**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provide supervision to prevent residents from sustaining injuries from falls and/or a burn from hot water for three (Residents (R) 40, R96, and R38) of eight sampled residents reviewed for accidents out of a total sample of 32. R40 was assessed to require two staff members for bed mobility; however, the resident was repositioned by one staff member and slid out of bed, which resulted in actual harm of bilateral femur fractures. R96 suffered actual harm of second degree burns when water, which had been heated in the microwave for three to four minutes, spilled on her. R38 suffered a fractured femur, and facility staff failed to implement identified interventions to prevent further falls and injury The deficient practices caused residents to experience a decrease in quality of life and quality of care problems. Findings include: Review of the facility's policy titled, Incidents and Accidents, updated 03/14/23, revealed, It is the policy of this facility for staff to utilize [electronic medical record program] Risk Management Portal to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care . A Fall policy and/or program addressing prevention and intervention was requested and not provided. Review of the facility's policy titled, Microwave Safety, updated 03/29/22, revealed, To allow resident food and/or beverages to be reheated via microwave while remaining safe within the facility . Heat food/ beverages in 30 second increments until appropriate temperature is reached. 145 degrees F [Fahrenheit] 5. Stir food items during microwave heating to ensure even heat distribution. 6. Use a sanitized thermometer (using a sanitizer wipe safe for food service) to check for safe temperatures prior to service . 10. Supervise/assist resident at risks for burns or who need help to eat (as their care plan directs) to maintain their safety and dignity. 1. Review of R40's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed R40 was readmitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, metabolic encephalopathy, and muscle wasting and atrophy of multiple sites. Review of R40's Lift, Transfer, Reposition assessment, dated 09/18/24 and located under the Assessment tab in the EMR, revealed R40 required two staff for repositioning in bed. Review of R40's annual Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 09/21/24, revealed R40 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. R40 was also coded as being dependent on staff in bed mobility. Review of R40's Care Plan, located under the Care Plan tab in the EMR and dated 09/19/24 revealed, The resident uses side rails to maximize independence with turning and repositioning in bed. Review of the facility's self-reported incident, dated 10/04/24 and provided by the facility, revealed R40 fell out of her bed when being turned by Certified Nursing Assistant (CNA)3 during incontinence care. The report read, . Resident had a witnessed fall this morning 10-04-24 at 7:00 am. Resident was being provided incontinence care and while rolled on her side residents legs started to slide off the bed. Resident then completely slid from the bed and landed on the floor on her right side. Resident denies hitting head, witness to fall also states resident did not hit her head. Resident was assessed by the nurse and had no complaints of pain and no injuries were noted. This afternoon 10.04.24 [sic] at approximately 1300 resident had a syncopal episode and was complaining of shortness of breath. Residents pulse ox [oximetry] was noted to be 87% on room air. Resident was placed on 02 at 2 liters via [by] nasal cannula and pulse ox increased to 95% Resident was also noted with and elevated pulse. Resident was assessed by NP and order [sic] was given to send to the ER for further evaluation . Review of R40's hospital CT Scan of Lower Extremity Bilateral results, dated 10/04/24 and provided by the facility, revealed, . Comminated fracture with impaction distal right femoral metaphysis .Comminated fracture with impaction distal left femoral metaphysis . During an interview on 01/21/25 at 9:30 AM, R40 stated she had fallen in October when a CNA rolled her over to the right side with the CNA standing behind her. R40 stated she was able to catch ahold of the bed railing to hold herself over to help staff. R40 stated she told the CNA that she was falling, and the CNA attempted to grab her leg, but she started falling and fell out of the bed that was in the high position. The resident stated the CNA was tall so she put the bed up high and then that was the height that she fell from. She reported that she had fractures of both legs, but the right leg fracture was worse than the left leg fracture. A phone interview was attempted with CNA3 on 01/22/25 at 1:52 PM and again on 01/23/25 at 10:07 AM. Voice messages were left each time with a call back number for CNA3 to call. No return phone call was received. During an interview on 01/23/25 at 11:46 AM, the Director of Nursing (DON) stated, [name of CNA2] was [R40's] CNA when this incident occurred. The resident [R40] had been turned to her side with [CNA3] providing peri care while the resident was holding onto the side rail. [R40's] legs began to slide off the bed and the aide attempted to get the resident not to fall. [CNA3] should have rolled [R40] towards her [CNA3] instead of away from her [CNA3]. The DON was asked how many staff members were required for repositioning R40 in bed as care planned. The DON stated, Two. The DON was asked how many staff members were assisting R40 in turning when this fall occurred and the DON stated, Only one, [CNA3]. The DON continued, We put [CNA3] on leave and before she took an assignment to return to work, [CNA3] was provided education on turning, repositioning and lifting of residents and of the door magnets. The door magnets will have, for example, TA2 XL which stands for total assistance of 2 staff members with XL standing for the size of the lift pad or sling to be used when using a lift for the resident. We even included this training for all staff. During an interview on 01/23/25 at 2:00 PM, the Administrator confirmed this incident was taken to QAPI (Quality Assurance Performance and Improvement), and a QAPP (Quality Assurance Performance Plan) dated 10/04/24 had been developed. Review of this plan revealed monitoring and compliance of this plan would be achieved by Performing random spot checks to observe staff compliance with care plans. Create a tracking log for high-risk residents to ensure plans are followed consistently. Assign the nurse manager or charge nurse to review adherence to the care plans weekly . Monitoring and follow up: Ongoing, with first evaluation at 30 days post implementation. Verification of this process was reviewed on 01/23/25 at 5:00 PM, and it was noted the facility had completed all training and implemented the door magnets on 10/06/24. The facility had completed the QAPI plan as outlined to this date. This was determined be past non-compliace with a verified compliance date of 10/6/24. 2. Review of R96's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 12/22/24 and located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 12/16/23 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R96's cognition was intact. It was recorded R96 had diagnoses of chronic pain, anxiety, and multiple sclerosis. Review of R96's investigation report, dated 10/05/24 and provided by the facility, revealed, [R96] is a resident at [facility name] who is alert and oriented x 2-3 with a BIMS of 15. At approximately 3:55pm, the resident asked a Certified Nurse Assistant [(CNA)4] [name] to heat up her hot water. The staff member stated he heated up the hot water for approximately three minutes and brought it to the resident. While helping the resident, he accidentally spilled hot water on her. Nursing immediately responded to this and provided first aid cooling treatment to her hand/wrist. Then nursing removed clothing and performed a whole-body skin assessment. Several reddened areas were identified: the dorsal side of left hand and wrist, left upper thigh, middle of abdomen, and side of left breast. First-aid cooling compresses were immediately applied to the affected areas. The nurse practitioner was contacted and an order for Silvadene was placed. Nursing is administering cooling compresses frequently on the areas as well as providing pain medication as needed, and the resident has stated that this has been effective for pain. Responsible party notified. Currently, the resident is calm and in good spirits. The facility is investigating this incident. We are providing re-education for staff on safe heating procedures. Review of R96's 10/05/24 Summary for Providers note located in the EMR in the Progress Note tab revealed, . Left hand opened blister observed measuring 6.4x4.9x< [less than]0.1. Left breast, left abdomen and left thigh with fading redness . Review of R96's Wound Assessment Report, dated 10/08/24, located in the EMR under the Miscellaneous tab revealed the following burns: Location: left forearm/hand, Measurements Length: 24.00 cm, Width: 16.00 cm . Depth: 0.10 cm, Etiology: Second Degree Burn. Location: left breast, Measurements Length: 3.00 cm, Width: 7.50 cm . Etiology: First Degree Burn. Location: abdomen, Measurements Length: 31.00 cm, Width: 30.00 cm . Depth: 0.10 cm, Etiology: Second Degree Burn. Location: left anterior thigh, Measurements Length: 17.00 cm, Width: 21.00 cm . Etiology: Second Degree Burn. On 01/20/25 at 2:46 PM, R96 was observed in bed awake with a sleep cover over her eyes. R96 was asked if she had been burned by hot water. R96 stated, Yes. R96 stated water for her coffee spilled on her lap after she asked the Certified Nurse Aide (CNA) to heat the water. R96 stated the CNA accidentally spilled it on her left hand, stomach, breast, and left leg a few weeks ago. R96 stated she received second-degree burns, but it was half healed now. R96 stated a treatment was ordered for Silvadene. R96 stated she thought the CNA used the microwave in the employee breakroom and heated her water for four minutes. R96's hands and body were covered with her blanket. R96 refused for her left hand and other areas previously burned to be observed. On 01/22/25 at 9:04 AM, the nourishment room on station two was observed and at 9:06 AM the nourishment room on station one was observed. Both microwaves had safety signs posted and the microwave policy. During an interview on 01/22/25 at 10:40 AM, the Director of Nursing (DON) was asked about the incident on 10/24 when R96 experienced a second-degree burn after a CNA spilled hot water on her. The DON stated CNA4 did not work at the facility anymore. The DON stated CNA4 used the microwave in the nourishment room on station two and this was the first time this type of incident had occurred. The DON stated CNA4 heated the water up for three minutes and poured it in R96's personal cup. The DON stated as CNA4 was putting on the lid to R96's travel mug, the hot water hit the bedside table and spilled on to R96 as she sat in her wheelchair in her room. The DON stated CNA4 immediately called the nurse who was in the hallway and CNA4 also reported to her soon after. The DON went on to say a treatment order for Silvadene was immediately obtained. The DON stated R96's skin has healed completely with no lasting issues and no scarring. During a telephone interview on 01/22/25 at 4:37 PM, CNA4 was asked about the incident when R96 was burned from hot water. CNA4 stated R96 had asked her to make her a cup of coffee. CNA4 stated she heated the water in the microwave in the nourishment room in another cup for about three minutes. CNA4 stated she returned to R96's room with the water, poured it in R96's cup, and while she was placing the lid on the cup, it spilled. CNA4 stated R96 felt the hot water sensation and screamed. CNA4 stated she immediately got the nurse who was in the hall. The nurse assessed R4's skin, undressed R96, and immediately applied cooling treatment on the skin. CNA4 stated she then reported the incident to the DON. CNA4 stated the facility conducted training on the use of the microwave and the aides cannot use the microwave. CNA4 stated water could only be heated by the nurse thirty seconds at a time and a thermometer must be used to measure the temperature. CNA stated she was not aware of other residents getting burns from hot liquids. During an interview on 01/23/25 at 8:10 AM, Registered Nurse (RN)1 was asked about the facility's policy for heating liquids in the microwave. RN1 stated only the nurses could heat something in the microwaves. RN1 then opened the nourishment room on station two that stored the microwave. The microwave was observed with signs posted with instructions that included Microwave Safety Until further notice the microwaves in Dining room and nourishment rooms are not to be used by staff and they have been taken out of service. Please read attached policies on microwave safety and use and storage of food brought in by residents and visitors. Complete Quiz and sign attestation indicating that you have read and understand the policies and directions for using a microwave. This education is mandatory. It is to promote safe practice and reduce risk of injury. Any questions please see a member of management. During a follow up interview on 01/23/25 at 9:41 AM, the DON confirmed only a nurse could heat up food and beverages for residents, and the microwaves available for staff to heat resident food and beverages were in the nourishment rooms on stations one and two. The facility provided documentation staff training on microwave safety occurred on 10/05/24, a performance improvement plan was implemented, and the surveyor observed safety signs and the microwave policy in place on 01/22/25. The surveyor confirmed training and policy implementation with staff interviews. On 01/23/25 at 12:31 PM, R96 was asked if she had staff heat water for her since the accident. R96 stated, No. R96 again declined her skin to be observed. This was determined to be past non-compliance with a verified compliance date of 10/5/24. 3. Review of R38's quarterly MDS, with an ARD date of 10/22/24 and located in the MDS tab of the EMR, revealed an admission date of 11/18/16 and a BIMS score of three out of 15, indicating R38's cognition was severely impaired. It was recorded that R38 had one fall since admission with injury, and had diagnoses of Alzheimer's disease, anxiety, and unspecified dementia, severe, with mood disturbance. Review of R38's Nursing Quarterly Assessment, dated 06/12/24 and located in the EMR under the Assessment tab, revealed R38 was High Risk for falls, as indicated by a score of 16.0. Review of R38's investigation, dated 07/09/24 and provided by the facility, revealed, On 07/04/24 resident was found sitting on the fall mat with her back against her bed that was in the low position. Resident assessed at that time and no injury was noted and resident did not express any pain. On 07/05/24 bruising was noted to residents [sic] right thigh so an x-ray [high-energy electromagnetic radiation] of the right hip and femur was ordered. This x-ray showed no acute fracture. On 07/08/24 bruising was noted on resident's right knee. An x-ray was ordered of the right knee, femur, right hip, and right tibia and fibula. The mobile x-ray tech [technician] was only able to complete the x-ray of the right hip and pelvis. On 7/9/24 NP [nurse practitioner] assessed resident and noted swelling in her knee. The NP requested resident be sent to the ER [emergency room] for evaluation due to the knee swelling. At the ER an x-ray of the right knee revealed a fracture of the lateral femoral condyle . An investigation was initiated and completed- Staff statements were completed and collected. Resident was last seen sitting up in her bed with her legs straight out on the bed and the over the bed table over her while she was eating dinner. The bed was in the lowest possible position to accommodate the over the bed table. The over bed table was placed on the left side of the bed. Staff noted the over the bed table had been pushed slightly towards the end of the bed when they found resident sitting on the floor. Residents [sic] legs were noted to be crossed with the left leg over top of the right. Due to resident's dementia, she was not able to be interviewed. Resident's roommate did not see resident fall. Resident is known to be fidgety and impulsive with poor safety awareness. At the hospital resident underwent an x-ray of right knee revealing a fracture of the lateral femoral condyle. Right hip x-ray was noted to be unremarkable. Pelvis x-ray showed no acute fracture. A CT [computed tomography scan] of the right knee was completed and revealed a displaced comminuted oblique fracture of the distal metaphysis. A CT of the head showed no acute fracture. A CT of the spine showed a C1 [upper cervical spine] fracture that was also noted back in 6/5/2023 so it is not acute. Resident currently remains admitted to the hospital- Hospital states resident is not a candidate for surgery and they are treating resident for pain and have splinted the fracture to immobilize. Care plan was reviewed, new intervention added to increase safety checks. Review of R38's Care Plan, revised 07/12/24 and located in the EMR under the Care Plan tab of the EMR, revealed, Resident is at high risk for falls: cognitive loss, lack of safety awareness, anxiety, ambulates with unsteady gait. The goal included, . The resident will not sustain serious injury through the review date . Interventions included to encourage the resident to participate in activities that minimize potential falls that provide diversion and distraction, keep the bed in low position, place a fall Mat on right side of bed, and increased safety checks. Review of R38's July 2024 TAR located in the EMR under the Order tab revealed Brace to Right lower extremity. skin check every shift. Maintain non weight bearing right lower extremity. every shift, order date 07/25/24 and discontinue date 09/23/24. On 01/20/25 at 11:36 AM, R38 was observed awake lying in a low bed talking nonsensical and holding a crayon. R38 was very fidgety and was noted to have a laceration on her forehead. The overbed table and a wheelchair were on the fall mat, leaving no space on the mat should R38 fall. On 01/21/25 at 8:49 AM, R38 was observed awake in a low bed dressed in pajamas with the lights off. R38's legs were pulled up to her chest, tugging up on her covers, and she was very fidgety. The fall mat next to R38's bed had an overbed table on top of the mat, leaving little space on the mat. On 01/22/25 at 9:54 AM, R38 was observed asleep in a low bed with covers up to her chin. The fall mat was in place with an overbed table and a wheelchair on the mat, leaving little room on the mat. During an interview on 01/22/25 at 10:57 AM, CNA2 was asked if R38 was a fall risk. CNA2 stated R38 does fall and stayed in her bed most of the time. CNA2 stated, [R38] can stand and that's when she falls. CNA2 stated when R38 was trying to get up from her low bed, they put her in the wheelchair and took her to the nurses' station so staff could keep an eye on her. On 01/23/25 at 7:28 AM, R38 was observed asleep in bed with the head of the bed up and the overbed table on top of the fall mat. During an interview on 01/23/25 at 8:52 AM, the DON and Regional Director of Nurses (RDON) were asked about R38's fall on 07/04/24. The DON stated it was unwitnessed, but later R38 complained of pain and a bruise was noted. The DON stated the first and second x-rays at the facility revealed no fracture, but R38 was still complaining of pain. She stated R38 was sent to the hospital where another x-ray revealed a fracture. The DON stated the origin of the injuries were unconclusive, stating staff were just in R38's room and the bed was in a low position with the fall mat in place. The DON stated it was possible the bedside table was nearby as R38 had just finished a meal and may have hit the base as she fell out of bed. The DON stated the plan of care was to have R38 in a low bed with fall mats. The DON stated staff knew R38 was at increased risk for falls and when [R38] gets antsy staff are to get R38 dressed and up in her wheelchair. The DON stated, Staff document by [R38]'s door to keep an eye on her. The DON stated R38 liked to color so staff should give her coloring activities to occupy her. The DON was asked if the overbed table should be on the fall mat between meals, obstructing the purpose of the mat. The DON stated, No. The DON was informed that the overbed table and wheelchair had been noted on R38's fall mat while R38 was in bed during the days of the survey. The DON was asked why R38 was always in bed and at times very fidgety. The DON stated nursing should be getting R38 out of bed and providing activities to occupy her such as coloring. The DON stated R38 was constantly in movement due to anxiety and her medication had been changed on the 12/24/24 and 01/07/25. The DON stated since R38's medication changes she still had the urge to get up out of bed and had high anxiety. The DON stated they were to make the environment safe in her room to prevent injury should R38 fall. The DON stated the placement of the overbed table was important. During an observation on 01/23/25 at 4:05 PM, R38 was observed in a low bed with a fall mat in place. The bedside table and wheelchair were on the mat, allowing little space on the mat should R38 fall. During an observation in R38's room on 01/23/25 at 4:07 PM, the Assistant Director of Nurses (ADON)was asked about the fall mat being obstructed with the overbed table and wheelchair. The ADON confirmed the overbed table and wheelchair should not be on the mat in case R38 fell as R38 could fall on the equipment. During a telephone interview on 01/23/25 at 5:52 PM, Licensed Practical Nurse (LPN)5 was asked about R38's fall on 07/04/24 and her fracture. LPN5 stated R38 was found on the floor on the fall mat but she did not see her fall. LPN4 stated R38's bed was in the low position and the fall mat was in place. LPN5 went on to say R38's plan to decrease falls included a low bed and a fall mat, and when R38 was restless staff would sit by her doorway and talk with her or get her up in the wheelchair. During a telephone interview on 01/23/25 at 5:59 PM, CNA7 was asked about R38's fall on 07/04/24. CNA7 stated she could not remember all the details but R38 was in a low bed and the fall mat was in place. CNA7 stated she thought the overbed table was in the way on the fall mat. CNA7 was asked what was in place to reduce R38's fall or injury. CNA7 stated all the staff took turns keeping an eye on R38 and keeping her in a low bed and fall mats next to her bed. CNA7 stated they were educated on R38's safety, saying, It's important to keep the mat clear of objects. During a telephone interview on 01/23/25 at 6:13 PM, RN2 was asked about R38's fall in 07/04/24. RN2 stated she could not remember exactly as it had been a while and she did not see R38 fall. RN2 asked what interventions were in place to reduce falls. RN2 stated R38 was in a low bed, had a fall mat, and they anticipated her needs. RN2 stated when R38 was restless, a CNA would sit close to her or inside the room when she was in bed, and R38 did sit in her wheelchair at times.

Based on interview, record review, and review of other documentaion as indicated, it was determined that for one (R211) out of one resident sampled for hospitalization, the facility failed to complete a comprehensive respiratory assessment, monitor, and provide respiratory interventions for a resident recognized as having an acute change in respiratory status. R211 was caused further distress when she remained without supplemental respiratory interventions (oxygen) until EMS (Emergency Medical Services) implemented interventions upon arrival at the facility. For one (R8) out of one resident reviewed for potential for constipation, the facility failed to assess the residents for signs or symptoms of constipation and administer medications as ordered for no bowel movement (BM) after three (3) days. For one (R34) out of six residents reviewed for unnecessary medications, the facility failed to follow Physician's orders to monitor for sedation with the usage of Melatonin. Additionally, the facility failed to obtain weights as per Physician order for one (R66) out of five residents reviewed for weight loss, which led to uncertainty of when R66's weight loss began. Findings include: A facility policy Acute Condition Changes - Clinical Protocol, adopted 11/2018 and last updated 10/2019 included: The nurse shall assess and document/report the following baseline information: - Vital signs; - Onset, duration, severity. 1. Review of R211's clinical record revealed: 7/1/21 - R211 was admitted to the facility with a history of a stroke, diabetes, difficulty swallowing, and a peg tube (feeding tube). 10/1/22- Review of the EMS (Emergency Medical Services) Patient Care Report revealed the dispatcher received a call at 3:52 PM from the facility to request an ambulance to transport a patient to the hospital. At 4:03 PM, EMS crew members arrived on scene at the facility and found R211 with a . room air oxygen saturation of 85% (normal blood oxygen saturation is 95-100%) and a blood glucose of 484 mg/dl (ADA recommendation for someone with diabetes 80-130) upon their contact, the patient is unresponsive, shallowed breathing, warm to the touch EMS placed a non-rebreather mask (enables delivery of high concentrations of oxygen) on R211. R211's response remained unchanged. 10/1/22 4:07 PM - A nurse progress note by E12 (RN) documented, Upon start of shift rounds at approx. 3:30 PM, observed patient with rapid respirations, unresponsive and diaphoretic (profuse sweating). R211's vital signs were as follows: blood pressure 168/77 (normal range for an adult is 120/80, 140/90 is high blood pressure); blood sugar 382 (high) temperature 98.2 Fahrenheit; pulse 144 beats per minute (normal range for an adult pulse is 60-100 beats per minute); respirations 24-28 breaths per minute (normal range for respirations [breathing] is 12-20 breaths per minute at rest). R211's clinical record lacked evidence that an oxygen saturation was obtained. The on-call E8 (NP) was notified and an order was obtained to transfer R211 to the hospital. 10/1/22 4:16 PM - A nursing progress note documented, R211 was transferred to the hospital via EMS. R211 had an abnormal heart beat was unresponsive. The facility lacked evidence of any monitoring or interventions until EMS arrived at the facility and EMS recorded a low oxygen saturation of 85% on room air. 10/1/22 (Untimed) - Hospital documentation included: . female with complicated past medical history brought to the emergency department by EMS with altered mental status.Patient was found unresponsive at the nursing facility satting (refers to oxygen saturation) at 85% on room air. Enroute to the ED (Emergency Department), EMS personnel attempted to intubate (place a plastic tube into the windpipe to maintain an open airway) R211 without success. Alternately, EMS initiated bag-valve-mask breathing. Upon arrival to the ED, R211 was successfully intubated (a breathing tube was placed), placed on a ventilator (a machine that breathes for you) and was admitted to the ICU (intensive care unit). 10/3/22 - A statement composed by E12 (RN) documented on September 30, 2022, patient's sister verbalized patient felt warm. E12 documented that R211 was in bed lying under thick, heavy, personal blanket. 12/8/22 12:50 PM - During an interview via telephone, E12 (RN) stated on the evening of 9/30/22 during her 3:00 PM - 11:00 PM shift, she recalled R211's family member approaching the nurses station and were concerned as R211 was warm to the touch. E12 stated that she went to assess R211 who was alert, but felt warm. E12 confirmed she did not take R211's temperature at that time and stated, I had no urgent concern at that time. E12 stated she worked the next day on 10/1/22 on the 3:00 PM-11:00 PM shift. The off going nurse did not report any concerns for R211. E12 confirmed that her observation and assessment of R211 revealed a significant change in condition; rapid respirations and a heart rate in the 140's. E12 stated she could not recall taking an oxygen saturation, but stated that it should have been part of her assessment. She further confirmed that no respiratory interventions were initiated such as supplemental oxygen administration and R211 was transferred out of the facility by EMS no later than 4:30 pm. 12/9/22 9:14 AM - During an interview, E13 (LPN) confirmed she was assigned to R11 on 10/1/22 7:00 PM - 3:00 PM shift. E13 did not obtain a temperature or a pulse ox. as R211 was alert and taken her meds. and was at her baseline. 12/9/22 9:40 AM - During an interview, E26 (LPN) confirmed he was assigned to R211 on 9/30/22 11:00 PM - 7:00 AM shift and at 12:41 AM R11's vital signs were as follows: pulse 78, respirations 18, temperature 97.8, pulse ox 96% room air, (no blood pressure documented). 12/9/22 9:48 AM - During an interview, E28 (LPN) confirmed she was assigned to R11 on 9/30/22 7:00 AM - 3:00 PM shift. Documentation lacked evidence of any vital signs obtained during that shift. 12/9/22 10:41 AM - During an interview, E29 (CNA) confirmed she was assigned to R211 on 9/30/22 3:00 PM - 7:00 AM 10/1/22. E29 confirmed that R211 did feel warm but stated it's always hot in that room because her room mate likes it hot. 12/9/22 11:03 AM - During an interview, E7 (UM) confirmed that per their facility policy following an acute change in condition, a comprehensive set of vital signs would include a pulse ox (same as oxygen saturation). Additionally, the clinical record lacked evidence that R211's pulse ox was obtained. Interviews of facility staff and review of facility documentation lacked evidence of a complete assessment of R211 on 9/30/22 on the evening shift when staff failed to complete a BP until after R211 was identified to have an acute change in respiratory status and EMS arrived on 10/1/22. The facility also lacked evidence of appropriate respiratory assessments and necessary interventions including the application of oxygen from when R211 was found at approximately 3:30 PM with rapid respirations, unresponsive and diaphoretic until the arrival of EMS at 4:03 PM. 12/9/22 - Findings were reviewed with E1 (NHA) and E4 (DON) during the Exit Conference, beginning at 2:14 PM. 3. Review of R34's clinical record revealed the following: 9/17/22 - R34 was readmitted from the hospital to the facility with a hip fracture. 9/17/22 - R34's Significant Change MDS Assessment revealed that R34's cognition was intact. 9/17/22 - R34 had a Physician's order for Melatonin (naturally occurring hormone/dietary supplement that helps promote sleep) 3 mg tablet at bedtime for insomnia, hold for sedation and notify the NP (Nurse Practitioner) if held twice. 9/20/22 - R34 was care planned for the use of Melatonin related to insomnia. Interventions included to monitor and document side effects and effectiveness every shift. 12/7/22 - Review of R34's September 2022 through November 2022 MAR (Medication Administration Record) lacked evidence that R34 was monitored for sedation. Further review of R34's MAR revealed that it was initiated on 12/6/22 that R34 had a Physician's order to monitor side effects for the use of Melatonin with targeted behaviors including sedation. 12/8/22 4:00 PM - In an interview, E6 (IP) stated that R34 went to the hospital for a right hip fracture. E6 confirmed that on readmission, E34 was still receiving Melatonin 3 mg but the Physician's order for side effect monitoring including sedation was not put in the EMR (Electronic Medical Record) until 12/6/22. 4. Review of R66's clinical record revealed the following: The facility policy titled, Weighing the Resident/Patient, last revised 5/2021, documented, .Weights will be recorded .Protocol .C either monthly or more frequently .as ordered by the physician . 2/1/22 - R66 was admitted to the facility. 2/7/22 (revised 8/15/22) - R66 had a care plan developed for potential nutritional problem related to significant weight loss, therapeutic diet and variable intake of meals with interventions, including weight as per policy (2/7/22) and RD (Registered Dietitian) to evaluate and make diet changes and recommendations PRN (as needed) or when necessary (2/7/22). 3/3/22 - R66 had an active Physician's order for monthly weights. 5/10/22 - R66's quarterly MDS assessment revealed that R66 was able to eat and drink independently with set up help. R66 was receiving a diuretic medication (helps reduce the amount of water/excess fluid in the body) and had a weight of 205 lbs with no known weight loss. 5/10/22 - The facility's Nutritional Assessment, completed by E24 (RD), documented R66's weight obtained on 4/3/22 as 205.2 lbs. (pounds). E24 noted R66's nutrition evaluation as .Stable weight since admission with meals and outside sources .rec (recommend) 75%-100% of most meals to meet needs .maintain stable weight or allow for gradual weight loss .no nutrition problem. Review of R66's weight records from April 2022 through June 2022 revealed that on 4/3/22, R66 weighed 205.2 lbs. On 6/1/22, R66 weighed 186.2 pounds which was a 9.26 % significant weight loss. There was a lack of evidence that R66's May 2022 weight was obtained. 12/8/22 10:32 AM - When asked whether R66's weight information of 205.2 lbs on 4/3/22 was the same information documented on the 5/10/22 Nutritional and MDS Assessments, E24 (RD) confirmed and stated that R66's weight was not obtained in May 2022. E24 stated that the facility was not able to determine the time frame in May 2022 when R66 started losing weight. 12/9/22 9:30 AM - During an interview, E4 (DON) confirmed that R66's Physician's order for monthly weights was not done in May 2022. The facility failed to follow the Physician's order to obtain R66's weight for the month of May 2022. 12/9/22 - Findings were reviewed with E1 (NHA) and E4 (DON) during the Exit Conference, beginning at 2:14 PM. 2. Review of R8's clinical records revealed: 7/19/21- R8 was admitted to the facility. 8/13/21 - The following Physician's orders were written for three laxative medications: - Milk of Magnesia (MOM) every 24 hours as needed for constipation to be given at bedtime if no BM in 3 days. - Dulcolax suppository every 24 hours as needed if no BM from MOM by the next shift. - Fleet Enema every 24 hours as needed if no BM Ducolax suppository within 2 hours. If no BM from Fleet enema, call MD/APP (Advanced Practice Providers) for further orders. 8/13/21 - A care plan for at risk for constipation related to decreased mobility was developed and implemented with a goal that R8 would have a normal BM every 3 days. The interventions included to follow the bowel protocol which included to monitor, document, and report signs and symptoms of constipation; monitor for change in mental status, including new onset of confusion and sleepiness; abdominal distention, vomiting, small loose stool, fecal smearing, bowel sounds, abdominal tenderness, fecal impaction; and to record BM pattern each day including the amount and consistency. 10/1/22 through 12/5/22 - The Bowel Report revealed there were a total of three (3) periods of time in which R8 did not have BM for greater than 3 days (more than 9 shifts) and there was lack of evidence that the facility assessed for signs or symptoms of constipation and/or administered medications as follows: - 10/2/22 night shift through 10/6/22 evening shift for total of 15 shifts. - 11/4/22 night shift through 11/9/22 night shift total of 16 shifts. - 11/15/22 evening shift through 11/21/22 day shift for total of 17 shifts. 12/7/22 1:59 PM - An interview with E5 (ADON) was conducted and the above findings were reviewed with E5 and confirmed.