn for nausea. Afebrile. CR#5 refused breakfast but stated I will eat some soup later. -3/26/2016 at 4:01 p.m. MD assessed CR#5 today and gave orders to insert peripheral intravenous and start intravenous hydration at 50 cc hour for 3 days. Complete metabolic panel and complete blood cell count in the morning and geri-mox 20 cc by mouth four times a day as needed for pressure and bloating Further record review of notes at 4:46 p.m. revealed in part CR#5 refused to let nurse attempt intravenous stick. MD made aware and stated to discontinued intravenous fluids but encourage by mouth intake -3/26/2016 at 7:25 p.m. at 1:30 p.m. C.N.A. reported a bruise on CR#5. On assessment noted a bruise to left upper arm that was purplish in color. When nurse asked CR#5 what happened, she stated I layed on it too long . When nurse lifted arm, CR#5 reported pain. Nurse immediately notified MD and received order for X-ray to left shoulder and humerus (long bone in the upper arm). RP made aware of findings and new orders Addendum at 7:30 p.m. head to toe assessment completed at 1:35 p.m. No evidence of any other injuries or discomfort noted at this time. Nurse treated with as needed Tylenol at 1:45 p.m. and CR#5 stated that Tylenol helped her a lot at 2:30 P.M . -3/26/2016 at 9:00 p.m. x-ray results: Impacted left humeral neck fracture. Nurse must be present when patient care is done Record review of CR#5's radiology reports dated 3/26/2016 at 11:06 p.m. revealed in part: -Humerus minimum view, left: Results: There is an impacted left humeral neck fracture. Conclusion: Acute impacted left humeral neck fracture. -Left shoulder 1 view: Results: There is a fracture involving humeral neck with impaction. Conclusion: Impacted left humeral neck fracture . Further record review revealed a hand written note that read MD notified 3/27/2016. Continued record review of departmental notes in part: -3/27/2016 at 9:01 a.m. Nurse received shift report this a.m. that CR#5 x-ray was positive for impacted left humeral neck fracture. Nurse immediately paged the MD and went to assess CR#5. On entering CR#5 was lying on her back in the bed. CR#5 stated that she was not in pain, but slurred speech was noted. CR#5 had difficulty swallowing fluids. MD with orders to send CR#5 to hospital for further evaluation. Emergency Medical Services arrived. CR#5 verbalized pain to the left hip at time of transfer from bed to stretcher . -3/28/2016 at 4:05 p.m. call placed to son, inquired how CR#5 was at the hospital. Son stated that CR#5 presented with a fractured pelvis and fractured arm and is being evaluated by the surgeon now. Son inquired about how CR#5 acquired fractures Record review of CR#5's incident investigation for bruise incident dated 3/26/2016 at 1:30 p.m. and printed out on 3/29/2016 at 8:49 a.m. and signed by ADON A revealed in part: CR#5 sent to a local hospital for a follow up after x-ray showed a fracture to the left shoulder. CR#5 presented with bruise that was reported to nurse and x-ray showed fracture. CR#5 stated when questioned that I must of laid on it wrong. Call placed to son and stated that CR#5 also had a pelvic fracture and will be having surgery soon. Interviewed all staff that could have come in to contact or gave care to CR #5 for past seven days, no reports given of any incidents of fall, etc. All witness statements have been obtained, unable to determine the root cause of the injuries . Record review of CR#5's Medication Administration Record for March 2016 revealed that [MEDICATION NAME] 5mg one tablet by mouth was administered three times a day from 3/24/2016 thru 3/26/2016. Further record review revealed that [MEDICATION NAME] 325 mg tablet (Tylenol) 650 mg every 6 hours as needed for pain was administered one time the entire month on 3/26/2016 at 1:45 p.m. Record review of CR#5's Pain Assessment MAR for March 2016 revealed a score of 0 throughout the entire month. Further record review revealed that under interventions for noted pain there were no interventions indicated on the MAR. Boxes had the licensed nurses initials instead of the legend numbers indicating interventions. In an interview on 3/29/2016 at 6:39 a.m. with ADON A, she stated that CR#5 had a bruise to her left upper arm that had turned into a fracture to her shoulder and that CR#5 was at the hospital since 3/27/2016. She further said that the facility had interviewed about 30 employees and that nobody knew how CR#5 had the fracture. In a phone interview on 3/29/2016 at 9:40 a.m. with C.N.A. B, she stated that she cared for CR#5 on 3/26/2016 and that she had received report from the night shift staff that CR#5 had been very combative during the night shift and that she was the last one to have incontinent care on the shift. C.N.A. B further said that when she first saw CR#5 in the morning, CR#5 was asleep and that her brief was dry the entire morning and that she did not need to do incontinent care because the brief remained dry the entire morning. C.N.A. B continued saying On Friday 3/25/2016 when I worked with her, CR#5 was talking, she was alert, she was her own self and did not have any bruising, on Saturday 3/26/2016, it was a big change, CR#5 complained that her stomach was hurting and did not want to eat breakfast or lunch. CR#5 was so sleepy the entire shift that she could barely talked, you could barely understand her and her eyes were rolling backwards. RN C was made aware. CR#5 could not drink from her straw, she could not suction water or fluids with the straw, she would not open her mouth, she was barely talking and was barely moving and stayed all day in bed that day. Sunday 3/27/2016, CR#5 could barely talk, she was super sleepy, pale and was not able to eat breakfast again. I tried to give her water but she could not sip her water . Continued interview with C.N.A. B, she stated that on 3/26/2016 at around 1 p.m., when she was about to do incontinent care to CR#5, she noticed a large bruise to her left upper arm and that she immediately reported the bruise to RN C and that she noticed when RN C moved CR #5's left arm, she complained of pain. In a phone interview on 3/29/2016 at 10:55 a.m. with C.N.A. D, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and that on 3/26/2016, she was the medication aide for CR#5 in the day shift and the aide in the afternoon shift. C.N.A. D further said that the day shift aide had discovered the bruise to CR#5's left upper arm and that CR#5 was supposed to have a shower that afternoon but she was not able to give the shower because CR#5 wasn't with it, she wasn't herself. C.N.A. D continued saying CR#5 did seem very drowsy on 3/26/2016, RN C was there and saw what I saw. On Friday 3/25/2016, CR#5 was fine. On 3/26/2016 her medications had to be crushed because she could not swallow. CR#5 was in pain when we changed her brief and when we turned her. CR#5 was complaining of pain all over, to her abdomen and her knees. Whenever we changed her brief, CR#5 would not let us and would say 'owww' and would grimaced her face, she would refused to allow us to change her brief and would point with her fingers to her left upper thigh, abdomen and knees. Family member was there and she reported that CR#5 was also complaining of pain in her chest and RN C was made aware. C.N.A. D further said that CR#5 had her brief changed at the beginning of her 2 - 10 p.m. shift and another time later during the shift and before the end of her shift at 10p.m. When asked if information about CR#5's pain during brief change was reported to the nurse. C.N.A. D said that she did report to whoever was the nurse present about CR#5 being in pain and not letting staff to touch her. Further interview at that time, when asked if CR#5's [MEDICATION NAME] was held due to her mental condition, C.N.A. D stated that charge nurse did not let her know to hold the medication. Observation on 3/29/2016 at 12:39 p.m. CR#5 was in a local hospital, she was non-verbal to surveyor and had oxygen via nasal cannula at 2.5 liters per minute and had an intravenous fluids to her right arm. In an interview on 3/29/16 at 12:39 PM with CR#5's family member, he stated that CR#5 had major surgery due to the trauma to her left hip bone. He further said that CR#5 had a broken left shoulder and left femur (thighbone) head and hip socket that had to be reconstruct as the head of the thighbone was pushed into the socket. CR#5's family member further said that an MD told him that for the trauma that CR#5 presented to her left hip and her left shoulder, it appeared that it was a hard fall. CR#5's family member continued saying as he exposed CR#5's left upper arm I believe that she was grabbed very hard from her left arm because of the extensiveness of the bruise and the swelling area. Further observation at that time, CR#5's left upper arm was dark purple in color and swollen. Continued interview at that time with CR#5's family member, he stated that he visited CR#5 on 3/25/2016 at around 1 p.m. and that she was doing well and that on 3/26/2016, he got a phone call from the facility at 3:15 p.m. and was reported that CR#5 did not eat dinner on Friday 3/25/2016 and that she had a big bruise and was not eating anymore and that the facility could not tell what had happened and that CR#5 was complaining of pain to her abdomen area. CR#5's family member further said that facility informed him that CR#5 had an x-ray to her left arm on 3/26/2016 at 6 p.m. and that his wife was in the facility on 3/26/2016 until 9:30 p.m. and that the facility did not let her know of any results. He continued saying that he had called the facility and had asked about CR#5's injuries because of the concern that CR#5 had a fall between Friday 3/25/2016 and Saturday 3/26/2016 and that he was told by the MD that it had to be a major fall and that somebody had to picked her up from the floor because CR#5 was not able to move without assistance. He further said that he wanted answers as well because why the [MEDICAL CONDITION] was not noticed until CR#5 arrived at the hospital. CR#5 should had been sent quicker to the hospital, if they would have told me on 3/26/2016 the x-ray results, I would had called an ambulance and bring her myself to the hospital, she needed help right away and they waited until the next day. CR#5's further said that he was not made aware of any medications changes by the facility staff and further said let's call (different family member) to ask her if she was notified about any recent medication changes. In a phone interview at that moment with a different family member for CR#5, she stated that she was in the facility visiting CR#5 on 3/26/2016 from around 3:00 p.m. to 9:30 p.m. and that she found CR#5 very sleepy and further said she was sleepy on and off and did say to me that she was hurting here and there and was pointing at her left hip. I did tell one of the nurses that CR#5 was complaining of pain to her hip area, to her side and they told me that CR#5 had a urinary tract infection. I told them that she was complaining of hip pain and one nurse just came and looked at CR#5 and said that CR#5 had a urinary tract infection. Then when the paramedics were about to bring CR#5 to the hospital on [DATE], I told them again that CR#5 had been complaining of pain to her left hip and leg and they told me that they would communicate the information to the ER so she could get an x-ray. CR#5 did not want to be moved. CR#5's family member further said that the facility did not notify her of any recent medication changes to CR#5 and that they were aware that CR#5 was on [MEDICATION NAME] but did not know that the MD had recently increased the medication. In an interview on 3/29/2016 at 1:10 p.m. with CR#5's MD from the facility, he stated that CR#5 had surgery to her left hip on 3/28/2016 and that she had an Open reduction Internal Fixation procedure to her left hip (type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone). In a phone interview on 3/29/2016 at 1:19 p.m. with C.N.A. E, she stated that she cared for CR#5 during the night shift on 3/25/2016 and stated that CR#5 had episodes of resisting care and that CR#5 would say no, no, no and would not let staff touch her. She further stated that she provided incontinent care to CR#5 at least twice during her shift and that she did not see any bruises or injuries to CR#5. She continued saying that the change nurse helped her once to do incontinent care to CR#5 because she was resistive to care. In a phone interview on 3/29/2016 at 2:08 p.m. with C.N.A. F, she stated that she was the aide that cared for CR#5 on the night shift on 3/26/2016 and that she did not need to do any care for her because CR#5 was clean the entire night. C.N.A. F further said I worked with her but I did not touch her because her brief was dry the entire shift. When I checked her brief, CR#5 would wake up and make noises like moaning, but I did not need to change her brief. The nurse told me that CR#5 had an injury and that she was in pain, that she had a bruise to her arm. The nurse said that if we did not need to touch her, not to touch her and not to get her up in the morning. CR#5 was on her back the entire shift, I did not even see her bruise. When asked if CR#5 was turned and repositioned during the night shift, C.N.A. F stated She turned herself, we don't need to turn her. In an interview on 3/29/2016 at 2:15 p.m. with RN G and ADON A, the ADON A stated that the facility had to notify the responsible party for antipsychotic medication changes. When asked if CR#5's family member was notified about [MEDICATION NAME] and [MEDICATION NAME] dose increase on 3/23/2016, the ADON A stated I know who got the order, let me call him right now. Further interview and observation revealed that ADON A called LVN H with her telephone and said further said while speaking on her telephone LVN H said that he did notify somebody about the increase in the dose of [MEDICATION NAME] and [MEDICATION NAME] for CR#5 but he did not remember who he spoke with and that he did not documented the information. When asked if [MEDICATION NAME] was held on 3/26/2016 when staff reported that CR#5 was out of it, ADON A said as she looked at the CR#5's MAR and departmental nurses notes you are right, she was lethargic, I think staff was cut off on the urinary tract infection and her bruise that they did not see the side effects of lethargy. [MEDICATION NAME] was not held. ADON A further said that the facility did not have a policy for family notification, that facility follows State guidelines. Further interview and record review at that time, when asked about the facility pain assessment tool, the ADON A stated that staff is supposed to monitor for pain every shift and write down on the boxes first how the residents are expressing their pain, then the score of the pain from 0 to 10 and document on the MAR any interventions for pain using the number legends. When asked if staff documented appropriately the pain assessments for CR#5, the ADON A stated as she looked at the MAR the staff is not using these tools to assess for pain, I don't know what else to say. I know that CR#5 was at least medicated for pain once on 3/26/2016 and once before she went to the hospital with Tylenol due to pain. Continued interview with RN G and ADON A, ADON A stated that RN G was made aware on 3/26/2016 at around 11:30 p.m. by LVN I, that CR#5 had positive x-ray results for fracture to her left humeral neck and that RN G instructed LVN I to call the MD at that moment and that when RN C arrived to work on 3/27/2016 at 6:30 a.m. she found out that the MD had not been notified yet or the family and that RN C called the MD and the family and sent CR#5 to the hospital. ADON A further said that LVN I had said that she did not call the MD or the family because it was 3:00 a.m. on 3/27/2016. ADON A then said that the facility had suspended LVN I due to not reporting to the MD the x-ray results and had left CR#5 laying in bed with a fracture bone. ADON A continued saying that she was made aware by CR#5's family member of the fracture pelvis in addition to the fracture shoulder and that the facility was still investigating. ADON further said I know that if CR#5 would had fallen, there is no way she could got up alone. In a phone interview on 3/29/2016 at 5:03 p.m. with RN C, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and said that CR#5 had complains of nausea on 3/26/2016 in the morning and that she gave her [MEDICATION NAME] (anti-nausea) medication. RN C further said that CR#5 was lethargic but responsive she was sleepy and did not want to eat. RN C then said that around 1:30 p.m. on 3/26/2016, it was brought to her attention by C.N.A. B that CR#5 had a large bruise to her left upper arm. RN C said that when she moved CR#5's left arm, she complained of pain and that she had call the MD and obtained order for X-ray. RN C further said CR#5 was in her night gown during the morning so did not notice any bruise. CR#5 received Tylenol for pain once during my shift that ended at 6:30 p.m. and the x-ray was done at around 6:30 p.m. MD saw CR#5 and I showed him the bruise to her left upper arm and her family member visited as well and there was no evidence of pain to her left hip. I am not aware of any falls. In an interview on 3/30/2016 at 11:15 a.m. with MA J, she stated that she was the medication aide for CR#5 on 3/25/2016 during the day time and that CR#5 was doing fine and had no pain or bruises. MA J further said that CR#5 first refused all her medications but that she then took all her medications later on. MA J continued saying that she even took CR#5's blood pressure and that she did not see any bruises or injuries. MA J said that the family member of CR#5 visited her at around noon time and that CR#5 was talking clear to him and was up on her chair. MA J further said If CR#5 had a fall, she could not get up by herself, she is one person extensive assistance for transfers and toileting. Further interview at that time, MA J stated that on 3/27/2016 at around 6:40 a.m. she went to see CR#5 because she got report that CR#5 was not doing well and that she had a STAT X-ray to her left upper arm and that was positive for fracture and further said CR#5 was so out of it, she was tired and she would tell me that she had pain, she was saying 'it hurts', her family members were present. RN C and myself changed her brief before CR#5 went to the hospital, she was really in pain during the brief change, she was saying 'ouch' . In a second interview with RN C on 3/30/2016 at 11:43 a.m., she stated that LVN I reported on 3/27/2016 during shift change that CR#5 had no pain the entire night and that she asleep well through the night. When asked about how the Pain Assessment MAR was supposed to be completed, she responded those forms are weird, they are supposed to have 2 boxes, one for the initials and the other for the assessment, they are a mixed up, we can only write our initials and not the assessment or interventions. When asked if she had written 0 on the pain assessment for 3/26/2016 and 3/27/2016 and she stated probably I completed the boxes before CR#5 complained of pain. I would not rely on that documentation, that is just repetitive. In an interview on 3/30/2016 at 2:15 p.m. with LVN I, she stated that she worked with CR#5 the 12 hour shift of 6:30 p.m. to 6:30 a.m. on 3/25/2016 and 3/26/2016. She further said that on 3/26/2016, she helped the C.N.A. E to change the brief of CR#5 at around 4:00 a.m. and that CR#5 had no pain or bruises and that nobody reported any injury. LVN I continued saying that on 3/26/2016 at 6:30 p.m. she was made aware of CR#5's bruise to her left arm and that she monitored CR#5 the entire night and that she was not in pain and further said I know that they changed her brief during the night but nobody reported any problems or any pain and every time I saw CR#5 she was sleeping, she was just resting comfortable. LVN I then said that CR#5 had a family member visiting on 3/26/2016 during the evening and that CR#5 was talking well with the family visitor and said she was alert and talking, she was even laughing with the family member, they were talking about old memories. LVN I continued saying that she got the X-ray results for CR#5 showing an impacted femur fracture and that she called RN G at around 1:00 a.m. on 3/27/2016 because she was the on-call supervisor and informed her of the x-ray results and that RN G told her to call the MD and the family until the morning and that she gave report to the oncoming shift to notify the MD and the family. When asked if she did not think about notifying the MD of the fracture results immediately, LVN I stated I did what the on call supervisor told me to do. When asked when would the MD be called during the night shift and LVN I responded if there is a change in condition, but I followed instructions. In an interview on 3/30/2016 at 2:40 p.m. with the DON, she stated that changes in condition required notification to the MD and the responsible party and that X-ray results such as the case of CR#5, it needed to be reported to the MD at that time and not wait until the morning and further said changes in condition need to be reported to the MD then the nurses are supposed to notify the on call nurse manager if it is after hours. We just implemented recently about the manager on call for nurses to call, but the MD needs to be notified first. In an interview on 3/30/2016 at 2:45 p.m. with LVN L, she stated that she was involved in the training of the nurses and that changes in condition of the residents are supposed to be notified to the MD as soon as possible. She further said that nurses are supposed to complete an SBAR form for all changes in condition and that the SBAR will guide them on the assessments and appropriate notifications that nurses are required to follow. When asked if CR#5 had any SBAR form completed, she responded as she flipped thru the chart I can not find any SBAR on CR#5's chart file. LVN L continued saying for X-ray results that are fracture, you are supposed to call the MD as soon as possible, we have a nurse manager on call, but you call the MD first then the on call manager. I will initiate a training as soon as possible today. In an interview on 3/30/2016 at 3:50 p.m. with the Administrator and the DON, the Administrator stated that CR#5 had been very aggressive to staff in the last week and that the MD had given orders for urinalysis and the results were that she had a urinary tract infection and was started on antibiotics. Administrator further said CR#5 had dementia and the psychiatrist was here and facility requested the psychiatrist to see CR#5 and her medications were changed. When asked about notification for [MEDICAL CONDITION] medications, the Administrator responded the family was notified, LVN H said he notified the family but he did not documented the information. Administrator continued saying CR#5's family member called and said CR#5 had also a pelvic fracture but we are still trying to get all the information. We don't know what happened, from what C.N.A. E was saying is that she left alone CR#5 in the morning because she was agitated. Our staff are saying that they do not know. We went through everything. CR#5 was very strong and she was able to transfer alone so if she would have fallen, she was able to get up alone. RN G instructed LVN I to call the MD and the family in the morning and CR#5 was resting comfortable. MD should had been notified but LVN I said that CR#5 was very comfortable and it was better to keep CR#5 here in the facility that for her to be in the ER waiting uncomfortable. Continued interview with the Administrator and the DON, the Administrator said Policy and protocol would be to call the MD and the family timely, that's what we need to do. In this case the MD and the family were called in the morning. The on call manager nurse is to get an additional support, not instead of calling the MD. They are there if you need help to walk thru the process. We will inservice all nurses on that. In an interview on 3/30/2016 at 4:20 p.m. with MA M, she stated that she saw CR#5 on 3/26/2016 during the afternoon shift and that CR#5 did not look good and further said her relative was there. She did not eat. I heard that CR#5 had a fall but do not know how. I only overheard it. It was not told directly to me. I heard that CR#6 had a fall on 3/25/2016. In a second interview on 3/30/2016 at 4:33 p.m. with the Administrator and the DON, the DON stated that when nurses assess the residents for pain, they are supposed to write the legend indicating the number for pain and the interventions and not only the nurses' initials. Administrator further said CR#5 was not lethargic on 3/26/2016, she was sleepy. Lethargic means that you are out of it. When surveyor pointed the documentation on CR#5's departmental notes that indicated that CR#5 was out of it, the Administrator stated out of it means that CR#5 was not herself, that she was sleepy, hard to wake up. She was not lethargic. Observation and interview on 3/30/2016 at 5:55 p.m. the DON and RN C came to surveyor and RN C stated I need to clarify my assessment with CR#5, she was sleepy but she was very responsive, lethargic was a heavy word that I used. I documented out of it because it was what the aide told me but CR#5 was doing good on 3/26/2016, she was talking and was doing better than any other day, she was answering questions appropriately and she was very alert. Record review of the facility policy and procedureAbuse Prevention Policy dated December 2013 revealed in part: .The facility will do all that it can within its control to prohibit abuse, neglect .Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of the facility policy and procedure change in a Resident's Condition or Status revised December 2006 revealed in part: .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition Record review of the facility policy and procedure Administering Medications revised April 2007 revealed in part: Medications shall be administered as prescribed Record review of the facility policy and procedure Pain Assessment and Management revised October 2010 revealed in part: ' The purpose of this procedure are to help the staff identify pain in the resident's goals and needs and that address the underlying causes of pain. Document the resident's reported level of pain with adequate detail (ie., enough information to gauge the status of pain and the effectiveness of interventions for pain) . CMS 672 dated 3/29/2016 revealed a census of 123.

Based on observation, interview and record review, the facility failed to immediately consult with resident's physician when there was a need to alter treatment significantly for one (CR#5) of 7 Residents reviewed for x-ray results. --The facility failed to promptly communicate to the MD and RP the CR#5's x-ray results of fracture to her left humeral neck (long bone of the upper arm). CR # 5 was admitted to the hospital with [REDACTED]. These failures affected one former resident (CR#5) and placed 123 residents residing at the facility at risk of not having their physicians aware of a change in their medical condition which could cause extended durations of pain and a delay in medical treatment. Findings included: Intake # 7 Record review of the facility face sheet revealed CR #5 was an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was admitted to a local hospital on [DATE] with a left humeral neck fracture and a left pelvic fracture. Record review of CR#5 annual MDS assessment dated [DATE] revealed that CR#5 had severe cognitive impairment with a BIMS score of 1 out of a total possible of 15. She usually understood others and usually made self understood. CR#5 required limited assistance with bed mobility, transfers, locomotion on and off unit, eating, toilet use and personal hygiene. CR#5 required extensive assistance for dressing and bathing. She was identified as always incontinent of bowel and bladder. Record review of CR#5's care plan dated 1/11/2016 revealed in part: .Problem:At risk for trauma related to poor bone density. Goal: CR#5 will not develop an unidentified fracture occurence during facility stay with interventions in place through 4/11/2016. Approaches: Notify MD and responsible party as indicated for changes identified in CR#5's status indicating possible injury occurence or for an actual fracture occurence . Record review of CR#5's departmental notes revealed in part: -3/23/2016 at 2:00 p.m. CR#5 in front of the facility stating she needs to leave to meet her family. CR#5 very insistent and verbally aggressive. Family made aware. Will continue to monitor Record review of Telephone orders dated 3/23/2016 revealed orders in part: - [DIAGNOSES REDACTED]. Discontinue [MEDICATION NAME] 2.5 mg three times a day and give [MEDICATION NAME] 5 mg by mouth three times a day for anxiety. Hold for lethargy. Get urinalysis with culture and sensitivity to rule out urinary tract infection Further record review of CR#5's departmental notes in part: -3/23/2016 at 7:12 p.m. MD in the facility and new orders obtained. Start [MEDICATION NAME] 5mg by mouth three times a day for anxiety, hold for lethargy and obtain urinalysis for culture to rule out urinary tract infection -3/25/2016 at 8:08 p.m. new orders for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for 7 days for urinary tract infection . Notes at 8:19 p.m. new order for [MEDICATION NAME] (anti-nausea) 4 mg every 6 hours as needed for nausea and vomiting -3/26/2016 at 8:07 a.m. Reported that CR#5 was 'out of it'. CR#5 complained of nausea. Positive bowel sounds. [MEDICATION NAME] prn for nausea. Afebrile. CR#5 refused breakfast but stated I will eat some soup later. -3/26/2016 at 4:01 p.m. MD assessed CR#5 today and gave orders to insert peripheral intravenous and start intravenous hydration at 50 cc hour for 3 days. Complete metabolic panel and complete blood cell count in the morning and geri-mox 20 cc by mouth four times a day as needed for pressure and bloating Further record review of notes at 4:46 p.m. revealed in part CR#5 refused to let nurse attempt intravenous stick. MD made aware and stated to discontinued intravenous fluids but encourage by mouth intake -3/26/2016 at 7:25 p.m. at 1:30 p.m. C.N.A. reported a bruise on CR#5. On assessment noted a bruise to left upper arm that was purplish in color. When nurse asked CR#5 what happened, she stated I layed on it too long . When nurse lifted arm, CR#5 reported pain. Nurse immediately notified MD and received order for X-ray to left shoulder and humerus (long bone in the upper arm). RP made aware of findings and new orders Addendum at 7:30 p.m. head to toe assessment completed at 1:35 p.m. No evidence of any other injuries or discomfort noted at this time. Nurse treated with as needed Tylenol at 1:45 p.m. and CR#5 stated that Tylenol helped her a lot at 2:30 P.M . -3/26/2016 at 9:00 p.m. x-ray results: Impacted left humeral neck fracture. Nurse must be present when patient care is done Record review of CR#5's radiology reports dated 3/26/2016 at 11:06 p.m. revealed in part: -Humerus minimum view, left: Results: There is an impacted left humeral neck fracture. Conclusion: Acute impacted left humeral neck fracture. -Left shoulder 1 view: Results: There is a fracture involving humeral neck with impaction. Conclusion: Impacted left humeral neck fracture . Further record review revealed a hand written note that read MD notified 3/27/2016. Continued record review of departmental notes in part: -3/27/2016 at 9:01 a.m. Nurse received shift report this a.m. that CR#5 x-ray was positive for impacted left humeral neck fracture. Nurse immediately paged the MD and went to assess CR#5. On entering CR#5 was lying on her back in the bed. CR#5 stated that she was not in pain, but slurred speech was noted. CR#5 had difficulty swallowing fluids. MD with orders to send CR#5 to hospital for further evaluation. Emergency Medical Services arrived. CR#5 verbalized pain to the left hip at time of transfer from bed to stretcher . -3/28/2016 at 4:05 p.m. call placed to son, inquired how CR#5 was at the hospital. Son stated that CR#5 presented with a fractured pelvis and fractured arm and is being evaluated by the surgeon now. Son inquired about how CR#5 acquired fractures Record review of CR#5's incident investigation for bruise incident dated 3/26/2016 at 1:30 p.m. and printed out on 3/29/2016 at 8:49 a.m. and signed by ADON A revealed in part: CR#5 sent to a local hospital for a follow up after x-ray showed a fracture to the left shoulder. CR#5 presented with bruise that was reported to nurse and x-ray showed fracture. CR#5 stated when questioned that I must of laid on it wrong. Call placed to son and stated that CR#5 also had a pelvic fracture and will be having surgery soon. Interviewed all staff that could have come in to contact or gave care to CR #5 for past seven days, no reports given of any incidents of fall, etc. All witness statements have been obtained, unable to determine the root cause of the injuries . Record review of CR#5's Medication Administration Record for March 2016 revealed that [MEDICATION NAME] 5mg one tablet by mouth was administered three times a day from 3/24/2016 thru 3/26/2016. Further record review revealed that [MEDICATION NAME] 325 mg tablet (Tylenol) 650 mg every 6 hours as needed for pain was administered one time the entire month on 3/26/2016 at 1:45 p.m. Record review of CR#5's Pain Assessment MAR for March 2016 revealed a score of 0 throughout the entire month. Further record review revealed that under interventions for noted pain there were no interventions indicated on the MAR. Boxes had the licensed nurses initials instead of the legend numbers indicating interventions. In an interview on 3/29/2016 at 6:39 a.m. with ADON A, she stated that CR#5 had a bruise to her left upper arm that had turned into a fracture to her shoulder and that CR#5 was at the hospital since 3/27/2016. She further said that the facility had interviewed about 30 employees and that nobody knew how CR#5 had the fracture. In a phone interview on 3/29/2016 at 9:40 a.m. with C.N.A. B, she stated that she cared for CR#5 on 3/26/2016 and that she had received report from the night shift staff that CR#5 had been very combative during the night shift and that she was the last one to have incontinent care on the shift. C.N.A. B further said that when she first saw CR#5 in the morning, CR#5 was asleep and that her brief was dry the entire morning and that she did not need to do incontinent care because the brief remained dry the entire morning. C.N.A. B continued saying On Friday 3/25/2016 when I worked with her, CR#5 was talking, she was alert, she was her own self and did not have any bruising, on Saturday 3/26/2016, it was a big change, CR#5 complained that her stomach was hurting and did not want to eat breakfast or lunch. CR#5 was so sleepy the entire shift that she could barely talked, you could barely understand her and her eyes were rolling backwards. RN C was made aware. CR#5 could not drink from her straw, she could not suction water or fluids with the straw, she would not open her mouth, she was barely talking and was barely moving and stayed all day in bed that day. Sunday 3/27/2016, CR#5 could barely talk, she was super sleepy, pale and was not able to eat breakfast again. I tried to give her water but she could not sip her water . Continued interview with C.N.A. B, she stated that on 3/26/2016 at around 1 p.m., when she was about to do incontinent care to CR#5, she noticed a large bruise to her left upper arm and that she immediately reported the bruise to RN C and that she noticed when RN C moved CR#5's left arm, she complained of pain. In a phone interview on 3/29/2016 at 10:55 a.m. with C.N.A. D, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and that on 3/26/2016, she was the medication aide for CR#5 in the day shift and the aide in the afternoon shift. C.N.A. D further said that the day shift aide had discovered the bruise to CR#5's left upper arm and that CR#5 was supposed to have a shower that afternoon but she was not able to give the shower because CR#5 wasn't with it, she wasn't herself. C.N.A. D continued saying CR#5 did seem very drowsy on 3/26/2016, RN C was there and saw what I saw. On Friday 3/25/2016, CR#5 was fine. On 3/26/2016 her medications had to be crushed because she could not swallow. CR#5 was in pain when we changed her brief and when we turned her. CR#5 was complaining of pain all over, to her abdomen and her knees. Whenever we changed her brief, CR#5 would not let us and would say 'owww' and would grimaced her face, she would refused to allow us to change her brief and would point with her fingers to her left upper thigh, abdomen and knees. Family member was there and she reported that CR#5 was also complaining of pain in her chest and RN C was made aware. C.N.A. D further said that CR#5 had her brief changed at the beginning of her 2 - 10 p.m. shift and another time later during the shift and before the end of her shift at 10p.m. When asked if information about CR#5's pain during brief change was reported to the nurse. C.N.A. D said that she did report to whoever was the nurse present about CR#5 being in pain and not letting staff to touch her. Further interview at that time, when asked if CR#5's [MEDICATION NAME] was held due to her mental condition, C.N.A. D stated that charge nurse did not let her know to hold the medication. Observation on 3/29/2016 at 12:39 p.m. CR#5 was in a local hospital, she was non-verbal to surveyor and had oxygen via nasal cannula at 2.5 liters per minute and had an intravenous fluids to her right arm. In an interview on 3/29/16 at 12:39 PM with CR#5's family member, he stated that CR#5 had major surgery due to the trauma to her left hip bone. He further said that CR#5 had a broken left shoulder and left femur (thighbone) head and hip socket that had to be reconstruct as the head of the thighbone was pushed into the socket. CR#5's family member further said that an MD told him that for the trauma that CR#5 presented to her left hip and her left shoulder, it appeared that it was a hard fall. CR#5's family member continued saying as he exposed CR#5's left upper arm I believe that she was grabbed very hard from her left arm because of the extensiveness of the bruise and the swelling area. Further observation at that time, CR#5's left upper arm was dark purple in color and swollen. Continued interview at that time with CR#5's family member, he stated that he visited CR#5 on 3/25/2016 at around 1 p.m. and that she was doing well and that on 3/26/2016, he got a phone call from the facility at 3:15 p.m. and was reported that CR#5 did not eat dinner on Friday 3/25/2016 and that she had a big bruise and was not eating anymore and that the facility could not tell what had happened and that CR#5 was complaining of pain to her abdomen area. CR#5's family member further said that facility informed him that CR#5 had an x-ray to her left arm on 3/26/2016 at 6 p.m. and that his wife was in the facility on 3/26/2016 until 9:30 p.m. and that the facility did not let her know of any results. He continued saying that he had called the facility and had asked about CR#5's injuries because of the concern that CR#5 had a fall between Friday 3/25/2016 and Saturday 3/26/2016 and that he was told by the MD that it had to be a major fall and that somebody had to picked her up from the floor because CR#5 was not able to move without assistance. He further said that he wanted answers as well because why the [MEDICAL CONDITION] was not noticed until CR#5 arrived at the hospital. CR#5 should had been sent quicker to the hospital, if they would have told me on 3/26/2016 the x-ray results, I would had called an ambulance and bring her myself to the hospital, she needed help right away and they waited until the next day. CR#5's further said that he was not made aware of any medications changes by the facility staff and further said let's call (different family member) to ask her if she was notified about any recent medication changes. In a phone interview at that moment with a different family member of CR#5, she stated that she was in the facility visiting CR#5 on 3/26/2016 from around 3:00 p.m. to 9:30 p.m. and that she found CR#5 very sleepy and further said she was sleepy on and off and did say to me that she was hurting here and there and was pointing at her left hip. I did tell one of the nurses that CR#5 was complaining of pain to her hip area, to her side and they told me that CR#5 had a urinary tract infection. I told them that she was complaining of hip pain and one nurse just came and looked at CR#5 and said that CR#5 had a urinary tract infection. Then when the paramedics were about to bring CR#5 to the hospital on [DATE], I told them again that CR#5 had been complaining of pain to her left hip and leg and they told me that they would communicate the information to the ER so she could get an x-ray. CR#5 did not want to be moved. CR#5's family member further said that the facility did not notify her of any recent medication changes to CR#5 and that they were aware that CR#5 was on [MEDICATION NAME] but did not know that the MD had recently increased the medication. In an interview on 3/29/2016 at 1:10 p.m. with CR#5's MD from the facility, he stated that CR#5 had surgery to her left hip on 3/28/2016 and that she had an Open reduction Internal Fixation procedure to her left hip (type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone). In an interview on 3/29/2016 at 2:15 p.m. with RN G and ADON A, the ADON A stated that the facility had to notify the responsible party for antipsychotic medication changes. When asked if CR#5's family member was notified about [MEDICATION NAME] and [MEDICATION NAME] dose increase on 3/23/2016, the ADON A stated I know who got the order, let me call him right now. Further interview and observation revealed that ADON A called LVN H with her telephone and said further said while speaking on her telephone LVN H said that he did notify somebody about the increase in the dose of [MEDICATION NAME] and [MEDICATION NAME] for CR#5 but he did not remember who he spoke with and that he did not documented the information. When asked if [MEDICATION NAME] was held on 3/26/2016 when staff reported that CR#5 was out of it, ADON A said as she looked at the CR#5's MAR and departmental nurses notes you are right, she was lethargic, I think staff was cut off on the urinary tract infection and her bruise that they did not see the side effects of lethargy. [MEDICATION NAME] was not held. ADON A further said that the facility did not have a policy for family notification, that facility follows State guidelines. Further interview and record review at that time, when asked about the facility pain assessment tool, the ADON A stated that staff is supposed to monitor for pain every shift and write down on the boxes first how the residents are expressing their pain, then the score of the pain from 0 to 10 and document on the MAR any interventions for pain using the number legends. When asked if staff documented appropriately the pain assessments for CR#5, the ADON A stated as she looked at the MAR the staff is not using these tools to assess for pain, I don't know what else to say. I know that CR#5 was at least medicated for pain once on 3/26/2016 and once before she went to the hospital with Tylenol due to pain. Continued interview with RN G and ADON A, ADON A stated that RN G was made aware on 3/26/2016 at around 11:30 p.m. by LVN I, that CR#5 had positive x-ray results for fracture to her left humeral neck and that RN G instructed LVN I to call the MD at that moment and that when RN C arrived to work on 3/27/2016 at 6:30 a.m. she found out that the MD had not been notified yet or the family and that RN C called the MD and the family and sent CR#5 to the hospital. ADON A further said that LVN I had said that she did not call the MD or the family because it was 3:00 a.m. on 3/27/2016. ADON A then said that the facility had suspended LVN I due to not reporting to the MD the x-ray results and had left CR#5 laying in bed with a fracture bone. ADON A continued saying that she was made aware by CR#5's family member of the fracture pelvis in addition to the fracture shoulder and that the facility was still investigating. ADON further said I know that if CR#5 would had fallen, there is no way she could got up alone. In a phone interview on 3/29/2016 at 5:03 p.m. with RN C, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and said that CR#5 had complains of nausea on 3/26/2016 in the morning and that she gave her [MEDICATION NAME] (anti-nausea) medication. RN C further said that CR#5 was lethargic but responsive she was sleepy and did not want to eat. RN C then said that around 1:30 p.m. on 3/26/2016, it was brought to her attention by C.N.A. B that CR#5 had a large bruise to her left upper arm. RN C said that when she moved CR#5's left arm, she complained of pain and that she had call the MD and obtained order for X-ray. RN C further said CR#5 was in her night gown during the morning so did not notice any bruise. CR#5 received Tylenol for pain once during my shift that ended at 6:30 p.m. and the x-ray was done at around 6:30 p.m. MD saw CR#5 and I showed him the bruise to her left upper arm and her family member visited as well and there was no evidence of pain to her left hip. I am not aware of any falls. In an interview on 3/30/2016 at 11:15 a.m. with MA J, she stated that she was the medication aide for CR#5 on 3/25/2016 during the day time and that CR#5 was doing fine and had no pain or bruises. MA J further said that CR#5 first refused all her medications but that she then took all her medications later on. MA J continued saying that she even took CR#5's blood pressure and that she did not see any bruises or injuries. MA J said that the family member of CR#5 visited her at around noon time and that CR#5 was talking clear to him and was up on her chair. MA J further said If CR#5 had a fall, she could not get up by herself, she is one person extensive assistance for transfers and toileting. Further interview at that time, MA J stated that on 3/27/2016 at around 6:40 a.m. she went to see CR#5 because she got report that CR#5 was not doing well and that she had a STAT X-ray to her left upper arm and that was positive for fracture and further said CR#5 was so out of it, she was tired and she would tell me that she had pain, she was saying 'it hurts', her family members were present. RN C and myself changed her brief before CR#5 went to the hospital, she was really in pain during the brief change, she was saying 'ouch' . In a second interview with RN C on 3/30/2016 at 11:43 a.m., she stated that LVN I reported on 3/27/2016 during shift change that CR#5 had no pain the entire night and that she asleep well through the night. When asked about how the Pain Assessment MAR was supposed to be completed, she responded those forms are weird, they are supposed to have 2 boxes, one for the initials and the other for the assessment, they are a mixed up, we can only write our initials and not the assessment or interventions. When asked if she had written 0 on the pain assessment for 3/26/2016 and 3/27/2016 and she stated probably I completed the boxes before CR#5 complained of pain. I would not rely on that documentation, that is just repetitive. In an interview on 3/30/2016 at 2:15 p.m. with LVN I, she stated that she worked with CR#5 the 12 hour shift of 6:30 p.m. to 6:30 a.m. on 3/25/2016 and 3/26/2016. She further said that on 3/26/2016, she helped the C.N.A. E to change the brief of CR#5 at around 4:00 a.m. and that CR#5 had no pain or bruises and that nobody reported any injury. LVN I continued saying that on 3/26/2016 at 6:30 p.m. she was made aware of CR#5's bruise to her left arm and that she monitored CR#5 the entire night and that she was not in pain and further said I know that they changed her brief during the night but nobody reported any problems or any pain and every time I saw CR#5 she was sleeping, she was just resting comfortable. LVN I then said that CR#5 had a family member visiting on 3/26/2016 during the evening and that CR#5 was talking well with the family visitor and said she was alert and talking, she was even laughing with the family member, they were talking about old memories. LVN I continued saying that she got the X-ray results for CR#5 showing an impacted femur fracture and that she called RN G at around 1:00 a.m. on 3/27/2016 because she was the on-call supervisor and informed her of the x-ray results and that RN G told her to call the MD and the family until the morning and that she gave report to the oncoming shift to notify the MD and the family. When asked if she did not think about notifying the MD of the fracture results immediately, LVN I stated I did what the on call supervisor told me to do. When asked when would the MD be called during the night shift and LVN I responded if there is a change in condition, but I followed instructions. In an interview on 3/30/2016 at 2:40 p.m. with the DON, she stated that changes in condition required notification to the MD and the responsible party and that X-ray results such as the case of CR#5, it needed to be reported to the MD at that time and not wait until the morning and further said changes in condition need to be reported to the MD then the nurses are supposed to notify the on call nurse manager if it is after hours. We just implemented recently about the manager on call for nurses to call, but the MD needs to be notified first. In an interview on 3/30/2016 at 2:45 p.m. with LVN L, she stated that she was involved in the training of the nurses and that changes in condition of the residents are supposed to be notified to the MD as soon as possible. She further said that nurses are supposed to complete an SBAR form for all changes in condition and that the SBAR will guide them on the assessments and appropriate notifications that nurses are required to follow. When asked if CR#5 had any SBAR form completed, she responded as she flipped thru the chart I can not find any SBAR on CR#5's chart file. LVN L continued saying for X-ray results that are fracture, you are supposed to call the MD as soon as possible, we have a nurse manager on call, but you call the MD first then the on call manager. I will initiate a training as soon as possible today. In an interview on 3/30/2016 at 3:50 p.m. with the Administrator and the DON, the Administrator stated that CR#5 had been very aggressive to staff in the last week and that the MD had given orders for urinalysis and the results were that she had a urinary tract infection and was started on antibiotics. Administrator further said CR#5 had dementia and the psychiatrist was here and facility requested the psychiatrist to see CR#5 and her medications were changed. When asked about notification for [MEDICAL CONDITION] medications, the Administrator responded the family was notified, LVN H said he notified the family but he did not documented the information. Administrator continued saying CR#5's family member called and said CR#5 had also a pelvic fracture but we are still trying to get all the information. We don't know what happened, from what C.N.A. E was saying is that she left alone CR#5 in the morning because she was agitated. Our staff are saying that they do not know. We went through everything. CR#5 was very strong and she was able to transfer alone so if she would have fallen, she was able to get up alone. RN G instructed LVN I to call the MD and the family in the morning and CR#5 was resting comfortable. MD should had been notified but LVN I said that CR#5 was very comfortable and it was better to keep CR#5 here in the facility that for her to be in the ER waiting uncomfortable. Continued interview with the Administrator and the DON, the Administrator said Policy and protocol would be to call the MD and the family timely, that's what we need to do. In this case the MD and the family were called in the morning. The on call manager nurse is to get an additional support, not instead of calling the MD. They are there if you need help to walk thru the process. We will inservice all nurses on that. In an interview on 3/30/2016 at 4:20 p.m. with MA M, she stated that she saw CR#5 on 3/26/2016 during the afternoon shift and that CR#5 did not look good and further said her relative was there. She did not eat. I heard that CR#5 had a fall but do not know how. I only overheard it. It was not told directly to me. I heard that CR#6 had a fall on 3/25/2016. In a second interview on 3/30/2016 at 4:33 p.m. with the Administrator and the DON, the DON stated that when nurses assess the residents for pain, they are supposed to write the legend indicating the number for pain and the interventions and not only the nurses' initials. Administrator further said CR#5 was not lethargic on 3/26/2016, she was sleepy. Lethargic means that you are out of it. When surveyor pointed the documentation on CR#5's departmental notes that indicated that CR#5 was out of it, the Administrator stated out of it means that CR#5 was not herself, that she was sleepy, hard to wake up. She was not lethargic. Observation and interview on 3/30/2016 at 5:55 p.m. the DON and RN C came to surveyor and RN C stated I need to clarify my assessment with CR#5, she was sleepy but she was very responsive, lethargic was a heavy word that I used. I documented out of it because it was what the aide told me but CR#5 was doing good on 3/26/2016, she was talking and was doing better than any other day, she was answering questions appropriately and she was very alert. Record review of the facility policy and procedure change in a Resident's Condition or Status revised December 2006 revealed in part: .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition Record review of the facility policy and procedure Administering Medications revised April 2007 revealed in part: Medications shall be administered as prescribed Record review of the facility policy and procedure Pain Assessment and Management revised October 2010 revealed in part: ' The purpose of this procedure are to help the staff identify pain in the resident's goals and needs and that address the underlying causes of pain. Document the resident's reported level of pain with adequate detail (ie., enough information to gauge the status of pain and the effectiveness of interventions for pain) . CMS 672 dated 3/29/2016 revealed a census of 123.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one of seven residents reviewed for abuse and neglect (CR#5). -- The facility neglected to evaluate, promptly address, provide adequate assessments, closely monitor and provide adequate treatment for [REDACTED]. --The facility neglected to consult with the MD in a timely manner. These failures affected one former resident (CR#5) and could place the 123 residents residing at the facility at risk of not receiving adequate assessments, medical care, pain and decline in their health condition well-being. Findings included: Record review of the facility policy and procedureAbuse Prevention Policy dated December 2013 revealed in part: .The facility will do all that it can within its control to prohibit abuse, neglect .Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Record review of the facility face sheet revealed CR #5 was an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was admitted to a local hospital on [DATE] with a left humeral neck fracture and a left pelvic fracture. Record review of CR#5 annual MDS assessment dated [DATE] revealed that CR#5 had severe cognitive impairment with a BIMS score of 1 out of a total possible of 15. She usually understood others and usually made self understood. CR#5 required limited assistance with bed mobility, transfers, locomotion on and off unit, eating, toilet use and personal hygiene. CR#5 required extensive assistance for dressing and bathing. She was identified as always incontinent of bowel and bladder. Record review of CR#5's care plan dated 1/11/2016 revealed in part: .Problem:At risk for trauma related to poor bone density. Goal: CR#5 will not develop an unidentified fracture occurence during facility stay with interventions in place through 4/11/2016. Approaches: Notify MD and responsible party as indicated for changes identified in CR#5's status indicating possible injury occurence or for an actual fracture occurence . Record review of CR#5's departmental notes revealed in part: -3/23/2016 at 2:00 p.m. CR#5 in front of the facility stating she needs to leave to meet her family. CR#5 very insistent and verbally aggressive. Family made aware. Will continue to monitor Record review of Telephone orders dated 3/23/2016 revealed orders in part: - [DIAGNOSES REDACTED]. Discontinue [MEDICATION NAME] 2.5 mg three times a day and give [MEDICATION NAME] 5 mg by mouth three times a day for anxiety. Hold for lethargy. Get urinalysis with culture and sensitivity to rule out urinary tract infection Further record review of CR#5's departmental notes in part: -3/23/2016 at 7:12 p.m. MD in the facility and new orders obtained. Start [MEDICATION NAME] 5mg by mouth three times a day for anxiety, hold for lethargy and obtain urinalysis for culture to rule out urinary tract infection -3/25/2016 at 8:08 p.m. new orders for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for 7 days for urinary tract infection . Notes at 8:19 p.m. new order for [MEDICATION NAME] (anti-nausea) 4 mg every 6 hours as needed for nausea and vomiting -3/26/2016 at 8:07 a.m. Reported that CR#5 was 'out of it'. CR#5 complained of nausea. Positive bowel sounds. [MEDICATION NAME] prn for nausea. Afebrile. CR#5 refused breakfast but stated I will eat some soup later. -3/26/2016 at 4:01 p.m. MD assessed CR#5 today and gave orders to insert peripheral intravenous and start intravenous hydration at 50 cc hour for 3 days. Complete metabolic panel and complete blood cell count in the morning and geri-mox 20 cc by mouth four times a day as needed for pressure and bloating Further record review of notes at 4:46 p.m. revealed in part CR#5 refused to let nurse attempt intravenous stick. MD made aware and stated to discontinued intravenous fluids but encourage by mouth intake -3/26/2016 at 7:25 p.m. at 1:30 p.m. C.N.A. reported a bruise on CR#5. On assessment noted a bruise to left upper arm that was purplish in color. When nurse asked CR#5 what happened, she stated I layed on it too long . When nurse lifted arm, CR#5 reported pain. Nurse immediately notified MD and received order for X-ray to left shoulder and humerus (long bone in the upper arm). RP made aware of findings and new orders Addendum at 7:30 p.m. head to toe assessment completed at 1:35 p.m. No evidence of any other injuries or discomfort noted at this time. Nurse treated with as needed Tylenol at 1:45 p.m. and CR#5 stated that Tylenol helped her a lot at 2:30 P.M . -3/26/2016 at 9:00 p.m. x-ray results: Impacted left humeral neck fracture. Nurse must be present when patient care is done Record review of CR#5's radiology reports dated 3/26/2016 at 11:06 p.m. revealed in part: -Humerus minimum view, left: Results: There is an impacted left humeral neck fracture. Conclusion: Acute impacted left humeral neck fracture. -Left shoulder 1 view: Results: There is a fracture involving humeral neck with impaction. Conclusion: Impacted left humeral neck fracture . Further record review revealed a hand written note that read MD notified 3/27/2016. Continued record review of departmental notes in part: -3/27/2016 at 9:01 a.m. Nurse received shift report this a.m. that CR#5 x-ray was positive for impacted left humeral neck fracture. Nurse immediately paged the MD and went to assess CR#5. On entering CR#5 was lying on her back in the bed. CR#5 stated that she was not in pain, but slurred speech was noted. CR#5 had difficulty swallowing fluids. MD with orders to send CR#5 to hospital for further evaluation. Emergency Medical Services arrived. CR#5 verbalized pain to the left hip at time of transfer from bed to stretcher . -3/28/2016 at 4:05 p.m. call placed to son, inquired how CR#5 was at the hospital. Son stated that CR#5 presented with a fractured pelvis and fractured arm and is being evaluated by the surgeon now. Son inquired about how CR#5 acquired fractures Record review of CR#5's incident investigation for bruise incident dated 3/26/2016 at 1:30 p.m. and printed out on 3/29/2016 at 8:49 a.m. and signed by ADON A revealed in part: CR#5 sent to a local hospital for a follow up after x-ray showed a fracture to the left shoulder. CR#5 presented with bruise that was reported to nurse and x-ray showed fracture. CR#5 stated when questioned that I must of laid on it wrong. Call placed to son and stated that CR#5 also had a pelvic fracture and will be having surgery soon. Interviewed all staff that could have come in to contact or gave care to CR #5 for past seven days, no reports given of any incidents of fall, etc. All witness statements have been obtained, unable to determine the root cause of the injuries . Record review of CR#5's Medication Administration Record for March 2016 revealed that [MEDICATION NAME] 5mg one tablet by mouth was administered three times a day from 3/24/2016 thru 3/26/2016. Further record review revealed that [MEDICATION NAME] 325 mg tablet (Tylenol) 650 mg every 6 hours as needed for pain was administered one time the entire month on 3/26/2016 at 1:45 p.m. Record review of CR#5's Pain Assessment MAR for March 2016 revealed a score of 0 throughout the entire month. Further record review revealed that under interventions for noted pain there were no interventions indicated on the MAR. Boxes had the licensed nurses initials instead of the legend numbers indicating interventions. In an interview on 3/29/2016 at 6:39 a.m. with ADON A, she stated that CR#5 had a bruise to her left upper arm that had turned into a fracture to her shoulder and that CR#5 was at the hospital since 3/27/2016. She further said that the facility had interviewed about 30 employees and that nobody knew how CR#5 had the fracture. In a phone interview on 3/29/2016 at 9:40 a.m. with C.N.A. B, she stated that she cared for CR#5 on 3/26/2016 and that she had received report from the night shift staff that CR#5 had been very combative during the night shift and that she was the last one to have incontinent care on the shift. C.N.A. B further said that when she first saw CR#5 in the morning, CR#5 was asleep and that her brief was dry the entire morning and that she did not need to do incontinent care because the brief remained dry the entire morning. C.N.A. B continued saying On Friday 3/25/2016 when I worked with her, CR#5 was talking, she was alert, she was her own self and did not have any bruising, on Saturday 3/26/2016, it was a big change, CR#5 complained that her stomach was hurting and did not want to eat breakfast or lunch. CR#5 was so sleepy the entire shift that she could barely talked, you could barely understand her and her eyes were rolling backwards. RN C was made aware. CR#5 could not drink from her straw, she could not suction water or fluids with the straw, she would not open her mouth, she was barely talking and was barely moving and stayed all day in bed that day. Sunday 3/27/2016, CR#5 could barely talk, she was super sleepy, pale and was not able to eat breakfast again. I tried to give her water but she could not sip her water . Continued interview with C.N.A. B, she stated that on 3/26/2016 at around 1 p.m., when she was about to do incontinent care to CR#5, she noticed a large bruise to her left upper arm and that she immediately reported the bruise to RN C and that she noticed when RN C moved CR#5's left arm, she complained of pain. In a phone interview on 3/29/2016 at 10:55 a.m. with C.N.A. D, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and that on 3/26/2016, she was the medication aide for CR#5 in the day shift and the aide in the afternoon shift. C.N.A. D further said that the day shift aide had discovered the bruise to CR#5's left upper arm and that CR#5 was supposed to have a shower that afternoon but she was not able to give the shower because CR#5 wasn't with it, she wasn't herself. C.N.A. D continued saying CR#5 did seem very drowsy on 3/26/2016, RN C was there and saw what I saw. On Friday 3/25/2016, CR#5 was fine. On 3/26/2016 her medications had to be crushed because she could not swallow. CR#5 was in pain when we changed her brief and when we turned her. CR#5 was complaining of pain all over, to her abdomen and her knees. Whenever we changed her brief, CR#5 would not let us and would say 'owww' and would grimaced her face, she would refused to allow us to change her brief and would point with her fingers to her left upper thigh, abdomen and knees. Family member was there and she reported that CR#5 was also complaining of pain in her chest and RN C was made aware. C.N.A. D further said that CR#5 had her brief changed at the beginning of her 2 - 10 p.m. shift and another time later during the shift and before the end of her shift at 10p.m. When asked if information about CR#5's pain during brief change was reported to the nurse. C.N.A. D said that she did report to whoever was the nurse present about CR#5 being in pain and not letting staff to touch her. Further interview at that time, when asked if CR#5's [MEDICATION NAME] was held due to her mental condition, C.N.A. D stated that charge nurse did not let her know to hold the medication. Observation on 3/29/2016 at 12:39 p.m. CR#5 was in a local hospital, she was non-verbal to surveyor and had oxygen via nasal cannula at 2.5 liters per minute and had an intravenous fluids to her right arm. In an interview on 3/29/16 at 12:39 PM with CR#5's family member, he stated that CR#5 had major surgery due to the trauma to her left hip bone. He further said that CR#5 had a broken left shoulder and left femur (thighbone) head and hip socket that had to be reconstruct as the head of the thighbone was pushed into the socket. CR#5's family member further said that an MD told him that for the trauma that CR#5 presented to her left hip and her left shoulder, it appeared that it was a hard fall. CR#5's family member continued saying as he exposed CR#5's left upper arm I believe that she was grabbed very hard from her left arm because of the extensiveness of the bruise and the swelling area. Further observation at that time, CR#5's left upper arm was dark purple in color and swollen. Continued interview at that time with CR#5's family member, he stated that he visited CR#5 on 3/25/2016 at around 1 p.m. and that she was doing well and that on 3/26/2016, he got a phone call from the facility at 3:15 p.m. and was reported that CR#5 did not eat dinner on Friday 3/25/2016 and that she had a big bruise and was not eating anymore and that the facility could not tell what had happened and that CR#5 was complaining of pain to her abdomen area. CR#5's family member further said that facility informed him that CR#5 had an x-ray to her left arm on 3/26/2016 at 6 p.m. and that his wife was in the facility on 3/26/2016 until 9:30 p.m. and that the facility did not let her know of any results. He continued saying that he had called the facility and had asked about CR#5's injuries because of the concern that CR#5 had a fall between Friday 3/25/2016 and Saturday 3/26/2016 and that he was told by the MD that it had to be a major fall and that somebody had to picked her up from the floor because CR#5 was not able to move without assistance. He further said that he wanted answers as well because why the [MEDICAL CONDITION] was not noticed until CR#5 arrived at the hospital. CR#5 should had been sent quicker to the hospital, if they would have told me on 3/26/2016 the x-ray results, I would had called an ambulance and bring her myself to the hospital, she needed help right away and they waited until the next day. CR#5's further said that he was not made aware of any medications changes by the facility staff and further said let's call (different family member) to ask her if she was notified about any recent medication changes. In a phone interview at that moment with a different family member of CR#5, she stated that she was in the facility visiting CR#5 on 3/26/2016 from around 3:00 p.m. to 9:30 p.m. and that she found CR#5 very sleepy and further said she was sleepy on and off and did say to me that she was hurting here and there and was pointing at her left hip. I did tell one of the nurses that CR#5 was complaining of pain to her hip area, to her side and they told me that CR#5 had a urinary tract infection. I told them that she was complaining of hip pain and one nurse just came and looked at CR#5 and said that CR#5 had a urinary tract infection. Then when the paramedics were about to bring CR#5 to the hospital on [DATE], I told them again that CR#5 had been complaining of pain to her left hip and leg and they told me that they would communicate the information to the ER so she could get an x-ray. CR#5 did not want to be moved. CR#5's family member further said that the facility did not notify her of any recent medication changes to CR#5 and that they were aware that CR#5 was on [MEDICATION NAME] but did not know that the MD had recently increased the medication. In an interview on 3/29/2016 at 1:10 p.m. with CR#5's MD from the facility, he stated that CR#5 had surgery to her left hip on 3/28/2016 and that she had an Open reduction Internal Fixation procedure to her left hip (type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone). In a phone interview on 3/29/2016 at 1:19 p.m. with C.N.A. E, she stated that she cared for CR#5 during the night shift on 3/25/2016 and stated that CR#5 had episodes of resisting care and that CR#5 would say no, no, no and would not let staff touch her. She further stated that she provided incontinent care to CR#5 at least twice during her shift and that she did not see any bruises or injuries to CR#5. She continued saying that the change nurse helped her once to do incontinent care to CR#5 because she was resistive to care. In a phone interview on 3/29/2016 at 2:08 p.m. with C.N.A. F, she stated that she was the aide that cared for CR#5 on the night shift on 3/26/2016 and that she did not need to do any care for her because CR#5 was clean the entire night. C.N.A. F further said I worked with her but I did not touch her because her brief was dry the entire shift. When I checked her brief, CR#5 would wake up and make noises like moaning, but I did not need to change her brief. The nurse told me that CR#5 had an injury and that she was in pain, that she had a bruise to her arm. The nurse said that if we did not need to touch her, not to touch her and not to get her up in the morning. CR#5 was on her back the entire shift, I did not even see her bruise. When asked if CR#5 was turned and repositioned during the night shift, C.N.A. F stated She turned herself, we don't need to turn her. In an interview on 3/29/2016 at 2:15 p.m. with RN G and ADON A, the ADON A stated that the facility had to notify the responsible party for antipsychotic medication changes. When asked if CR#5's family member was notified about [MEDICATION NAME] and [MEDICATION NAME] dose increase on 3/23/2016, the ADON A stated I know who got the order, let me call him right now. Further interview and observation revealed that ADON A called LVN H with her telephone and said further said while speaking on her telephone LVN H said that he did notify somebody about the increase in the dose of [MEDICATION NAME] and [MEDICATION NAME] for CR#5 but he did not remember who he spoke with and that he did not documented the information. When asked if [MEDICATION NAME] was held on 3/26/2016 when staff reported that CR#5 was out of it, ADON A said as she looked at the CR#5's MAR and departmental nurses notes you are right, she was lethargic, I think staff was cut off on the urinary tract infection and her bruise that they did not see the side effects of lethargy. [MEDICATION NAME] was not held. ADON A further said that the facility did not have a policy for family notification, that facility follows State guidelines. Further interview and record review at that time, when asked about the facility pain assessment tool, the ADON A stated that staff is supposed to monitor for pain every shift and write down on the boxes first how the residents are expressing their pain, then the score of the pain from 0 to 10 and document on the MAR any interventions for pain using the number legends. When asked if staff documented appropriately the pain assessments for CR#5, the ADON A stated as she looked at the MAR the staff is not using these tools to assess for pain, I don't know what else to say. I know that CR#5 was at least medicated for pain once on 3/26/2016 and once before she went to the hospital with Tylenol due to pain. Continued interview with RN G and ADON A, ADON A stated that RN G was made aware on 3/26/2016 at around 11:30 p.m. by LVN I, that CR#5 had positive x-ray results for fracture to her left humeral neck and that RN G instructed LVN I to call the MD at that moment and that when RN C arrived to work on 3/27/2016 at 6:30 a.m. she found out that the MD had not been notified yet or the family and that RN C called the MD and the family and sent CR#5 to the hospital. ADON A further said that LVN I had said that she did not call the MD or the family because it was 3:00 a.m. on 3/27/2016. ADON A then said that the facility had suspended LVN I due to not reporting to the MD the x-ray results and had left CR#5 laying in bed with a fracture bone. ADON A continued saying that she was made aware by CR#5's family member of the fracture pelvis in addition to the fracture shoulder and that the facility was still investigating. ADON further said I know that if CR#5 would had fallen, there is no way she could got up alone. In a phone interview on 3/29/2016 at 5:03 p.m. with RN C, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and said that CR#5 had complains of nausea on 3/26/2016 in the morning and that she gave her [MEDICATION NAME] (anti-nausea) medication. RN C further said that CR#5 was lethargic but responsive she was sleepy and did not want to eat. RN C then said that around 1:30 p.m. on 3/26/2016, it was brought to her attention by C.N.A. B that CR#5 had a large bruise to her left upper arm. RN C said that when she moved CR#5's left arm, she complained of pain and that she had call the MD and obtained order for X-ray. RN C further said CR#5 was in her night gown during the morning so did not notice any bruise. CR#5 received Tylenol for pain once during my shift that ended at 6:30 p.m. and the x-ray was done at around 6:30 p.m. MD saw CR#5 and I showed him the bruise to her left upper arm and her family member visited as well and there was no evidence of pain to her left hip. I am not aware of any falls. In an interview on 3/30/2016 at 11:15 a.m. with MA J, she stated that she was the medication aide for CR#5 on 3/25/2016 during the day time and that CR#5 was doing fine and had no pain or bruises. MA J further said that CR#5 first refused all her medications but that she then took all her medications later on. MA J continued saying that she even took CR#5's blood pressure and that she did not see any bruises or injuries. MA J said that the family member of CR#5 visited her at around noon time and that CR#5 was talking clear to him and was up on her chair. MA J further said If CR#5 had a fall, she could not get up by herself, she is one person extensive assistance for transfers and toileting. Further interview at that time, MA J stated that on 3/27/2016 at around 6:40 a.m. she went to see CR#5 because she got report that CR#5 was not doing well and that she had a STAT X-ray to her left upper arm and that was positive for fracture and further said CR#5 was so out of it, she was tired and she would tell me that she had pain, she was saying 'it hurts', her family members were present. RN C and myself changed her brief before CR#5 went to the hospital, she was really in pain during the brief change, she was saying 'ouch' . In a second interview with RN C on 3/30/2016 at 11:43 a.m., she stated that LVN I reported on 3/27/2016 during shift change that CR#5 had no pain the entire night and that she asleep well through the night. When asked about how the Pain Assessment MAR was supposed to be completed, she responded those forms are weird, they are supposed to have 2 boxes, one for the initials and the other for the assessment, they are a mixed up, we can only write our initials and not the assessment or interventions. When asked if she had written 0 on the pain assessment for 3/26/2016 and 3/27/2016 and she stated probably I completed the boxes before CR#5 complained of pain. I would not rely on that documentation, that is just repetitive. In an interview on 3/30/2016 at 2:15 p.m. with LVN I, she stated that she worked with CR#5 the 12 hour shift of 6:30 p.m. to 6:30 a.m. on 3/25/2016 and 3/26/2016. She further said that on 3/26/2016, she helped the C.N.A. E to change the brief of CR#5 at around 4:00 a.m. and that CR#5 had no pain or bruises and that nobody reported any injury. LVN I continued saying that on 3/26/2016 at 6:30 p.m. she was made aware of CR#5's bruise to her left arm and that she monitored CR#5 the entire night and that she was not in pain and further said I know that they changed her brief during the night but nobody reported any problems or any pain and every time I saw CR#5 she was sleeping, she was just resting comfortable. LVN I then said that CR#5 had a family member visiting on 3/26/2016 during the evening and that CR#5 was talking well with the family visitor and said she was alert and talking, she was even laughing with the family member, they were talking about old memories. LVN I continued saying that she got the X-ray results for CR#5 showing an impacted femur fracture and that she called RN G at around 1:00 a.m. on 3/27/2016 because she was the on-call supervisor and informed her of the x-ray results and that RN G told her to call the MD and the family until the morning and that she gave report to the oncoming shift to notify the MD and the family. When asked if she did not think about notifying the MD of the fracture results immediately, LVN I stated I did what the on call supervisor told me to do. When asked when would the MD be called during the night shift and LVN I responded if there is a change in condition, but I followed instructions. In an interview on 3/30/2016 at 2:40 p.m. with the DON, she stated that changes in condition required notification to the MD and the responsible party and that X-ray results such as the case of CR#5, it needed to be reported to the MD at that time and not wait until the morning and further said changes in condition need to be reported to the MD then the nurses are supposed to notify the on call nurse manager if it is after hours. We just implemented recently about the manager on call for nurses to call, but the MD needs to be notified first. In an interview on 3/30/2016 at 2:45 p.m. with LVN L, she stated that she was involved in the training of the nurses and that changes in condition of the residents are supposed to be notified to the MD as soon as possible. She further said that nurses are supposed to complete an SBAR form for all changes in condition and that the SBAR will guide them on the assessments and appropriate notifications that nurses are required to follow. When asked if CR#5 had any SBAR form completed, she responded as she flipped thru the chart I can not find any SBAR on CR#5's chart file. LVN L continued saying for X-ray results that are fracture, you are supposed to call the MD as soon as possible, we have a nurse manager on call, but you call the MD first then the on call manager. I will initiate a training as soon as possible today. In an interview on 3/30/2016 at 3:50 p.m. with the Administrator and the DON, the Administrator stated that CR#5 had been very aggressive to staff in the last week and that the MD had given orders for urinalysis and the results were that she had a urinary tract infection and was started on antibiotics. Administrator further said CR#5 had dementia and the psychiatrist was here and facility requested the psychiatrist to see CR#5 and her medications were changed. When asked about notification for [MEDICAL CONDITION] medications, the Administrator responded the family was notified, LVN H said he notified the family but he did not documented the information. Administrator continued saying CR#5's family member called and said CR#5 had also a pelvic fracture but we are still trying to get all the information. We don't know what happened, from what C.N.A. E was saying is that she left alone CR#5 in the morning because she was agitated. Our staff are saying that they do not know. We went through everything. CR#5 was very strong and she was able to transfer alone so if she would have fallen, she was able to get up alone. RN G instructed LVN I to call the MD and the family in the morning and CR#5 was resting comfortable. MD should had been notified but LVN I said that CR#5 was very comfortable and it was better to keep CR#5 here in the facility that for her to be in the ER waiting uncomfortable. Continued interview with the Administrator and the DON, the Administrator said Policy and protocol would be to call the MD and the family timely, that's what we need to do. In this case the MD and the family were called in the morning. The on call manager nurse is to get an additional support, not instead of calling the MD. They are there if you need help to walk thru the process. We will inservice all nurses on that. In an interview on 3/30/2016 at 4:20 p.m. with MA M, she stated that she saw CR#5 on 3/26/2016 during the afternoon shift and that CR#5 did not look good and further said her relative was there. She did not eat. I heard that CR#5 had a fall but do not know how. I only overheard it. It was not told directly to me. I heard that CR#6 had a fall on 3/25/2016. In a second interview on 3/30/2016 at 4:33 p.m. with the Administrator and the DON, the DON stated that when nurses assess the residents for pain, they are supposed to write the legend indicating the number for pain and the interventions and not only the nurses' initials. Administrator further said CR#5 was not lethargic on 3/26/2016, she was sleepy. Lethargic means that you are out of it. When surveyor pointed the documentation on CR#5's departmental notes that indicated that CR#5 was out of it, the Administrator stated out of it means that CR#5 was not herself, that she was sleepy, hard to wake up. She was not lethargic. Observation and interview on 3/30/2016 at 5:55 p.m. the DON and RN C came to surveyor and RN C stated I need to clarify my assessment with CR#5, she was sleepy but she was very responsive, lethargic was a heavy word that I used. I documented out of it because it was what the aide told me but CR#5 was doing good on 3/26/2016, she was talking and was doing better than any other day, she was answering questions appropriately and she was very alert. Record review of the facility policy and procedure change in a Resident's Condition or Status revised December 2006 revealed in part: .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition Record review of the facility policy and procedure Administering Medications revised April 2007 revealed in part: Medications shall be administered as prescribed Record review of the facility policy and procedure Pain Assessment and Management revised October 2010 revealed in part: ' The purpose of this procedure are to help the staff identify pain in the resident's goals and needs and that address the underlying causes of pain. Document the resident's reported level of pain with adequate detail (ie., enough information to gauge the status of pain and the effectiveness of interventions for pain) . CMS 672 dated 3/29/2016 revealed a census of 123.

Based on observation, interview and record review the facility failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of seven residents (CR#5) reviewed for quality of care. --The facility failed to obtain consent from CR#5's RP when the MD increased the dose of [MEDICATION NAME] (anti-anxiety medication) and [MEDICATION NAME] (antidepressant) and did not follow the MD orders when CR #5 was administered [MEDICATION NAME] three times in one day when she was showing sign and symptoms of lethargy. The MD had ordered to withhold [MEDICATION NAME] for lethargy. -- The facility failed to evaluate, promptly address, provide adequate assessments, closely monitor and provide adequate treatment for [REDACTED]. --The facility failed to consult with the MD in a timely manner. These failures affected one resident (CR#5) who had delayed medical treatment and could place the 119 residents who required assistance for transferring at the facility at risk of not receiving adequate assessments, medical care, pain and decline in their physical, mental and psychosocial health and self esteem. Findings included: Intake # 7 Record review of the facility face sheet revealed CR #5 was an [AGE] year old female admitted to the facility on [DATE] with following [DIAGNOSES REDACTED]. CR #5 was admitted to a local hospital on [DATE] with a left humeral neck fracture and a left pelvic fracture. Record review of CR#5 annual MDS assessment dated [DATE] revealed that CR#5 had severe cognitive impairment with a BIMS score of 1 out of a total possible of 15. She usually understood others and usually made self understood. CR#5 required limited assistance with bed mobility, transfers, locomotion on and off unit, eating, toilet use and personal hygiene. CR#5 required extensive assistance for dressing and bathing. She was identified as always incontinent of bowel and bladder. Record review of CR#5's care plan dated 1/11/2016 revealed in part: .Problem:At risk for trauma related to poor bone density. Goal: CR#5 will not develop an unidentified fracture occurence during facility stay with interventions in place through 4/11/2016. Approaches: Notify MD and responsible party as indicated for changes identified in CR#5's status indicating possible injury occurence or for an actual fracture occurence . Record review of CR#5's departmental notes revealed in part: -3/23/2016 at 2:00 p.m. CR#5 in front of the facility stating she needs to leave to meet her family. CR#5 very insistent and verbally aggressive. Family made aware. Will continue to monitor Record review of Telephone orders dated 3/23/2016 revealed orders in part: - [DIAGNOSES REDACTED]. Discontinue [MEDICATION NAME] 2.5 mg three times a day and give [MEDICATION NAME] 5 mg by mouth three times a day for anxiety. Hold for lethargy. Get urinalysis with culture and sensitivity to rule out urinary tract infection Further record review of CR#5's departmental notes in part: -3/23/2016 at 7:12 p.m. MD in the facility and new orders obtained. Start [MEDICATION NAME] 5mg by mouth three times a day for anxiety, hold for lethargy and obtain urinalysis for culture to rule out urinary tract infection -3/25/2016 at 8:08 p.m. new orders for [MEDICATION NAME] (antibiotic) 100 mg by mouth twice a day for 7 days for urinary tract infection . Notes at 8:19 p.m. new order for [MEDICATION NAME] (anti-nausea) 4 mg every 6 hours as needed for nausea and vomiting -3/26/2016 at 8:07 a.m. Reported that CR#5 was 'out of it'. CR#5 complained of nausea. Positive bowel sounds. [MEDICATION NAME] prn for nausea. Afebrile. CR#5 refused breakfast but stated I will eat some soup later. -3/26/2016 at 4:01 p.m. MD assessed CR#5 today and gave orders to insert peripheral intravenous and start intravenous hydration at 50 cc hour for 3 days. Complete metabolic panel and complete blood cell count in the morning and geri-mox 20 cc by mouth four times a day as needed for pressure and bloating Further record review of notes at 4:46 p.m. revealed in part CR#5 refused to let nurse attempt intravenous stick. MD made aware and stated to discontinued intravenous fluids but encourage by mouth intake -3/26/2016 at 7:25 p.m. at 1:30 p.m. C.N.A. reported a bruise on CR#5. On assessment noted a bruise to left upper arm that was purplish in color. When nurse asked CR#5 what happened, she stated I layed on it too long . When nurse lifted arm, CR#5 reported pain. Nurse immediately notified MD and received order for X-ray to left shoulder and humerus (long bone in the upper arm). RP made aware of findings and new orders Addendum at 7:30 p.m. head to toe assessment completed at 1:35 p.m. No evidence of any other injuries or discomfort noted at this time. Nurse treated with as needed Tylenol at 1:45 p.m. and CR#5 stated that Tylenol helped her a lot at 2:30 P.M . -3/26/2016 at 9:00 p.m. x-ray results: Impacted left humeral neck fracture. Nurse must be present when patient care is done Record review of CR#5's radiology reports dated 3/26/2016 at 11:06 p.m. revealed in part: -Humerus minimum view, left: Results: There is an impacted left humeral neck fracture. Conclusion: Acute impacted left humeral neck fracture. -Left shoulder 1 view: Results: There is a fracture involving humeral neck with impaction. Conclusion: Impacted left humeral neck fracture . Further record review revealed a hand written note that read MD notified 3/27/2016. Continued record review of departmental notes in part: -3/27/2016 at 9:01 a.m. Nurse received shift report this a.m. that CR#5 x-ray was positive for impacted left humeral neck fracture. Nurse immediately paged the MD and went to assess CR#5. On entering CR#5 was lying on her back in the bed. CR#5 stated that she was not in pain, but slurred speech was noted. CR#5 had difficulty swallowing fluids. MD with orders to send CR#5 to hospital for further evaluation. Emergency Medical Services arrived. CR#5 verbalized pain to the left hip at time of transfer from bed to stretcher . -3/28/2016 at 4:05 p.m. call placed to son, inquired how CR#5 was at the hospital. Son stated that CR#5 presented with a fractured pelvis and fractured arm and is being evaluated by the surgeon now. Son inquired about how CR#5 acquired fractures Record review of CR#5's incident investigation for bruise incident dated 3/26/2016 at 1:30 p.m. and printed out on 3/29/2016 at 8:49 a.m. and signed by ADON A revealed in part: CR#5 sent to a local hospital for a follow up after x-ray showed a fracture to the left shoulder. CR#5 presented with bruise that was reported to nurse and x-ray showed fracture. CR#5 stated when questioned that I must of laid on it wrong. Call placed to son and stated that CR#5 also had a pelvic fracture and will be having surgery soon. Interviewed all staff that could have come in to contact or gave care to CR #5 for past seven days, no reports given of any incidents of fall, etc. All witness statements have been obtained, unable to determine the root cause of the injuries . Record review of CR#5's Medication Administration Record for March 2016 revealed that [MEDICATION NAME] 5mg one tablet by mouth was administered three times a day from 3/24/2016 thru 3/26/2016. Further record review revealed that [MEDICATION NAME] 325 mg tablet (Tylenol) 650 mg every 6 hours as needed for pain was administered one time the entire month on 3/26/2016 at 1:45 p.m. Record review of CR#5's Pain Assessment MAR for March 2016 revealed a score of 0 throughout the entire month. Further record review revealed that under interventions for noted pain there were no interventions indicated on the MAR. Boxes had the licensed nurses initials instead of the legend numbers indicating interventions. In an interview on 3/29/2016 at 6:39 a.m. with ADON A, she stated that CR#5 had a bruise to her left upper arm that had turned into a fracture to her shoulder and that CR#5 was at the hospital since 3/27/2016. She further said that the facility had interviewed about 30 employees and that nobody knew how CR#5 had the fracture. In a phone interview on 3/29/2016 at 9:40 a.m. with C.N.A. B, she stated that she cared for CR#5 on 3/26/2016 and that she had received report from the night shift staff that CR#5 had been very combative during the night shift and that she was the last one to have incontinent care on the shift. C.N.A. B further said that when she first saw CR#5 in the morning, CR#5 was asleep and that her brief was dry the entire morning and that she did not need to do incontinent care because the brief remained dry the entire morning. C.N.A. B continued saying On Friday 3/25/2016 when I worked with her, CR#5 was talking, she was alert, she was her own self and did not have any bruising, on Saturday 3/26/2016, it was a big change, CR#5 complained that her stomach was hurting and did not want to eat breakfast or lunch. CR#5 was so sleepy the entire shift that she could barely talk, you could barely understand her and her eyes were rolling backwards. RN C was made aware. CR#5 could not drink from her straw, she could not suction water or fluids with the straw, she would not open her mouth, she was barely talking and was barely moving and stayed all day in bed that day. Sunday 3/27/2016, CR#5 could barely talk, she was super sleepy, pale and was not able to eat breakfast again. I tried to give her water but she could not sip her water . Continued interview with C.N.A. B, she stated that on 3/26/2016 at around 1 p.m., when she was about to do incontinent care to CR#5, she noticed a large bruise to her left upper arm and that she immediately reported the bruise to RN C and that she noticed when RN C moved CR#5's left arm, she complained of pain. In a phone interview on 3/29/2016 at 10:55 a.m. with C.N.A. D, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and that on 3/26/2016, she was the medication aide for CR#5 in the day shift and the aide in the afternoon shift. C.N.A. D further said that the day shift aide had discovered the bruise to CR#5's left upper arm and that CR#5 was supposed to have a shower that afternoon but she was not able to give the shower because CR#5 wasn't with it, she wasn't herself. C.N.A. D continued saying CR#5 did seem very drowsy on 3/26/2016, RN C was there and saw what I saw. On Friday 3/25/2016, CR#5 was fine. On 3/26/2016 her medications had to be crushed because she could not swallow. CR#5 was in pain when we changed her brief and when we turned her. CR#5 was complaining of pain all over, to her abdomen and her knees. Whenever we changed her brief, CR#5 would not let us and would say 'owww' and would grimace her face, she would refused to allow us to change her brief and would point with her fingers to her left upper thigh, abdomen and knees. Family member was there and she reported that CR#5 was also complaining of pain in her chest and RN C was made aware. C.N.A. D further said that CR#5 had her brief changed at the beginning of her 2 - 10 p.m. shift and another time later during the shift and before the end of her shift at 10p.m. When asked if information about CR#5's pain during brief change was reported to the nurse. C.N.A. D said that she did report to whoever was the nurse present about CR#5 being in pain and not letting staff to touch her. Further interview at that time, when asked if CR#5's [MEDICATION NAME] was held due to her mental condition, C.N.A. D stated that charge nurse did not let her know to hold the medication. Observation on 3/29/2016 at 12:39 p.m. CR#5 was in a local hospital, she was non-verbal to surveyor and had oxygen via nasal cannula at 2.5 liters per minute and had an intravenous fluids to her right arm. In an interview on 3/29/16 at 12:39 PM with CR#5's family member, he stated that CR#5 had major surgery due to the trauma to her left hip bone. He further said that CR#5 had a broken left shoulder and left femur (thighbone) head and hip socket that had to be reconstruct as the head of the thighbone was pushed into the socket. CR#5's family member further said that an MD told him that for the trauma that CR#5 presented to her left hip and her left shoulder, it appeared that it was a hard fall. CR#5's family member continued saying as he exposed CR#5's left upper arm I believe that she was grabbed very hard from her left arm because of the extensiveness of the bruise and the swelling area. Further observation at that time, CR#5's left upper arm was dark purple in color and swollen. Continued interview at that time with CR#5's family member, he stated that he visited CR#5 on 3/25/2016 at around 1 p.m. and that she was doing well and that on 3/26/2016, he got a phone call from the facility at 3:15 p.m. and was reported that CR#5 did not eat dinner on Friday 3/25/2016 and that she had a big bruise and was not eating anymore and that the facility could not tell what had happened and that CR#5 was complaining of pain to her abdomen area. CR#5's family member further said that facility informed him that CR#5 had an x-ray to her left arm on 3/26/2016 at 6 p.m. and that another family member was in the facility on 3/26/2016 until 9:30 p.m. and that the facility did not let her know of any results. He continued saying that he had called the facility and had asked about CR#5's injuries because of the concern that CR#5 had a fall between Friday 3/25/2016 and Saturday 3/26/2016 and that he was told by the MD that it had to be a major fall and that somebody had to picked her up from the floor because CR#5 was not able to move without assistance. He further said that he wanted answers as well because why the [MEDICAL CONDITION] was not noticed until CR#5 arrived at the hospital. CR#5 should had been sent quicker to the hospital, if they would have told me on 3/26/2016 the x-ray results, I would had called an ambulance and bring her myself to the hospital, she needed help right away and they waited until the next day. CR#5's further said that he was not made aware of any medications changes by the facility staff and further said let's call (different family member) to ask her if she was notified about any recent medication changes. In a phone interview at that moment with a different family member of CR#5, she stated that she was in the facility visiting CR#5 on 3/26/2016 from around 3:00 p.m. to 9:30 p.m. and that she found CR#5 very sleepy and further said she was sleepy on and off and did say to me that she was hurting here and there and was pointing at her left hip. I did tell one of the nurses that CR#5 was complaining of pain to her hip area, to her side and they told me that CR#5 had a urinary tract infection. I told them that she was complaining of hip pain and one nurse just came and looked at CR#5 and said that CR#5 had a urinary tract infection. Then when the paramedics were about to bring CR#5 to the hospital on [DATE], I told them again that CR#5 had been complaining of pain to her left hip and leg and they told me that they would communicate the information to the ER so she could get an x-ray. CR#5 did not want to be moved. CR#5's family member further said that the facility did not notify her of any recent medication changes to CR#5 and that they were aware that CR#5 was on [MEDICATION NAME] but did not know that the MD had recently increased the medication. In an interview on 3/29/2016 at 1:10 p.m. with CR#5's MD from the facility, he stated that CR#5 had surgery to her left hip on 3/28/2016 and that she had an Open reduction Internal Fixation procedure to her left hip (type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone). In a phone interview on 3/29/2016 at 1:19 p.m. with C.N.A. E, she stated that she cared for CR#5 during the night shift on 3/25/2016 and stated that CR#5 had episodes of resisting care and that CR#5 would say no, no, no and would not let staff touch her. She further stated that she provided incontinent care to CR#5 at least twice during her shift and that she did not see any bruises or injuries to CR#5. She continued saying that the charge nurse helped her once to do incontinent care to CR#5 because she was resistant to care. In a phone interview on 3/29/2016 at 2:08 p.m. with C.N.A. F, she stated that she was the aide that cared for CR#5 on the night shift on 3/26/2016 and that she did not need to do any care for her because CR#5 was clean the entire night. C.N.A. F further said I worked with her but I did not touch her because her brief was dry the entire shift. When I checked her brief, CR#5 would wake up and make noises like moaning, but I did not need to change her brief. The nurse told me that CR#5 had an injury and that she was in pain, that she had a bruise to her arm. The nurse said that if we did not need to touch her, not to touch her and not to get her up in the morning. CR#5 was on her back the entire shift, I did not even see her bruise. When asked if CR#5 was turned and repositioned during the night shift, C.N.A. F stated She turned herself, we don't need to turn her. In an interview on 3/29/2016 at 2:15 p.m. with RN G and ADON A, the ADON A stated that the facility had to notify the responsible party for antipsychotic medication changes. When asked if CR#5's family member was notified about [MEDICATION NAME] and [MEDICATION NAME] dose increase on 3/23/2016, the ADON A stated I know who got the order, let me call him right now. Further interview and observation revealed that ADON A called LVN H with her telephone and said further said while speaking on her telephone LVN H said that he did notify somebody about the increase in the dose of [MEDICATION NAME] and [MEDICATION NAME] for CR#5 but he did not remember who he spoke with and that he did not documented the information. When asked if [MEDICATION NAME] was held on 3/26/2016 when staff reported that CR#5 was out of it, ADON A said as she looked at the CR#5's MAR and departmental nurses notes you are right, she was lethargic, I think staff was cut off on the urinary tract infection and her bruise that they did not see the side effects of lethargy. [MEDICATION NAME] was not held. ADON A further said that the facility did not have a policy for family notification, that facility follows State guidelines. Further interview and record review at that time, when asked about the facility pain assessment tool, the ADON A stated that staff is supposed to monitor for pain every shift and write down on the boxes first how the residents are expressing their pain, then the score of the pain from 0 to 10 and document on the MAR any interventions for pain using the number legends. When asked if staff documented appropriately the pain assessments for CR#5, the ADON A stated as she looked at the MAR the staff is not using these tools to assess for pain, I don't know what else to say. I know that CR#5 was at least medicated for pain once on 3/26/2016 and once before she went to the hospital with Tylenol due to pain. Continued interview with RN G and ADON A, ADON A stated that RN G was made aware on 3/26/2016 at around 11:30 p.m. by LVN I, that CR#5 had positive x-ray results for fracture to her left humeral neck and that RN G instructed LVN I to call the MD at that moment and that when RN C arrived to work on 3/27/2016 at 6:30 a.m. she found out that the MD had not been notified yet or the family and that RN C called the MD and the family and sent CR#5 to the hospital. ADON A further said that LVN I had said that she did not call the MD or the family because it was 3:00 a.m. on 3/27/2016. ADON A then said that the facility had suspended LVN I due to not reporting to the MD the x-ray results and had left CR#5 laying in bed with a fracture bone. ADON A continued saying that she was made aware by CR#5's family member of the fracture pelvis in addition to the fracture shoulder and that the facility was still investigating. ADON further said I know that if CR#5 would had fallen, there is no way she could got up alone. In a phone interview on 3/29/2016 at 5:03 p.m. with RN C, she stated that she cared for CR#5 on 3/26/2016 and 3/27/2016 and said that CR#5 complained of nausea on 3/26/2016 in the morning and that she gave her [MEDICATION NAME] (anti-nausea) medication. RN C further said that CR#5 was lethargic but responsive she was sleepy and did not want to eat. RN C then said that around 1:30 p.m. on 3/26/2016, it was brought to her attention by C.N.A. B that CR#5 had a large bruise to her left upper arm. RN C said that when she moved CR#5's left arm, she complained of pain and that she had call the MD and obtained order for X-ray. RN C further said CR#5 was in her night gown during the morning so did not notice any bruise. CR#5 received Tylenol for pain once during my shift that ended at 6:30 p.m. and the x-ray was done at around 6:30 p.m. MD saw CR#5 and I showed him the bruise to her left upper arm and her family member visited as well and there was no evidence of pain to her left hip. I am not aware of any falls. In an interview on 3/30/2016 at 11:15 a.m. with MA J, she stated that she was the medication aide for CR#5 on 3/25/2016 during the day time and that CR#5 was doing fine and had no pain or bruises. MA J further said that CR#5 first refused all her medications but that she then took all her medications later on. MA J continued saying that she even took CR#5's blood pressure and that she did not see any bruises or injuries. MA J said that the family member of CR#5 visited her at around noon time and that CR#5 was talking clear to him and was up on her chair. MA J further said If CR#5 had a fall, she could not get up by herself, she is one person extensive assistance for transfers and toileting. Further interview at that time, MA J stated that on 3/27/2016 at around 6:40 a.m. she went to see CR#5 because she got report that CR#5 was not doing well and that she had a STAT X-ray to her left upper arm and that was positive for fracture and further said CR#5 was so out of it, she was tired and she would tell me that she had pain, she was saying 'it hurts', her family members were present. RN C and myself changed her brief before CR#5 went to the hospital, she was really in pain during the brief change, she was saying 'ouch' . In a second interview with RN C on 3/30/2016 at 11:43 a.m., she stated that LVN I reported on 3/27/2016 during shift change that CR#5 had no pain the entire night and that she asleep well through the night. When asked about how the Pain Assessment MAR was supposed to be completed, she responded those forms are weird, they are supposed to have 2 boxes, one for the initials and the other for the assessment, they are a mixed up, we can only write our initials and not the assessment or interventions. When asked if she had written 0 on the pain assessment for 3/26/2016 and 3/27/2016 and she stated probably I completed the boxes before CR#5 complained of pain. I would not rely on that documentation, that is just repetitive. In an interview on 3/30/2016 at 2:15 p.m. with LVN I, she stated that she worked with CR#5 the 12 hour shift of 6:30 p.m. to 6:30 a.m. on 3/25/2016 and 3/26/2016. She further said that on 3/26/2016, she helped the C.N.A. E to change the brief of CR#5 at around 4:00 a.m. and that CR#5 had no pain or bruises and that nobody reported any injury. LVN I continued saying that on 3/26/2016 at 6:30 p.m. she was made aware of CR#5's bruise to her left arm and that she monitored CR#5 the entire night and that she was not in pain and further said I know that they changed her brief during the night but nobody reported any problems or any pain and every time I saw CR#5 she was sleeping, she was just resting comfortable. LVN I then said that CR#5 had a family member visiting on 3/26/2016 during the evening and that CR#5 was talking well with the family visitor and said she was alert and talking, she was even laughing with the family member, they were talking about old memories. LVN I continued saying that she got the X-ray results for CR#5 showing an impacted femur fracture and that she called RN G at around 1:00 a.m. on 3/27/2016 because she was the on-call supervisor and informed her of the x-ray results and that RN G told her to call the MD and the family until the morning and that she gave report to the oncoming shift to notify the MD and the family. When asked if she did not think about notifying the MD of the fracture results immediately, LVN I stated I did what the on call supervisor told me to do. When asked when would the MD be called during the night shift and LVN I responded if there is a change in condition, but I followed instructions. In an interview on 3/30/2016 at 2:40 p.m. with the DON, she stated that changes in condition required notification to the MD and the responsible party and that X-ray results such as the case of CR#5, it needed to be reported to the MD at that time and not wait until the morning and further said changes in condition need to be reported to the MD then the nurses are supposed to notify the on call nurse manager if it is after hours. We just implemented recently about the manager on call for nurses to call, but the MD needs to be notified first. In an interview on 3/30/2016 at 2:45 p.m. with LVN L, she stated that she was involved in the training of the nurses and that changes in condition of the residents are supposed to be notified to the MD as soon as possible. She further said that nurses are supposed to complete an SBAR form for all changes in condition and that the SBAR will guide them on the assessments and appropriate notifications that nurses are required to follow. When asked if CR#5 had any SBAR form completed, she responded as she flipped thru the chart I can not find any SBAR on CR#5's chart file. LVN L continued saying for X-ray results that are fracture, you are supposed to call the MD as soon as possible, we have a nurse manager on call, but you call the MD first then the on call manager. I will initiate a training as soon as possible today. In an interview on 3/30/2016 at 3:50 p.m. with the Administrator and the DON, the Administrator stated that CR#5 had been very aggressive to staff in the last week and that the MD had given orders for urinalysis and the results were that she had a urinary tract infection and was started on antibiotics. Administrator further said CR#5 had dementia and the psychiatrist was here and facility requested the psychiatrist to see CR#5 and her medications were changed. When asked about notification for [MEDICAL CONDITION] medications, the Administrator responded the family was notified, LVN H said he notified the family but he did not documented the information. Administrator continued saying CR#5's family member called and said CR#5 had also a pelvic fracture but we are still trying to get all the information. We don't know what happened, from what C.N.A. E was saying is that she left alone CR#5 in the morning because she was agitated. Our staff are saying that they do not know. We went through everything. CR#5 was very strong and she was able to transfer alone so if she would have fallen, she was able to get up alone. RN G instructed LVN I to call the MD and the family in the morning and CR#5 was resting comfortable. MD should had been notified but LVN I said that CR#5 was very comfortable and it was better to keep CR#5 here in the facility that for her to be in the ER waiting uncomfortable. Continued interview with the Administrator and the DON, the Administrator said Policy and protocol would be to call the MD and the family timely, that's what we need to do. In this case the MD and the family were called in the morning. The on call manager nurse is to get an additional support, not instead of calling the MD. They are there if you need help to walk thru the process. We will inservice all nurses on that. In an interview on 3/30/2016 at 4:20 p.m. with MA M, she stated that she saw CR#5 on 3/26/2016 during the afternoon shift and that CR#5 did not look good and further said her relative was there. She did not eat. I heard that CR#5 had a fall but do not know how. I only overheard it. It was not told directly to me. I heard that CR#6 had a fall on 3/25/2016. In a second interview on 3/30/2016 at 4:33 p.m. with the Administrator and the DON, the DON stated that when nurses assess the residents for pain, they are supposed to write the legend indicating the number for pain and the interventions and not only the nurses' initials. Administrator further said CR#5 was not lethargic on 3/26/2016, she was sleepy. Lethargic means that you are out of it. When surveyor pointed the documentation on CR#5's departmental notes that indicated that CR#5 was out of it, the Administrator stated out of it means that CR#5 was not herself, that she was sleepy, hard to wake up. She was not lethargic. Interview on 3/30/2016 at 5:55 p.m. the DON and RN C came to surveyor and RN C stated I need to clarify my assessment with CR#5, she was sleepy but she was very responsive, lethargic was a heavy word that I used. I documented out of it because it was what the aide told me but CR#5 was doing good on 3/26/2016, she was talking and was doing better than any other day, she was answering questions appropriately and she was very alert. Record review of the facility policy and procedure change in a Resident's Condition or Status revised December 2006 revealed in part: .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition Record review of the facility policy and procedure Administering Medications revised April 2007 revealed in part: Medications shall be administered as prescribed Record review of the facility policy and procedure Pain Assessment and Management revised October 2010 revealed in part: ' The purpose of this procedure are to help the staff identify pain in the resident's goals and needs and that address the underlying causes of pain. Document the resident's reported level of pain with adequate detail (ie., enough information to gauge the status of pain and the effectiveness of interventions for pain) . CMS 672 dated 3/29/2016 revealed 119 residents that require assistance with transferring.

Based on observation, interview and record review the facility failed to provide the necessary assessment and management of one of 16 sampled resident's (Resident #12) pain so that she could attain her highest practicable physical, mental, and/or psychosocial well-being. The staff failed to assess and manage the pain for Resident #12 for the 21 days following her admission. The staff did not assess daily, monitor the pain worsening and report to the physician. This failure resulted in pain and emotional distress for 1 resident and placed 19 residents at risk of not having their pain assessed and managed. Findings include: Review of Resident #12's Face Sheet revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Gastrointestinal Doctor ' s letter dated 2/23/04 stated that she had [MEDICATION NAME] (a [MEDICAL CONDITION] neuromuscular condition of the digestive system). Review of Resident #12's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #12' s MDS dated [DATE] revealed she was alert and oriented, with minor impairment of cognitive skills, and was able to make her needs known to staff. Review of the MDS revealed that within the last 5 days she had received prn pain medication and no non-medication intervention for pain. Further review revealed that the resident experienced frequent pain in the last 5 days and rated it as a 7 on a scale of 0-10. Review of Resident #12's Care Plan dated 1/19/2011 revealed she experienced frequent pain. The documented goal for the pain was by 4/11/11 she would verbalize that pain had decreased to a 3 or less. Review of the approaches to this goal were 1) evaluate pain daily using 1-10 scale, 2) administer resident's pain medication as ordered, 3) assist resident with diversional activities, and 4) monitor for worsening of pain symptoms and report to physician. Review of the Nurse's Treatment Book revealed pain assessments completed by staff for various residents but there were no pain assessments completed for Resident #12. Review of Nurse' s Note dated 1/9/2011 at 2:11 p.m. revealed LVN #1 documented that resident complained of shortness of breath, chest pain and stomach pain. Review of Resident #12's MAR indicated [REDACTED].M. and again at 5:00 p.m. The same MAR indicated [REDACTED].M. Record Review Resident #12's Medication Administration Records dated January 2011 revealed an order for [REDACTED]. 1/8/11- 2 times 1/9/11- 2 times 1/10/11- 2 times 1/11/11- 2 times 1/12/11- 3 times 1/13/11- 2 times 1/14/11- 1 time 1/15/11- 1 time 1/16/11- 3 times 1/17/11- 2 times 1/18/11- 2 times 1/19/11- 2 times 1/20/11- 2 times 1/21/11- 2 times 1/22/11- 1 time 1/23/11- 1 time 1/24/11- 3 times 1/25/11- 2 times Review of the back of the same MAR indicated [REDACTED]. This documentation did not reflect any assessment of the pain prior to administering the medication or the effectiveness of the medication for pain control. Observation on 1/25/11 at 8:55 a.m., during initial tour, revealed Resident #12 in bed receiving a breathing treatment, grimacing and holding her stomach. She stated she was in pain and did not feel good. Interview with Resident #12 on 1/26/11 at 10:05 a.m. she stated she did not get out of her room often because she was in so much pain. Interview on 1/27/11 at 1:35 p.m. Resident #12 stated she took a pain pill at noon, felt some relief around 12:30 but the pain returned by 1:00 p.m. She said no staff came back to ask her about the pain after giving her the medication. She said her pain was not assessed each shift and felt the staff was not listening to her when she tried to explain the intensity and consistency of her pain. She stated, "Right now, it hurts to breathe." She stated she was "in excruciating pain" most of the time and she needed help. She said she did not think staff had reviewed her entire medical history or understood her condition. She stated when she spoke with LVN #1 about pain management; LVN #1 called the doctor and asked if something could be done. Resident #12 said that that was the only time she was aware of when the doctor was contacted regarding her pain management being ineffective. She stated she had told numerous staff (CNAs and MAs) daily that she was in pain. She said she was told that the medication [MEDICATION NAME], that she also took as needed for anxiety, would help control her pain. Observation at the completion of the interview at 2:05 p.m. revealed there had been no interaction from the facility staff regarding the effectiveness of the pain medication the resident received at noon. Interview on 1/26/11 at approximately 2:30 P.M. LVN #1 stated that she remembered calling the doctor concerning Resident #12's doctor on 1/9/11. She stated the doctor explained to her that he felt some of the pain may be coming from anxiety and he had ordered [MEDICATION NAME] to be given for the anxiety. She stated she gave the [MEDICATION NAME] medication that day but could not remember assessing the resident's pain. She stated she did not remember consulting the doctor any other time concerning the resident's pain. Observation on 1/28/11 at 10:10 a.m. Resident #12 was in a wheelchair grimacing. Interview at this same time she stated her pain was from her lower chest to lower abdominal region. She stated she had taken a pain pill at 8:00 a.m. but it had worn off by 9:00 a.m. Interview on 1/28/11 at 1:10 p.m. Resident #12 stated she was to go to physical therapy but she hurt so bad she did not know if she would be able to participate. Observation at this time revealed she turned on her call light and requested pain medication from the DON who stated she would check to see what resident could have. The resident stated she did not think she would be able to have another pain pill because she had asked the staff earlier and they said she could only have the pain medication every 4 hours and it had not been enough time. Interview on 1/28/11 at 4:15 p.m. Resident # 12 stated she had told staff often that she was in pain but got the impression that there was not much that could be done for her. She said that her pain had woke her up at night, and prevented her from being as active as she would like. She stated that when she was at home in November 2010 her [MEDICATION NAME] had her pain under control with [MEDICATION NAME], and [MEDICATION NAME]. At that time she lived alone, was able to care for herself and ambulate inside and outside of her home. She stated that her recent hospital stay was due to [MEDICAL CONDITION] and that she became weak in the hospital and required therapy so was discharged to the nursing home for therapy. She stated that since she had been at the facility her previous medications had been discontinued and she now took only [MEDICATION NAME] 5/325 every 4-6 hours as needed and [MEDICATION NAME] 0.5 mg as needed. Interview on 1/28/11 at 10:28 a.m. LVN #5, the Nurse Supervisor, stated that Resident #12 ' s pain was assessed daily. She stated that there was a pain assessment flow sheet in the "NStep Weekly Skin & Wound Log" on which the resident ' s pain level was documented every shift. She stated she did not "specifically remember documenting on her (pain) daily." She stated the resident ' s pain originated from her [MEDICAL CONDITION] and also "something went wrong with her implants" and they leaked into her body. She stated the resident had an as-needed pain medication ordered. She stated when the resident asked for a pain pill the nurse would ask about her pain. She stated she was not aware the pain medication was not controlling her pain so she had not reported anything to the physician. When asked, LVN #5 was not able to provide any pain assessment flow sheets completed for Resident #12. During interviews on 1/28/11 at 9:59 a.m. and 4:00 p.m. the ADON stated she was unable to locate any pain assessment flow sheets for Resident #12. No pain assessment forms were provided for review prior to exit. Review of facility Policy Pain Assessment revealed, "The purpose of this procedure is to assess the resident' s pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team . . . continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident . . . Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours of administration." Further review of the Pain Assessment Policy revealed that the daily assessment of pain was recorded in the resident's medical record. Documentation would include a 2 hour reassessment of the pain and the resident ' s response to the pain relief. The physician would be notified of any unrelieved pain. Review of Wikipedia, the free encyclopedia, at <http://en.wikipedia.org/wiki/[MEDICATION NAME]> revealed that " ... the main symptom of [MEDICATION NAME] was severe and constant pain ... " It further revealed that symptom management was very important and the main priority was to get on top of the pain. Facility CMS 672 form listed 20 residents on a pain management program.