Every finding on record at Anberry Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:A pot with food and debris in it was stored in the clean area.A black bean veggie patty bag with one patty in it, in the walk-in freezer, was open and undated.The walk-in freezer fan had ice buildup on it. A plastic container in the walk-in refrigerator with sliced pink fruit inside was unlabeled and undated. A box of mushrooms and a box of celery was open and exposed to air in the walk-in refrigerator.Mushrooms and white liquid were observed on the walk-in refrigerator floor.The sanitizer spray bottle used for cleaning food countertops, contained water in it instead of the sanitizer. These failures had the potential to cause cross-contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for 90 of the 97 residents that consumed food from the kitchen.1. During a concurrent observation and interview on 1/20/26 at 10:40 a.m. with the Certified Dietary Manager (CDM) in the kitchen, a pot was observed stored upright with white and brown debris inside, in the food prep area. CDM stated the area was a clean area and was used to store clean pots. During an interview on 1/23/26 at 10:20 a.m. with the CDM stated the pot with white and brown debris inside appeared to have grease and food debris inside of it. CDM stated if the pot was stored in the food prep area it should be clean. CDM stated the pot should've been clean and maintained as such. CDM stated the general best practice was food contact areas on pots are stored inverted/face down to prevent possible contamination (the presence of unwanted, harmful, or impure substances in or on a material making it unsafe or unsuitable for use). During an interview on 1/23/26 at 11:50 a.m. with the Registered Dietician (RD), RD stated the pot with white and brown debris inside appeared to have food particles in it and was dirty. RD stated the pots should be stored inverted/face down to avoid getting anything inside that could contaminate it. 2. During an observation on 1/20/26 at 10:21 a.m. in the kitchen walk-in freezer, a black bean veggie (non-meat) patty was in an open plastic bag. The plastic bag was not labeled with an open date or expiration date. During an interview on 1/23/26 at 10:05 a.m. with the CDM, CDM stated it appeared the veggie patty bag was open with one burger in the bag. CDM stated his expectation was that when food was opened, there should have been an open and use by date on the package of the burger patties. CDM stated there was no open date or use by date on the bag. CDM stated it was important for open dates to be on the packages so that staff adequately rotated the food in a manner that everything opened got used first. CDM stated his expectation was to have an open date on the package/bag of the item because once the package/bag is open, it is good for a certain amount of time. CDM stated dating food items when they were opened was important because it ensured residents were given in-date quality food and ensured meals being provided to the residents were safe.During an interview on 1/23/26 at 11:35 a.m. with the RD, RD stated the opened bag had one black bean burger was not dated. RD stated the bag needed to be labeled with an opened and used by date to prevent cross-contamination and food-borne illness. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the Refrigerators and Freezers P&P indicated, .All food is appropriately dated to ensure proper rotation by expiration dates. Use by dates are completed with expiration dates on all prepared food in refrigerators. use by dates are indicated once food is opened. Supervisors inspect refrigerators and freezers monthly for.fan condition.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, (undated), the Food Receiving and Storage P&P indicated, .Refrigerated/Frozen Storage. All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date) .Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. 3. During an observation on 1/20/26 at 10:22 a.m. in the kitchen walk-in freezer, the walk-in freezer fan was observed with ice buildup on it. During an interview on 1/23/26 at 9:50 a.m. with the CDM, CDM stated he saw ice buildup on the bottom of the unit and on the fan in the walk-in freezer. CDM stated the ice buildup could cause freezer burn on the food and could diminish the food quality. CDM stated his expectation was that there be a minimal amount of ice on the unit so that it did not interfere with the function of the unit. CDM stated that to his personal standards, he would want to remove the ice buildup on the unit that was currently on the walk-in freezer fan. During a concurrent interview and record review on 1/23/26 at 9:54 a.m. with the CDM, the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022 was reviewed. The P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket conditions, fan conditions, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed.Refrigerator and freezer are kept clean, free of debris. The CDM stated that when inspecting the fan condition as stated in the P&P, he checked that there was no excessive ice buildup in freezer, it was running smoothly, and there were no unusual noises coming from the unit. CDM stated, having no ice buildup on the unit was important for the unit to continue to run efficiently and maintain appropriate temperatures. CDM stated the accumulation of ice could get on the food.During an interview on 1/23/26 at 11:30 a.m. with the RD, RD stated the ice buildup on the walk-in freezer was under and around the fan. RD stated if the ice buildup thawed, the water liquid could meet items stored in the freezer and could cause cross-contamination and food-borne illness.4. During an observation on 1/20/26 at 10:25 a.m. in the kitchen walk-in refrigerator, the walk-in refrigerator had a metal rack with an unlabeled and undated plastic container containing sliced pink fruit. During an interview on 1/23/26 at 10:59 a.m. with the CDM, CDM stated the pink fruit that was in the unlabeled undated plastic container was watermelon that had been cut the night before [Monday 1/19/26] on the evening shift for lunch dessert Tuesday [1/20/26]. CDM stated all food items should be labeled. CDM stated, once food is put into another container for use, it should be labeled with the date that it is made, use by date, and the employees initials. CDM stated it was important to label and put expiration dates on food items for quality and to ensure food does not sit in the refrigerator for a time that would make it unsafe.During an interview on 1/23/26 at 11:17 a.m. with the RD, RD stated the plastic container containing watermelon in the walk-in refrigerator was not labeled. RD stated, the cook missed the labeling of the food. RD stated her expectation was that all food needed to be labeled and dated. RD stated it was important to label and date food items to identify the food, identify when the food was made, and to determine when the food should be discarded if not used. RD stated they would not want to use expired food items that could lead to food-borne illness. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, .All food is appropriately dated to ensure proper rotation by expiration dates. Use by dates are completed with expiration dates on all prepared food in refrigerators. use by dates are indicated once food is opened.Supervisors inspect refrigerators and freezers monthly for.fan condition.During a review of the facility's P&P titled, Food Receiving and Storage, (undated), the P&P indicated, .Refrigerated/Frozen Storage.All foods stored in the refrigerator or freezer are covered, labeled, and dated ( use by date).Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded .5. During an observation on 1/20/26 at 10:24 a.m. inside the walk-in refrigerator, a metal rack had an one open uncovered box containing mushrooms and one open uncovered box containing celery. During an interview on 1/23/26 at 10:50 a.m. with the CDM, CDM stated, the walk -in refrigerator had an open box of mushrooms and celery. CDM stated, the mushrooms and celery were delivered in the manufacturer's original packaging. CDM stated, most food items were stored in the manufacturer's box. CDM stated, the celery box needed to be closed, and the mushroom box kept open for good air flow. CDM stated, I would bring up the idea to the corporate team, I think it is better for the mushrooms. CDM stated, all food items should be covered to prevent contamination. CDM stated, the facility's policy and procedures said all food should be covered.During an interview on 1/23/26 at 11:27 a.m. with the RD, RD stated mushroom and celery box were opened and not covered. RD stated, all foods should be covered and stored properly to prevent cross contamination, food borne illnesses and potential harm to anyone who eats it. During a review of the facility's policy and procedure (P&P) titled, Food receiving and Storage, dated 2001, the P&P indicated, .All foods stored in the refrigerator or freezer are covered. 6. During an observation on 1/20/26 at 10:27 a.m., inside the walk-in refrigerator, a couple of mushroom slices and a white liquid residue consistent with milk were on the floor. During an interview on 1/23/26 at 9:57 a.m. with CDM, CDM stated, milk drippings and couple of mushrooms were observed on the floor inside the walk-in refrigerator. CDM stated, the floor appeared unclean but did not believe it would cause harm. CDM stated, mushrooms were served Monday [1/19/26] night. CDM stated, all kitchen staff were responsible for maintaining cleanliness. CDM stated, nothing should be on the floor. I would expect them to be cleaned up at the end of the night when they were served, and the next day. During an interview on 1/23/26 at 11:20 a.m. with RD, RD stated, Cleanliness of the freezer, everyone is responsible. RD stated, a white liquid spill, which may be milk and a couple of slices of mushrooms, were on the floor inside the walk-in refrigerator. RD stated, her expectation was for staff to clean it right away. RD stated, it is a safety issue, and we don't want to contaminate anything else. During a review of the facility's P&P titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, .Refrigerators and freezers are kept clean, free of debris.7. During a concurrent observation and interview on 1/21/26 at 8:35 a.m. with Dietary Aid (DA), in the kitchen, the DA tested the sanitizer sprayer bottle used for cleaning countertops with a sanitizer test strip (a little paper strip that changes color to tell how acidic or alkaline something is) by spraying liquid from the bottle unto the test strip and the test result was zero. DA stated, zero meant the sanitizer sprayer bottle did not have enough sanitizer. DA stated, maybe its water, if you don't let the water run long enough, the sanitizer won't come out. DA stated the test result should have been at 400 parts per million (ppm- unit of measurement), not zero. DA stated, the sanitizer sprayer bottle was refilled in the sink and water needed to run for 30 seconds to a minute, then it should be tested to check the result to make sure it worked properly. DA stated the test result should be between 200 - 400 ppm. DA stated, someone could get sick if surfaces were not properly sanitized and became contaminated. During an interview on 1/23/26 at 10:41 a.m. with CDM, CDM stated, the manufacturer-recommended sanitizer was used to wipe down food-prep countertops. CDM stated, everyone in the kitchen was responsible for cleaning them after use, after food preparation or when visibly soiled. CDM stated, the kitchen staff must test the water from the dispenser at the faucet. CDM stated, water pressure can fluctuate throughout the day. CDM stated test results were normally 200 ppm and not zero. CDM stated, the acceptable range of sanitizer was 150-400 ppm. CDM stated, the task may have been overlooked from the previous night. CDM stated the kitchen staff were required to empty and refill the sanitizer sprayer bottle at the beginning of each shift. CDM stated, it was not acceptable for the food countertops to be improperly sanitized. CDM stated, if food countertops were not properly sanitized, food could be unsafe, and residents who were served unsafe food could develop foodborne illnesses. During an interview on 1/23/26 at 11:51 a.m. with RD, RD stated kitchen staff used a manufacturer-recommended sanitizer and test strips to ensure countertops were properly sanitized. RD stated, the sanitizer should be maintained at 200-400 ppm per manufacturer guidelines. RD stated 200 to 400 ppm was important for effectively reducing microbes and bacteria on surfaces to prevent food-borne illnesses. RD stated if the sanitizer test strip result was zero, the kitchen staff need to recheck the sanitizer. During a review of the manufacturer's guidelines titled, [brand name of sanitizer], undated, the manufacturer's guidelines indicated, .The solution's broad efficacy range of 150-400 ppm stays within proper range longer.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for five of nine sampled residents (Residents 7, 8, 52, 63, and 92) when the Controlled Substance Record (CSR) and the Controlled Drug Record (CDR) (a mandatory document used for tracking drugs from the moment they arrive at a facility until they are given to a patient or destroyed, acting as a security measure to prevent theft or misuse) were not completed by the Licensed Nurses upon receipt from the pharmacy.These failures had the potential to result in compromised resident safety including medication errors and drug diversion (the illegal transfer of prescription drugs-especially controlled substances from their intended legal recipient to someone else for personal use or sale).During a review of Resident 7's admission Records (AR) dated January 23, 2026, the AR indicated, Resident 7 was admitted on [DATE] and had a diagnosis of chronic pain. During a review of Resident 7's Order Summary Report (OSR) dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .HYDROcodone-Acetaminophen [a medication prescribed for moderate to severe pain] Oral Tablet 5-325 MG [milligram - unit of measurement] (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube [a small tube placed directly into the stomach through a small, surgical opening in the belly that acts as a direct, alternative route to deliver formula, liquids, and medication directly to the stomach] every 6 hours as needed for chronic pain. HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet via G-Tube two times a day for chronic pain.During a concurrent interview and record review on 1/22/26 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 1, Residents 7's CDR, (undated) was reviewed. The CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated it was important to fill out and sign the CDR, so medication could be tracked and to minimize the risk of diversion. LVN 1 stated the record should be filled out with the nurses first name, last name, signature, title, and date.During a review of Resident 8's AR dated January 23, 2026, the AR indicated, Resident 8 was admitted on [DATE] and had a diagnosis of Pain in the left hip. During a review of Resident 8's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 3 hours as needed for Severe Pain .During a concurrent interview and record review on 1/22/26 at 3:02 p.m. with LVN 1, Residents 8's CSR, (undated) was reviewed. The CSR did not indicate the received date, received time, or the nurses signature. LVN 1 stated the record should have been filled out with the nurses' first name, last name, signature, title, and date.During a review of Resident 52's AR dated January 23, 2026, the AR indicated, Resident 52 was admitted on [DATE] and had a diagnosis of low back pain and other chronic pain. During a review of Resident 52's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .traMADol [a medication prescribed for moderate to moderately severe pain] HCL [hydrochloride - salt] Oral Tablet 50 MG (Tramadol HCL) Give 1 tablet by mouth two times a day for pain.During a concurrent interview and record review on 1/22/26 at 3:05 p.m. with LVN 1, Residents 52's CDR, (undated) was reviewed. The CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated the record should have been filled out with the nurses first name, last name, signature, title, and date.During a review of Resident 63's AR dated January 23, 2026, the AR indicated, Resident 63 was admitted on [DATE] and had a diagnosis of other chronic pain. During a review of Resident 63's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Morphine Sulfate [a medication prescribed for severe pain] (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 3 hours as needed for severe pain .traMADol HCL Oral Tablet 100 MG (Tramadol HCL) Give 1 tablet by mouth two times a day for for chronic pain. During a concurrent interview and record review on 1/22/26 at 3:08 p.m. with LVN 1, Residents 63's CSR, (undated) was reviewed. The CSR did not indicate the received date, received time, or the nurses signature. Resident 63's CDR, (undated) did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. LVN 1 stated the record should have been filled out with the nurses' first name, last name, signature, title, and date.During a review of Resident 92's AR dated January 23, 2026, the AR indicated, Resident 92 was admitted on [DATE] and had a diagnosis of other chronic pain, muscle wasting and atrophy [waste away], not elsewhere classified, unspecified site, and Hypopituitarism [when a gland at the base of the brain does not produce enough hormone]. During a review of Resident 92's OSR dated January 23, 2026, the OSR indicated, . Pharmacy Order Summary .Testosterone Cyplonate Solution [hormone replacement] 200 MG/ML [mililiter - unit of measurement] inject 1 ML intramuscularly [given into the muscle] one time a day every 3 month(s) starting on the 17th for 1 day(s) for Hormone replacement therapy .During a concurrent interview and record review on 1/22/26 at 3:10 p.m. with LVN 1, Residents 92's CSR, (undated) was reviewed. The CSR did not indicate the start quantity, number of CC (cubic centimeter - unit of measure) remaining, received date, received time, or the nurses signature. LVN 1 stated the record should have been filled out with the nurses first name, last name, signature, title, and date. LVN 1 stated the record was not filled out and does not have the start quantity, or signature on the document. During a concurrent interview and record review on 1/23/26 at 2:02 p.m. with the Director of Nursing (DON), Resident 92, 63, 52, 8, and 7's Controlled Substance Record/ Controlled Drug Record, (undated) were reviewed. Resident 92's CSR did not indicate the start quantity, number of CC (unit of measure) remaining, received date, received time, or the nurses signature. The DON validated the CSR was not filled out and had no starting amount, initial of nurse receiving it, and no date on the record. DON stated the CSR needed to have the date, time, and signature on it. Resident 63's CSR did not indicate the received date, received time, or the nurses signature. Resident 63's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. The DON validated the CSR and CDR should have been signed by the receiving nurse. Resident 52's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. The DON validated the CDR should have been signed by the receiving nurse. Resident 8's CSR did not indicate the received date, received time, or the nurses signature. DON validated the CSR should have been signed by the receiving nurse. Resident 7's CDR did not indicate the total amount of medication received, the medication amount on the sheet, the received by signature, or received date. DON validated the CDR should have been signed by the receiving nurse. The DON validated that the process when receiving medications from pharmacy was to document when they received the narcotics on a log and place the count sheet (CDR/CSR) in the count book. The DON validated the CDR/CSR was required and should be signed, dated, and initialed to ensure medications that come into the facility are accounted for because of the potential for drug diversion.During a concurrent interview and record review on 1/23/26 at 2:07 p.m. with the DON, the facility's policy and procedure (P&P) titled, Controlled Substances, dated November 2022, was reviewed. The P&P indicated, . Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substance together. Both individuals sign the designated controlled substance record.This record contains. quantity received. number on hand. date and time received. signature of person receiving medication.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The DON stated the facility's policy was not followed if the date, time, and signature was not filled out on the CDR/CSR.

Based on observation, interview, and record review, the facility failed to ensure essential kitchen equipment was in safe operating condition when:The food preparation sink did not have an air gap (a space between the drain spout and the in-floor drain inlet that prevents contaminated water from flowing back into a clean water supply). 2.The ice machine that supplies ice to the residents in the facility did not have an air gap. These failures had the potential to contaminate food sources for 90 of 97 residents who received food from the kitchen, causing foodborne illness in a vulnerable population and resulting in severe patient harm or death.Findings:1. During a concurrent observation and interview on 1/20/26 at 3:05 p.m. with the Dietary Manager (DM) in the kitchen, the food prep sink was piped directly into the wall. On the floor, under the food prep sink there was a drain without any piping going to it. The DM stated they were not using an air gap and the pipe from the food prep table went directly into the city sewer.During an interview on 1/23/26 at 1:54 p.m. with Maintenance Director (MD), MD stated there was no air gap in the food prep sink and it should not be like that. MD stated the backflow could get into the food and could cause infection or food borne illness when no airgap was utilized.During an interview on 1/23/26 at 11:17 a.m. with Registered Dietician (RD), RD stated, Food prep sink has no air gap is an oversight and we have an old building. RD stated, We know there is supposed to be airgap. RD stated if there is a back flow, it could potentially cause food borne illnesses.2.During a concurrent observation and interview on 1/20/26 at 2:56 p.m. with the DM, in the breakroom, the ice machine was observed with the hose hanging over the rim of the drain passing below the level of the floor. DM stated the ice machine drainpipe was sitting past the threshold of the floor. DM stated the ice machine in the breakroom was the only ice machine of the facility. DM stated there was no air gap for the ice machine.During an interview on 1/23/26 at 11:17 a.m. with RD, RD stated the ice machine drainpipe was below the floor and needed to be above the floor. RD stated it should be one and a half to two inches above to prevent back flow. RD stated the piping should not ever be below the floor. RD stated when the piping went past the floor, there was potential for backflow and food borne illnesses.During an interview on 1/23/26 at 1:52 p.m. with MD, the MD stated the ice machine drainpipe was sitting level with the drain on the floor. MD stated there should be an air gap at least two times the size of the pipe. MD stated with no air gap there was a potential for backflow problems and possibility for causing infectious diseases to residents.During a review of the facility's policy and procedure (P&P) titled, Drainage Air Gap Policy, dated March 8, 2019, the P&P indicated, .This policy outlines our policy on the air gap requirement for drains in all areas of the facility .All air gaps (the distance between the button of the pipe and the drain it flows into),must be twice (2 times) the diameter of the pipe. The distance between the pipe and the top of drain is defined as an air gap .The purpose of this air gap is to allow for proper space in the case of the drain backing up, the soiled water will not re-enter the drainpipe and result in unsanitary conditions.This policy applies to all on ice machines, dish machines, floor drains under sinks, etc. to include any drain is seen in which a pipe if flowing to.If at any time a drain is seen to be not meeting regulation, action steps of notifying the maintenance director and administrator should occur.Maintenance Director is responsible for ensuring drain meet the regulations.

Based on observation, interview and record review, the facility failed to maintain professional standards of practice for one of six sampled residents (Resident 48) when Resident 48's physician's orders had directions to give a total dosage of 150 milligrams (mg- a unit of measurement) of clozapine (medication used for reducing hallucinations, delusions, and risk of suicide) when Resident 48 was prescribed 175 mg.This failure had the potential to cause Resident 48 to receive less medication than what was prescribed.Findings:During a review of Resident 48's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/22/26, the AR indicated Resident 48 was admitted on [DATE] with diagnoses which included: schizoaffective disorder, bipolar type ( a mental health condition where a person has symptoms of psychosis [hallucinations and delusions] and strong mood changes like mania [very high energy] and depression [extreme sadness]) and anxiety disorder (mental health conditions characterized by excessive, persistent fear and worry about everyday situations). During a concurrent interview and record review on 01/23/26 at 8:37 a.m. with Registered Nurse (RN) 2, Resident 48's Order Summary Report, dated 1/23/26 was reviewed. The Order Summary Report, indicated Resident 48 had three orders for clozapine to add up to a total of 175 mg. Resident 48's clozapine orders were the following: clozapine oral tablet 100 mg, clozapine oral tablet 25 mg, and clozapine oral tablet 50 mg all three clozapine tablets were to add up to a total of 175 mg. The summary on the 50 mg order indicated, . Give 1 tablet by mouth two times a day for SCHIZOEFFECTIVE DISORDER, BIPOLAR TYPE to be given with 50 mg tablet total dose 150 mg . RN 2 stated the summary in the order stated the total medication should add up to 150 mg when Resident 48 was supposed to be on 175 mg. RN 1 stated this could be confusing to a new nurse or one unfamiliar with the actual order and could lead to potentially giving Resident 48 more than his prescribed dosage of medication.During a concurrent observation and interview on 1/23/26 at 9:17 a.m. Resident 48's clozapine medication blister packs were reviewed. RN 2 stated Resident 48's blister pack should have contained an orange sticker on top of them to ensure nurses were aware of a medication order change. RN 1 stated Resident 48 had his dosage of clozapine increased from 150 mg to 175 mg on 1/14/26 and nurses needed to double check the order to make sure Resident 48 did not receive the wrong dose of medicine.During an interview on 1/23/26 at 11:15 a.m. with the Director of Nursing (DON), the DON stated all the dosage information listed in the resident's medication orders should match. Matching the dosage information with the summary helped eliminate the chance for potential medication administration errors.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2/25, the P&P indicated . psychotropic medication management is an interdisciplinary process involves the resident, family, and /or the representative and includes: . b. establishing appropriate dose .

Number of residents sampled: 5Number of residents cited: 2Based on observation, interview, and record review, the facility failed to ensure residents who were not able to carry out activities of daily living (ADLs- routine tasks/activities a person perform daily to care for themselves) were provided assistance to maintain personal hygiene and grooming for two of five sampled residents (Resident 4 and 56) when Resident 4 and Resident 56 had fingernails that were long, jagged and had colored particles under their fingernails.These failures resulted in poor personal hygiene and had the potential to result in serious health condition for Resident 4 and Resident 56. During a concurrent observation and interview on 1/20/26 at 10:45 a.m. during initial tour in Resident 56s room, Resident 56 was observed lying in bed with the TV on. Resident stated she had been in the facility since 2001 and had no issues or concerns. Resident 56 fingernails were observed and appeared long, jagged and with some discolored particles under the nails. Resident stated she did not remember the last time her fingernails were trimmed and stated she did not mind the long nails as long as they had smooth edges. During a review of Resident 56's admission Record [AR-a document containing resident profile information], dated 1/23/26, the AR indicated Resident 56 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities) and anxiety (feeling of worry, nervousness, or unease about an imminent event or something with an uncertain outcome, triggering the body's stress response). During a review of Resident 56's Minimum Data Set (MDS-a federally mandated resident assessment tool) assessment dated [DATE]. The MDS indicated, Resident 56's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 56 had no cognitive deficit. During concurrent observation and interview on 1/20/26 at 10:58 a.m. during initial tour in Resident 4's room, Resident 4 was observed lying in bed watching TV. Resident 4 stated he had been in the facility for a long time. Resident 4's was observed with long and jagged fingernails with dark colored particles under the nails. Resident 4 stated he did not like having long nails because he always scratched self especially during shower and he was afraid he will develop an infection. Resident 4 stated he did not remember the last time his fingernails were cut or trimmed. Resident 4 stated he was not sure how many times a week were to provide nail care. Resident 4 stated he was wearing a sling on his left arm because he had a stroke and it affected his left side. Resident 4 stated he was not able to move his left side. During a review of Resident 4's AR dated 1/22/26, the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness or incomplete paralysis on one side), Diabetes Mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). During a review of Resident 4's MDS assessment dated [DATE], the MDS indicated, Resident 4's BIMS-assessment score was 15 out of 15 indicating Resident 4 had no cognitive deficit. During a concurrent observation and interview on 1/22/26 at 9:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 checked Resident 56 and Resident 4's fingernails. CNA 1 stated Resident 56 fingernails are long with jagged edges. CNA 1 stated Resident 56 had refused care including nail care. CNA 1 stated Resident 56 fingernails should at least been filed and reported to licensed nurse when she refused nail care. CNA 1 stated Resident 4 is diabetic, and his fingernails are long, dirty, with rough edges and needed to be trimmed. CNA 1 stated licensed nurses provide nail care to diabetic residents and CNAs perform nail care to non-diabetic residents. CNA 1 stated long jagged fingernails were not safe because Residents' 56 and 4 could scratch themselves which could lead to infection. CNA 1 stated she did not know why Resident 4 and Resident 56's fingernails were not trimmed because nail care is scheduled on resident's shower days and every Sunday. During a concurrent interview and record review on 1/22/26 at 9:48 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated nail care is scheduled every Sunday. LVN 1 stated she was familiar with Resident 4 and Resident 56 and stated Resident 4 is diabetic and sometimes refused nail care. LVN 1 reviewed Resident 4's care plan and stated she did not find a care plan indicating Resident 4 refusing care. LVN 1 stated she did not remember any CNAs' reporting long fingernails for Resident 4 and Resident 56's and that they needed to be trimmed. LVN 1 stated she did not remember checking their fingernails and whether they needed to be trimmed or filed. LVN 1 stated long fingernails could lead to residents scratching themselves creating breaks in the skin and if not treated could lead to infection. LVN 1 stated fingernails should be kept clean, trimmed, and filed. During an interview on 1/23/26 at 10:58 a.m. with the Director of Nursing (DON), the DON stated her expectation was to make sure CNAs are checking resident's fingernails on their shower days. The DON stated the CNAs complete a shower form of their observations and give to the licensed nurse for her signature. The form is then filed in a binder. The DON stated licensed nurses are responsible for taking care of diabetic residents nails. The DON stated fingernails or nail care are also scheduled every Sunday since there are no scheduled showers. The DON stated her expectation was to ensure all residents' nails are clean, trimmed and filed because residents could scratch themselves with their long and dirty nails which could lead to infection. During a review of facility document titled, Job Description: Certified Nursing Assistants, dated 2003, the Job Description indicated, . Participate in and receive the nursing report upon reporting for duty .Assist residents with bath functions .Assist resident with nail care(i.e., clipping, trimming, and cleaning the finger/toenails) .During a review of facility document titled, Job Description: Charge Nurse, dated 2003, the Job Description indicated, .Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas . Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity, and respect .During a review of facility policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated 2001, the P&P indicated, . Nail care includes regular cleaning and trimming. Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Documentation . If the resident refused the treatment, the reason(s) why and the intervention taken . Reporting: Notify the supervisor if the resident refuses the care .

Number of residents sampled: 6Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 10) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not attempt or implement behavior monitoring for Resident 10's use of haloperidol (medications used to treat schizophrenia [a mental illness that is characterized by disturbances in thoughts]).This failure placed Resident 10 at risk for experiencing adverse effects from receiving medication without behavior monitoring. During a concurrent observation and interview on 1/20/26 at 2:45 p.m. Resident 10 was observed ambulating in the hallway using a front wheel walker, walked to the activity room and joined group activities other residents. Resident 10 stated she was not sure how long she had been in the facility. Resident 10 was observed with involuntary shaking of hands and did not answer when asked if she had any concerns. During a review of Resident 10's admission Record [AR- document containing resident profile information], dated 1/22/26, the AR indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder [a mental illness that can affect thoughts, mood, and behavior], extrapyramidal and movement disorder ([EPS-drug-induced movement disorders, most commonly caused by antipsychotics, that produce involuntary motor issues] and chronic kidney disease [kidneys damaged and cannot filter waste, toxins, and excess fluid from the blood]. During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated, Resident 10's Brief Interview for Mental Status (BIMS-screening tool sed to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 10 had no cognitive deficit. During a review of Resident 10's Transfer/Discharge Report [medications order list], dated 1/22/26, the Transfer/Discharge Report, indicated, . Haloperidol Oral tablet five [5] MG [milligram-unit of measurement]. Directions: Give 1.5 tablet by mouth two times a day for Schizoaffective Disorder total of 7.5mg BID [twice a day] .Start Date 11/22/25 . During an interview on 1/22/26 at 9:04 a.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated she was familiar with Resident 10's care. CNA 1 stated Resident 10 wanted to be independent with all her activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). CNA 1 stated Resident 10 sometimes refused care and CNA 1 observed Resident 10 yelling at staff. During a concurrent interview and record review on 1/22/26 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 10's medication orders were reviewed. LVN 1 stated Resident 10 had behaviors of physical and verbal aggressiveness towards staff. LVN 1 stated Resident 10 was on psychotropic medications including haloperidol. LVN 1 stated she did not find behavior monitoring for haloperidol and there should have been. During a concurrent interview and record review on 1/22/26 at 11:30 a.m. with Minimum Data Set Coordinator (MDSC), Resident 10's medication orders were reviewed. The MDSC stated, Resident 10's psychotropic medication order was incomplete and monitoring was incomplete. The MDSC stated the monitoring of behavior should have been started when the medication was started. The MDSC stated it was her responsibility and other licensed nurses to ensure monitoring was started when psychotropic medications are prescribed. During an interview on 1/23/26 at 10:50 a.m. with the Director of Nursing (DON), the DON stated her expectation was to ensure behavior monitoring was in place when starting resident on psychotropic medication. The DON stated behavior monitoring was important in order to evaluate if medications are working and to track episodes residents are having. The DON stated the licensed nurse receiving the order was responsible in ensuring there was a behavior monitoring started. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, Revision date 2/25, the P&P indicated, .Psychotropic medication is any medication that affects brain activity associated mental processes and behavior . Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: a. determining adequate indications for use; . c. adequate monitoring for efficacy and adverse consequences . Documentation must include that behavioral [non-pharmacological] interventions were attempted . Diagnosis alone does not necessarily warrant the use of psychotropic medication . Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records .

Number of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 2) when Resident 2 did not have a care plan for a diagnosis of dementia (a progressive state of decline in mental abilities).This failure placed Resident 2 at risk for harm by not identifying and monitoring signs and symptoms and care of resident with dementia. During a concurrent observation and interview on 1/20/26 at 10:15 a.m. during initial tour in Resident 2's room, Resident 2 was observed sitting at the edge of her bed, oxygen concentrator (medical device that takes in the air around you, removes impurities (mostly nitrogen), and delivers purified, high-concentration oxygen to breath) at bedside with nasal cannula (flexible tube with two small prongs placed just inside the nostrils to deliver supplemental oxygen) placed in a plastic bag. Resident 2 stated she did not have any complaints.During a review of Resident 2's admission Record [AR- a document containing resident profile information], dated 1/22/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder (a mental illness that is can affect thoughts, mood, and behavior), and bipolar disorder (mental health condition causing extreme shifts in mood, energy, and activity levels, swinging between intense highs (mania or hypomania) and deep lows (depression -persistently sad, empty, or hopelessness).During a review of Resident 2's Minimum Data Set (MSA- a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 2's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit. 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 2 had no cognitive deficit.During a concurrent interview and record review on 1/22/26 at 9:38 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's clinical record was reviewed. LVN 1 stated she was familiar with Resident 2's care. LVN 1 stated Resident 2 has a diagnosis of dementia. LVN 1 stated she did not find a care plan initiated to care for Resident 2's diagnosis of dementia. LVN 1 stated it was the responsibility of licensed nurses to make sure care plan was initiated for resident's diagnosis.During a concurrent interview and record review on 1/22/26 at 11:10 a.m. with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 2's clinical record. The MDSC stated Resident 2 had a diagnosis of dementia since admission on [DATE]. MDSC stated she did not find a care plan for dementia and a care plan should have been initiated when Resident 2 was admitted to the facility. The MDSC stated she was responsible in ensuring care plan was initiated for Resident 2's diagnosis of dementia. The MDSC stated Resident 2 had other care plans but were not focused on dementia. The MDSC stated, Care plan should be focused on the diagnosis of dementia in order to care for Resident 2's behaviors. The MDSC stated a care plan was important for facility staff to care for Resident 2.During an interview on 1/23/26 at 10:55 a.m. with the Director of Nursing (DON), the DON stated her expectation and the expectation of department heads was for licensed nurses are responsible in developing their own care plan. The DON stated, Care plan was important so everyone can follow residents plan of care. The DON stated care plans should be individualized and specific to resident needs. The DON stated the MDSC was responsible in ensuring there were care plans for resident diagnosis's when completing MDS assessments. The DON stated if the MDS encounters a missing care plan the MDS would create care plans when needed. During a review of facility's document titled, Charge Nurse Job Description, dated 2003 the Job Description indicated, . Completing medical forms, reports, evaluations, studies, charting .Review care plans daily to ensure that appropriate care is being rendered. Inform the Nurse Supervisor of any changes that need to be made on the care plan . Review resident care plans for appropriate resident goals, problems approaches, and revisions based on nursing needs .During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered. Revision date: 3/22, the P&P indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission . 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 .

Based on observation interview and record review the facility failed to ensure residents were free from unnecessary drugs for one of three sampled residents (Resident 1) when Resident 1 was prescribed and received an antipsychotic medication (Quetiapine-used for the treatment of mental illness) with a black box warning (serious warning from the FDA that appears on medication label indicating it has a significant risk or life threatening increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death), for the treatment of Dementia (brain disorder that affects the ability to remember) with documented behaviors of restlessness, inability to sleep and voiced sadness on 2/11/25. This failure placed Resident 1 at risk for adverse reactions that included Dry Mouth, Blurred Vision, Tachycardia (increased heart rate), Urine Retention, Constipation (inability to defecate), Confusion, Delirium (confused thinking), Hallucinations (perception of having seen, heard something that wasn ' t present), increased Blood Pressure, Sedation, Loss of Appetite, Photosensitivity (sensitivity to light), Fainting, Falls, Poorly Controlled Blood Sugar, Weight Gain, and death. Findings: During a review of Resident 1's Admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for anxiety (intense worry and fear), adult urinary tract infection, unspecified dementia ( brain disorder that affects the ability to remember) with unspecified severity with other behavioral disturbance, type 2 diabetes mellitus (condition that causes increased blood sugar), depression (feeling of sadness) . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 1/20/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 5 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment [memory loss, poor decision making skills. During a concurrent observation an interview on 2/18/25 at 10:45 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 was observed lying in bed, dressed, groomed and calm. Resident 1 stated she was unable to get out of bed without assistance and would use the call light to alert staff, Resident 1 observed reaching for the call light. Resident 1 stated she felt agitated with the facility staff when they would not let her talk. Resident 1 was observed calm and answering all questions during the interview. During a record review of Resident 1 ' s, Antipsychotic medication Care Plan (CP), dated 2/18/25, the CP indicated, . admitted with antipsychotic medication related to medical diagnosis Dementia as evidenced by (AEB) psychosis . During a review of Resident 1 ' s acute care hospital, Discharge Instruction Document, dated 2/11/25, the document indicated, . New Quetiapine [Brand Name] 25 mg (unit of measure) oral tablet 0.5 tab by mouth every bedtime . next dose 2/11/25 . The document indicated there was no documented diagnosis or indication of use for this medication. During an interview on 2/18/25 at 11:43 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 1 had not exhibited any behaviors while CNA 1 provided care. CNA 1 stated she had provided care for Resident 1 on numerous occasions and was familiar with Resident 1. CNA 1 stated, Resident 1 ' s behaviors of yelling, kicking doors and accusation happened in the late afternoon and had not observed behaviors during the day. During a record review of Resident 1 ' s, Order Summary, dated 2/11/25, the order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . black box warning . increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The order summary indicated medication (Quetiapine) was initiated on 2/11/25 for indefinite time of use. During a review of Resident 1 ' s, Facility Verification of Informed Consent-Psychotropic Drug, dated 2/11/25, the form indicated, . [medication brand name] 25 mg (unit of measure) 0.5 tablet bedtime . medical symptom/target behavior to monitor dementia, verbal aggression, drug classification anti-psychotic . medication order status: newly started (started at skilled nursing facility) . indicate severe dementia upon emergency room visit . antipsychotic drugs: purpose treatment of individuals who have been diagnosed with one or more of the following: schizophrenia (disorder affecting a person ' s ability to think, feel, behave clearly), Schizo-affective disorder (mental health disorder that includes mood changes and hallucinations), schizophreniform (mental disorder that impacts reality) disorder, delusional disorder, mood disorder (example bipolar disorder, severe depression refractory to other therapies and or with psychotic features, psychosis (disconnection from reality) in the absence of dementia, medical illness with psychotic symptoms, treatment related to psychosis or mania . During a review of a professional reference from the National library of Medicine titled, Quetiapine Drug information, dated 6/15/2020, the professional reference indicated, . Important warning for older adults with dementia, studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly and perform daily activities and that may cause changes in mood and personality) who take antipsychotics such as quetiapine have an increased risk for death during treatment. Quetiapine is not approved by the Food and Drug Administration (FDA) for the treatment of behavioral problems in older adults with dementia . During a review of Resident 1 ' s, Medication Administration Record (MAR), dated 12/1/24-12/31/24, the MAR indicated, . Monitor for episodes of Anxiety as evidenced by (AEB) restlessness, every evening shift for 14 days . Monitor of depression AEB voiced sadness every shift . The MAR indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a review of Resident 1 ' s, MAR, dated 1/1/25-1/31/25, the MAR indicated, . Monitor of depression as evidenced by (AEB) voiced sadness every shift . The MAR indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a review of Resident 1 ' s, MAR, dated 2/1/25-2/28/25, the MAR indicated, . Monitor of depression as evidenced by (AEB) inability to sleep every evening and night shift . Monitor of episodes of Anxiety AEB restlessness . every shift . Quetiapine Give 0.5 tablet by mouth at bed time related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . The MAR indicated Resident 1 received medication every evening beginning on 2/11/25 and indicated Resident 1 was not being monitored for hallucinations, delirium or symptoms of psychosis. During a concurrent interview and record review on 2/18/25 at 11:55 a.m. with licensed vocational nurse (LVN) 1, Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . LVN 1 reviewed and read the order for medication [brand name] with the black box warning. LVN 1 stated Resident 1 ' s diagnosis of dementia was not a proper diagnosis for the use of medication [brand name] because of the increased risk for death in elderly residents according to the black box warning. LVN 1 stated, Resident 1 ' s behaviors had improved since 2/11/25 but was unsure if behaviors had improved due to medication [brand name] use or because Resident 1 had been recently treated for a urinary tract infection which could have caused increased behaviors. During a concurrent interview and record review on 2/18/25 at 12:39 p.m. with the social services director (SSD), Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . black box warning . increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The SSD stated it was the facility process to monitor the use of psychotropic medications prescribed in the facility and monitor Resident ' s behaviors to establish if medications were effective. The SSD stated with the use of medication [brand name] for dementia, was not an appropriate diagnosis unless there were behaviors exhibited. The SSD stated, Resident 1 exhibited behaviors and was currently prescribed a psychotropic but had not been evaluated or treated by the facility psychologists. The SSD stated the use of medication [brand name] was a recommendation to the facility and Resident 1 ' s physician from Resident 1 ' s family. During a concurrent interview and record review on 2/18/25 at 1:15 p.m. with the director of nursing (DON), Resident 1 ' s Order Summary, dated 2/11/25 was reviewed. The order summary indicated, . [medication brand name] give 0.5 tablet by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . black box warning . increased mortality in elderly patients with dementia related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Anti-psychotic medications is not approved for the treatment of patients with dementia-related psychosis. Suicidal thoughts & behaviors . The DON reviewed and read the order with the black box warning. The DON stated the diagnosis of Dementia was not an appropriate indication of use for this medication [brand name]. The DON stated it was not a usual diagnosis seen for the use of this psychotropic medication in the facility and the black box warning indicated not to use on elderly residents. The DON stated, the facility would clarify diagnosis and reason for medication use with psychotropics in the future. During an interview on 2/18/25 at 1:55 p.m. with the administrator (ADM), the ADM stated the expectation was for the facility nurses to clarify physician orders with the physician or DON when unsure of physician orders. The ADM stated, the facility nursing staff should have called the DON or physician when something did not feel right. During a telephone interview on 2/25/25 at 2:28 p.m. with Resident 1 ' s physician, the physician stated Resident was admitted to the facility for rehabilitation from an injury. The physician stated, during Resident 1 ' s stay in the facility, Resident 1 needed more care than usual and began behaviors of staying up all night and possible hallucinations. The physician stated Resident 1 was admitted to the hospital for a fall, while in the hospital Resident 1 was prescribed the antipsychotic medication. The physician stated the medication (Quetiapine) was used for a diagnosis of schizophrenia and bipolar disorder but Resident 1 did not have those diagnosis. The physician stated the medication was used off label for behaviors and believed it was a good idea to continue Resident 1 with medication following the hospital discharge orders for the diagnosis of Dementia. The physician stated it was for the treatment of behaviors of yelling and pointing at CNAs and staff. The physician stated the medication was discontinued from Resident 1 ' s use solely on his assessment of Resident 1 on 2/18/25. During a record review of the facility ' s policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2001, the P&P indicated, . Residents will not receive medications that are not clinically indicated to treat a specific condition . a psychotropic medication is any medication that affects brain activity associated with mental processes and behavior . Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record . use of psychotropic medications may be considered appropriate in specific circumstances . acute or emergency situations, enduring conditions, and/or new admissions where the resident is already on psychotropic medication . non-pharmacological approaches are used to minimize the need for medications . when determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether other causes for symptoms including symptoms that mimic a psychiatric disorder have been ruled out, signs and symptoms are clinically significant enough to warrant medication therapy .

Based on observation interview and record review the facility failed to provide a safe environment for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1's emergency room visit on 10/24/24. Findings: During a review of Resident 1's Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident's care) Note, dated 10/24/24, the note indicated, . Resident eloped on 10/23/2024. Discussed and reviewed with IDT. After reviewing with staff, resident removed door lock and eloped through sliding glass door sometime after hourly check. Staff reported resident was last seen during hourly checks at 0700 (7:00 a.m.). At 0720 (7:20 a.m.) resident unable to be located for breakfast and medication pass . During an interview on 10/25/24 at 2:00 p.m. with the director of nursing (DON), the DON stated on 10/23/24, Resident 1 had eloped from the facility. The DON stated it was concluded that Resident 1 had removed the secured lock on Resident 1's room sliding door and left the facility. During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis for Schizoaffective disorder (mental disorder that includes seeing or hearing and holding false beliefs), depression (mental disorder that causes sad mood or loss of interest in activities), need for assistance with personal care . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/13/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1 ' s, Elopement Care plan (CP), dated 9/17/24, the CP indicated, . Special treatment Program facility . at risk for elopement related to involuntary placement, refusal to take medication, danger to self/community, self-well-being history of substance abuse, past history of elopement . will not leave facility unattended .admit to a locked/secured (egress) facility . During an interview on 10/25/24 at 2:48 p.m. with the mental health worker (MHW), the MHW stated he had been notified of the incident in which Resident 1 had eloped from the facility and exited through the sliding door. The MHW stated the sliding doors in resident' s rooms were always kept locked and all doors were secured with a window screw. During an interview on 10/25/24 at 2:58 p.m. with licensed vocational nurse (LVN) 1, the LVN 1 stated she was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1's room. LVN 1 stated the facility expectation was for all sliding doors in resident ' s rooms to have been locked and secured at all times. During a concurrent observation and interview on 10/25/24 at 3:06 p.m. in Resident 1's room with the maintenance assistant (MA), the MA stated he was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1 ' s room. The MA stated Resident 1 had removed the lock stopper that was in place to secure the resident ' s sliding door from opening. The MA stated the sliding doors should have been locked at all times as the sliding doors were not used. The MA stated the sliding door locks were tightened with pliers, but if continued disruption occurred, the locks could have loosened allowing the sliding door to open. The MA stated the sliding doors were checked during monthly inspections. The MA stated checking the sliding doors was not documented on the maintenance checklist and was just something they did. During an interview on 10/25/24 at 3:18 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1 ' s room. CNA 1 stated the sliding door locks were put in place to keep the sliding doors locked and closed. CNA 1 stated it was easy to open the sliding doors because the sliding door locks were simple to remove. CNA 1 stated since (after the incident) the sliding doors were secured with wood, the doors could no longer open and were effectively locked. During a telephone interview on 10/30/24 at 11:59 a.m. with the administrator (ADM) and the Maintenance Director (MD), the ADM stated the sliding doors were not used and could have been considered a wall as the sliding doors had no purpose. The ADM stated the sliding doors should have been locked at all times. The ADM stated Resident 1 figured out how to open the door and remove the lock. The MD stated the sliding doors should have been locked and secured at all times and were checked monthly and randomly to ensure they were secured. During a review of Resident 1 ' s acute care hospital document titled, Emergency Department Notes, dated 10/24/24, the document indicated, . History of bipolar (mental illness that causes mood swings) disorder and suicide risk brought in by police department for anxiety and medical clearance for placement. Per law enforcement, patient is conserved and recently ran away from the facility he is staying in . Patient comes in with complaints of increased anxiety. Upon evaluation patient is here for medical clearance and admits to methamphetamine [is a synthetic (man-made) stimulant(a substance that raises levels of physiological or nervous activity in the body)] use . Amphetamine (is a stimulant drug) use on 10/24/2024 . During a review of the facility ' s policy and procedure (P&P) titled, Maintenance Service, dated 12/09, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the building in good repair and free from hazards . During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Health Elopement, dated 5/1/2024, the P&P indicated, . To establish a clear and effective process for preventing elopement, managing elopement incidents, and ensuring resident safety in a Special Treatment Program . To maintain a safer and secure environment for all residents. Elopement or unauthorized departure from the facility is a serious risk and requires immediate attention. This policy outlines the procedures for preventing, identifying, and responding to elopement incidents in our mental health facility . During a review of the facility ' s P&P titled, Safety and Supervision of Resident ' s, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety .

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when on 10/23/24, Resident 1 eloped (leaves a facility without supervision or permission and may be a danger to themselves or others) from his bedroom through the sliding door that should have been securely locked in place. This failure resulted in Resident 1 allegedly removing the sliding door lock, opening the sliding door and eloped from the facility, resulting in Resident 1 ' s emergency room visit on 10/24/24. Findings: During a review of Resident 1's Interdisciplinary Team (IDT- team that consists of various staff that are involved with resident ' s care) Note, dated 10/24/24, the note indicated, . Resident eloped on 10/23/2024. Discussed and reviewed with IDT. After reviewing with staff, resident removed door lock and eloped through sliding glass door sometime after hourly check. Staff reported resident was last seen during hourly checks at 0700 (7:00 a.m.). At 0720 (7:20 a.m.) resident unable to be located for breakfast and medication pass . During an interview on 10/25/24 at 2:00 p.m. with the director of nursing (DON), the DON stated on 10/23/24, Resident 1 had eloped from the facility. The DON stated it was concluded that Resident 1 had removed the secured lock on Resident 1 ' s room sliding door and left the facility. During a review of Resident 1's Admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis for Schizoaffective disorder (mental disorder that includes seeing or hearing and holding false beliefs), depression (mental disorder that causes sad mood or loss of interest in activities), need for assistance with personal care . During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 9/13/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1's, Elopement Care plan (CP), dated 9/17/24, the CP indicated, . Special treatment Program facility . at risk for elopement related to involuntary placement, refusal to take medication, danger to self/community, self-well-being history of substance abuse, past history of elopement . will not leave facility unattended .admit to a locked/secured (egress) facility . During an interview on 10/25/24 at 2:48 p.m. with the mental health worker (MHW), the MHW stated he had been notified of the incident in which Resident 1 had eloped from the facility and exited through the sliding door. The MHW stated the sliding doors in resident ' s rooms were always kept locked and all doors were secured with a window screw. During an interview on 10/25/24 at 2:58 p.m. with licensed vocational nurse (LVN) 1, the LVN 1 stated she was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1 ' s room. LVN 1 stated the facility expectation was for all sliding doors in resident ' s rooms to have been locked and secured at all times. During a concurrent observation and interview on 10/25/24 at 3:06 p.m. in Resident 1's room with the maintenance assistant (MA), the MA stated he was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1's room. The MA stated Resident 1 had removed the lock stopper that was in place to secure the resident ' s sliding door from opening. The MA stated the sliding doors should have been locked at all times as the sliding doors were not used. The MA stated the sliding door locks were tightened with pliers, but if continued disruption occurred, the locks could have loosened allowing the sliding door to open. The MA stated the sliding doors were checked during monthly inspections. The MA stated checking the sliding doors was not documented on the maintenance checklist and was just something they did. During an interview on 10/25/24 at 3:18 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she was aware of the incident that occurred on 10/23/24, when Resident 1 eloped from the facility and exited through the sliding door in Resident 1's room. CNA 1 stated the sliding door locks were put in place to keep the sliding doors locked and closed. CNA 1 stated it was easy to open the sliding doors because the sliding door locks were simple to remove. CNA 1 stated since (after the incident) the sliding doors were secured with wood, the doors could no longer open and were effectively locked. During a telephone interview on 10/30/24 at 11:59 a.m. with the administrator (ADM) and the Maintenance Director (MD), the ADM stated the sliding doors were not used and could have been considered a wall as the sliding doors had no purpose. The ADM stated the sliding doors should have been locked at all times. The ADM stated Resident 1 figured out how to open the door and remove the lock. The MD stated the sliding doors should have been locked and secured at all times and were checked monthly and randomly to ensure they were secured. During a review of Resident 1's acute care hospital document titled, Emergency Department Notes, dated 10/24/24, the document indicated, . History of bipolar (mental illness that causes mood swings) disorder and suicide risk brought in by police department for anxiety and medical clearance for placement. Per law enforcement, patient is conserved and recently ran away from the facility he is staying in . Patient comes in with complaints of increased anxiety. Upon evaluation patient is here for medical clearance and admits to methamphetamine [is a synthetic (man-made) stimulant(a substance that raises levels of physiological or nervous activity in the body)] use . Amphetamine (is a stimulant drug) use on 10/24/2024 . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/09, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the building in good repair and free from hazards . During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Health Elopement, dated 5/1/2024, the P&P indicated, . To establish a clear and effective process for preventing elopement, managing elopement incidents, and ensuring resident safety in a Special Treatment Program . To maintain a safer and secure environment for all residents. Elopement or unauthorized departure from the facility is a serious risk and requires immediate attention. This policy outlines the procedures for preventing, identifying, and responding to elopement incidents in our mental health facility . During a review of the facility ' s P&P titled, Safety and Supervision of Resident ' s, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Resident supervision is a core component of the systems approach to safety .

Based on observation, interview, record review and facility policy review, the facility failed to ensure staff performed hand hygiene during wound care for 1 (Resident #55)of 1 sampled resident reviewed for pressure ulcer/injury. Findings include: A facility policy titled, Handwashing/Hand Hygiene, revised 10/2023, specified, Indications for Hand Hygiene. 1. Hand hygiene is indicated: f. before moving from work on a soiled body site to a clean body site on the same resident. The policy further specified, 4. Single-use disposable gloves should be used: a. before aseptic procedures. An Admission Record revealed the facility admitted Resident #55 on 04/14/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of pressure ulcer of the sacral region, stage 4. Resident #55's Order Summary Report, revealed an order dated 08/09/2024, for staff to cleanse Resident #55's coccyx wound with wound cleanser, pat it dry, pack the wound with collagen powder, cover with calcium alginate and a foam dressing every day. During an observation of wound care on 08/21/2024 from 10:11 AM to 10:25 AM, Licensed Vocational Nurse (LVN) #1 provided wound care to Resident #55. At 10:19 AM, LVN #1 removed the resident's soiled dressing and packing. LVN #1 disposed of the dressings and gloves, washed her hands, and applied clean gloves. At 10:21 AM, LVN #1 cleaned and dried the resident's wound according to the physician's order, and then immediately packed the wound with collagen powder and calcium alginate and applied the foam dressing. LVN #1 did not perform hand hygiene and apply clean gloves before she applied medication and a clean dressing to the resident's wound, after cleaning the soiled wound. At 10:23 AM, LVN #1 washed her hands, applied clean gloves, washed a second surface wound on the resident's right buttock, patted it dry, and applied zinc cream. LVN #1 did not perform hand hygiene or change gloves between cleaning the wound and applying the medicated cream. During an interview on 08/21/2024 at 11:29 AM, LVN #1 stated cleaning the wound was considered a dirty procedure and the application of the medication and dressing was considered a clean procedure. LVN #1stated she should have cleaned her hands after she cleaned each wound and before she applied the medications on both of the resident's wounds and the clean dressing on the resident's coccyx wound. During an interview on 08/21/2024 at 12:59 PM, the Infection Preventionist (IP) stated the nurse should have cleaned her hands after she cleaned the wound, because it was considered a dirty procedure. The IP stated the nurse should have cleaned her hands and applied clean gloves before she applied medication and clean gloves because it was considered a clean procedure. The IP stated the way the nurse completed wound care meant she wore dirty gloves during the clean procedure, and the potential risk was transmission an infection. During an interview on 08/21/2024 at 1:44 PM, the Director of Nursing (DON) stated she expected the nurse to perform wound care to wash her hands, apply clean gloves, remove the soiled dressing, wash her hands, and apply clean gloves and then clean the wound. The DON stated next, the nurse should have washed her hands and applied clean gloves before she applied medication and a clean dressing. The DON stated for the second wound, the nurse should have cleaned her hands, applied clean gloves and after cleaning the area and then applied the medicated cream. The DON stated cleaning a wound was considered a dirty procedure, and the application of medication and dressings, was considered a clean procedure. The DON stated potential risk was the nurse's contaminated hands could cause an infection in the wound. During an interview on 08/21/2024 at 1:48 PM, the Administrator stated she expected the nurse to clean her hands before she applied medications and dressings. She stated for the second wound she expected the nurse to wash her hands before she applied the medicated cream. The Administrator stated hand hygiene prevented the spread of infection.

Based on interview and record review, the facility failed to ensure services provided meet professional standards of quality for one of four sampled residents (Resident 1), when LVN 1 did not notify the attending physician in a timely manner and did not accurately document in medical record for Resident 1's fall (change in condition) and physician's orders were not obtained before Resident 1 was transferred to acute care hospital (ACH) according to facility's policies and procedures. These failures resulted in Resident 1 transfer to an Acute Care Hospital (ACH) without a physician notification and orders and the potential for him not to receive the necessary medical interventions prior to transfer to acute care hospital. Findings: During a review of Resident 1's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/11/22, the AR indicated, Resident 1 was admitted from an acute care hospital on 09/20/16 to the facility, with diagnoses which included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Dysphagia (difficulty in swallowing), and History of Falling. During a review of Resident 1's Minimum Data Set (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 1/3/22, the MDS indicated, . BIMS (Brief Interview for Mental Status) Summary Score . 3 [indicating severe memory impairment] . During a concurrent phone interview and record review on 1/27/22, at 9:00 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing Progress Note (NPN), dated 1/7/22 was reviewed. The NPN indicated, . 2:00 [a.m.] . CNA [Certified Nurse Assistant] heard a crash noise went to check rooms of where it came from found resident in sitting position between bed and wall of room facing the bed back towards the wall with bedside table next to resident . Resident was assessed . when asked of any pain resident responded no 4 staff members transferred resident to bed . After in bed asked resident if he had any pain resident responded, my leg and points to the lower left leg. Called 911 two EMS staff assessed resident and transferred resident from bed to gurney with no issue or c/o [complaint of] pain but when EMS gently touched resident left knee resident c/o pain. Called RP [Responsible Party], and notified [Attending Physician 2, AP2] via phone call . LVN 1 stated her documentation was incorrect. LVN 1 stated she did not call AP 2 for Resident 1. LVN 1 stated she called Attending Physician 1 [AP1], also the Medical Director for the facility] for Resident 1 on 1/7/22 at 7:00 a.m., five hours after the reported fall. LVN 1 stated AP 1 told her during their phone conversation to not send any of his patient without his knowledge. LVN 1 stated her intent was for Resident 1 to get the care he needed without any delay. LVN 1 stated the facility's policy was to notify the attending physician regarding all changes in a resident's condition. LVN 1 stated her nursing note regarding notification of attending physician was inaccurate. During a phone interview on 1/27/22, at 9:45 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1 failed to follow the facility's policy on timely notification of attending physician and should notify the doctor right away. The DSD stated, The expectations are that Licensed Nurse (LN) should notify the doctor for any change of condition and not wait for the daytime or five hours after the incident. The DSD stated Resident 1 was transferred to an acute hospital without physician notification and physician order. The DSD stated the licensed nurse was expected to discuss the resident's change in condition with the physician, including interventions that could be carried out by the nursing staff. The DSD stated Resident 1's medical record should be accurate and reflect the care provided by staff and communications with other care team members, including the attending physician. During a phone interview on 1/27/22, at 9:55 a.m., with the Director of Nursing (DON), the DON stated LVN 1 failed to notify the attending physician in a timely manner and failed to accurately document on Resident 1's medical record. The DON stated Resident 1 was transferred to an acute hospital without physician notification and physician order. The DON stated she expects all licensed nurses to follow the facility's policy on timely notification of the attending physician or medical director regarding all changes in a resident's condition. The DON stated she expects all licensed nurses to immediately notify the doctor for any change in condition and document appropriate information in the medical record, including the communication with the attending physician. During a review of the facility's document titled, Job Title: Charge Nurse undated, the document indicated, . JOB SUMMARY . Responsible to administer resident care . JOB RESPONSIBILITIES . A. Performs all functions according to facility policy and procedures, the nurse practice act, and current nursing standards of practice . D. Implement Patient Care . Notify physician and/or other health care professionals immediately of significant changes in conditions, falls and skin issues . During a review of the facility's Policy and Procedure (P&P) titled, Change in Condition Assessment, dated 9/15/17, the P&P indicated, . 4. The licensed nurse is to notify the attending physician when: a. An unusual occurrence involves a resident . 12. The licensed nurse is to discuss the resident's change with the physician. Discussion should include interventions that can be carried out by the nursing staff in the facility . During a review of a professional reference from The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, . Standards of practice General Principles . 1 The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . During a professional reference review retrieved from https://www.oregonrn.org/news/551321/Failure-to-report-changes-in-a-patients-condition.htm#:~:text=The%20failure%20to%20report%20changes,should%20avoid%20these%20costly%20consequences titled, Failure to report changes in a patient's condition, dated 2/9/21, the article indicated, . A nurse's ability to recognize and respond to changes in a patient's condition is a crucial element of professional nursing practice. Failure to respond appropriately to clinical changes can lead to complications and even death.1 In a study that investigated the impact of communication in malpractice lawsuits, communication failure was a factor in 32% of cases involving nurses, with most involving poor communication with other healthcare professionals about the patient's status. These cases often result in huge financial consequences in cost of care and legal damages. Communication of a patient's status has been the focus of much attention and research, and various communication frameworks have been generated to facilitate clinical communication among healthcare professionals about patient status. Widely used examples include SBAR (situation, background, assessment, and recommendation) and ISBARR (introduction, situation, background, assessment, recommendation, and read back). In some cases, however, it is not about the nurses' ability to communicate with primary care providers. Rather, they are about the competence and decision-making skills needed that enables a nurse to assess a patient's condition and determine the appropriate intervention, including when to escalate care and seek the expertise of appropriate personnel. Barriers to Communication Many factors can play into why nurses may not communicate a patient's status promptly or at all. These include a busy schedule, a reluctance to bother the primary care provider, or a failure to recognize the circumstances under which a primary care provider should be notified due to a lack of clinical competence. Nurses need to recognize the severity and emergent nature of a patient's condition. A nurse's failure to recognize an emergency indicates a lack of competence in nursing fundamentals and a lack of knowledge about the possible physiologic consequences. This gap in knowledge can contribute to a catastrophic deterioration in the patient's condition. Critical thinking extends beyond mere information, attentiveness, and assessment. How do nurses acquire the decision-making and critical-thinking skills necessary for their practice? The clinical competence needed to make decisions, especially in acute situations, develops over time as the nurse advances from novice to expert .

Based on interview and record review, the facility failed to meet the minimum requirement of a registered nurse on duty for eight consecutive hours per day, seven days per week when a registered nurse was not on duty for the minimum eight consecutive hours per day for six of 30 days sampled. This failure had the potential to result in residents not receiving services required to be provided by an RN. Findings: During an interview on 3/11/2020, at 8:20 a.m., with the Staffing Coordinator (SD), the SD stated, the facility was a 99 bed facility and the Director of Nurses (DON) served as the RN from Monday to Friday eight hours a day. The SD stated she was not aware she was required to schedule an RN seven days a week for eight hours a day. The SD stated she was directed by the DON to schedule an RN on Saturday and Sunday when the facility admitted residents who had intravenous (IV) therapy (therapy that delivers fluids and medications directly into a vein). The SD stated, the facility had a total of three Registered Nurses, the DON, one full time RN and one on-call RN (a person able to be contacted in order to provide a professional service if necessary, but not formally on duty). The SD stated when the facility had IV's on the weekends an RN was scheduled to come into the facility and was instructed to stay for two hours and did not have to work eight hours. During a concurrent interview and record review on 3/11/2020, at 8:45 a.m., with the SD, the Assignment Sheet (AS) dated February 2020 were reviewed. The AS indicated on 2/1/20, 2/8/2020, 2/9/2020, 2/15/2020, 2/29/2020 and 3/1/2020, there were no RN's scheduled to work eight hours a day for the morning, evening or night. The SD verified all the nurses who were scheduled were LVN's and not RN's. During an interview on 3/11/2020, at 10:56 a.m., with the DON, the DON stated, the facility process to schedule an RN was five days a week because the facility had a bed capacity of 99. The DON stated, she worked in the facility Monday through Friday. During an interview on 3/11/2020, at 12:04 p.m., with the Administrator (ADM), the ADM stated she believed the facility required RN coverage Monday to Friday. The ADM stated, she was not aware the facility required coverage on Saturday and Sundays. During an interview, on 3/11/2020, at 2:18 p.m., with the ADM, the ADM stated, she did not have a policy and procedure on the required RN coverage.

Based on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety for 91 residents when: 1. There was expired food in the refrigerators and freezer available for resident consumption. 2. Food items in the dry storage area were open and past the use by date. 3. Two kitchen staff members failed to properly cover facial hair while they performed kitchen duties. These failures had the potential for unsafe food handling in a highly susceptible resident population. Findings: 1. During a concurrent observation and interview on [DATE], at 9:36 a.m., with Cook 1, in the kitchen, a jar of tartar sauce with an expiration date written on it of [DATE] and a container of ketchup with an expiration date of [DATE] written on it was found in the reach in refrigerator with the other condiments. Cook 1 stated condiments were to be thrown out within one month of being opened. During a concurrent observation and interview on [DATE], at 9:36 a.m., with Cook 1, the refrigerator contained two opened jugs of milk with no open or use by date. Cook 1 stated refrigerated liquids were to be discarded within 3 days of being opened. Cook 1 stated all items in the refrigerator should have had a label to indicate the open and use by date. Cook 1 stated if a resident consumed expired milk, it could cause GI (gastrointestinal) illness. During an observation, in the freezer with Cook 1, a box of bacon was on the bottom shelf with a stamped manufacturer's expiration date [DATE]. Cook 1 stated the expired bacon should have been discarded and was not. During a concurrent interview and record review on [DATE], at 10:46 a.m., with the Director of Dietary Services (DD), he stated the policy and procedure on food storage did not have specific dates for discarding food. The DD stated the (untitled) charts hanging in the kitchen were considered the policy for discarding food for the kitchen staff to follow. He stated the charts indicated bottled containers in the reach in refrigerator should have been discarded after 1 month of being opened. 2. During a concurrent observation and interview on [DATE], at 9:36 a.m., with Cook 1, in the dry storage area, two packs of hamburger buns were on the shelf with a use by date of [DATE]. Cook 1 stated they should have been thrown away. A container of ketchup was on the shelf with an expiration date of [DATE]. Cook 1 stated these items should not be in the dry storage area and available for use. On a cart in the dry storage area there was one jug each of liquid cooking ingredients found and available for use during preparation of residents food. Cook 1 referred to a chart hanging on the door of the dry storage room, stated all open liquid items in the dry storage room were supposed to be discarded within one month of opening. Cook 1 stated the chart hanging on the door was the policy for the kitchen staff to follow regarding dates to discard food. Cook 1 found the following expired items in the kitchen storage: Liquid Smoke, opened [DATE], Worcestershire sauce opened [DATE], White Cooking Wine opened [DATE], Apple Cider Vinegar opened [DATE], Red Wine Vinegar opened [DATE], Light Corn Syrup with vanilla opened and unmarked, and Red Cooking Wine opened [DATE]. During a concurrent interview and record review on [DATE], at 10:46 a.m., with the DD, he stated the policy on food storage did not have specific dates for discarding food. The DD stated the (untitled) the charts hanging in the kitchen were considered to be the policy for discarding food in the kitchen and the kitchen staff needed to follow the charts. A review of the facility's policy and procedure titled, Dry Good Storage dated [DATE], indicated, .5.products should be dated .7.Food items will be labeled and dated with an open date and use by date . 3. During an observation on [DATE], at 11:18 a.m., in the kitchen, two employees, the director of dietary (DD) and a dietary aide (DA) 2, had facial hair exposed outside of the beard guards. During an interview on [DATE], at 12:57 p.m., with the DD and the registered dietician (RD), the DD stated all hair including facial hair needed to be covered. The DD stated if hair was not completely covered it could cause physical contamination, visual contamination and cross contamination of the food. The RD stated facial hair should have been covered to prevent cross contamination. During a concurrent observation and interview on [DATE], at 12:51 p.m., with DA 2, DA 2's side burn hair was exposed and not covered completely by the beard guard. DA 2 stated he was trained that the beard guard must cover all facial hair to keep hair out of the resident's food. DA 2 stated hair could cause cross contamination of food. A review of the facility's policy and procedure titled, Personal Hygiene dated [DATE], indicated Purpose: To ensure all Food and Nutrition Services staff maintain sanitary conditions .it is the policy of this facility that Food and Nutritional Services staff will maintain good personal hygiene .3. Men with beards or mustaches will be required to have their beards or mustaches closely cropped and neatly trimmed. Men without a clean-shaven face will be required to wear a beard/mustache net when working in the kitchen . A review of the professional reference from the 2017 Federal Food and Drug Administration (FDA) Food Code, indicated, .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and Linens; and unwrapped single-service and single-use articles.

Based on observation and interview, the facility failed to ensure medications stored in the Central Supply Room were disposed of after the expiration date was reached. This failure had the potential to place ninety-one residents at risk of receiving expired medications. Findings: During a concurrent observation and interview on 3/10/20, at 10:20 a.m., with Director of Nursing (DON), in the Central Supply Room, five bottles of centirizine (medication used for allergy symptoms) 10 milligrams, (mg a unit of measurement) 90 tablets in each bottle, were found to have gone past their expiration date of 2/2020 and remained on the shelf with the non-expired medications. The DON confirmed the medication bottles were expired and should have been removed from the shelf. A review of the facility's policy and procedure titled, Medication administration dated 8/8/18, indicated, To ensue that all medications are handled and administered accurately and safely to each resident .bottles that are clearly marked .expiration date.

Based on interview and record review, the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN-a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume responsibility) and Notice of Medicare Provided Non-Coverage (NOMNC) for one of three sampled residents (Resident 57) when the Medicare coverage was terminated. This deficient practice resulted in not protecting Resident 57's (and the resident representative) right to appeal the termination of Medicare Part A and possibly denying Resident 57 needed services. Findings: During a concurrent interview and record review on 3/10/2020, at 1:44 P.M., with Director of Social Services (DSS), the DSS reviewed the facility document titled, Skilled Nursing Facility Beneficiary Protection Notification Review which indicated Resident 57's Medicare Part A Skilled Services Episode start date was on 1/8/2020 and the last covered day of Medicare Part A Services was on 1/17/2020. The DSS stated she did not issue a SNFABN to Resident 57 or the Resident Representative (RR) because she did not know Resident 57 received Medicare Part A services. The DSS stated, I thought (Resident 57) was only under Medicare part B when she came back from the hospital. The DSS stated the SNF-ABN and NOMNC letter should have been issued at least three days prior to the last day of Medicare A coverage for Resident 57. The DSS stated the SNF-ABN and NOMNC forms were very important because they provided Resident 57 and the RR steps to follow if they wanted to continue receiving Medicare A benefits and steps to follow for an appeal. The DSS stated Resident 57 and RR were not able to appeal because they were not given the forms and information. During an interview on 3/11/2020, at 10:20 a.m., with Minimum Data Set Coordinator (MDSC), the MDSC stated the business office determined the insurance and sent an email to all the department heads if a new or readmitted resident has under Medicare part A or part B coverage. The MDSC stated the DSS was responsible in making sure the SNF-ABN and NOMNC letters were signed prior to the last covered Medicare A day. The MDSC stated the SNF-ABN and NOMNC letters were both important because it gave the residents and family an opportunity to appeal the discontinuation of Medicare A coverage. During an interview on 3/11/2020, at 2:05 p.m., with Resident 57's Resident Representative (RR), the RR stated she did not receive a notice her Medicare part A coverage was going to be discontinued on 1/17/2020. The RR stated she did not receive information from the facility staff explaining Resident 57 had the right to appeal the discontinuation of Medicare part A coverage and believed Resident 57 would have benefited from additional physical therapy. During an interview on 3/11/2020, at 3:32 p.m., with the Administrator (ADM), the ADM stated the SNF-ABN and NOMNC letters were supposed to be issued three days prior to the last covered Medicare part A day to Resident 57 and was not. During a review of the facility's policy and procedure titled, Notice of Medicare Provider Non-Coverage, (NOMNC) dated 5/31/17, the policy and procedure indicated, .All residents must receive a NOMNC prior to discharge from the facility or at the time that Medicare coverage is terminated . 10. Residents or their responsible party have the right to appeal the facility's decision to discontinue Medicare coverage if the do not agree with the decision . During a review of the facility's policy and procedure titled, Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN) of non-Coverage, dated 5/31/17, the policy and procedure indicated, . It is the policy of this facility to keep residents informed of their Medicare coverage and those items or services that are not covered by Medicare . 10. When the facility properly issues the appropriate SNF-ABN, timely to the beneficiary, and Medicare denies payment on the related claims, the facility must wait for the beneficiary to receive a Medicare Summary Notice before collecting payments from the resident. 11. The SNF-ABN may not be issued to shift financial responsibility to the resident in the case of services for which full payment is bundled into other payments .

Based on observation, staff interview and document review, the facility failed to ensure the nutritional needs were met for residents on a small portions diet when the lunch meal on 3/9/2020 was not plated in accordance with menu guidance for one of two sampled residents (Resident 34). This failure had the potential to result in weight gain, further compromising the medical status. Findings: During a concurrent observation, interview and record review on 3/9/2020, at 12:36 p.m., with Cook 1 and Director of Dietary Services (DD), in the kitchen during tray service, all portions of chicken were observed in the same pan with no separation of portion sizes. Cook 1 stated she checked the portion sizes when she prepared the chicken and separated the small and regular portions within the tray. Cook 1 stated the small portions were at the top side of the pan and the regular portions were at the bottom side of the pan. Cook 1 placed a large piece of chicken on Resident 34's plate. When the plate was at the end of the tray line Cook 1 removed the chicken from plate and weighed the piece of chicken with the DD, chicken observed to weigh 4 ounces. Cook 1 stated a small portion for the chicken was required to weigh 2 ounces in accordance to the menu. Cook 1 stated, The chicken was too big for Resident 34's small portions diet. Review of tray ticket for Resident 34 indicated, .Special Diets: NAS (no added salt), small portions . The DD stated the portion was too large for Resident 34's prescribed diet. Cook 1 stated residents were usually on a small portion diet to control how much they were eating and for weight control. During an interview 03/09/2020, at 12:57 p.m., with the Registered Dietician (RD), in presence of the DD, the RD stated that Resident 34's prescribed diet was small portions as part of his weight loss program. The RD stated if the resident received bigger portions than ordered it could affect Resident 34's ability to lose weight. A review of the lunch meal on the, Spring Menus cook's spreadsheet, dated 3/9/2020, indicated, Chicken with Parmesan .small portions, 2 ounces meat .regular portions, 3 ounces meat . large portions, 3 ounces meat. A review of Resident 34's doctor's orders titled, Order Summary Report dated 3/11/2020, indicated Dietary, Small Portions Diet . order date 8/20/19 . A review of dietician note, dated 2/28/2020, 3:05 p.m., titled RD weight note indicated Pt. (patient) reviewed d/t (due to) being on a weight loss program .weight went up slightly .Pt. (patient) wishes to lose weight but happy his weight remains stable. Diet remains regular texture, small portions Wt (weight): 221 lbs (pounds) (2/4/20), 219 lbs (1/6/20) . Dietician (e-signed). A review of the facility's policy and procedure titled, Trayline and Delivery of Carts, revision dated 5/1/2016, indicated, .All meals are checked by the Food and Nutrition Services personnel for accuracy .1. The menu spreadsheet displays food items and amounts for each regular or therapeutic diet .3. tray line and/or meal service positions for breakfast, lunch and dinner are determined and planned: a. according to menu .c. to obtain maximum accuracy .4. The meal is checked against the therapeutic diet spreadsheet to assure foods are served as listed on the menu .

Based on interview and record review the facility failed to timely notify the ordering physician for a laboratory result that fell outside of the normal reference range for one of two sampled residents (Resident 65) when Resident 65's urinalysis (UA-urine sampled to test for the presence of bacteria) result was positive for bacteria that was resistant to the physician ordered antibiotic (a medication to treat infections) regimen. This failure resulted in the administration of antibiotic treatment to Resident 65 that she was resistant to from 1/18/2020 through 1/25/2020 and placed her at risk for further complications from the Urinary Tract Infection [MEDICAL CONDITION]. Findings: During an interview on 3/9/2020, at 9:35 a.m., with Resident 65, Resident 65 stated she recently had a urinary tract infection and was in isolation. Resident 65 stated she was not sure what the infection was, but believed she may have had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA- a bacteria that causes infections) in the urine. During an interview on 3/10/2020, at 11:05 a.m., with the licensed vocational nurse (LVN) 3, LVN 3 stated the certified nurse assistant (CNA) would report if there were any changes in the residents mental status or if there was smell and change in the appearance of urine. LVN 3 stated the nurse would then perform a dip strip to test for [MEDICATION NAME] (an enzyme sometimes present in urine when certain bacteria is present during a urinary tract infection). LVN 3 stated if the urine was positive for [MEDICATION NAME] the doctor was notified and would order a urinalysis with a culture and sensitivity (UA C&S-test that verifies what antibiotic will be effective). During a concurrent interview and record review on 3/11/2020, at 10:51 a.m., with LVN 4, the Situation Background Assessment and Recommendation (SBAR) progress note for Resident 65, dated 1/18/20 10:41 a.m., was reviewed. The SBAR progress note indicated, situation: c/o burning with voiding, fishy foul odor to urine . background: Hx (history) UTI . assessment: noted urine dark yellow, fishy odor . request/recommendation: MD (Resident 65's doctor) made aware of ultrasound results and resident current symptoms. In house UA dip positive for [MEDICATION NAME]. MD ok to send UA sample to lab for C&S if indicated. MD also gave t.o. (telephone order) via phone for new ABX (antibiotics-a medication used to treat infection) for [MEDICATION NAME] (a cephalosporin antibiotic) 500 mg BID (twice a day) x7 days for UTI . LVN 4 stated the doctor did not have the results for the UA with C&S prior to ordering [MEDICATION NAME], LVN 4 stated if the resident is symptomatic of a UTI the doctor will order an antibiotic before receiving the results. Review of the UA C&S, dated 1/22/2020 was reviewed. LVN 4 stated the UA C&S result was received on 1/22/2020 at 3:30 p.m. The UA C&S, indicated .Org (organism) #1 ESBL (Extended Spectrum Beta-Lactamase -an enzyme made by some bacteria which prevents certain antibiotics from being able to kill the bacteria) pos. (positive) (resistant to all cephalosporins and [MEDICATION NAME]-types of antibiotics) . the sensitivity list indicated, Organism #1: >100,000 COLONIES/ML Escherichia coli (a type of bacteria) . sensitivity results indicated Antibiotics . [MEDICATION NAME] R (resistant) . [MEDICATION NAME] S (sensitive) . Review of the social services note written on 1/22/2020 at 18:42 by LVN 5, indicated . Resident was placed in isolation for ESBL in urine. Dr. (Resident 65's doctor) was made aware of Urine cx (culture) via fax . LVN 4 stated while she reviewed Resident 65's medical record, she could not find an acknowledgement from Resident 65's physician that he received or reviewed the UA C&A results. LVN 4 stated Resident 65's physician signed and faxed the UA C&S back to the nurses station on 1/25/2020. LVN 4 stated the physician usually would sign and fax the result back with new orders written on it. LVN 4 stated on the UA C&S results there was a hand written note by LVN 5 which indicated started 1/18/20 [MEDICATION NAME](antibiotic)500 mg 1 BID (twice daily) X 7 days . on isolation for ESBL . faxed to MD (Resident 65's doctor) 1/25/20 1642 (4:42 p.m.), the UA C&S results have Resident 65's physician signed initial at bottom of page with the date of 1/25/2020. LVN 4 stated there was no documentation to indicate nursing staff called to notify the physician after the 1/22/2020 fax. LVN 4 stated an abnormal UA C&S especially with ESBL should have been followed up with a phone call to the physician. LVN 4 stated if Resident 65's primary doctor did not acknowledge the abnormal test results on 1/22/20, the nurse should have called the medical director of the facility to discuss the results. LVN 4 stated Resident 65's UTI could have worsened from being on an antibiotic that is not sensitive to the bacteria. LVN 4 stated the resident could have wound up in the hospital with a serious infection like ESBL. LVN 4 stated Resident 65's physician orders [REDACTED]. LVN 4 stated according to the nurses note dated 1/29/20 at 11:12 a.m., written by LVN 3 indicated .MD notified of resident (Resident 65) s/p (after) ABX and c/o (complained of) dysuria (painful urination) this AM shift. Noted cloudy yellow urine in bedside commode with noted foul odor. MD gave new orders for ABX. LVN 4 stated the physician ordered a second and different antibiotic [MEDICATION NAME] 50 mg from 1/29/20 until 3/10/20 because the first antibiotic was not effective. During a concurrent interview and record review on 3/11/2020, at 2:34 p.m. with the Director of Nurses (DON), Resident 65's nurses notes were reviewed. The DON stated the UA C&S result indicated Resident 65's physician was faxed on 1/25/2020. The DON stated there was no way to verify if the doctor reviewed the UA lab result that day. The DON stated the LVN should have also called the doctor because the UA C&S was abnormal. The DON stated if Resident 65's physician did not return the nurses phone call the LVN should have called the medical director. The DON stated the LVN should have followed up on the lab result prior to the end of her shift. The DON stated the resident received the wrong antibiotic for 3 days after the UA C&S results were received. Review of the nurses note dated 1/29/20 at 11:15 a.m. written by LVN 3 , indicated .(Resident 65) continues with isolation for ESBL in the urine. MD notified of resident s/p ABX and c/o (complains of) dysuria this AM (morning) shift. Noted cloudy yellow urine in bedside commode with noted foul odor MD gave new orders for ABX, The DON stated because the bacteria was resistant to the antibiotic ([MEDICATION NAME]) Resident 65 was originally prescribed, Resident 65's urinary tract infection did not completely clear. The DON stated the physician gave a new order on 1/29/20 for [MEDICATION NAME], which showed sensitivity to the bacteria in Resident 65's urine on the UA C&S. The DON stated if Resident 65 was not started on correct treatment the resident could have wound up with dehydration, confusion [MEDICAL CONDITION] (a potential life threatening response to an infection). A review of the facility's policy and procedure titled, Laboratory Services, dated 11/24/17, indicated Purpose: to provide laboratory services for residents .it is the policy of this facility that all physician ordered laboratory tests are carried out per the physician's orders [REDACTED]. on a timely basis .5. the laboratory is to send all resident results to the facility via facsimile (fax) . 8. Licensed nurse is to communicate lab results to the ordering physician . based on the physician's communication preference: fax or telephone . b. Results Abnormal: Telephone/page physician and fax to physician with date and time noted on results. If no response from physician within four (4) hours, call again. If no response, contact the Medical Director . 11. The licensed nurse is to monitor for timely physician response . 12. Faxed lab reports are to be filed in the resident medical record after the physcian has responded with acknowledgment and/or new orders.

Based on interview, and record review, the facility failed to revise a person centered comprehensive care plan in a timely manner for one of three sampled residents (Resident 87) when Resident 87's care plan did not accurately reflect the current physician's orders [REDACTED].). This failure had the potential to result in respiratory complications and failure for Resident 87. Findings: During a concurrent interview and record review, on 3/11/2020, at 10:42 a.m., with LN 4, she reviewed Resident 87's care plan dated 3/11/2020 which indicated, focus- (Resident 87) is at risk for alteration in respiratory function related to [MEDICAL CONDITION] ([MEDICAL CONDITION]-a group of lung diseases that makes it harder to breathe) .OSA . revision 8/14/19 . Goal indicated, Resident 87 will display optimal breathing pattern daily through review date, with a target date of 5/18/2020 .interventions/tasks, Bi-Pap as ordered, 10-6 with continuous oxygen 2-3 L (liters per minute-a measurement of oxygen flow) date initiated 8/30/19. During a review of the current physician order [REDACTED]. LN 4 stated the current physician order [REDACTED]. LN 4 stated Resident 87 was at risk to not receive LN the correct dosage of oxygen because the care plan and doctors orders did not match. During a concurrent interview and record review, on 3/11/20, at 2:05 p.m., with the Director of Nurses (DON), Resident 87's care plan and physician orders [REDACTED]. During a review of the clinical record for Resident 87, the Face Sheet (a document with resident demographic and medical [DIAGNOSES REDACTED]. Resident 87's [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 1/01/2011, the P&P indicated, purpose: to provide comfort and administer high-purity oxygen for the treatment of [REDACTED].It is the policy of this facility that oxygen will only be administered by physician's orders [REDACTED]. Oxygen use is to be noted on the resident's care plan .

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one of three sampled residents (Resident 45), when Resident 45 did not have a care plan for his customary routines and activities. This failure had the potential to result in Resident 45's activity needs to go unmet. Findings: During a review of Resident 45's clinical record titled, ADMISSION RECORD (a document containing resident profile information) undated, the admission record indicated, Resident 45 was admitted to the facility on [DATE]. During a review of Resident 45's Minimum Data Set (MDS- assessment of healthcare and functional needs) dated 1/11/2020, the MDS assessment indicated Resident 45's Brief Interview for Mental Status (BIMS- an assessment of cognitive status) had a score of 2 of 15 points which indicated Resident 45's cognition was severely impaired. The MDS Preference for Customary Routines and Activities indicated Resident 45's activity preferences; very important to listen to music, keep up with the news, do favorite activities, go outside to get fresh air when weather is good and participate in religious services or practices. During a concurrent interview and record review on 3/10/2020, at 8:45 A.M., with the Director of Activities (DOA), the DOA reviewed Resident 45's facility record and stated, I did not find a care plan for activities for Resident 45. The DOA stated the care plan should had been started within two days of Resident 45's admission to the facility. The DOA stated a care plan was important because it provided guidance for the staff to provide the care or activity that are important for Resident 45. The DOA stated Resident 45 was confused and needed assistance with daily needs and that included activities. The DOA stated without the care plan the staff did not know what type of activities Resident 45 preferred and enjoyed. During an interview on 3/10/2020, at 3:51 p.m., with the Unit Manager (UM), the UM stated she was a Licensed Nurse and helped develop care plans for all residents. The UM stated Resident 45's care plan for activities was supposed to be completed within 24 hours of Resident 45's admission to the facility. The UM stated the interdisciplinary team was supposed to review all care plans with the residents and or their families within 48 hours of admission. The UM stated Resident 45's activity care plan was missed. The UM stated a care plan was very important because it measured if the interventions were meeting the goals for the resident. During an interview on 3/11/2020, at 10:45 a.m., with the Director Of Nursing (DON), the DON stated Resident 45's care plan should have been started within two days after admission. The DON stated the activity care plan was very important in order for the staff to implement the type of activities Resident 45 preferred and enjoyed. During a review of the facility's policy and procedure titled, Care Plans dated 11/24/2017, the policy and procedure indicated, . The facility is to develop and implement a baseline care plan for each resident within 48 hours after admission to the facility . 1. Baseline care plan is to be developed by the interdisciplinary team within 48 hours of the resident's admission .3. The baseline care plan is to be reviewed with the resident, and their representative if the resident is unable to participate .

Based on interview and record review, the facility failed to ensure 1 of 3 resident's (Resident 1) was wearing closed footwear or footwear with a back strap, in accordance with the care plan when Resident 1 fell in the dining room while he was ambulating unassisted. This failure resulted in an avoidable fall and fracture to the right hip which required surgical repair and in-patient care at the General Acute Care Hospital (GACH) for 13 days. Findings: During a review of Resident 1's clinical record, titled, Face sheet (a document containing resident profile information) dated 8/12/19, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. to perform everyday activities). During a review of Resident 1's Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment dated [DATE], the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS- an assessment of cognitive status) had a score of 3 of 15 points which indicated Resident 1's cognition was severely impaired. The MDS functional assessment indicated Resident 1 required 1-person physical assistance for transfers, to walk in the room, walk in corridor and locomotion on the unit. During an interview on 8/14/19, at 1:45 p.m., with the Rehabilitative Nursing Aide (RNA) she stated Resident 1 was lying on the floor on his left side by the doorway of the dining room on 8/9/19, at approximately 4 p.m. The RNA stated she heard Resident 1 complained of pain pointing to his lower back when the Licensed Nurse (LN) was assessing Resident 1. The RNA stated she did not remember what type of footwear Resident 1 was wearing at the time of the fall. During an interview on 8/14/19, at 2:15 p.m., with LN 1, she stated Resident 1 was lying on his back on 8/9/19 at 4:10 p.m. by the dining room door preventing the door from opening and closing. LN 1 stated she did not perform a head to toe assessment. LN 1 stated the fall was avoidable if Resident 1 was wearing footwear with a strap in the back or a closed shoe. LN 1 stated Resident 1's gait was not steady and required 1 person assistance during ambulation. During a concurrent interview and record review of Resident 1's X-Ray report on 8/14/19, at 2:30 p.m., with LN 2, she stated she assessed Resident 1 after the fall on 8/9/19. LN 2 stated she observed Resident 1's right leg which appeared shorter than the left leg and the right foot was turned inward. LN 2 stated Resident 1 had a portable X-ray (a picture taken to check for broken bones) done to the right hip and right shoulder. LN 2 stated the X-ray result indicated, Acute right femoral neck fracture ([MEDICAL CONDITION] bone). LN 2 stated Resident 1 was sent out to the GACH for evaluation and treatment of [REDACTED]. LN 2 reviewed the clinical record titled, Fall Risk assessment dated [DATE]. LN 2 stated the record indicated Resident 1 had a fall risk score of 15 which meant Resident 1 was at a moderate risk for falls. LN 2 reviewed the clinical record of Resident 1 titled Care Plan dated 3/26/19, interventions, . ensure resident wears appropriate footwear (closed shoes or with a strap in the back) when out of bed and kept at bedside when the resident is in bed . LN 2 stated Resident 2 was wearing a slide on sandal without a strap in the back at the time of fall. LN 2 stated the fall was preventable if Resident 1 was wearing footwear with a strap in the back or a closed shoe. During an interview on 8/14/19, at 3:05 p.m., with LN 3, LN 3 stated, Resident 1 was wearing regular socks and slide sandals that had no strap in the back. LN 3 stated Resident 1 was only wearing one of his slide sandals when the resident was found on the floor on 8/9/19. During a telephone interview on 8/19/19, at 9:05 a.m., with the Activity Assistant (AA) she stated she had worked in the facility for two months. The AA stated she had a group of residents in the activity/dining room for the afternoon activities when Resident 1 fell on [DATE]. The AA stated she was helping another resident when she saw Resident 1 walk towards the door and fell . The AA stated when she saw Resident 1 on the floor on 8/9/19, Resident 1 had the slide sandal on one foot and the other sandal was next to Resident 1's foot. During a telephone interview on 10/7/19, at 9:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was lying on his back when she responded to the fall on 8/9/19. CNA 1 stated Resident 1 was wearing a slide sandal. CNA 1 stated Resident 1 was not safe to ambulate alone. CNA 1 stated Resident 1 needed assistance with ambulation. During a telephone interview on 11/27/19, at 2:50 p.m., with CNA 2, CNA 2 stated she was working the day shift on 8/9/19 when Resident 1 fell . CNA 2 stated she was assigned to Resident 1 that day. CNA 2 stated she assisted Resident 1 to get ready that morning but did not remember what footwear Resident 1 was wearing. During a concurrent interview and record review with the Director of Nursing (DON) on 8/14/19, at 3:30 p.m., the DON reviewed Resident 1's clinical record titled, Fall Risk assessment dated [DATE]. The DON stated Resident 1 was at a moderate risk of falling. The DON stated Resident 1 had impaired safety awareness and had inappropriate footwear at the time of the fall. The DON stated inappropriate footwear was a footwear that did not have a strap in the back. The DON stated appropriate footwear would be a closed shoe or footwear with a strap in the back to prevent slipping. The DON stated Resident 1 was wearing a slide on sandal without a strap in the back and it was not the right footwear for Resident 1. The DON stated the fall was preventable had Resident 1 been wearing the proper footwear. The DON reviewed Resident 1's clinical record titled Care Plan dated 3/26/19 which indicated, .ensure resident wears proper footwear when out of bed and kept at bedside . The DON stated the staff did not follow the care plan. During a review of the facility's policy and procedure (P&P) titled, Fall Program, dated 11/24/17, the P&P indicated, 7. Interventions that may appear on a care plan include the following, but are not limited to the following list. The higher a resident's risk for falls is, the more individualized interventions should be considered: d. Non skid, well fitting shoes that provide the resident with adequate support; e. Educate the resident/responsible party to the importance of asking for assistance 1. Supervised walking

Based on observation, interview, and record review, the facility failed to ensure two of 40 sampled residents (Resident 70 and Resident 56) received treatment and care in accordance with professional standards of practice, comprehensive person centered care and the residents' choices to enable residents to maintain their highest practicable level when: 1a. The facility failed to ensure the bed's dimension were appropriate for Resident 70's size and weight prior to the installation of the side rails. There were no appropriate alternatives prior to installation of side rails for Resident 70. The facility failed to assess the risk of entrapment prior to the use of the side rail for Resident 70, when Resident 70 was observed with four bed rails up and his legs between the gap of the bed rails almost touching the ground. 1b. Resident 70 was assessed as a high risk for falls on 4/26/18 and experienced 10 falls between 6/25/18 and 12/3/18, including a fall in which his right arm was caught between the side rail and the mattress on 11/15/18. The fall assessment and interventions following each fall did not address resident behaviors and possible triggers to the falls. 1c. The facility failed to appropriately assess Resident 70's needs and preferences for activities. 1d. The facility failed to assess Resident 70 for duplicate therapy (prescribing multiple medications for the same medical indication) when resident was receiving [MEDICATION NAME] and did not follow Pharmacy Consultant recommendations to discontinue one of the medications. 1e. Resident 70 was prescribed and administered multiple [MEDICAL CONDITION] medications and the Pharmacy Consultant (PHARM) recommended a reduction or elimination of drugs to comply with standards of practice. 1f. Resident 70 was admitted on [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) without [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Resident 70 did not have [MEDICAL CONDITION] episode since admission to the facility. The facility failed to follow up with Resident 70's PCP and evaluate if Resident 70 had a [MEDICAL CONDITION] diagnosis. Because of the serious potential harm related to the use of side rails used without proper assessment of the size of the bed, the weight of the resident, and without an intervention to prevent entrapment an Immediate Jeopardy (IJ) situation was called on 12/19/18 at 1:45 p.m. with the Administrator, Director of Nursing, Chief Nursing Officer and Director of Operations. The facility submitted an Action Plan to address the IJ situation which included one on one supervision for Resident 70, identifying and monitoring his behaviors for the Interdisciplinary Team (a team of healthcare providers including nurses, social services staff, dietary staff and physician who meet to plan resident care) to determine the root cause of his falls. Resident 70's Primary Care Physician (PCP) reviewed his medication regimen, discontinued the use [MEDICATION NAME]([MEDICAL CONDITION] medication) and decreased the dose of [MEDICATION NAME] ([MEDICAL CONDITION] medication) from 50 milligrams (mg- a unit of measurement) once a day (QD) at bedtime (HS) to 25 mg QD HS. The facility in-serviced all staff on side rail assessment, [MEDICAL CONDITION] medications, preventing falls, and developed a care plan that was specific, measurable and resident centered. The Action Plan was accepted on 12/20/18 at 3:05 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 12/21/18 at 11 a.m. 2. Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on 11/29/18 and staff did not recognize the emergent situation and delayed calling emergency services or 9-1-1. Resident 56 was diagnosed with [REDACTED]. Resident 56's [DIAGNOSES REDACTED]. Based on this new [DIAGNOSES REDACTED]. Resident 56 had multiple teeth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple teeth extractions could have placed the resident at a higher risk of choking affecting his chewing and swallowing ability. These facts were not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a [DIAGNOSES REDACTED]. The facility did not respond timely to an emergent situation and the delay in response led to Resident 56's death. Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56 's death, an IJ situation was called on 1/3/19 at 3:29 p.m. with the Administrator and Director of Operations in attendance. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency which included calling 911. The Licensed Nurses were also provided in-service education on assessment and documentation when a resident returns from an appointment, has a new [DIAGNOSES REDACTED]. The Action Plan was accepted on 1/3/19 at 6:47 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. Findings: 1a. Resident 70's face sheet (a document containing resident profile information) indicated Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to the extremities). Review of Resident 70's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 70's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score of 3 of 15 points which indicated Resident 70 was severely cognitively impaired. Section G indicated Resident 70 was totally dependent on staff members to transfer from one surface to another. Section P Restraints and Alarms Bed rail and Other coded as 0 (Not used); MDS dated [DATE] section P indicated Bed rail coded as 0 (Not used) and Alarms 2 (Bed alarm); MDS dated [DATE] section P indicated Bed rail coded as 0 (Not used and 2 (Used daily) for Bed alarm, floor mat alarm, and Motion sensor alarm. MDS dated [DATE], indicated Bed rail or Other coded as 0 (Not used). On 12/7/18 at 8:30 a.m., during an observation, Resident 70 was in his bed lying on his right side with his legs over the side of the bed. The bed had four side rails in the up position and Resident 70's legs were positioned in the gap between the right upper side rail and the right lower side rail. The call light cord was looped on a hook on the wall at the head of the bed and out of reach from Resident 70. Resident 70 was in his room alone without staff to assist him. On 12/7/18 at 8:31 a.m., during a concurrent observation and interview, LN 5 observed the position of Resident 70's legs dangling off the bed in the gap between the lower and upper side rails on the right side. LN 5 immediately repositioned Resident 70 so his legs were on the bed and no longer in the gap between the upper and lower side rails. LN 5 then called CNA 8 to assist in repositioning the resident up on the bed and attempted to lower the side rails. LN 5 was unable to lower the side rail on the lower left side of the bed. The left side rail was left in the up position. The bed rail on the lower right side was lowered by the LN 5 with ease. LN 5 stated the call light was not where it should be. On 12/7/18 at 9:45 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed with three side rails up. LN 5 stated there were three side rails up and only the right lower side rail was down. LN 5 stated, I'm pretty sure the right bottom side rail was up (during the 8:31 a.m. observation). On 12/7/18 at 9:48 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed, resting and there were three side rails in the up position (right and left upper and left lower). Certified Nursing Assistant (CNA) 8 stated he had worked with Resident 70 for several months and was assigned to Resident 70 since six a.m. on 12/7/18. CNA 8 stated, We (Facility staff) were told not to use the bottom side rails and I don't know how they got in the upper position. I overlooked that four side rails were up. CNA 8 stated he did not know why the call light cord was on the wall and out of the reach of Resident 70. On 12/7/18 at 10:00 a.m., during an interview, LN 5 stated she understood there was an order to use only the upper right and upper left side rails. LN 5 stated she did not know who put the lower side rails in the up position. On 12/10/18 at 10:55 a.m., during an interview, the Director of Nursing (DON) stated, Yes, all four side rails would be considered a restraint. It could be for safety, but the consent does not include all four side rails. On 12/17/18 at 4:55 p.m., during a concurrent interview and record review, the DON stated a side rails assessment was completed on 4/19/18 but did not include alternative measures tried prior to the decision to use side rails. The DON stated, The CNAs and nurses are responsible to see that a bed assessment is completed. The bed already came with side rails. He is dead weight; he is non-ambulatory; he came as a LTC (Long Term Care) resident. A Hoyer lift (mechanical lift to assist a resident to transfer who is unable to assist in self transfer) is used due to dead weight (115.8 pounds). The DON stated a reassessment of the side rails was not done in (MONTH) and started reassessment in October. The DON stated no one admitted who put up the lower side rails. The DON emphasized staff were aware they were not to put all four rails in the up position. The DON stated Resident 70 could have injured himself while the four rails were up. The DON stated, (Resident 70) could be at risk for entrapment, but with all the side rails up he could still get through. The DON stated, We do not consider this (meaning side rails up) a restraint if used for mobility. The DON stated there was no monitoring plan to make sure the use of the side rails was safe. Resident 70's Resident Bed Rail Consent Form dated 4/19/18, indicated, . Mobility Assist .Can enable (Resident 70) to independently reposition self in bed, or to assist caregivers to reposition him/herself in bed, from side to side, move closer to the head of the bed, or to move from a lying to sitting to lying position .Medical Safety .can be a safety measure identified in the resident's care plan by preventing (Resident 70) from slipping or rolling out of bed due to [MEDICAL CONDITION] .It is the policy of this facility to use bed rails only after evaluation and care planning deemed it is appropriate to treat the resident's medical symptoms and assist the resident in maintaining his/her highest practicable physical and psychosocial wellbeing .Recommendations .Type of rail (s) . 1/4 partial rail, left upper, right upper .Frequency .Rail(s) are to be used at all times when (Resident 70) is in bed .Bed rail (s) are to be released PRN (as needed) to allow the resident to move in and out of bed, exercising his/her extremities . Benefits (versus) Risk indicated, . Area of concern . (Resident 70) side rails . Benefits .Security-feel safe, mobility assist from side to side, move from a lying to sitting to lying position, help with transferring, medical safety . Risks related to Noncompliance (sic) . skin tears, possible Fall (with) injury, bruising, strangulation, suffocation, caught between rail (and) mattress . Resident 70's physician orders dated 4/20/18, indicated, .May use side rails for assist in mobility, repositioning, and assist with ADL (Activities of Daily Living) . The physician orders did not specify how many side rails could be used. Resident 70's Progress note dated 4/19/18 at 4:50 p.m., indicated, Fall Score: 12, fall category: Moderate Risk . Resident 70's Progress note dated 4/26/18 at 1:26 p.m., indicated, Fall Score: 18, fall category: High Risk . Residents 70's care plan dated 4/20/18 indicated (Resident 70) uses side rails r/t (related to) assisting with physical functioning such as for mobility to independently reposition self or to assist or to assist caregivers to reposition .type of rails: ½ Partial Rail Left Upper and Right Upper (side rail informed consent dated 4/19/18 indicated ¼ side rails were to be used not 1/2) .Evaluate the resident's side rail use PRN (as needed): Evaluate/record continuing risks/benefits of side rails, alternatives to the use of side rails, need for ongoing use, reason for side rail use .Discuss and educate with the resident/family/caregivers, the risks and benefits of side rails, when the side rails should/will be applied, and an concerns or issues regarding side rail use . On 12/18/18 at 3:10 p.m., during a concurrent observation and interview, the Maintenance Man (MM) 1 took off the lower side rails from the bed. MM 1 stated he had been instructed by the ADM to take the side rails off so they could no longer be used. On 12/19/18 at 8:05 a.m., during an interview, the Administrator (ADM) stated it had been a mistake that the bottom side rails were used. The ADM stated, They should have already been removed; just like all the rest of the beds in the facility. I don't know why that one was different. It appears that one was missed. I wish we could have seen it before. The maintenance man has removed them (side rails). The ADM stated there was no way to know if the lower side rails had been used before (the observation of 12/7/18 were Resident 70 was dangling off his bed with legs between the side rails). The ADM stated the survey had prompted them to look at all side rails in the facility. The ADM stated, My goal is to never let it happen again. The facility document titled Quarterly Maintenance Inspection Check List for New equipment inspection (Bed) dated 12/20/18 indicated a check mark for Resident 70's Bedrails and Beds Operations. The Preventative Maintenance-Resident's Rooms log dated 11/14/18 indicated Resident 70's bed had been checked, but does not indicate what parts had been checked or if repairs were needed. 1b. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the Unit Manager (UM) reviewed Resident 70's progress notes dated 6/25/18 for Fall number 1 which indicated . Author heard (Resident 70) yell out, looked in the room and saw (Resident 70) with legs hanging from the bed and (Resident 70) slipping to the floor (Resident 70) noted to have hit his head on the foot of the bed on the plastic foot rail that was down . (Resident 70) said he was leaving and that he had purposely thrown himself to the floor. (Resident 70) stated he knew what he was doing and that he would continue to do it . The UM reviewed Resident 70's care plan dated 6/25/18 which indicated, . Added floor mats . Resident 70's progress notes dated 6/26/18 indicated, IDT (Interdisciplinary Team) met including DON, DSD (Director of Staff Development), SSA (Social Service Assistant), Unit Manager, MDS Coordinator, RD (Registered Dietician), ADM regarding (Resident 70) episode of throwing himself on the floor. Floor mats and bed alarm added. Staff will continue to monitor and re-direct. Patient teaching was done as well . The IDT did not contain documentation evidence of Resident 70's behavior or approaches for the behaviors. The IDT was aware Resident 70 had a BIMS of less than 3 and did not address whether resident education or patient teaching was appropriately understood by resident due severe cognitive impairment. The UM stated, Resident 70 was not on the falling star program (system used by the facility to identify residents who are high risks for falls). Resident 70's care plan dated 4/20/18, indicated (Resident 70) has impaired cognitive function due to Dementia, [MEDICAL CONDITION], BIMS score 0.0 (severe cognitive impairment) .Interventions .Ask simple yes/no questions in order to determine the resident's needs .Assure the resident understands consistent, simple, directive sentences. Provide the resident with necessary cues . On 12/17/18 at 10:48 a.m., during an interview, CNA 8 stated the falling star program (residents identified at high risk for falls) was implemented just two months ago. CNA 8 stated, We do one on one with (Resident 70) when he is in his chair because he will try to throw himself out (of the wheelchair onto the floor) . Resident 70's Progress Note dated 6/25/18 at 9:30 a.m., indicated Fall Score: 20.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 7/1/18, for fall number 2 which indicated, .nurse walked in (room number) to find (Resident 70) on floor on top of the mat, head by foot of bed, (Resident 70) was supporting himself on (right) side arm . The UM reviewed Resident 70's care plan dated 7/2/18, indicated .Shower resident daily . The UM stated she put daily showers as an intervention to prevent Resident 70 from falling. The UM stated the showers helped him to calm him, but Resident 70's response varied whether or not it calmed him. The UM stated showers were used to prevent Resident 70 from falling. The UM was unable to state how the showers would prevent Resident 70 from falling. On 12/17/18 at 1:13 p.m., during a concurrent interview and record review, LN 4 stated, We give him a shower every day, it helps him relax for a couple of hours then he starts yelling again. I'm familiar with the resident since admission. He doesn't use the call light. He curses in Spanish, screams and yells. He will ask to be changed even if he is dry and ask to get up even after we just placed him back to bed. LN 4 was unable to state how the showers would prevent Resident 70 from falling. Resident 70's Progress Note dated 7/1/18 at 9 p.m., indicated Fall Score: 19.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 8/11/18 at 7:50 a.m. for Fall number 3, indicated . (Resident 70) noted on knees, on floor mat, between the bed and sliding glass door . Resident 70's care plan dated 8/11/18, indicated . (Provide Resident 70 with) Frequent reminders to ask for help (due to) safety . Resident 70's progress notes dated 8/13/18, indicated .IDT met .regarding (Resident 70) episode of falling. Resident is non-compliant, attempts to get out of bed, makes repetitive statements, and yells out most of the time. He has alarms, floor mats, is on (every 2) hours for bladder incontinence, and is on daily shower schedule. Staff will continue to monitor and educate. The UM stated she added a new intervention in Resident 70's fall care plan to remind Resident 70 to ask for assistance. The UM stated, (Resident 70) does not make sense with his repetitive behavior of yelling out. The UM was unable to explain how the new intervention will address Resident 70's behavior and prevent further falls. The UM was unable to stated how Resident 70 would understand the education provided with his severe cognitive impairment. Resident 70's Progress Note dated 8/11/18 at 7:30 a.m., indicated Fall Score: 25.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 10/15/18 at 3 p.m. for Fall number 4 which indicated, . (Resident 70 sliding off the bed, (bed alarm) turned on. Resident was holding onto the side rail and bed sheets .Resident had left foot on the floor and right foot bent at 90 degrees .Resident stated I was looking for something to clean my mouth . Resident 70's care plan dated 10/15/18 indicated .Staff to anticipate needs. Educate staff on residents' oral care needs . The facility document titled, Interdisciplinary (IDT) Meeting Summary dated 10/16/18 at 9:18 a.m., indicated . Root Cause/Contributing Factors (Resident 70's fall) . Resident noted with behavior issues, resident is impulsive, seeking attention, resident wanted his mouth clean, however did not ask for assistance .IDT Recommendations .Resident is on falling star program. resident is up for daily showers. staff to anticipate his needs, and educate staff on residents' oral care needs . The UM stated the recommended intervention was to provide oral care. The UM was unable to state how the recommended intervention to provide oral care would prevent Resident 70 from falling. Resident 70's Progress Note dated 10/15/18 at 3 p.m., indicated Fall Score: 23.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 10/26/18 at 5:45 p.m. for Fall number 5 which indicated, . (Resident 70's) alarm went off . (Resident 70) in a sitting position on the floor mats . Resident 70's care plan dated 10/26/18 indicated, . Toilet every 2 hours with routine care for incontinence . The UM stated they provided a radio/CD (computer disc) to play Spanish music. The UM was unable to state how the radio/CD (computer disc) playing Spanish music would prevent Resident 70 from falling. Resident 70 Progress Note dated 10/26/18 at 5:45 p.m. indicated Fall Score: 28.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note 11/7/18 at 8:30 a.m. for Fall number 6 which indicated (Resident 70) was noted to be on the floor, on the floor mat .near the foot of the bed leaning on his right side/elbow/hip with his feet towards the door .stated he wanted a shower and was trying to get up and go . The facility document titled, Interdisciplinary (IDT) Meeting Summary dated 11/8/18 at 9:44 a.m. indicated, .Root Cause/Contributing Factors .resident was noted to be yelling out staff names earlier in the morning, however did not yell out for shower. resident stated he was getting up to take shower .resident is aware of daily showers. resident is noted to be impulsive and can be hard to redirect at times . IDT Recommendations .provided resident with digital wall clock and dry erase board to be able to direct resident as to when showers will be given to provide resident with a time frame to aid with a visual for the resident . The UM was unable to explain if Resident 70 was able to understand these instructions. The UM was unable to stated how a digital wall clock and dry erase board would prevent Resident 70 from falling. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note dated 11/15/18 at 5:35 p.m. for Fall number 7 which indicated .Residents RT (right) arm was caught between the right side rail and the bed . The IDT Summary dated 11/15/18 at 10:00 a.m. indicated, The IDT discussed resident and current safety/fall interventions. BIMS 0 .on the falling star program .has daily showers, new clock provided .and a white board to let resident know when his showers will be .cd player in room to play music to calm resident . resident has alarms and will stay in place at this time . The UM stated the environment should have been checked for potential hazards. The UM stated no education was provided on measuring the gap between side rails and mattress. The UM stated a side rail assessment should had been done after the fall when Resident 70's arm was caught in between the side rail and the mattress and that was not done. Resident 70's Progress Note dated 11/15/18 at 8:35 p.m., indicated Fall Score: 29.0 Fall Category: High Risk. On 12/17/18 at 3:36 p.m., during an interview and record review, the DON stated the interventions for the falls worked to a degree. The DON stated Resident 70 needed more supervision than every hour to provide care and repositioning. The DON stated the alarms are not going to prevent a fall but to alert staff when Resident 70 was on the floor. The DON stated that even when staff sat with Resident 70, he was still agitated and wanted to get up. The DON stated she would check on him more often if she was assigned as the nurse to the residents. The DON stated she was unable to show documentation for every two hour check and it was the responsibility of all staff to help when Resident 70 called. On 12/18/18 at 9:14 a.m., during an interview, CNA 10 stated she remembered the fall event (on 11/15/18) when Resident 70's leg was hanging from the right side of the bed and his arm was caught between the side rail and the mattress. CNA 10 stated, Two upper side rails were up that day. The side rails help him roll to the side during care. Most of the time he was not able to use the side rails, maybe 15% of the time. CNA 10 stated, The side rails I think for him is to help him prevent from falling, because he can't even use the side rails, he is total care. CNA stated she could not remember receiving education from the DSD on side rail use, but recalled there was a huddle for the bed alarms to alert staff. CNA 10 stated, The interventions with side rails and bed alarms are not helping him because he still falling. On 12/18/18 at 9:44 a.m., during an interview, LN 10 stated Resident 70 had fallen a lot of times, and recalled the incident on 11/15/18 when it looked like Resident 70 slid off the right side of his bed. LN 10 stated LN 9 saw part of his arm caught between the side rails and the mattress. LN 10 stated, The chance of the resident getting caught in the side rails is high. He is full care but I know he can hold onto the side rails. LN 10 stated Resident 70 always yelled out and he needed more one on one supervision. LN 10 stated, Yes, the side rail is preventing him from moving so it is considered a restraint. Despite the side rail and bed alarm he is still falling. On 12/18/18 at 11:08 a.m. during a telephone interview, CNA 11 stated she recalled the incident on 11/15/18 when Resident 70's feet were on the floor and his arm was caught in the space between the right upper side rail and mattress. CNA 11 stated another CNA then helped Resident 70 get back onto the bed. On 12/18/18 at 11:38 a.m., during an interview, the LN 9 stated she was at the nurses' desk when Resident 70 yelled out at the time of the fall on 11/15/18. LN 9 stated she went to Resident 70's room across from the nurses' desk and saw Resident 70 sitting on the floor with his arm up between the side rail and the mattress. LN 9 stated, That's why we have the risk versus (as opposed to) benefit statement but (the rails) also help with mobility and he helps by using the side rails during care. LN 9 stated the side rails could be a potential hazard. LN 9 stated Resident 70 should have been on the RNA (restorative nurse assistant) program and the nurse was responsible to do an evaluation at the time of a fall. On 12/18/18 at 12:17 p.m., during a concurrent interview and record review, the DON and ADM reviewed the progress notes for the fall on 11/15/18 which indicated Resident 70's arm was caught between the upper right side rail and the mattress. The ADM stated, We brainstorm every single time; our immediate intervention is based on discussion of falls. It doesn't mean they don't have a right to fall. The ADM stated they considered a low bed but a low bed was not used. The DON stated, I don't see how more supervision could have been provided. These falls are not contributing to anything PT (Physical Therapy) could help with. The DON stated, Side rails can help and they can hurt. The ADM stated they had followed their policy for fall prevention. On 12/19/18 at 11:41 a.m., during a concurrent observation and interview, LN 1 measured the gap between mattress and upper right and left side rail on Resident 70's bed. The gap for both sides of the bed was a space of 1.5 inches. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note of Fall number 8 dated 11/16/18 at 5:52 a.m. which indicated .witnessed fall . (Resident 70) sitting on the floor mat next to the right side of bed while holding to the rail to get out of bed while holding to the rail . The facility document titled, Interdisciplinary (IDT) Meeting Summary dated 11/16/18 at 9:32 a.m., indicated . Root Cause/Contributing Factors .Resident noted to be more agitated and restless lately since return from acute . IDT Recommendations . Immediate intervention was that nursing called family to come in and see resident. MD to review medications and request labs . The UM stated staff provided one on one supervision when resident was in a high back wheelchair. Resident 70's Progress Note dated 11/16/18 at 2:30 a.m., indicated Fall Score: 29.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note for Fall number 9 dated 11/16/18 at 11a.m. which indicated . (Resident 70) . yell(ed) out HELP HELP .Pt was on the floor on the left side of the bed, near the foot of the bed .leaning on his right elbow and hip with his legs towards the sink .noted with abrasion to right elbow .Pt continues with 1:1 supervision . The UM stated the intervention of one on one supervision started on 11/19/18 but was not documented on the care plan. The UM stated the staff use the high back wheel chair to take Resident 70 around the inside and outside of the building after his shower. The UM was unable to stated why the one on one intervention was not part of the plan of care. Resident 70's Progress Note dated 11/16/18 at 11:05 a.m., indicated Fall Score: 20.0 Fall Category: High Risk. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note for Fall number 10 dated 12/3/18 at 8:40 a.m. which indicated .pt. was on the floor .right .of the bed, facing the sliding door, with legs stretched in front of him and his right arm still holding onto the side of the bed .sitting upright on his bottom on the floor mat . The UM stated the new intervention was a Psychologist consultation for Resident 70 to review the prescribed [MEDICAL CONDITION] medications. The UM was unable to state how the Psychologist consultation would prevent Resident 70 from falling. Resident 70's Progress Note dated 12/3/18 at 8:40 a.m., indicated Fall Score: 24.0 Fall Category: High Risk. On 12/17/18 at 10:48 a.m., during an interview, CNA 8 stated Resident 70 needed total assistance to transfer and a Hoyer lift was used. On 12/17/18 at 12:47 p.m., during a concurrent interview and record review, the MDS Coordinator reviewed Resident 70's MDS assessment section P (restraint and alarms) dated 10/17/18 and stated the side rails were coded 0 (not used). On 12/17/18 at 3:36 p.m., during a concurrent interview record review, the DON stated interventions to prevent f

Based on observation, interview, and record review, the facility failed to assess one of 40 sampled residents (Resident 70) for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed), prior to installation and failed to ensure safety standards were met for the installation of bed rails when Resident 70 was observed with four bed rails up and his legs entrapped between the gap of the bed and side rails almost touching the ground . The Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued on 3/10/06, indicated that entrapment may occur in flat or articulated (raised) bed positions. To reduce the risk of head entrapment, rail perimeter openings should not be greater than four and three quarter inch. To reduce the risk of neck entrapment the gap between the mattress and under the rail should be less than four and three quarter inches. The recommendation also indicated the dimension limits for the open space within the perimeter of the rail should be small enough to prevent the head from entering. The recommended space should be less than four and three-quarter inches . This failure resulted in bed (side) rail entrapment for Resident 70 (bed user's legs were entrapped within openings of the two side rails and between the bed mattress) and place Resident 70 at potential risk for serious harm, injury or death. Because of the serious potential harm related to the use of side rails used without proper assessment of the size of the bed, the weight of the resident, and without an intervention to prevent entrapment an Immediate Jeopardy (IJ) situation was called on 12/19/18 at 1:45 p.m. with the Administrator, Director of Nursing, Chief Nursing Officer and Director of Operations. Findings: Resident 70's Order Summary Report dated 4/19/18 indicated, Admit to (facility) on 4/19/2018 under care of (physician name) for skilled nursing services with the [DIAGNOSES REDACTED].all meds (medications) via (by way of) pe[DEVICE] . (Percutaneous [MEDICAL CONDITION] Tube-surgically placed for administration of medications or feeding). Resident 70's Progress Notes undated, indicated, (Resident 70) was admitted on [DATE] to room (number of room) via stretcher from (Acute Care Hospital) with a [DIAGNOSES REDACTED].Resident was oriented to the facility including the use of the call light and bed controls (bed with four side rails) . Pt (patient) A&O x2 (alert and oriented to person and time), able to make needs known, calm and cooperative with staff and care pt is 1-2 person assist . Resident 70's physician order [REDACTED]. On 12/7/18 at 8:30 a.m., during an observation, Resident 70 was in his bed lying on his right side with his legs over the side of the bed. The bed had four side rails in the up position and Resident 70's legs were dangling off the bed entrapped in the gap between the right upper side rail and the right lower side rail. The call light cord was looped on a hook on the wall at the head of the bed and out of reach from Resident 70. During the observation Resident 70 was alone in his room with no staff available to provide assistance to Resident 70. On 12/7/18 at 8:31 a.m., during a concurrent observation and interview, Licensed Nurse (LN) 5 observed the position of Resident 70's legs dangling off the bed entrapped in the gap between the bed and upper and lower side rails on the right side. LN 5 immediately attempted to repositioned Resident 70 so his legs were on the bed and no longer entrapped in the gap between the upper and lower side rails. LN 5 then called CNA 8 to assist in repositioning Resident 70 up on the bed because she was unable to reposition his without another staff member's assistance and attempted to lower the side rails. LN 5 was unable to lower the side rail on the lower left side of the bed and left the lower left side rail in the up position. The side rail on the lower right side was lowered by the LN 5 with ease. LN 5 stated the call light was not where it should be. On 12/7/18 at 9:45 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed with three side rails up. LN 5 stated there were three side rails up and only the right lower side rail was down. LN 5 stated, I'm pretty sure the right bottom side rail was up (during the 8:31 a.m. observation). On 12/7/18 at 9:48 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed, resting and there were three side rails in the up position (right and left upper and left lower). Certified Nursing Assistant (CNA) 8 stated he had worked with Resident 70 for several months and was assigned to Resident 70 since 6 a.m. on 12/7/18. CNA 8 stated, We (Facility staff) were told not to use the bottom side rails and I don't know how they got in the upper position. I overlooked that four side rails were up. CNA 8 stated he did not know why the call light cord was on the wall and out of the reach of Resident 70. On 12/7/18 at 10:00 a.m., during an interview, LN 5 stated she understood there was an order to use only the upper right and upper left side rails. LN 5 stated she did not know who put the lower side rails in the up position. On 12/10/18 at 10:55 a.m., during an interview, the Director of Nursing (DON) stated, Yes, all four side rails would be considered a restraint. It could be for safety, but the consent does not include (consent to use) all four side rails. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note dated 11/15/18 at 5:35 p.m. for Resident 70's fall number 7 which indicated .Residents RT (right) arm was caught between the right side rail and the bed . The IDT Summary dated 11/15/18 at 10:00 a.m. indicated, The IDT discussed resident and current safety/fall interventions. BIMS 0 .on the falling star program .has daily showers, new clock provided .and a white board to let resident know when his showers will be .cd player in room to play music to calm resident . resident has alarms and will stay in place at this time . The UM stated the environment should have been checked for potential hazards. The UM stated no education was provided on measuring the gap between side rails and mattress. The UM stated a side rail assessment should had been done after the fall when Resident 70's arm was caught in between the side rail and the mattress and that was not done. On 12/17/18 at 4:55 p.m., during a concurrent interview and record review, the DON stated a side rails assessment was completed on 4/19/18 but did not include alternative measures tried prior to the decision to use side rails or a risk of entrapment assessment. The DON reviewed side rail informed consent and stated the informed consent had documented risk of Resident 70 side rail entrapment. The DON stated, The CNAs and nurses are responsible to see that a bed assessment is completed. The bed already came with side rails. He is dead weight; he is non-ambulatory; he came as a LTC (Long Term Care) resident. A Hoyer lift (mechanical lift to assist a resident to transfer who is unable to assist in self transfer) is used due to dead weight (115.8 pounds). The DON stated a reassessment of the side rails was not done in (MONTH) and started reassessment in October. The DON stated no one admitted who put up the lower side rails. The DON emphasized staff were aware they were not to put all four rails in the up position. The DON stated Resident 70 could have injured himself while the four rails were up. The DON stated, (Resident 70) could be at risk for entrapment, but with all the side rails up he could still get through. The DON stated, We do not consider this (meaning side rails up) a restraint if used for mobility. The DON stated there was no monitoring plan to make sure the use of the side rails was safe. Resident 70's Resident Bed Rail Consent Form dated 4/19/18, indicated, . Mobility Assist .Can enable (Resident 70) to independently reposition self in bed, or to assist caregivers to reposition him/herself in bed, from side to side, move closer to the head of the bed, or to move from a lying to sitting to lying position .Medical Safety .can be a safety measure identified in the resident's care plan by preventing (Resident 70) from slipping or rolling out of bed due to [MEDICAL CONDITION] .It is the policy of this facility to use bed rails only after evaluation and care planning deemed it is appropriate to treat the resident's medical symptoms and assist the resident in maintaining his/her highest practicable physical and psychosocial wellbeing .Recommendations .Type of rail (s) . 1/4 partial rail, left upper, right upper . Frequency . Rail(s) are to be used at all times when (Resident 70) is in bed . Bed rail (s) are to be released PRN (as needed) to allow the resident to move in and out of bed, exercising his/her extremities . Benefits (versus) Risk indicated, . Area of concern . (Resident 70) side rails . Benefits .Security-feel safe, mobility assist from side to side, move from a lying to sitting to lying position, help with transferring, medical safety . Risks related to Noncompliance (sic) . skin tears, possible Fall (with) injury, bruising, strangulation, suffocation, caught between rail (and) mattress . Review of the clinical record indicated Resident 70 did not have a [MEDICAL CONDITION] diagnosis. UM confirmed that Resident 70 did not have documented [DIAGNOSES REDACTED]. On 12/17/18 at 4:52 p.m., during a concurrent interview and record review, the DON stated side rails were ordered on [DATE] and a side rail consent was obtained on 4/19/18 and side rails were in use as of 4/19/18 (day of admission). Fall risk assessment dated [DATE] indicated Resident 70 was a Moderate risk for falling. The DON stated there was no documentation for side rail alternative for least restrictive intervention used before side rails were implemented. The DON stated, All staff is responsible to assess if the side rails are working properly and will notify maintenance if there is something wrong with the side rails. The DON stated the side rails were determined necessary for Resident 70 by an assessment and speaking with RP (responsible person). The DON was unable to find documentation of a [MEDICAL CONDITION] diagnosis. The DON stated a Hoyer lift (hydraulically operated device used to enable caregiver to transfer a resident from the bed to wheelchair) was the safest way to transfer Resident 70 because he could not bear weight or help with transfer from bed to chair. The DON stated the process to wean residents off from side rail use was for nurses to reassess (for side rail need) every three months. The DON stated the side rails would not impede Resident 70 from doing anything. The DON stated resident was able to move out of bed and had been found on the floor multiple times. The DON stated, I can't tell you why the four side rails were up. The nurses didn't tell me. They should not have been up. The DON stated the risk for entrapment and injury was high with four side rails up. The DON stated Resident 70 was able to move himself out of his bed which increased the risk of entrapment when the four side rails were in the up position. On 12/18/18 at 9:20 during an interview, the Director of Rehabilitation (DOR) stated, Resident 70 had frequent falls and used a motion alarm to alert the staff when resident was attempting to get out of his bed. DOR stated the motion is activated When a resident has a fall, it sets off an alarm. The DOR reviewed resident 70 clinical record and stated, With that many falls (10 since (MONTH) (YEAR)) he (Resident 70) should be in our study (for QAPI - quality assurance prevention and intervention) and should be reviewed for intervention. We should be asking the questions how to keep him safe. The DOR stated the facility does not involve her department with assessments for side rail safety. (DOR) stated she had been working for [AGE] years with the facility and the DON or ADM would let her know if someone had a mobility decline, falls or a need for therapy services. The DOR stated Resident 70 was not referred to receive therapy services each time he had a fall and would benefit from these services with his safety risk. The DOR stated the process of referral depended upon the nurses to inform the therapy department of the need and change of condition. On 12/18/18 at 10:26 a.m., during a concurrent interview and record review with the DON and ADM, the DON stated she was unable to find documentation of the incident (dated 12/7/18 when Resident 70 was observed dangling off the bed with his legs between the side rails). The ADM stated, We have called it a mistake. On 12/18/18 at 12:00 p.m., during a concurrent interview and record review, the Social Service Assistant (SSA) stated she had worked at the facility for one year and had taken the lead position one week ago. The SSA stated the side rail assessment was not addressed in IDT meetings and it would require another IDT (interdisciplinary team - a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best patient outcomes) meeting to assess for the need of the side rails. The SSA reviewed the records and was unable to find documented evidence where Resident 70 had been referred to RNA (restorative nursing therapy services) or PT (Physical Therapy) because of his climbing out of bed and falling. The SSA stated she knew staff had been performing one on one supervision for resident 70 because of his high risk of falling but the one on one was only performed on as needed bases. The SSA stated she was not involved with the assessment or when the decision was made to place Resident 70 on a one on one supervision. The SSA stated, I am still learning his needs. I do IDT notes and always attend IDT meetings. On 12/18/18 at 3:29 p.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated she was not involved in any assessment of side rails and had no knowledge of any alternative or reassessment of side rails. The DSD stated, If I'm not present during the IDT meeting there is no way for me to get the information that was discussed. The DSD stated Resident 70 would have benefited from a restorative nurse assistant (RNA) program to provide range of motion exercise for Resident 70. The DSD stated, The side rails pose more of a threat or a hazard to him if the staff was not present. The DSD stated keeping the side rails up was not preventing Resident 70 from falling Because he was still falling, even with the side rails. On 12/18/18 at 5:18 p.m., during a telephone interview, the family member (FM) stated, At the time (Resident 70) was admitted , the consent for side rails was not filled out when they gave it to me. They told me to sign it and they would fill it in later. The FM stated she did not want the side rails all the time and was told the side rails were going to be on the right side of the bed to help with his mobility. FM stated the facility did not attempt alternatives prior to implementing the side rails on the day of admission. On 12/18/18 at 5:45 p.m., during a concurrent observation and interview, the DON stated she did not know how the right lower side rail worked. The DON stated, Usually the CNAs know better. The DON called for a CNA who had difficulty finding the release lever and putting the lower rails up or down. On 12/19/18 at 8:05 a.m., during an interview in the ADM's office, the ADM stated it was a mistake for the staff to have used the bottom two side rails on 12/7/18. The ADM stated the lower two side rails should have already been removed, just like all the rest of the beds in the facility. The ADM stated the maintenance staff had removed the lower side rails on Resident 70's bed on 12/18/18. The ADM stated she did not know why Resident 70's bed had four side rails and it appeared his bed had been missed when they checked all the beds for removal of lower end side rails. The ADM stated there was no way to know if the lower side rails had been used before the observation of Resident 70 dangling off the bed with his legs between the side rails. On 12/19/18 at 9:19 a.m., during a telephone interview, LN 5 stated on the day of 12/7/18 the two upper side rails were up and the right lower side rail was up on Resident 70's bed. LN 5 stated the lower left side rail was up and even with the bed mattress. LN 5 stated, I didn't even know where the lever was to put it down. LN 5 stated the left lower side rails remained in the up position because she did not know how to release the side rail. LN 5 stated her understanding was that a restraint was something that prevented movement and she did not consider the side rails as a risk for Resident 70 because Resident 70 could move in bed. On 12/19/18 at 9:23 a.m., during a telephone interview, CNA 8 stated, I'm pretty sure all four side rails were up (on 12/7/18) . I was a little late that day, and I was rushing . CNA 8 stated that all four side rails would be considered a restraint according to nursing home regulations. On 12/19/18 at 11:05 a.m., during a concurrent interview and record review, the DON stated she was unable to find documentation of the incident where Resident 70 was dangling off the bed with his legs between the side rails on 12/7/18. The DON stated the only way to identify delayed injuries as a result of the incident dated 12/7/18 was for the nurses to document. The DON stated, The nurse does weekly skin assessments and would see if there had been (delayed) bruising. The DON stated she had asked the Chief Nurse Executive (CNE) if there should be documentation and was told by the CNE she would not view it as a fall so no documentation was necessary. The facility policy and procedure titled, Physical Restraints, dated, 11/24/17, indicated, .physical restraints are to be only when there is a physician's orders [REDACTED]. on the effect .of restricting freedom of movement or normal access to one's body .Alarms that prevent the resident the freedom to move around, or cause fear in the resident who attempts to move independently, are considered restraints . The facility policy and procedure titled, Fall Program dated 11/24/17, indicated .a licensed nurse is to complete the Fall Risk Assessment .upon admission to determine the resident's risk factors associated with the potential for falls .is to then be completed .after any actual fall .The higher a resident's risk for falls is, the more individualized interventions should be considered .Bed in low position .Medication review by the pharmacist. Eliminate or reduce medications when appropriate .Restorative program to improve mobility, lower extremity strengthening and/or coordination .

Based on interview and record review, the facility failed to ensure residents were free from neglect for one of 40 sampled resident's (Resident 56) when Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on [DATE] and staff did not recognize the emergent situation and delayed calling emergency services or [DATE]. Resident 56 was diagnosed with [REDACTED]. Resident 56's [DIAGNOSES REDACTED]. Based on this new [DIAGNOSES REDACTED]. Resident 56 had multiple teeth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple teeth extractions could have placed the resident at a higher risk of choking affecting his chewing and swallowing ability. These facts were not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a [DIAGNOSES REDACTED]. The facility did not respond timely to an emergent situation and the delay in response led to Resident 56's death. Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56 's death, an IJ situation was called on [DATE] at 3:29 p.m. with the Administrator and Director of Operations in attendance. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency which included calling 911. The Licensed Nurses were also provided in-service education on assessment and documentation when a resident returns from an appointment, has a new [DIAGNOSES REDACTED]. The Action Plan was accepted on [DATE] at 6:47 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on [DATE] at 12:23 p.m. Findings: Resident 56's face sheet (a document containing resident profile information) indicated Resident 56 was [AGE] years of age, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 56's Minimum Data Set assessment (MDS) (a resident assessment tool used to identify resident cognitive and physical function) assessment, dated [DATE] indicated the following for Resident 56: Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) score of 9 of 15 points (moderate cognitive impairment)required supervision (oversight, encouragement or cueing) with setup assistance for meals and had no problems or difficulty with swallowing. On [DATE] at 8:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, I have been working in the facility for [AGE] years. I took care of (Resident 56) for 1 year. He eats breakfast in his room. I open the lid of his tray and he would feed himself. That's all I do for him and he will eat by himself, then I would get his tray back (once resident was finished with his meal). CNA 1 stated on [DATE] while in the room giving Resident 56's roommate his breakfast tray, he heard Resident 56 cough. CNA 1 stated, I went over (to Resident 56), he was sitting upright, he just nodded, he didn't say anything. I told the charge nurse (Resident 56) might be aspirating (breathing foreign objects into airways). That was the only time I heard (Resident 56) cough like that. On [DATE] at 9:16 a.m., during an interview, Licensed Nurse (LN) 2 stated, A CNA came to me (on [DATE]) and told me (Resident 56) might be aspirating. (Resident 56) didn't talk. I told him to lift up his head, I looked into his mouth and I saw a white drool mixed with food. I ran out to the nurses' station (calling out) that I need help (Resident 56) is choking. I called (Name of Ambulance Company) at around 7:25 a.m. ([DATE]) that I need an emergency transport, a resident is choking. I told them to send an ambulance with lights and sirens. I need emergency transfer now. LN 2 pointed at a paper written with the name and number of the ambulance company located at the nurses station and stated that was the number she used to call for the ambulance. LN 2 stated, I came back to the nurses station and (the time) was 7:55 a.m. I was angry. Where are (the paramedics). I see them out there parked at the front door (located across the street from the facility). I asked them are you guys the lights and siren guys and he said yeah that's how busy we are. I told them I think our patient just passed away and they said what room . I don't understand what took them so long. They could have saved him. They are well equipped. They didn't even come with the lights and sirens on. I would have heard it but I didn't hear it. I never have to send a resident on a real emergency. Usually it's planned and (paramedics) respond right away but this time, I don't know why they didn't come right away. Review of Resident 56's progress note dated [DATE] indicated, . This writer (LN 2) was notified at 0725 (a.m.) by CNA (1) that (Resident 56) may be possibly choking on breakfast, immediately went to assess resident and (Resident 56) was found sitting up in bed with a tray in front of him containing a freshly served breakfast that included a partially eaten tortilla. Resident pulse at 65, SpO2 sat (oxygen saturation- level of oxygen in the blood) is only 65% on RA (room air), asked resident if he was choking and no response was given, had resident sit more upright and looked in his mouth and could see nothing, immediately went to nurses station to get help from N[NAME] (night nurse), returned to resident with N[NAME] nurse and he (N[NAME] nurse) immediately began to do abdominal thrusts after quick assessment and attempting a finger sweep with no success because resident would not open his mouth and partially clenching his teeth, after N[NAME] nurse gave approximately 4 abd (abdomen) trust (thrusts)with no success (LN 1) ran back to nurses station to call for emergency assistance from (name of Ambulance Company) . dispatcher states that she will send ambulance with lights and sirens due to patient's inability to breathe . at 7:45 (LN 1) went back to desk and called resident's emergency contact . and notified them of situation (choking) . returned to resident's bedside, abd thrust still are ineffective . however resident still has strong pulse ,[DATE] and Sp02 in 60's, resident suddenly went limp, cyanotic (turned blue in color) and without a pulse at (7:55 a.m.) . Resident 56's progress note dated [DATE] at 8 a.m., indicated (name of Ambulance Company) arrived at (approximately) 0758 (a.m.) . resident was no longer breathing . time of death announced (sic) at (7:55 a.m., by (RN) . On [DATE] at 3:06 p.m., during an interview, Resident 17 stated she was Resident 56's sister. Resident 17 stated, I just don't understand, they knew he had problems with swallowing. He needed to have supervision while eating. Somebody should have been there watching him. Nobody supervised him. They just put his tray and leave. My sister comes in on Monday, Wednesday and Friday. We eat lunch together. When we eat together, he coughs a lot that's why he needed some supervision. My sister was not here every day to watch for him. Somebody with that problem shouldn't be left alone in the room while eating. We shouldn't have to be mourning his death if they would have supervised him. On [DATE] at 3:46 p.m., during a concurrent interview and record review, the Speech Pathologist (SP) reviewed Resident 56's speech therapy notes and plan of care dated [DATE] which indicated the facility referred Resident 56 to SP for a swallow evaluation due to reports from caregivers of Resident 56 having swallowing difficulties during meals. The SP stated he performed the initial swallow evaluation on [DATE] and documented Resident 56 was having difficulty masticating (chewing) foods, and was observed with occasional coughing during meals. The SP stated Resident 56 and the family report intermittent (swallowing) difficulty. The SP stated Resident 56 was at risk for aspiration on liquids and required intermittent supervision. The SP stated, He (Resident 56) was admitted on mechanical soft diet (is a diet that includes soft and easy to chew foods for people who have difficulty chewing and swallowing), honey thick liquids. When I discharged him (on [DATE]), he did not require cueing and supervision with mechanical soft texture. He was safe to eat by himself. I told him to take small sips, small bites and he was able to demonstrate it safely. The SP note dated [DATE] indicated, The (Resident 56) wishes to remain on current mechanical soft texture diet with nectar thick liquids to minimize risk of aspiration . Precautions: .Aspiration . (Resident 56) and family report intermittent (swallowing) difficulty). The SP stated it was a team effort that involved Licensed Nurses and CNA's to observe him and supervise him while eating. The SP stated, (The facility) would have to let me know if (Resident 56) had any problems and would make a referral for me to do another swallow (evaluation). SP stated the facility did not request a second referral for Resident 56 to receive a swallowing evaluation. On [DATE] at 4:26 p.m., during a telephone interview, Family Member (FM) 1 stated she took Resident 56 to an appointment with Neurologist (Neuro- brain and spinal cord Medical Doctor (Neuro MD)) on [DATE] and Resident 56 was diagnosed with [REDACTED]. FM 1 stated Resident 56's voice was, Very soft spoken that you could hardly hear his voice or understand him. FM 1 stated she was concerned and wanted to know what was wrong with him. FM 1 stated she wanted to know if Resident 56 had Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular stiffness, and slow, rough movement). FM 1 stated, (Resident 56) got diagnosed last (MONTH) (2018) with [DIAGNOSES REDACTED]. It was paralysis in the muscles. It affected his speech, walking and swallowing. The (Neuro MD) told me it's a progressive disease. FM 1 stated she comes to the facility every Monday, Wednesday and Friday to visit Resident 56 and Resident 17 and they would have lunch together. FM 1 stated, One time, we had lunch and something got stuck in his throat. I took (Resident 56) out to the nurses' station and told the nurse something got stuck in his throat. I told a (Licensed Nurse) and she just gave him a pudding. I cut (Resident 56's) food in small pieces when I am there. He needs supervision while eating. He coughs up a lot . I wouldn't want it to happen to anybody else. Review of Resident 56's clinical record fax to physician dated [DATE], indicated, (Attention) . (Name of PCP) . Problem, (Resident 56) and (FM) want (Resident 56) referred to Neurology. (FM) states (Resident 56) has slurred speech, swallowing problems (on thickened liquids) . gait imbalance . The clinical record indicated Resident 56's PCP ordered a referral to a Neuro MD. On [DATE] at 9:10 a.m., during an interview, CNA 2 stated she had been working in the facility for [AGE] years and took care of Resident 56. CNA 2 stated Resident 56 was observed to decline for the past months. CNA 2 stated Resident 56's voice changed to a very low tone and was at times difficult to understand. CNA 2 stated Resident 56 was becoming weaker and began to fall more often. CNA 2 stated she was unaware if he had swallowing issues because she would only set-up the meal tray for Resident 56 to eat his meal in his room and was not present while Resident 56 was eating. CNA 2 stated Resident 56 was not supervised during his meals. On [DATE] at 9:47 a.m., during a concurrent interview and record review, LN 4 reviewed Resident 56's Neuro MD progress notes dated [DATE] indicating, . Had PSP ([DIAGNOSES REDACTED]) with degeneration . need to be monitored closely . LN 4 stated she was the LN assigned to Resident 56 when he returned from his appointment with the Neuro MD. LN 4 stated Resident 56 returned with a doctor progress note indicating Resident 56 was newly diagnosed with [REDACTED]. LN 4 stated she did not know what PSP meant for Resident 56's care and did not inform the Unit Manager (UM), Director of Nursing (DON) or the IDT team about the new diagnosis. LN 4 stated she should have informed the UM and DON in order to communicate and plan Resident 56's care and needs especially with a new [DIAGNOSES REDACTED]. LN 4 reviewed Resident 56's clinical record and was not able to find a care plan for his new [DIAGNOSES REDACTED]. LN 4 stated, I have never done a care plan. It should be care planned so the nursing team would communicate and take care of his needs. It should also be (added) in his [DIAGNOSES REDACTED]. When I received the document after his appointment I should have documented it (in the clinical record). I just wrote no new orders and no new diagnosis. I should not have done that. It made it look like I didn't do it. I didn't put it in the electronic health care record (EHR). I should have put it (in the EHR). That is what we were trained as nurses. LN 4 stated Resident 56's Primary Care Physician (PCP) should have been informed of his new [DIAGNOSES REDACTED]. LN 4 stated, If we noticed that residents are having problems with swallowing we get a referral for a speech therapist (evaluation). He had no problems with eating and swallowing. Sometimes I see him when I pass meds (medications) and he was okay. The facility document titled, Job Description LVN undated, indicated, . As LVN . you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties . Assist in developing methods for coordinating nursing services with other patient services to ensure the continuity of the patients' total regimen of care . Participate in the development of a written plan of care (preliminary and comprehensive) for each patient that identifies the problems/needs of the patient, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care . On [DATE] at 9:59 a.m., during a concurrent interview and record review, the UM reviewed Resident 56's Neuro MD progress notes dated [DATE] indicating, . Had PSP ([DIAGNOSES REDACTED]) with degeneration . need to be monitored closely . The UM stated she was not aware of Resident 56's new [DIAGNOSES REDACTED]. The UM stated, It should have been communicated with all staff. It was not care planned and it should have been care planned. If I was the one doing the care plan, I would put it under ADL's (Activities of Daily Living) and to monitor for decreased ADL functions such as difficulty in swallowing, to monitor how he eats, decreased in mobility function and to monitor for falls. (Resident 56) does not have a progressive disease like [MEDICAL CONDITION] (progressive nervous system disorder that affects movement) before but now that he has a [DIAGNOSES REDACTED]. The UM stated the SP and PCP should have been notified about his newly diagnosed condition but was not informed by the nursing staff. On [DATE] at 10:05 a.m., during a concurrent interview and record review, the DON reviewed Resident 56's Neuro MD progress notes dated [DATE] and indicated, . Had PSP ([DIAGNOSES REDACTED]) with degeneration . need to be monitored closely . The DON stated she was not familiar with PSP or what it meant for Resident 56's care needs. The DON stated, I did not know that (Resident 56) had that diagnosis. The healthcare team should have been notified about the diagnosis. If it got worst, we would have to send him back to the doctor. A referral to Speech (Pathologist) should have been made with the new diagnosis. It is important to monitor his swallowing if it got worse. The DON reviewed Resident 56's clinical record and was unable to find a care plan addressing his needs with his new diagnosed condition of PSP. The DON was unable to find Resident 56's PSP [DIAGNOSES REDACTED]. The DON stated, It should be included in the [DIAGNOSES REDACTED]. The supervision (how he eats and level of assistance when eating) for (Resident 56) might have been different if the facility was aware of the new diagnosed condition. The DON reviewed the Neuro progress note with the PSP [DIAGNOSES REDACTED]. On [DATE] at 11:44 a.m., during a telephone interview, the SP stated he was not aware of Resident 56's [DIAGNOSES REDACTED]. of that diagnosis. Unfortunately I wasn't aware. It would have warranted a (speech therapy) screen . The SP stated a speech therapy screening was not requested by the facility. On [DATE] at 1:39 p.m., during a telephone interview, the PCP stated the new [DIAGNOSES REDACTED]. The PCP stated, I'm looking at (internet search engine name) right now for the meaning of PSP. It means the resident will have swallowing problems . (The facility) has my direct number. They can call me anytime but I was not informed about the new diagnosis. It's a progressive disease so all the symptoms he was having will get worse over time (swallowing problems). The nurses need to monitor his swallowing, the food and diet texture is a big thing . On [DATE] at 8:46 a.m., during a telephone interview, the Neuro MD stated, I saw (Resident 56) last (MONTH) (YEAR) and I diagnosed him with PSP. It means the patient cannot swallow, (he) will fall more. It's like a death sentence for the patient. With a swallow eval (evaluation) it may prolong his life . The facility should have known he had PSP. I wrote monitoring but (the facility) has their own speech therapist. They should have made a referral with the speech therapist when they saw the [DIAGNOSES REDACTED]. A speech evaluation should have been made. The resident needs supervision with eating and walking because (he) will have more difficulty with swallowing and walking as the disease progresses. It's a simple job they need to do. They need to look at the [DIAGNOSES REDACTED]. That's why nursing homes are there to provide the best care for the patient. They should not just file the paper with the diagnosis. They should read it and find out about it and what it means to the patient's care. That's what nursing care is for, to be able to provide a better care for the patient and their needs. (The facility) has a speech therapist that should work with him. Professional reference titled, [DIAGNOSES REDACTED] (PSP) information undated, (found at www.movementdisorders.ufhealth.org) indicated, . Treating speech and swallow impairments is equally important . Choking or swallow difficulty is very common in PSP and another potential hazard. Aspiration of food, liquids or saliva can result in death. As such, formal swallow evaluation is strongly recommended and should include regular follow-up exams . On [DATE] at 9:14 a.m., during an interview, LN 5 stated she has been working in the facility for 6 years. LN 5 stated, If (residents) are choking or having a stroke, I start the [MEDICATION NAME] maneuver . I would call 911 first because it's an emergency situation. I never had to send somebody out on an emergency. The most recent one I sent out was a resident had a (Urinary Tract Infection- infection of the bladder) so I called (Name of Ambulance Company) but if it's an emergency I would call 911. On [DATE] at 9:25 a.m., during an interview, LN 1 stated she would call 911 in a life and death situation such as when a resident was choking. LN 1 stated she would call the (name of Ambulance Company) for non-threatening situations. On [DATE] 9:49 a.m., during an interview, CNA 3 stated, I notify the nurse if I came across a resident that needs emergency attention, and after that the nurse takes over. I would call 911 for an emergency situation . On [DATE] 10:04 a.m., during an interview, CNA 4 stated, For emergency situation, I call code blue from the nurses station. The nurses will do whatever they need to do for the resident and if delegated to me to call the ambulance, I will call 911. We have a different ambulance (phone number) for non-emergent situation. I will call 911 whether outside, home or in the facility for emergency situation. On [DATE] at 10:01 a.m., during a telephone interview, LN 2 stated, We call (Name of Ambulance Company) for everything, for emergency and non-emergency . I will not call 911. That's what (licensed nurses) were trained when I got hired and that's what I did. On [DATE] at 9:35 a.m., during an interview, the CNO stated, For both emergency and non-emergency, nurses are supposed to call (Name of Ambulance Company). If it is an emergency, we specify lights and sirens. It will not make any difference if we call 911 because there's only one Ambulance Company in this area. The CNO stated new hires and current staff are given in-service training for unusual occurrence such as fall prevention program, skin integrity and choking. On [DATE] at 9:45 a.m., during an interview, the DON stated, .If I am in that situation, I could have handled it differently. I would have called 911 directly since they will come immediately and 911 would have dispatched the fire department to respond competently in an emergency situation. The DON stated the facility does not have a specific policy for responding in an emergency situation. The DON stated it was included in the LN's Basic Life Support (BLS) training that they knew how to respond to an emergency like choking and how to perform the [MEDICATION NAME] maneuver. On [DATE] 9:55 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated the LN's are in-serviced annually on how to respond to an emergency situation like choking prevention. The DSD was not able to provide a specific policy on how the facility responds to an emergency situation like choking. The DSD stated the facility does not have a specific policy on how to respond when a resident was choking. The DSD stated LN's are supposed to call 911 for an emergency situation. The DSD provided a facility document titled, CPR (Cardiopulmonary Resuscitation- an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped) undated, indicated . First Aid for the Choking Victim: The [MEDICATION NAME] maneuver .(the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea) Choking is caused by an obstructed airway and is one of the leading causes of death. Everyone should know how to help a person who is choking, and as medical professionals, all CNAs are required to know how to assist someone with an obstructed airway caused by a foreign body . It is sensible to have someone call 911. The [MEDICATION NAME] maneuver may be successful. But it may not work and it is much, much better to have emergency personnel on the way then wait until the person loses consciousness and then call for help . Always call 911 or have someone call for help . The DSD stated she goes over this document when she performs her annual in-service training on choking with the Licensed Nurses. On [DATE] at 10:16 a.m., during an interview, LN 6 stated, If it's an emergency, I would immediately call 911. If it's a non-emergency situation, I would assess the resident and I would call the PCP. If the PCP says to send resident out then I would call the ambulance which is (Name of Ambulance Company) but if they are having a [MEDICAL CONDITION] or choking, I would definitely call 911 because it's an emergency. The nurses on the floor trained me what to do in case of an emergency situation and they told me to call 911. On [DATE] at 10:43 a.m., during a telephone interview, (Ambulance Company) representative stated, (The facility) usually gets a hold of us through 911 or by calling us directly. Sometimes it depends on the situation . but I would think if it's a real emergency situation (staff) would call 911 as far as I know. On [DATE] at 12:16 p.m., during a concurrent interview and record review, LN 7 opened a facility binder located at the nurse's station and pointed at the (Name of Ambulance Company) number and stated, I would call (name of Ambulance Company) for any emergency situation. I was trained on orientation to call direct line (name of Ambulance Company) for all emergencies. On [DATE] at 9:40 a.m., during an interview, the DSD stated she would call 911 for an emergency situation such as when a resident was choking. The DSD stated she would call (Name of Ambulance Company) for non-emergency situations such as when a resident will be transferred out of the facility to General Acute Care Hospital (GACH) for a procedure. On [DATE] at 9:50 a.m., during an interview, LN 8 stated she would call 911 for every emergency situation such as when a resident was choking or having chest pain. LN 8 stated she would call (Name of Ambulance Company) for non-emergency situations and if residents were stable enough to be transferred to GACH for an evaluation. LN 8 stated, The difference between calling 911 and the (name of Ambulance Company) is that, 911 can dispatch an ambulance that is available right away. On [DATE] at 10:41 a.m., during an interview, LN 2 stated she was not sure if anybody checked to see if the ambulance arrived to the facility while Resident 56 was still choking. LN 2 stated she did not call the paramedics to ask if they were on the way to the facility. On [DATE] at 10:53 a.m., during an interview, the DON stated nobody from the facility staff checked to see if the ambulance arrived at the facility while Resident 56 was still choking. The DON stated, Someone should have called (the ambulance to (ask) when they are arriving to the facility). The (facility staff) should call 911 . On [DATE] at 9:17 a.m., during a telephone interview, (Ambulance Company) Compliance Officer stated, If the facility needs emergency transport, they should call 911. They should not be calling for the ambulance number. The ambulance number is different from 911. The Ambulance Compliance Officer stated 911 was used for emergency situations and the ambulance direct phone number was used for non-emergency situations. On [DATE] at 8:20 a.m., during a telephone interview, FM 1 stated, (Resident 56) was having a lot of problems with speech, swallowing and walking. That's why I wanted him seen by a neurologist. (The facility staff) were saying (Resident 56) was high functioning. I was trying to get my brother more help. FM stated Resident 56 was admitted to the facility on (MONTH) (YEAR) FM stated, (Resident 56's) voice was not clear enough. I have to tell him to speak louder and he told me he couldn't. I requested another appointment to a neurologist and the reason for the referral was his speech problem so he could communicate better and other things that needs to be addressed like swallowing. On [DATE] at 9:28 a.m., during a concurrent interview and record review at the nurse's station, LN 4 reviewed the appointment calendar and stated Resident 56 went to dental appointments on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. LN 4 stated, I don't know why (Resident 56) went to the dentist. LN 4 stated she was not aware Resident 56 had tooth extractions whenever he would go to his dental appointments or what procedure was performed by the dentist on Resident 56. LN 4 stated, (Resident 56) has never had any tooth extractions, not that I am aware of. LN 4 reviewed Resident 56's progress notes in the computer and was unable to find documented assessment for the reason Resident 56 went to multiple dental appointments. LN 4 stated, It should be documented in the progress notes. It should have been documented when the (dental) appointment was made so (Licensed Nurses) knew why (Resident 56) was going to the (dentist). It should be documented in case it doesn't get passed on (to the next shift). LN 4 stated it was important Licensed Nurses assessed and documented in the nurse's progress notes every time Resident 56 went to his dental appointment and after Resident 56 comes back from his dental appointment to ensure continuity of care and provide his care needs. LN 4 stated Resident 56 has a low tone voice and it was difficult for staff to understand him at times. LN 4 stated, . In the morning, (Resident 56's) voice would be louder, it varies, but that would be his usual (tone of voice). LN 4 stated, the facility would call the PCP to get an order for [REDACTED]. (Resident 56) should have been evaluated (by SP). LN 4 stated she did not inform the PCP on Resident 56's change of voice. LN 4 stated, For me (Resident 56) has always been that way (difficult to understand speech). On [DATE] at 10:24 a.m., during a telephone interview, FM stated Resident 56 was having dental pain and had tooth extractions. FM stated, I do not know how many teeth (the dentist) pulled. He was complaining about tooth pain for about a year and the dentist was working with him for one year. I do not remember how many teeth (were extracted). The facility should have notes from the dentist. On [DATE] at 12:03 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated [DATE], indicated, . Treatment (Tx) Recommendation . # (number) 27 (tooth) sharp edge . # 27 painful- cuts tongue (with) sharp edge . The DON stated the dental consultation notes should have been given to the Licensed Nurse for a follow up after the dentist evaluated Resident 56. The DON was unable to find a documented nurse's assessment or follow up in Resident 56's clinical record. The DON stated, It would be painful for a resident when they are eating. If you have a cut in the tongue, it makes (the resident) not want to eat. It will hurt more with spices (on the food) . On [DATE] at 12:09 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated [DATE], indicated, . Tx Recommendation . (Extraction) # 21 (tooth) . The DON was unable to find documented nurse's assessment in Resident 56's clinical record, Licensed Nurses followed up after Resident 56 was evaluated by the dentist. The DON stated, Social Service gets (the consultation notes) and files them away. On [DATE] at 12:10 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated [DATE], and indicated, . Referred for Extraction of Teeth . (#) 6, (#) 21 . The DON stated, For taking a tooth out, (facility) would monitor (the resident) for 72 hours, every shift. The