Every finding on record at Avir at Jeffrey Place

Based on observation, interview and record review the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure food safety by not labeling & dating food correctly, wearing hair restraints, and sanitizing equipment during food service. These failures could place residents at risk for foodborne illnesses.Findings include: Observation in the standalone refrigerator on 04/07/2026 at 8:40 AM revealed the following: Cheese in the Ziplock bag had no open date or use-by date on the bag. Lunch meat in a sealed container had the date 4-3 with no use-by date. A clear container with individual butter packages had no date on the container or the packages. Unknown soup in a metal container was exposed to the air and not dated. Observation in the standalone Freezer on 04/07/2026 at 8:50 AM revealed the following: Raw chicken in a Ziplock bag with no open date or use-by date on the bag. Cooked diced chicken with a date of 4-6 with no use-by date. Packaged waffles with no dates on the bag. Breaded okra with no open date or use-by date on the bag. Dinner Rolls with a date of 4-3-2026 and no use-by date. Observation in the walk-in Pantry on 04/07/2026 at 9:00 AM revealed the following: Breadcrumbs with dates of 2-10 and no use-by date. Tortillas with no open date or use-by date on the package. Fruit Loops cereal in a clear container dated 3-12 with no use-by date. Frosted Flakes cereal in a clear container dated 3-12 with no use-by date. Observation in the kitchen on 04/07/2026 at 9:07 AM revealed the following: The ice scoop holder had dirty water in the bottom of the container, along with a black piece of plastic. Observation of the taking of food temperatures on 04/07/2026 at 9:07 AM revealed the following:CK A had a hairnet covering only the bun on top and the hair that was uncovered was below the cheek. While CK A was taking the temperature of food on the warming table, she wiped the thermometer off with a paper towel, then took the temperature of another food item. CK A did not take the temperature of the beans on the warming table. CK A did not take the temperature of the chicken tenders that were in the basket over the fryer. An interview on 4/09/2026 at 10:04 AM, the DA stated everyone was responsible for labeling and dating food items in the kitchen. The DA stated she was responsible for maintaining the refrigerators and ensuring everything was dated. The DA stated that she was off for two days and did not realize some food items were not labeled and dated. The DA stated all food items in the kitchen should have an open date and a use-by date. The DA stated all food should be covered or wrapped in plastic. The DA stated that she did not put the food item in the refrigerator that was left uncovered. All food items should be labeled and dated. The DA stated hair restraints should always cover the hair. The DA stated residents could get sick if they were served food that was out of date or if hair fell into the food. The DA stated they didn't have in-service training on labeling, hair nets, and sanitation. An interview on 4/09/2026 at 10:13 AM, CK A stated it was everyone's responsibility to label and date food items in the kitchen. CK A stated food items in the refrigerator should be checked daily, and all out-of-date products should be discarded. CK A stated all food items should be labeled and dated. The CK A stated all food items in the kitchen should be covered and not be exposed to air. CK A stated hairnets should cover all hair. The CK A stated that she was not provided with a hair net to cover all her hair. CK A stated when taking food temperatures before service, the thermometer should be sanitized between each food item. The CK A stated that she was in a hurry and got nervous was the reason she did not sanitize the thermometer. The CK A stated residents could get sick if they're served food that was out of date, if hair fell into the food, or if the food's temperature was taken with a dirty thermometer. An interview on 4/09/2026 at 10:41 AM, the DM stated it was everybody's responsibility to label and date food items in the kitchen. The DM stated dates in the refrigerators should be checked daily, and foods in the freezer and pantry should be checked at least once a week. DM stated that she is responsible for checking once a week. The DM stated hairnets should always be worn in the kitchen when hair was exposed. The DM stated all food items in the kitchen should be labeled with the contents of the bag, the date it was opened, and the use-by date. The DM stated that the food content was not on the label because she missed it. The DM stated when taking food temperatures, the thermometer should be sanitized between each food item. The DM stated failing to follow these procedures could result in a resident becoming ill. An interview on 4/9/2026 at 2:00 PM, CK B stated when taking temperatures of food items on the warming table, the thermometer should be sanitized before the temperature was taken for each food. She stated she was nervous and that's why she was using a paper towel to wipe off the thermometer. CK B stated when wearing a hair net, it should cover all her hair. CK B stated she did not have a hair net to cover all her hair, only the top part. CK B stated she would have to ask for a hairnet that could cover all her hair. CK B stated it was everybody's responsibility for labeling and dating food items in the kitchen. CK B stated there were times she forgot to put the use by date on some of the Ziploc bags in the refrigerator. Record review of the facility's Food Preparation and Service Policy, updated on 11-2022, reflected Policy Interpretation and Implementation When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.All food service equipment and utensils will be sanitized.Expiration dates on unopened food are observed and use by dates are indicated once food is opened.Reviewed the federal food code that the facility had on file.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of six residents (Resident #4 and Resident #46) reviewed for medication errors.The facility failed to administer scheduled time-sensitive medication to Resident #4 on 04/09/26. The facility failed to administer scheduled medications to Resident #46 on 04/07/2026.This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings include: 1, Record review of Resident #4's face sheet, dated 04/09/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had a diagnosis which included partial traumatic amputation of left midfoot, sequela. Record review of Resident #4's care plan, dated 02/13/26, reflected Focus: Resident #4 had pain r/t partial amputation with infected vascular wound on Lt. foot. Goal: Resident #4 will not have an interruption in normal activities due to pain through the review date. Interventions/Tasks: Monitor to pain q shift and administer medication as ordered. Monitor/document for probably cause of each pain episode. Remove/limit causes where possible. Notify physician if interventions are unsuccessful or if current complaint is a significant change from Resident #4's experience of pain. Record review of Resident #4's MDS, dated [DATE], reflected Resident #4 had a BIMS score of 15, which indicated cognitively intact. Record review of Resident #4's MAR, dated 04/2026, reflected oxycodone HCI oral tablet 15 mg given once every 8 hours for pain-severe related to unspecified open wound, left food, sequela at 08:00 AM and 04:00 PM. The MAR did not include reason for late administration. Observation of medication administration on 04/09/26 at 09:20 AM revealed Resident #4 was administered 08:00 AM scheduled medication (Oxycodone) by MA B. In an interview with Resident #4 on 04/09/26 at 09:20 AM, he stated his pain medication was scheduled for 08:00 AM and at 09:20 AM, he still had not received his medication. In a subsequent interview with Resident #4 on 04/09/26 at 11:12 AM, he stated he was not in pain and added he received a PRN pain medication the night before. Resident #4 stated he normally received scheduled meds on time every day, and added this occurrence was unusual. 2. Record review of Resident #46's face sheet, dated 04/07/26, reflected a [AGE] year-old female who was admitted to the facility 06/03/2020. Resident #46 had diagnoses which included fibromyalgia (chronic disorder of unknown etiology characterized by pain, stiffness, and tenderness in the muscles of neck, shoulders, back, hips, arms, and legs), bipolar disorder, current episode manic severe with psychotic features (a period of abnormally elevated, extreme changes in your mood or emotions, energy level or activity level), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), acute respiratory failure with hypoxia (a sudden inability of the lungs to provide sufficient oxygen to the blood, defined by a PaO below 60 mmHg without elevated carbon dioxide), edema, unspecified (swelling caused by excess fluid in the body's tissues when the exact cause is not identified). Record review of Resident #46's care plan, dated 02/19/26, reflected Focus: Resident #46 complained of chronic pain R/T fibromyalgia. Goal: Resident #46 would not have an interruption in normal activities due to pain through the review date. Interventions/Tasks: Administer medications as ordered and report adverse side effects. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Notify physician if interventions were unsuccessful or if current complaint was a significant change from Resident #46's experience of pain. Position for comfort with physical support as necessary. Record review of Resident #46's MDS, dated [DATE], reflected Resident #46 had a BIMS score of 15, which indicated cognitively intact.Record review of Resident #46's MAR, dated 12/02/2025, reflected lidocaine external patch 4% apply to affected area topically one time a day related to pain; acetaminophen-codeine oral tablet 300-3-MG give 1 tablet by mouth 2 times a day related to pain. The MAR did not include a reason for late administration. Observation on 4/7/2026 at 11:40 AM, MA A revealed Resident #46 was administered AM medication that should have been given between 06:00 AM to 10:00 AM, which are scheduled medications (lidocaine and acetaminophen-codeine) at 11:40 AM. In an interview with Resident #46 on 04/07/26 at 11:20 AM, she stated her pain medication, and her lidocaine patch should have been put on her since early that morning (she didn't give the time), and she still had not received her medication. Resident #46 stated the med tech was late with the medication. Resident #46 stated her pain level was at about seven. She stated MA A was her friend and she normally received her medications from her. In an interview with MA A on 04/07/2026 at 11:36 AM, MA A stated she was late today passing medication. MA A stated Resident #46 was supposed to have her lidocaine patch placed between 6 AM -10 AM. MA A stated Resident #46 took Tylenol 3 that should have been given between 6 AM -10 AM for pain. Resident #46 was given medication and patch at 11:36 AM. In an interview with MA B on 04/09/26 at 10:16 AM, she stated she had been with the facility 4 days. She stated she was licensed since 2011. She stated she knew med passes were an hour before or after the scheduled time. She stated she had not yet learned the resident faces and tried to catch them in their rooms. She stated she was also reading orders to ensure all information matched up because she was real thorough. She stated Resident #4 received amlodipine 10 mg for BP, aspirin 81mg chewable for heart, oxycodone 15 mg for pain, carvedilol 6.25 mg 2 tablets for BP, sennas for constipation, probiotic. She stated his pain med was scheduled for 8 AM while all others were on a block time. She stated risk to resident health because of receiving meds late was him being in pain. She stated the facility policy was to give medications an hour before or after the scheduled time. She stated she was trained by the DON on medication administration. In an interview with the DON on 04/09/26 at 10:27 AM, she stated scheduled medications were to be administered an hour before or after, unless there were special instructions. She stated Resident #4 did not have special instructions for his medications. The DON stated the reason medications were late was because this was MA B's first day by herself. She stated she let the med aide know if she was running late, she needed to inform management. She stated the med aide told her Resident #4 was outside smoking at his scheduled time. She stated Resident #4 sent the med aide away. She stated the risk was poor pain management and poor outcomes for untimely medications. She stated late med administration did not occur regularly. The DON stated she was responsible for training and added she started an in-service on controlled substances and med administration. The DON stated the med aid needed to get the nurse if they had any questions. She stated if the resident had high blood pressure medication and the medication was late, it could run their pressure to high; if it was a diabetic medication, it could elevate their blood sugar unnecessarily. If the resident's medication was late, it could potentially result in a bad outcome. The DON stated Resident #46 was supposed to have the patch put on an hour before or an hour after. That was all meds unless it was a special medication with special instructions attached to the order. Record review of Medication Administration Schedule policy, dated 2001, reflected Policy Statement Medications are administered according to established schedules. Policy Interpretation and Implementation 3. Scheduled medications are administered within one (1) hour of their prescribed time, unless otherwise specified. 4. Scheduled medications designated as time-critical (medications that may cause harm or sub-therapeutic effect if administered before or after the scheduled time) are administered at the scheduled time (for example, rapid-acting insulin) or withing 30 minutes of the scheduled time. 5. Time critical medications are designated by the pharmacy and include: b. scheduled opioids used for chronic pain or palliative care. 7. The exact time of medication administration is documentation in the MAR. If medication is administered early, late (beyond the allowable interval), or is omitted, the reason is also documented. 8. A physician's order for specific times supersedes any routine schedule. Record review of the, undated, Medication Administration Times list reflected:*Hall 200 and 500 - Med Room Located 200 hall (first door on right) 1 Medication Cart and 1 Treatment cart *AC pass begin at 7AM *HS pass begins at 7PM *TID Administration - 6AM, 11AM, 7PM *QID Administration - 7AM, 11AM, 3PM, 7PM Record review of facility in-services reflected: *04/08/26: Competency: Medication Administration*04/09/26: Medication Administration Schedule & Charting and Documentation

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the need of each resident. The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change on one of two medication carts reviewed for shift change reconciliation documentation This failure could place residents at risk of drug diversions and could result in diminished health and well-being.Findings include: Record review of the Change of Shift Narcotic Count Sheets for the 300 Hall revealed missing documentation for the following: 04/01/2026 6am-2pm Start and End Counts04/03/2026 10pm-6am Oncoming Nurse Signature04/03/2026 6am-2pm Off going Nurse Signature04/04/2026 2pm-10-pm Oncoming Nurse Signature04/05/2026 6am-2pm Start and End Counts04/05/2026 10pm-6am Start and End Counts04/06/2026 6am-2pm Start Counts and Oncoming Nurse Signature04/06/2026 2pm-10pm Off going Nurse Signature04/06/2026 10pm-6am End Count and Off going and Oncoming Nurse Signature04/07/2026 6am-2pm Off going Nurse Signature04/07/2026 10pm-6am Start and End Counts and Oncoming Nurse Signature During an interview with MA C, on 04/09/2026 at 9:35AM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. She stated sometimes they didn't sign off if it's the same person working the next shift. She stated they received training on the process for change of shift narcotic count and documentation at new hire and then every year. There were also in-services at different times, the last one being about 2 weeks ago. During an interview on 04/09/2026 at 9:48AM with the DON, she stated it was her expectation that the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. The DON stated a negative outcome of not consistently following the narcotic count expectations was a possibility of drug diversion. The DON stated the staff were trained at New Hire and annually thereafter. She stated there were also in-services throughout the year on this topic, the last one being two weeks ago. During an interview with MA D on 04/09/2026 at 10:00AM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. She stated she was trained on this process at new hire. Record review of the Controlled Substances Policy, dated November of 2022, reflected, Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 4 (Resident #1, #2, #3, and #4) of 15 residents reviewed for accurate medical records.The facility failed to ensure the accuracy of Resident # 1, #2, #3 and # 4's, pain PRN narcotic drug record versus residents' eMARs for June and July 2025. The documentation between the two records did not match.This deficient practice could result in errors in care and treatment.Findings included:Review of Resident #1's face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included myocardial infarction (a condition where blood flow to a part of the heart muscle is blocked, causing damage or death to that tissue), chronic obstructive pulmonary (a progressive lung disease characterized by airflow obstruction and breathing difficulties), anxiety disorder (a group of related conditions characterized by excessive and persistent fear or worry in situations that are not threatening), and schizoaffective disorder, depressive type (a mental illness characterized by a combination of symptoms from both schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and behaves)).Review of Resident #1's quarterly MDS assessment, dated 07/07/25, reflected a BIMS score of 05, indicating severe cognitive impairment. Section J - Health Conditions - Resident #1 received PRN pain medications or was offered or declined.Review of Resident #1's admission care plan reflected a problem start date of 02/18/17 category - Pain, Resident #1 was at risk for pain due to history of fracture and generalized osteoarthritis (a condition that causes the breakdown of cartilage in joints, leading to pain, stiffness, and swelling). Approach dated 07/26/21 administer medications as ordered and notify medical doctor if not effective. Review of Resident #1's medication orders reflected tramadol - Schedule IV (substances that have potential for abuse and dependence) tablet; 50 mg; amount to administer: 1 tab; oral, frequency Every 6 Hours - PRN, diagnosis - pain, start dated 10/13/2024 - open endedReview of Resident #1's handwritten Narcotic Drug Record (provided for documentation, including route, date, time, and dose, of a narcotic administered to an individual patient/resident) for tramadol 50 mg tablet 1 tablet by mouth every 6 hours as needed revealed the tramadol 50 mg tablet reflected:06/01/25 handwritten time illegible 1 tab.06/05/25 handwritten time illegible 1 tab.06/09/25 handwritten time illegible 1 tab.06/11/25 time 4:00 pm 1 tab.06/16/25 handwritten time illegible 1 tab.06/19/25 handwritten time illegible 1 tab.06/20/25 time 2:30 pm 1 tab.06/21/25 time 6:30 pm 1 tab.06/23/25 time 3:00 pm 1 tab. 06/26/25 handwritten time illegible 1 tab.06/28/25 time 7:00 pm 1 tab.07/03/25 time 2:00 pm 1 tab.07/08/25 time 7:15 pm 1 tab.07/11/25 time 2:45 pm 1 tab.07/14/25 handwritten time illegible 1 tab.07/18/25 handwritten time illegible 1 tab.07/19/25 time 7:30 pm 1 tab.07/20/25 handwritten time illegible 1 tab.07/22/25 handwritten time illegible 1 tab.07/22/25 handwritten time illegible 1 tab.07/22/25 handwritten time illegible 1 tab.07/23/25 handwritten time illegible 1 tab.Record review of Resident #1's June 2025 MAR reflected no entries of tramadol - Schedule IV (substances that have a low potential for abuse and addiction compared to Schedule III drugs, but still have the potential for abuse and dependence) tablet; 50 mg; Amount to Administer: 1 tab; oral, frequency Every 6 Hours - PRN, diagnosis - pain, start dated 10/13/2024 - Open Ended administered to Resident #1.Record review of Resident #1's July 2025 MAR reflected tramadol - Schedule IV (substances that have a low potential for abuse and addiction compared to Schedule III drugs, but still have the potential for abuse and dependence) tablet; 50 mg; Amount to Administer: 1 tab; oral, frequency Every 6 Hours - PRN, diagnosis - pain, start dated 10/13/2024 - open ended administered to Resident #1 was administered on:07/28/25 time 9:29 pm for PRN reason pain; pain before administered level 4 (moderated) PRN result effective Review of Resident #2's face sheet, undated, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (usually caused by a stroke, is a condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on one side of the body), chronic obstructed pulmonary disease (a progressive lung disease that makes it difficult to breathe) and bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression).Review of Resident #2's quarterly MDS assessment, dated 06/06/25, reflected a BIMS score of 06, indicating severe cognitive impairment. Section J - Health Conditions - Resident #2 received PRN pain medications or was offered or declined.Review of Resident #2's care plan reflected problem start date 02/26/2019 and edited 07/17/25 reflected Resident #2 has complaints of chronic pain related to hemiplegia, pain site back pain, generalized pain approach date edited 07/17/25 administer PRN mediations Tylenol (Acetaminophen) and/or Tylenol #3 (Acetaminophen) PRN return to assess effectiveness.Review of Resident #2's medication orders reflected acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - open endedReview of Resident #2's handwritten Narcotic Drug Record for Acetaminophen/codeine 300/30 (brand: Tylenol #3) mg tablet give 1 tablet by mouth every 4 hours as needed revealed the tramadol 30 mg tablet reflected:06/11/25 time 9:00 am 1 tab.06/11/25 time 3:00 pm 1 tab.06/13/25 time 9:00 am 1 tab.06/17/25 time 8:40 pm 1 tab.06/20/25 time 7:00 pm 1 tab.06/21/25 time 8:00 am 1 tab.06/21/25 time 7:00 pm 1 tab.06/22/25 time 8:00 am 1 tab.06/22/25 time 7:00 pm 1 tab.06/23/25 time 8:00 am 1 tab.06/23/25 time 7:00 pm 1 tab.06/24/25 time 8:00 am 1 tab.06/24/25 time 8:00 pm 1 tab.06/25/25 time 8:00 am 1 tab.06/25/25 time 8:00 pm 1 tab.06/26/25 time 8:00 am 1 tab.06/26/25 time 7:00 pm 1 tab.06/27/25 time 8:00 am 1 tab.06/27/25 time 7:00 pm 1 tab.06/28/25 time 8:00 am 1 tab.06/28/25 time 7:00 pm 1 tab.06/29/25 time 8:00 am 1 tab.06/29/25 time 7:00 pm 1 tab.06/30/25 time 8:00 am 1 tab.06/30/25 time 8:00 pm 1 tab.07/01/25 time 8:00 am 1 tab.07/01/25 time 8:00 pm 1 tab.07/02/25 time 8:00 am 1 tab.07/02/25 time 8:00 pm 1 tab.07/03/25 time 8:00 am 1 tab.07/03/25 time 8:00 pm 1 tab.07/04/25 time 8:00 pm 1 tab.07/05/25 time 8:00 am 1 tab.07/06/25 time 3:00 am 1 tab.07/06/25 time 8:00 am 1 tab.07/06/25 time 7:00 pm 1 tab.07/07/25 time 8:00 am 1 tab.07/07/25 time 8:00 pm 1 tab.07/07/25 time 2:00 am 1 tab.07/08/25 time 8:00 pm 1 tab.07/09/25 time 7:00 am 1 tab.07/09/25 time 8:00 pm 1 tab.07/10/22 time 8:00 am 1 tab.07/10/22 time 7:00 pm 1 tab.07/10/22 time 11:30 pm 1 tab.07/11/22 time 8:00 am 1 tab.07/11/22 time 7:00 pm 1 tab.07/12/22 time 8:00 am 1 tab.07/12/22 time 7:00 pm 1 tab.07/13/22 time 8:00 am 1 tab.07/13/22 time 7:00 pm 1 tab.07/14/22 time 7:00 am 1 tab.07/14/22 time 7:00 pm 1 tab.07/15/22 time 7:00 am 1 tab.07/15/22 time 8:00 pm 1 tab.07/16/22 time 0800 [8:00 am] 1 tab.07/16/22 time 8p 1 tab.07/16/22 time 0800 [8:00 am] 1 tab.07/17/25 time 8:00 am 1 tab.07/17/25 time 8:00 pm 1 tab.07/18/25 time 8:00 am 1 tab.07/18/25 time 8:00 pm 1 tab.07/19/25 time 8:00 am 1 tab.07/19/25 time 8:00 pm 1 tab.07/20/25 time 8:00 am 1 tab.07/20/25 time 8:00 pm 1 tab.07/21/25 time 8:00 am 1 tab.07/21/25 time 7:00 pm 1 tab.07/22/25 time 8:00 am 1 tab.07/22/25 time 7:00 pm 1 tab.07/23/25 time 8:00 am 1 tab.07/23/25 time 6:40 pm 1 tab.Record review of Resident #2's June 2025 MAR reflected, acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - Open Ended was administered on:06/08/25 time 7:16 am, for pain, pain level before administered level 5 (moderate) PRN result follow up effective06/09/25 time 8:38 pm, for pain, pain level before administered level 6 (moderate) PRN result follow up effective06/12/25 time 9:32 pm, for pain, pain level before administered level 6 (moderate) PRN result follow up effective06/19/25 8:03 am, for pain, pain level before administered level 4 (moderate) PRN result follow up effective06/19/25 5:03 pm for pain, pain level before administered level 5 (moderate) PRN result follow up effectiveRecord review of Resident #2's July 2025 MAR reflected, acetaminophen-codeine - Schedule III (substances with a moderate potential for abuse and dependence) tablet; 300-30 mg; Amount to Administer 1 tablet oral, Every 4 Hours - PRN, 06/03/2025 - Open Ended was administered on:07/10/25 11:23 pm for pain, pain level 3 (noticeable and distracting) PRN result follow up effective.Review of Resident #'3s face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sequelae of cerebral infarction (also known as stroke (occurs when blood flow to the brain is disrupted, either by a blockage or a bleed) refers to the long-term consequences or complications that arise after a stroke), moderate intellectual disabilities (individuals with an intelligence quotient between 35 and 39), and schizophrenia, unspecified (a diagnostic term used when a person experiences symptoms of schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels, and behaves) or other psychotic disorders, but their symptoms don't fully meet the criteria for a more specific diagnosis within the schizophrenia spectrum. Review of Resident #3's quarterly MDS assessment, dated 06/06/25, reflected a BIMS score of 11, indicating moderate cognitive impairment. Section J - Health Conditions - reflected Resident #3 did not received PRN pain medications or was offered or declined.Review of Resident #3's admission care plan reflected no care plan for pain involving the administration of tramadol. Resident #3's care plan reflected problem start date - 09/13/2023 Pain- Ibuprofen, Muscle Rub, edited: 06/12/2025 approach start date: - 09/13/2023 administer pain medications as ordered.Review of Resident #3's medication orders reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 06/26/2025 - Open EndedReview of Resident #3's handwritten Narcotic Drug Record for tramadol 50 mg tablet 1 tablet by mouth every 6 hours as needed revealed the tramadol 50 mg tablet reflected:06/29/25 time 11:00 1 tab06/30/25 time 10:00 1 tab.06/30/25 time 7:42 1 tab.07/10/25 time 7:45 1 tab.07/12/25 time 8:00 am 1 tab.07/12/25 time illegible 1 tab.07/21/25 time 11:00 am 1 tab.07/21/25 time 7:15 pm 1 tab.Record review of Resident #3's June 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 06/26/2025 - Open Ended was administered on: 06/26/25 time 6:49 pm, for pain, PRN result follow up effective06/30/25 time 8:14 am, for pain, PRN result follow up effectiveRecord review of Resident #3's July 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 06/26/2025 - Open Ended was administered on: 07/01/25 time 5:46 am, for pain, PRN result follow up effective07/02/25 time 4:35 pm, for pain PRN result follow up effective07/04/25 time 9:47 am, for pain, PRN result follow up effective07/05/25 time 5:50 am, for pain PRN result follow up effective07/05/25 time 9:18 pm for pain PRN results follow up effective07/07/25 time 9:51 pm for pain PRN results follow up effective 07/12/25 time 6:20 pm for pain PRN results follow up effective 07/13/25 time 12:49 am for pain PRN results follow up effective07/13/25 time 9:27 am for pain PRN results follow up effective07/14/25 time 2:20 am for pain PRN results follow up effective07/15/25 time 1:14 pm for pain PRN results follow up effective07/16/25 time 9:20 pm for pain PRN results follow up effective07/17/25 time 7:38 am for pain PRN results follow up effective07/17/25 time 6:37 pm for pain PRN results follow up effective07/18/25 time 4:20 am for pain PRN results follow up effective07/18/25 time 9:21 pm for pain PRN results follow up effective07/19/25 time 4:27 pm for pain PRN results follow up effective07/20/25 time 11:16 pm for pain PRN results follow up effective07/23/25 time 9:24 am for pain PRN results follow up effective07/23/25 time 7:36 pm for pain PRN results follow up effective07/24/25 time 7:33 am for pain PRN results follow up effectiveReview of Resident #4's face sheet, undated, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of right femur (the thigh bone, the longest and strongest bone in the human body) unspecified abnormalities of gait and mobility and other lack of coordination, cognitive communication deficit (difficulties in communication that arise from impairments in cognitive processes like attention, memory, and executive functions, rather than issues with speech or language production themselves).Review of Resident #4's resident assessment and care screening MDS assessment, dated 07/24/25, reflected a BIMS score of 10, indicating moderate cognitive impairment. Section J - Health Conditions - Resident #4 received PRN pain medications or was offered or declined.Review of Resident #4's admission care plan reflected problem start date 07/18/2025 pain related to right femur fracture - Tramadol approach start date - 07/18/2025 administer pain medications as orderedReview of Resident #4's medication orders reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed for pain, indications: acute pain start date 07/18/2025 - Open Ended Review of Resident #4's handwritten Narcotic Drug Record for tramadol 50 mg tablet give 1 tablet by mouth every 6 hours as needed reflected:07/22/25 time 1:00 pm 1 tab.07/24/25 time 7:10 pm 1 tab.Record review of Resident #4's July 2025 MAR reflected tramadol Schedule IV (have a low potential for abuse relative to other controlled substances) tablet; 50 mg; amount to administer: 1 tablet; oral Every 6 Hours - PRN, take 1 tablet by mouth every 6 hours as needed start date 07/18/2025 - Open Ended was administered on: 07/19/25 time 5:30 am PRN reason pain, pain level before 3 (notable pain that can be distracting) PRN result effective07/19/25 time 11:24 pm PRN reason pain, pain level before 4 (moderate) PRN result effective.Interview on 07/29/25 at 12:40 pm with Resident #1 who stated she was not getting her pain medications.Interview on 07/29/25 at 2:33 pm with Resident #1's hospice RN reflected when she visited Resident #1, Resident #1's pain was controlled and her review of Resident #1's hospice facility visits records reflected that Resident #1's pain had been controlled. Interview on 07/29/25 at 3:40 pm with Resident #2 who stated the staff at the facility treated him respectfully and he felt safe at the facility. She said he received all of his pain medication, and he did not have any concerns. Interview on 07/29/25 at 3:45 pm with Resident #3 who stated the staff treated her respectfully and she got all of her pain medications. Interview on 07/29/25 at 6:14 pm with Resident #4 who stated the staff treated her respectfully and she received all of her PRN pain medications. She stated the staff was responsive when she asked for the medication and she received it, she did not have any concerns. Interview on 07/28/25 at 5:04 pm with LVN A via phone stated she had administered PRN controlled substance medications to residents. She said the facility procedure was to sign on the individual resident Narcotic Drug Record that the medication was given then to record in the eMAR that the resident was administered the medication. She said the negative effect of medication that was administered but not documented in the eMAR was there was no documentation that it was given to the resident. She said that could be bad for the resident because you do not know how much medication the resident received. She said if a resident goes to the hospital, there was no record in the eMAR of what the resident had taken. She said everyone was responsible for making sure that medication given to the resident was documented in the eMAR and all staff have a role to plan. She said there was a computer problem that caused an interruption when documenting PRN medication in the eMAR and she let the DON know. She said the PRN eMAR documentation did get better. She said it was important to make sure the resident was not in pain, and they had received their correct medications. Interview on 07/29/25 at 4:36 pm with LVN D who stated he administered PRN controlled substance pain medications to facility residents. He said that when a controlled substance was going to be administered to a resident, the medication was signed out on the individual resident's Narcotic Drug Record, administered to the resident, then documented in the resident's eMAR that they received the medication. He said he was not properly trained in documenting PRN medications in eMAR and until a recent in-service involving documenting PRN controlled substances in the eMAR. He said he did not realize that he was making an error on the computer when documenting that the resident received their medication. He said that if it was not documented in the eMAR that a resident received their pain medication, the resident could go without their pain medication. He said it was a problem because you would not know if the medication the resident received was effective if it was not documented that they received it. He said that at times, the facility internet did not work well and there was an interruption in service that did not enable the documentation of the medication in the eMAR. He said it was the responsibility of the DON to confirm that PRN controlled substance medications given to the residents were documented as given in the eMAR. Interview on 07/28/25 at 4:33 pm with LVN B via phone stated she administered PRN pain medications to residents. She said when you administer PRN controlled substances the procedure was to sign on the individual resident's Narcotic Drug Record documenting that you gave the resident the controlled substance and to document in the eMAR that the medication was administered to the resident. She said the eMAR should match the resident's Narcotic Drug Record for that date and time. She said the negative effect of not documenting in the eMAR that the resident received the medication would be that you would not know if the resident was given the medication, and the resident could be in pain. She said the nurse was supposed to make sure she residents' get their medication. She said the ADON and DON were responsible for make sure that the medications have been correctly administered to the residents. Interview on 07/28/25 at 4:51 pm with LVN C via phone stated she had administered PRN controlled substance to facility residents. She said the facility policy is to sign out the medication on the resident's Narcotic Drug Record and then document in the eMAR that the medication was administered to the resident. She said medication administered to a resident should always be documented in the eMAR. She said the negative effect of not documenting medication administered in the eMAR would be that you don't know if the resident really got the medication, and it does not accurately reflect what medications were given to the resident. She said the resident's Narcotic Drug Record should match eMAR and it was the responsibility of the nurse to follow through and confirm that it was documented. She said there was an interruption in the internet system and at times the staff thought the medication was successfully documented in the eMAR, but it did not show up. She said anytime there was a glitch in the emery system she told the DON. She said it was very important to make sure that the resident was not in pain, and they were given the correct medications. Interview on 07/28/25 at 4:15 pm with the ADON revealed she had administered PRN tramadol to Resident #3. She stated that the facility procedure for administering PRN tramadol to Resident #3 was to write on the resident's Narcotic Drug Record that the medication was administered to Resident #3 and then document the administration of the medication on MAR in the computer. The ADON said all kinds of things could happened if the tramadol was not marked as administered on the MAR. She said you could give the resident too much medication. She said the resident's Narcotic Drug Record and the MAR should match. She said that there was a computer glitch in the facility system and the documentation in residents' MARs that PRN medication was administered did not stick on the MAR. She said it was an on and off problem and she reported it to the DON. She said it was the responsibility of the nurse administering the medication to the resident to make sure that medications reflected on the Narcotic Drug Record and the residents' MAR matched. Interview on 07/28/25 at 2:31 pm with the DON who stated if a resident was administered a pain medication it was signed out on the resident Narcotic Drug Record and, when administered, entered into the eMAR documenting that the medication was administered. She said there was a problem if the PRN pain medication was not marked administered in the eMAR because you would not know how the medication was being used and if it was effective. She said when it is documented it the eMAR, there was a pain assessment if it was not documented, you are not really tracking the residents' pain. She said if medication was not charted, then it was not given. She said the charge nurse was responsible for making sure the eMAR and the resident Narcotic Drug Record matched. Interview on 07/29/25 at 6:17 pm with the Administrator who stated it was important that the resident Narcotic Drug Record matched the eMAR to make sure resident was administered the correct dosage and to monitor residents' pain. A resident might need a pain medication review the MD and if the eMAR does not accurately reflect what was administered to the resident, it would be difficult to review the pain and what pain medication would be beneficial to the resident. It was the responsibility of the charge nurse and the nursing administration to audit the medications recorded in the eMAR. She thought that part of the problem with the eMAR documentation was an internet issue, but that had been repaired. Additionally, she thought that the nurses administering the medication were missing a computer step in the eMAR that did not record that the resident received the information. Interview on 07/29/25 at 4:15 pm with the facility MD who stated he was concerned that the PRN controlled substances were not documented in the eMAR because it was an internal inconsistency and there needed to be better oversight. He said he was not concerned that the residents did not receive the PRN controlled substance pain medication because he said the DON was very good. He was concerned that if the problem was not corrected, people could find an opportunity to take advantage of the situation and corporate needed to know because they might need a better program. Review of facility policy Medication Administration - General Guidelines dated 06/01/2022 reflected the medication administration record (MAR) is always employed during medication administration.Documentation (including electronic). The individual who administers the medication dose records the administration on the residents' s MAR/eMAR directly after the medication is given. To ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications.The resident's MAR/eMAR is initialed by the person administering the medication in the space provided under the date and on the line for that specific medication dose administration.When PRN medications are administered, the following documentation is provided:a. date and time of administration, dose, route of administration (if other than oral).b. Complaints or symptoms for which the medication was given.c. Results achieved from giving the dose and the time results were noted.d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.

Based on observation, interview, and record review, the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident #2).On 5/30/2025 at approx. 12:00 p.m., CNA D had been providing incontinent care to Resident #2. While care was being provided, the resident rolled off the bed onto the floor, hitting his face on the nightstand. Resident #2 sustained swelling and redness to the right side of his face, redness to his right knee, and required admission to the hospital on 5/30/25, for further treatment. A review of the care plan dated 5/20/20 reflected that Resident #2 required one-person assistance for bed mobility and transfers. And two-person assistance for ADL care.The noncompliance was identified as PNC. The IJ began on 05/30/25 and ended on 05/31/25 due to the in-services and CNA D had been suspended. The facility had corrected the noncompliance before the survey began. This failure resulted in resident #2 sustaining a femur fracture and hematoma.Findings included:A record review of Resident #2's face sheet reflected that he was a [AGE] year-old male admitted to the facility on [DATE]. He had been admitted with diagnoses including acute neurologic cerebral infarction, sepsis of an unspecified organ, dysphagia, cerebrovascular disease, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, generalized muscle weakness, lack of coordination, and enterocolitis due to Clostridium difficile.A review of the MDS quarterly assessment dated [DATE] reflected a BIMS score of 6, indicating severe cognitive impairment. Section GG, which reflects functional abilities, indicated that Resident #2 required dependent, two-person assistance for showers, toileting, hygiene, and bed transfers. The MDS reflected prior to the incident resident #2 did not require a 2 person assist. A care plan dated 5/20/2025 reflected that Resident #2 required one-person assistance for bed mobility and transfers and two-person assistance for ADLs. Resident #2's care plan was updated after the incident to reflect the changes made to D/C the mattress.A record review of medical records dated 5/30/2025 reflected that Resident #2 had been admitted to the hospital with complaints of pain to his right knee and right cheek. The report stated that Resident #2 sustained an acute fracture of the right femur and a hematoma to the head without facial fracture.The record of doctors' orders reflected the doctor had put in an order for a low air mattress on 4/16/2025 for the resident and the resident denied wanting his mattress to be changed out. The doctor finally talked the resident into using the new mattress because it will help his wound heal and relieve the pressure. The day of the fall, the DON contacted the doctor and advised him of the fall and that the resident requested the mattress be taken off his bed and his old mattress be put back on and the doctor agreed to and D/C the low air mattress.An interview conducted on 6/24/2025 with Resident #2 revealed that he was not able to recall the incident.An interview on 6/24/2025 at 12:30 p.m. with CNA D who stated that on 5/30/2025 she had been providing incontinent care to Resident #2. She stated that while providing care, Resident #2 rolled off the bed, hitting his face and knee on the floor. CNA D reported that she immediately called for help, the nurse assessed Resident #2, and he was sent to the hospital. CNA D stated she had been employed at the facility since October 2024 and was not aware that Resident #2 was a two-person assist. She explained that she had always provided care to him alone. CNA D said she was suspended for one day after her shift ended at 2:00 p.m. She also stated that the Director of Nursing (DON) later informed her that Resident #2 was a two-person assist.An interview with the DON on 6/24/25 at 2:57pm revealed that she had not known whether CNA D was aware of the two-person assist requirement because the care plan and MDS conflicted-one stated one-person assist, while the other stated two-person assist. The DON explained that CNAs were responsible for reviewing a resident's care plan before providing care. She stated she had not been aware when the incident occurred. After the incident, the DON said she completed a return demonstration with CNA D for peri care and bed mobility when CNA D returned to work. The DON was uncertain whether CNA D had completed her shift before being suspended. She also reported that Resident #2 told her he had fallen out of bed.Interview with the Administrator dated 6/25/25 at 09:38am, who stated that she became aware of the fall around shift change at on 5/20/25 around 2:00 p.m. Resident #2 had been assessed by a nurse and immediately transferred to the hospital. The Administrator stated that CNA D was suspended pending investigation and returned to work on 6/1/2025 after being suspended on 5/31/2025. She explained it was her expectation that charge nurses ensure CNAs are aware of residents' care needs.A review of the facility's Fall Prevention Program policy, revised in November 2024, indicated that Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility completed a Plan of Removal.Interviews with two CNAs on 6/24/25 at 1:13pm, revealed that they had been in-serviced on Abuse/Neglect and assistance with mobility. CNA A and CNA B both stated they were aware of where to locate a resident's care needs in the care plan, and they stated they would notify the nurse if there was conflicting information.An interview with the Charge nurse A on 6/24/25 at 1:04pm revealed she had been trained on Abuse/Neglect and mobility assistance. She stated that when conflicting information was present, the DON would be contacted for clarification.A record review of in-services titled Assisting Dependent Residents, Abuse and Neglect, dated 5/31/2025 and conducted by the DON showed all employees had signed the documentation.A record review of a Perineal Care/Incontinent Care Competency dated 5/31/25 reflected that the DON had observed CNA D. All observation points were marked as satisfactory.Observations of CNA E and CNA F conducted at the facility on 6/24/2025 of two-person transfers using a mechanical lift revealed no concerns-staff appeared trained in mechanical lift usage. Observations of two-person in-bed peri-care also showed no concerns, and staff followed appropriate steps to ensure care and resident safety. In an interview on 7/11/2025 with the MDS Coordinator at 2:35pm revealed, that once the IJ (immediate jeopardy) was called all MDS's and care plans were reviewed and updated to reflect correct and accurate information for each resident. A record review was completed of 7 residents' (Residents #3, #4, #6, #7, #8, #9, #10) MDS's and Care plans to ensure they were correct and identified the resident's level of care required they had all been updated and were correct for each resident's chart reviewed. An observation was completed on 7/11/2025 of CNA D and another staff at 2:05pm completing a transfer using the mechanical lift with a resident no concern was noted during this observation. In an interview with CNA D on 7/11/2025 at 1:31pm revealed she was not trained but she was given an in-service, but she was not trained. She stated she watched another staff member perform the use of the mechanical lift. She stated she worked at another facility and in total she has been using the mechanical lift for 2 years. She stated she has the DON personally showed her how to locate the residents plan of care (POC). She stated the resident was a 1 person assist and after the fall he became a 2 person assist. She stated the resident could roll on his own from side to side. She stated she was not aware of them changing his mattress. She stated she position herself as she always does and when he tuned, he slid straight off the bed. CNA D stated she was trained by the DON where to find the POC (plan of care) and if she needed more training she would provide it to her. In an interview on 7/11/2025 with the Administrator at 12:20pm revealed, to ensure that the information reflected in a resident's plan of care was accurate they were going to meet with the IDT tea. The Administrator stated they would discuss the change in condition per resident and once the changes have been placed in the computer, they would notify the nurses, so everyone could be aware of what changes had been made to a resident's plan of care.The noncompliance was identified as PNC. The IJ began on 05/30/25 and ended on 05/31/25 due to the in-services and CNA D had been suspended. The facility had corrected the noncompliance before the survey began.

Based on the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1(resident # 1) of 6 reviewed for significant medication errors.The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: Insulin glargine prescribed for diabetes, Lactulose prescribed for weakness, Allopurinol prescribed for hypertension, Clotrimazole prescribed for a disorder of the skin, Docusate sodium prescribed for obesity, fish oil prescribed for hyperlipidemia, Gabapentin prescribed for type 2 diabetes mellitus with foot ulcer, Rosuvastatin prescribed for hyperlipidemia, Tamsulosin prescribed for diabetes mellitus, and Valsartan prescribed for hypertension according to the physicians' orders on June 5, 2025 and June 6, 2025. Medication Technician #1 failed to ensure that resident #1 was free of a medication error.This deficit practice could place residents at risk of serious harm, up to and including death.Findings included:Based on the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1(resident # 1) of 6 reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: Insulin glargine prescribed for diabetes, Lactulose prescribed for weakness, Allopurinol prescribed for hypertension, Clotrimazole prescribed for a disorder of the skin, Docusate sodium prescribed for obesity, fish oil prescribed for hyperlipidemia, Gabapentin prescribed for type 2 diabetes mellitus with foot ulcer, Rosuvastatin prescribed for hyperlipidemia, Tamsulosin prescribed for diabetes mellitus, and Valsartan prescribed for hypertension according to the physicians' orders on June 5, 2025 and June 6, 2025. Medication Technician #1 failed to ensure that resident #1 was free of a medication error. This deficit practice could place residents at risk of serious harm, up to and including death.Findings included:A record review of Resident #1's face sheet dated on 6/24/25 reflected that a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had a medical history of acute osteomyelitis (a rapidly developing inflammation and infection of the bone, often caused by bacteria, that can lead to bone damage if not treated promptly), Diabetes mellitus due to underlying condition with other diabetic kidney complication (kidney disease (diabetic nephropathy) that develops as a consequence of diabetes caused by another underlying condition, and is characterized by specific kidney issues), Acute pain due to trauma (a sudden, intense pain that arises from an injury or physical damage, like a fall, car accident, or bone fracture), Essential hypertension (a condition characterized by persistently elevated blood pressure where no specific underlying medical cause can be identified), non-pressure chronic ulcer of part of right foot with necrosis of bone (a persistent open sore on the foot, specifically on the right foot, that is not caused by pressure, and involves the death of bone tissue (necrosis)), Disorder of the skin and subcutaneous tissue, unspecified (a skin or subcutaneous tissue disorder where the specific nature of the condition), Type 2 diabetes mellitus with foot ulcer (a situation where a person with type 2 diabetes develops a wound on their foot that doesn't heal properly), Hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), unspecified Sepsis in right foot, unspecified organism (Unspecified sepsis in the right foot with an unspecified organism means that the patient has a serious condition where their body's response to an infection is causing damage to its own tissues and organs, and the source of that infection is located in their right foot), Streptococcus (a type of bacteria that can cause skin, soft tissue and respiratory tract infections), Obesity (a chronic condition characterized by excessive accumulation of body fat that poses a risk to health). On 6/7/25, Resident #1 was discharged voluntarily due to him feeling that the facility had failed him by not providing prescribed medications. A record review for Resident's #1 care plan, was not able to be reviewed. Resident #1 was at the facility for two days; a care plan was not yet in place. A record review of Residents #1 MAR dated 6/7/2025, reflected that Insulin glargine, Lactulose, Allopurinol, Clotrimazole, Docusate sodium, fish oil, Gabapentin, Rosuvastatin, Tamsulosin, and Valsartan, where missed June 5th and June 6th, 2025. Next to the medications, the medication Technician noted that the medications were not in the facility. A record review of Residents #1 progress report dated 6/6/25 10:30pm reflected that resident c/o pain, tramadol had not come in. Hydrocodone 5/325 mg was delivered earlier 06/5/25, by the pharmacy. This medication was prescribed from Doctor #A. According to the progress note entered by Charge nurse A, notified the DON, the DON gave an okay to give Hydrocodone for pain, until the Tramadol could be delivered to the facility. Hydrocodone would be dc' d when Tramadol was delivered. On 6/6/25 at 8:03pm a progress note entered by Charge nurse A stated that Lantus, prescribed for diabetes, was given. A record review of Resident #1 notes dated 6/7/25 3:36pm entered by CNA A, reflected that Resident #1 had been yelling for 911 to be called, it stated that his right leg was hurting, and he didn't want to be at the facility any longer. Charge nurse A, talked to him several times, but he continued to state that he wanted to go to the hospital. The facility Called 911 for non-emergency. When EMS arrived, Resident #1 stated that no one had been in his room since June 6/6/26. Resident #1 was transferred out as requested. A record review of Resident's #1 orders as well as medical discharge summary, on 6/24/25, at 1:34pm, reflected that [NAME] #B prescribed Allopurinol, Aspirin, Docusate Sodium, Lovenox, Gabapentin, Insulin Glargine, Insulin, Lactulose, Rosuvastatin, Tamsulosin, and Valsartan. During an interview via phone on 06/24/25 at 9:35am hospital Social Worker A stated that she was not present when Resident #1 came into the hospital, however she was able to read a report written by Social Worker B, both social workers work at the local hospital. Social Worker B stated that the report from the nursing facility reflected Resident #1 came into the ER with pain in his right foot from sepsis. She stated that Residents #1's foot was amputated a week prior to his admission the facility. Social Worker A stated that the report read that Resident #1 reported that the facility had not given him his Antibiotics, Sepsis medication or his insulin shots. According to Social Worker B, Social Worker #A wrote that she was sent medical records from the nursing facility. The medical records indicated that medications had been missed. According to the report read by Social Worker #B, missing the medications would have no lasting or harmful impact. An interview with the DON on 6/25/25 at 9:15am, who stated that the medications were in the facility. She said that all medical technicians are aware of this fact. DON also stated that there are over the counter medications in the medication room. She said that the Insulin glargine was given however, due to Medication Technician #A not being able to get into the MAR she was unable to see this. DON acknowledged that Resident #1 was supposed to receive his insulin shot twice, however he received it only once on 6/6/25. A second interview with the DON on 6/25/25 at 12:13pm reflected that there was an error with central intake. Central intake is a data base that send/hold residents' information. DON said that when Resident #1 was admitted to the nursing facility, he arrived with the incorrect social security number. DON said that Resident #1 arrived with the social security number of a different Resident from another facility with the same name. She said that once Central intake fixed the issue, Resident #1 received his medication at the end of the day 6/5/25. DON reported again that Resident #1, had still missed medication on 6/5/25 and 6/6/25. During an interview with the Medication Technician A on 6/25/25 at 10:30am, she stated that she takes her own notes of when she gives residents medication. She keeps these notes in a personal notebook that she keeps on her person during medication pass. Medical Technician A said that she does not include names when taking these notes. She said that Resident #1 has been aggressive since he arrived on 6/5/25. She stated that Resident #1 missed his morning medication of 6/5/25 due to entering the facility after medication pass had already been completed. Medication Technician #1 stated Resident #1 refused his medication on 6/6/25. Medication Technician A stated that she notated in the MAR that the medication was not in the building because she was unsure how to document that Resident #1 refused. During an interview with 3 CNA's on 6/25/25 at 11:14am, they stated that no resident has never reported not receiving medication to them. They said they were in-serviced on 6/24/25 about how and what to document if a resident refuses medication. CNA A stated that if she is unsure if a medication was given, she would ask a charge nurse. CNA B and CNA C said that they would ask their DON about it if the charge nurse was unavailable. During an interview with Resident #3 and Resident #4 (who reside at the nursing facility), on 6/25/25 at 12:23pm, Resident #3 stated that he enjoys being at the facility. He said that he feels safe, and that staff treat him with respect. Resident #2 stated he has never missed any medication since he has been present at the nursing facility. Resident #3 stated that he was new to the facility, however he feels comfortable, and he has received all his medications at the prescribed times. He stated that when he has asked for his pain medication, he has had no problem with receiving it.A Record review of Medication Unavailable in-service dated on 6/24/25 was completed and signed by Medication Technician A LVN's and CNA's. A record review of Employee Corrective Action Form completed on 6/24/25 signed by Medication Technician 1 indicated that she would follow policy moving forward and the MAR. During a record of undated policy When a Medication in NOT on Cart Unavailable Medication Policy it reads When a medication is unavailable on the med cart get medication from EKIT if not in EKIT notify Charge nurse. During a record review of undated policy When a Med is not Available policy it read Charge nurse will notify physician for a substitute or an order to hold until available from pharmacy. The communication should be documented in nurse notes.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure staff did not use bare or gloved hands when serving food. B. Ensure stored food was properly labeled, dated and stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: An observation of the facility freezer on 2/4/25 at 8:45 am, revealed: a box of frozen cookie dough, open to air and crumbs in the bottom of the freezer. An observation of the facility cooler on 2/4/25 at 8:46 am, revealed: a box of chopped pecans, open to air and an opened package of turkey lunchmeat dated 1/30/25 and a use by date of 2/1/25. In an observation and interview on 2/4/25 at 11:20 am, the DA was observed touching kitchen surfaces with gloved hands in the kitchen. [NAME] A touched the steam table and picked up silverware rolls and placed the silverware on each tray. DA then picked up a plate and then walked to the tray of rolls on the counter and placed a roll on the tray of food. DA placed the tray on the serving cart. DA did not wash her hands or change her gloves. DA then picked up another plate of food then walked to the rolls and placed a roll on the second plate with her gloved hand. DA did not wash hands or change gloves between tasks. DA stated she just forgot and was supposed to use tongs when touching bread. DA stated not changing gloves and not using tongs could cause cross contamination and illness for the residents. An observation of the facility freezer on 2/5/25 at 10:33 am, revealed: a box of frozen cookie dough, open to air and crumbs in the bottom of the freezer. An observation of the facility cooler on 2/5/25 at 10:34 am, revealed: a box of chopped pecans, open to air and an opened package of turkey lunchmeat dated 1/30/25 and a use by date of 2/1/25. In an interview on 2/6/25 at 9:50 am, the DM stated all food items should be labeled and dated when taken out of the box. She stated all food had to have a date and a label. The DM stated foods should be labeled and dated as soon as it comes in or is taken out of the box. The DM stated foods should be thrown out by the expiration date and they just missed the lunchmeat. The DM stated tongs should always be used when serving food. The DM stated all kitchen staff know they should secure foods when storing. The DM stated she had done an in-service on all the kitchen issues with the staff, and they were aware of the kitchen policies. Record review of the policy dated 12/1/11 titled, Food Storage revealed to ensure freshness opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. All refrigerator foods are stored per state and federal guidelines. All refrigerator foods are labeled, dated and tightly sealed including leftovers using clean covered containers. All leftovers are used within 48 hours. Items that are over 48 hours are discarded. Frozen foods are stored in moisture proof wrap or containers that are labeled and dated. Record review of the policy dated 6/1/19 titled, Food Preparation and Handling revealed prepare food with the least manual contact as possible. Record review of the policy dated 10/1/18 titled, Employee Sanitation revealed Employees must wash hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service articles. Use gloves for one single task. When using gloves wash hands before touching or putting on new gloves. Change gloves between each food preparation task, after touching items utensils or equipment not related to task. Record review of the policy dated 12/1/11 titled, General Kitchen Sanitation revealed clean and sanitize all food preparation areas, food contact surfaces, and equipment. Keep food contact surfaces free of accumulated soil. to ensure freshness

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (LVN F, CNA I, CNA J, CNA K, and LVN G) of 5 staff reviewed for resident care -LVN F came out of resident room fully donned in PPE. -LVN F did not clean glucometer before or after checking glucose level for Resident #61. -CNA I did not perform hand hygiene or glove change during incontinent care of Resident #31. -CNA J wore gloves from the hallway into Resident #31's room to assist with incontinent care. -CNA J did not perform HH or glove change during incontinent care of Resident #31. -CNA K did not retract foreskin for cleaning procedure indicated in catheter care for Resident #265. -CNA K did not don PPE before performing Catheter care for Resident #265. -CNA I did not perform HH or glove changes during assisting with wound care for Resident #6. -LVN G did not don PPE to administer medications via Peg tube to Resident #43. These failures could place residents at risk of cross-contamination and infections. Findings include: During an observation on 02/04/25 at 08:57 AM revealed LVN F coming out of unidentified residents' room fully garbed in PPE. Room had posting on the door for droplet precautions. LVN F never removed gloves or PPE, reached for the medication cart that was outside of the room and pulled it closer to herself in the doorway. LVN F came out of room after doffing PPE in bathroom of room. LVN F went to medication cart to get some tape to take into the Isolation room. LVN F then proceeded to grab PPE and placed gloves on, then a face mask. LVN F took a gown out of the packaging and pushed the outer packaging of the gown down into the trash on the side of the medication cart. LVN F never switched gloves before going back into the unidentified resident's room. Observation from the hallway revealed that LVN F placed tape on oxygen tubing in the residents' room with the same gloves that was used to push down the trash with. During an observation on 02/04/25 at 11:31 AM revealed a medication administration performed by LVN F. LVN F did not clean glucometer before performing glucose check for Resident #61. LVN F did not perform HH before performing finger stick for Resident #61 or wipe the skin with alcohol before sticking the Residents skin. LVN F then removed the gloves and did not perform HH and started to prep insulin to administer to Resident #61. LVN F did not perform HH before donning gloves to administer insulin to Resident #61 and LVN F did not perform HH after administering insulin to Resident #61. During an observation on 02/04/25 at 11:42 AM revealed a medication administration performed by LVN F. LVN F did not clean the glucometer before the glucose check for Resident #265. LVN F did not perform HH before donning gloves to perform finger stick. LVN F did not perform HH before donning gloves to administer insulin to Resident #265 and did not perform HH after doffing gloves after insulin administration to Resident #265. During an observation on 02/05/25 at 10:54 AM revealed incontinent care performed for Resident #31 by CNA I and CNA M. No HH was performed before starting incontinent care for Resident #31. CNA M had gloves on before entering into room and never changed gloves before starting to assist with incontinent care. CNA I used dirty gloves to place a clean brief under Resident #31 after the back side of Resident #31 had been cleaned. Protective cream was placed on Resident #31 by CNA I with the same gloves that were used to clean the Resident #31. No hand hygiene or glove change was performed between the dirty and clean aspects of incontinent care. HH was not performed after incontinent care was completed by either CNA. During an interview on 02/05/25 at 11:01 AM CNA M stated that the negative outcome for not performing hand hygiene or changing gloves could lead to an infection control issue. During an interview on 02/05/25 at 11:03 AM CNA I stated that the negative outcome for not performing HH and glove changes would be infection control. During an observation on 02/05/25 at 11:22 AM revealed catheter care was performed for Resident #265 by CNA K. CNA K did not don PPE to perform catheter care for Resident #265 who was on EBP precautions due to catheter placement. CNA K did not retract the foreskin to clean the head of the penis of Resident #265 during catheter care. CNA K did not perform HH after the care was completed. During an interview on 02/05/25 at 11:22 AM CNA K stated that she just didn't put the PPE on and did not have a response when asked about the performance of catheter care. CNA K also stated I forgot to when asked why Hand hygiene wasn't done. CNA K stated that a negative outcome would be infection control. During an observation on 02/06/25 at 9:52 AM revealed wound care for Resident #6 performed by LVN F and CNA I. CNA I was observed changing her gloves to assist LVN F twice with no hand hygiene performed in between glove changes. During an interview on 02/06/25 at 10:11 AM CNA I stated that HH was not performed because I just forgot. CNA I stated that a negative outcome would be infection control. During and observation on 02/06/25 at 10:18 AM revealed LVN G perfored medication administration via PEG-tube for Resident #43. LVN G did not don PPE due to Resident #43 being on EBP due to Peg-tube being present. During an interview on 02/06/25 at 10:38 AM LVN G stated that the reason for not utilizing PPE was I don't know, I just didn't put it on, I was nervous. LVN G stated that the negative outcome was that it could lead to the spread of infection among other residents. During an interview on 02/06/25 at 11:37 AM DON stated that a negative outcome of staff not performing hand hygiene, not utilizing PPE for Residents on EBP and other areas of care could lead to infection control issues. Record review of facility provided policy titled Perineal Care, revised 01/20/2023, revealed the following: .Steps in the procedure . .3. Perform hand hygiene and done gloves .B. For a Male Resident: .3. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently clean and dry the area. 4. Retract foreskin of the uncircumcised mail. 5. Clean urethral area with a cleansing wipe using a circular motion. Use a clean section of the cleansing wipe for each stroke by folding each used section inward. Use a new cleansing wipe, as needed. 6. Continue to clean the perineal area including the penis, scrotum, inner thighs. 7. Thoroughly clean perineal area in same order, using a new cleansing wipe as needed. 8. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. 9. Gently dry perineum following same sequence. 10. Reposition foreskin of uncircumcised male. .13. Perform hand hygiene. Record review of facility provided policy titled Obtaining a Fingerstick Glucose level, revised October 2011, revealed the following: . Equipment and Supplies . 3. Disinfected blood glucose meter(glucometer) with sterile lancet; or single-resident use spring-loaded device (e.g., Penlet) or automatic or safety type lancet; . .6. Single use alcohol swab; and 7. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed.) Steps in the Procedure .3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. .20. Wash hands. Record review of facility provided policy titled Handwashing/Hand Hygiene, revised 01/20/2023, revealed the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. .5. Hand Hygiene must be performed prior to donning and after doffing gloves. 6. hand hygiene is the final step after removing a disposing of personal protective equipment. Record review of facility provided policy titled Infection Prevention and Control Program, dated July 2024 revealed the following: Policy and interpretation and implementation . .C. Standard and transmission-based precautions to be followed to prevent the spread of infections; . .F. The hand hygiene procedures to be followed by staff involved in direct resident contact.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was provided for 1 of 16 resident (Resident # 19) and 1 of 1 facility observed for environment 1. Hall 2 and Hall 4 had residue on the floor causing it to feel sticky while walking. 2. Hall 2 had a roach walking across the floor. 3. Resident #19's room was not homelike with her personal items stacked up against the wall, gnats flying around resident's face. 4. Gnats flying around in the conference room. 5. Phone outlet in the unlocked conference room was hanging out of the wall and wires attached. These failures could affect residents by placing them in an uncomfortable and unsanitary environment. Findings include: In an observation on 02/24/2025 at 8:27 AM, Conference room located on hall 5 was unlocked and the phone outlet was hanging out of the wall, wires attached. In an interview and observation on 02/04/2025 at 9:31 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. Resident #19 stated that she cannot put the items up herself and stated she did not like the clutter in her room., Resident #19 said she moved into the room on January 30, 2025, and her personal items have been piled up since then. In an observation on 02/05/2025 at 7:04 AM, shoes were sticking to floor while walking. In an observation on 02/05/2025 at 8:27 AM several gnats were flying around in the conference room. In an observation on 02/05/2025 at 9:40 AM, A roach was observed crawling across the hall on Hall 2. In an observation on 02/05/2025 at 9:41 AM, this surveyor was walking on Hall 2 and her feet were sticking to the floor. The floor appeared to have a type of residue causing the floor to feel sticky. In an interview and observation on 02/05/2025 at 9:45 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. 2 to 3 Gnats were flying around Resident, Resident #19 stated that the gnats were bothering her. In an interview on 02/05/2025 at 10:00 AM, CMA A stated the negative outcome for having a cluttered environment would that it could affect the resident's wellbeing. In an interview and observation on 02/05/2025 at 10:30 AM, the DON stated that the nursing staff and all staff were responsible for ensuring items were put up in resident's room. The DON stated they had a contract with a pest control company and facility was treated monthly and the last treatment was in January. The DON showed surveyor the pest control book where they keep track of any pest sightings and treatments. The negative outcome would be to have clutter around in a room would the room would not feel homelike for the resident. In an interview and observation on 02/05/2025 at 10:43 AM, CMA B stated that it was all staff's responsibility to ensure residents had a homelike environment and that a possible negative outcome for having a dirty environment would be that it could cause the residents to get depressed. In an interview on 02/06/2025 at 8:50 AM, the ADM stated it was not normal for rooms to be cluttered and that it was the nurses responsibility to ensure items were put up in the room. The negative outcome for having a dirty environment would be that that it was not homelike for the residents. In an observation on 02/06/2025 at 9:30 AM, Resident #19 was in her room, the room was cluttered with her personal items in bags and piled up against the wall. In an interview on 02/06/2025 at 10:33 AM, the MS stated it was his responsibility to ensure the residents had a clean homelike environment. The MS stated they had a contract with Pest Control but because residents bring their personal items in the facility roaches can come with their items. The MS also stated it was his responsibility to ensure any residue on floors need to be cleaned but staff need to let him know if any issues of such were going on. The MS said that negative outcome for not having homelike clean environment would that it may not feel like home. Record Review of the grievances from the past three months revealed on 12/28/2024 a grievance was filed due to a roach was observed on a bedside table in their room. Record review of the Homelike Environment policy dated February 2021 reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongs to the extent possible. Staff provides person-centered care that emphasized the resident's comfort, independence and personal needs and preferences. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment and personalized furniture and room arrangements, clean bed and linens that are in good condition.

Based on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 16 residents (Resident #19) reviewed for right to receive written notification in that: The facility did not provide evidence that Resident #19 was given a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings included: Record review of Resident #19's face sheet dated 2/5/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but not limited to acute kidney failure, heat failure, major depressive disorder, and weakness. Record review of Resident #19's Quarterly MDS dated [DATE] revealed resident had a BIMS score of 15 out of 15 indicating cognition was intact. Record review of Resident #19's care plan dated 12/16/2024 revealed resident had a problem with psychosocial wellbeing with approach to allow resident to participate in daily care and decision making. Record review of Resident #19's progress notes dated 01/30/2025 revealed resident was moved to another room on 1/30/2025, no information of how the resident was notified of the moved. Interview on 02/04/2025 at 9:31 AM, Resident #19 stated she was moved to a different room because the staff told her the room, she was in was a Medicare room and she needed to be changed to a Medicaid room. Resident #19 said she didn't understand what the staff meant and didn't realize she could say she didn't want to move. Resident #19 said she didn't like the room she was in because in her old room she could see out the window and in her new room she cannot. Resident #19 said she was never given any type of written notice about moving rooms. Resident #19 said she was told verbally when she was moved. Interview on 02/05/2025 the DON said she was new and that she was told that the resident had to move rooms because of payment reason so she had the resident moved. The DON said she did not give Resident #19 anything in writing about the move. The DON stated that a possible negative outcome for moving a resident without consent would be it wouldn't be good for their wellbeing. Interview on 02/05/25 at 9:00 AM, the ADM said she only gave verbal notice to Resident #19 about the move. The ADM said that they were going to do some remodeling in that room and that was why she was moved, it wasn't because of the any type of billing. The ADM said the resident should have been given a notice in writing as to why she was moving. Interview on 02/06/2025 at 11:09 AM, the SW said she did not assess the resident's wellbeing before the resident was moved, the SW was unsure if that was protocol to do so. The SW stated that moving a resident without consent or notification could be viewed as punishment by the resident. Record Review of the Resident Rights policy dated February 2021 reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Self Determination. Be informed of and participate in his or her care planning and treatment. Refuse a transfer from distinct part within the institution. Record Review of Policy Statement Room Change/Roommate Assignment dated June 25, 2024 When a resident is being moved at the request of facility staff, the resident, family, or resident representative must receive an explanation in writing of why the move is required.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 16 residents (Resident #14) reviewed for accommodation of needs. Resident #14's call light was not within her reach. The call light was located at the bottom of the bed out of reach of the resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings included: Record review of Resident #14's face sheet, dated 02/04/2025, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, cerebral infarction(stroke) unspecified lack of coordination, weakness, unspecified convulsions, nausea with vomiting. Record review of Resident #14's quarterly MDS, dated [DATE], revealed a BIMS score of 14 out of 15 which indicated Resident #14 was cognitively intact. Resident #14 required maximal assistance with bed mobility and dressing, with eating, toileting hygiene and upper and lower body dressing. Resident #14 also requires maximal assistance to roll left and right, and dependent on chair to bed transfer. Record review of Resident #14's care plan, dated 02/04/25, revealed, in part, Resident #14 is at risk for seizures with the approach to have call light in reach. During an observation and attempted interview on 02/04/2025 at 9:54 AM, Resident #14 was lying in her bed, resident would not talk with surveyor. Observation of call light on resident's bed at the foot of the bed out of reach of resident. During an observation on 02/04/2025 at 11:50 AM, Resident #14 was lying in her bed, observation of call light on resident's bed at the foot of the bed out of reach of resident. During an interview and observation on 02/05/2025 at 11:53 AM, the DON was observed putting call light in reach of resident . The DON stated not having the call light in reach could cause the resident to need something and not be able to call for help. During an interview on 02/04/2025 at 10:00 AM, CMA A stated that Resident #14 just yells out when she needs help. When asked if the Resident #14 was not able to yell for help what possibly could happen, CMA A stated the resident could try to get up and fall. During an observation on 02/06/2025 at 8:35 AM, Resident #14 was lying in her bed, observation of call light on resident's bed at the foot of the bed out of reach of resident. During an interview on 02/06/2025 at 8:45 AM CNA C stated that all staff were responsible for iensuring call lights were in reach. The possible negative outcome for not having it in reach of the resident would be that residents could get hurt. During an interview on 02/06/2025 at 8:50 AM, the ADM and the DON were in the ADM's office, the ADM stated Resident #14 couldn't use the regular call light so she hollers for help., When asked if Resident #14 could use the pad style call light, the ADM said she could use that type. The DON stated the facility had that type of call light and said she would change out Resident #14's regular call light to the pad type call light. The ADM did not have a negative outcome for not having a call light in reach. During an interview on 02/06/2025 at 9:32 AM with Resident #14's family member, the family member stated Resident #14 can and will use the call light if it was near her. The family member said the call light that the facility should be using was the pad type call light to accommodate Resident #14's lack of movement in her hands. Record Review of Accommodations of Needs Policy dated March 2021 reflected the following: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and or achieving safe independent function, dignity, and wellbeing. The resident's individual needs and preferences including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning was provided consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #24) of 16 residents reviewed for respiratory care. The facility failed to ensure Resident #24's oxygen was set to the 4 lpm indicated in her physician's order. This failure could place residents who receive oxygen at an increased risk for hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: Record review of Resident #24's admission record dated 02/04/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute and chronic respiratory failure (failure of lungs to provide oxygen), chronic obstructive pulmonary disease with (acute) exacerbation (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and heart failure (heart muscle fails to pump blood as it should). Record review of Resident #24's quarterly MDS completed on 10/30/24 revealed the following: Section C: Resident #24 had a BIMS score of 14 which indicated intact cognition. Section O: Resident #24 was receiving continuous oxygen at admission and while resident of the facility. Record review of Resident #24's care plan, last reviewed by DON on 01/01/25 revealed Resident #24 had shortness of breath related to pneumonia, heart failure, and chronic obstructive pulmonary disease was to receive oxygen at 4 lpm to address the issues. Record review of Resident #24's physician's orders dated 02/04/25 revealed an order for continuous oxygen at 4 lpm via NC. This order had a start date of 07/15/22. Record review of Resident #24's oxygen saturations from 01/04/25 to 02/04/25 revealed 83 entries. In 16 of the entries Resident #24 was receiving oxygen at lower rates than the 4 lpm ordered. In one of the entries Resident #24 was receiving oxygen at a higher rate than the 4 lpm ordered. During an observation and interview on 02/04/25 at 10:33 AM Resident #24 was in her room, seated in her wheelchair, receiving O2 via NC at 5 lpm. She stated she had been on O2 for over a year. When asked if she moved the dial to adjust the flow rate of the O2 she stated the nurses set the flow rate and she did not touch the dial. She stated her oxygen was supposed to be set at 3 lpm. During an observation on 02/04/25 at 11:24 AM Resident #24's O2 concentrator was set at 5 lpm. During an observation on 02/05/25 at 10:16 AM Resident #24 was seated in her w/c receiving O2 via NC at 5 lpm. During an interview on 02/05/25 at 02:02 PM CNA J stated nurses were responsible for setting flow rates for O2. During an observation on 02/05/25 at 02:05 PM Resident #24 was lying on her bed receiving O2 via NC at 4.5 lpm. During an observation and interview on 02/05/25 at 02:08 PM LVN D stated nurses were responsible for setting flow rates on O2. He stated nurses knew what level to set O2 flow rate by referring to physician's orders. LVN D looked on his computer and found Resident #24's order for O2 at 4 lpm. During an interview on 02/06/25 at 08:46 AM CMA stated nurses were responsible for setting oxygen flow rates. During an interview on 02/06/25 at 08:50 AM LVN F stated nurses were responsible for setting oxygen flow rates. She stated the physician's orders revealed what level to set the flow rate. LVN F stated if the O2 was set lower or higher than the order called for, it could have a negative outcome for the resident. She stated, If they got CHF (congestive heart failure) it could mess with they [sic] heart. During an interview on 02/06/25 at 08:53 AM LVN G stated nurses set O2 flow rates and know what rate to set by looking at physician's orders. She stated if O2 was set lower than the order the resident would not get the O2 they need and if it was set higher the resident would get too much (O2) yeah, it's not good. During an interview on 02/06/25 at 10:39 AM DON stated a possible negative outcome of O2 administered at lower or higher rates than ordered was, Not enough O2 if lower than ordered and too high can cause some disease processes to exacerbate. Record review of facility policy titled Medication Administration-General Guidelines and dated 06/01/22 revealed the following: . Medications are administered as prescribed in accordance with good nursing principles and practices . 2) Medications are administered in accordance with written orders of the prescriber. Record review of facility policy titled Oxygen Administration and dated 2010 revealed the following: . The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Turn on the oxygen.

Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (Hall 200 and Hall 300) reviewed for medication storage. -Medication cart for 200 Hall had 9 medication cups with multiple medications in them for unidentified residents in top drawer of medication cart. -Medication cart for 300 Hall had Lantus Solo-star for Resident #33 with no open date. -Medication cart for 300 Hall had Insulin Aspart for Resident #61 with no open date. -Medication Triamcinolone acetonide cream was on Resident #27's bed. The facility's failures could place residents receiving medication at risk for drug diversion, lack of drug efficacy, and adverse reactions. Findings included: During an observation on [DATE] at 08:45 AM revealed the medication cart for 200 Hall had 9 medication cups with multiple medications in top drawer. Medication cart was observed with CMA B. CMA B stated that she shouldn't do that and apologized. CMA B stated that the negative outcome for pre-prepping medications was it's bad. When CMA B was asked if she could possibly pick up the wrong medication cup, CMA B stated, Oh no, I would never do that. During an observation on [DATE] at 09:03 AM revealed the mediation cart for Hall 300 with LVN F contained Lantus Solo-star for Resident #33 with no open date on the pen. Medication cart also revealed Insulin Aspart for Resident #61 with no open date written on the pen. During an interview on [DATE] at 09:10 AM LVN F stated that a negative outcome for not writing the open dates on the insulin could result in a write up for her. During an interview on [DATE] at 11:06 AM DON stated that a negative outcome for having medications pre-prepped before administering medications to residents could lead to a medication error. DON stated that a negative outcome for not having open dates on medications could lead to a nurse or MA giving an expired medication. Record review of facility provided policy titled, Storage of Medications, revised [DATE], revealed the following: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of facility provided policy titled, Preparation and General Guidelines, dated [DATE], revealed the following: . Procedures A. Preparation .4. FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) When the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. .B. Administration . .4. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #43) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #43, resulting in ineffective communication. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being. Findings included: Record review of Resident #43's clinical face sheet, dated 02/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 08 indicating moderate cognitive impairment with a diagnosis of, but not limited to, Cerebral infarction (stroke) Aphasia (inability to speak) following cerebral infarction, Dysphasia (difficulty swallowing)following cerebral infarction, Muscle wasting and atrophy, not elsewhere classified, Unsteadiness on feet, lack of coordination, Type 2 diabetes mellitus with unspecified complications, Gastrostomy status, Gastro-esophageal reflux disease without esophagitis, Cellulitis of left finger, Pain, Constipation, disorders of bile acid and cholesterol metabolism, Anxiety disorder, Insomnia, chronic pain, hypertension The face sheet also stated that Resident #43 speaks Mandarin. Record review of Resident #43's MDS dated [DATE] revealed in section A1110-Language A) Resident's preferred language is Mandarin and B) stated that Resident #43 will need/want an interpreter to communicate with doctor or health care staff. Section B-hearing, Speech, and Vision revealed that Resident #43 has unclear speech, and is sometimes understood and usually understands others. In section C-Cognitive patterns under C0200 the repetition of three words revealed that Resident #43 could repeat 3 words after first attempt. Record review of Resident #43's Care Plan dated 12/30/2024 revealed the following: Communication: [Resident #43] primary language is Mandarin and has expressive aphasia r/t late effects of CVA. Goal: Will be able to communicate his/her wants, needs. Approach: -Ask simple yes/no questions and allow adequate time to respond, communication board as needed -Do not pretend to understand, request clarification when needed -Speak directly to resident in clear voice facing him/her -ST referral During an observation on 02/04/25 at 08:52 AM revealed Resident #43 lying in bed on his back with covers pulled up to chest. Resident #43 was unable to answer any questions that were asked of him. During an interview on 02/05/25 at 01:20 PM the MDS nurse revealed that the SW performs the BIMS for residents. and that Resident #43 should be using a translator to communicate. During an interview on 02/05/25 at 01:22 PM the SW stated that Resident #43 used SW's Google translate APP to communicate to Resident #43. The SW stated that Resident #43 speaks back to the phone, and it will translate what he says from Mandarin to English. The surveyor asked SW if she could demonstrate how she communicates with Resident #43 using her phone. During an observation on 02/05/25 at 01:26 PM revealed demonstration with Resident #43 and SW using her google translate. The SW fumbled quite a bit and had to find the languages to be translated in the APP. The process of communicating with Resident #43 took approximately 25minutes. Resident #43 never spoke to the phone head shaking and thumbs up was his only form of communication. There was no communication board utilized during this demonstration. During an interview on 02/06/25 at 08:44 AM LVN G who was responsible for the care of Resident #43 for the day was asked if a translator was utilized during his care, and LVN G stated that it was not due to the resident answering questions with shaking his head or give a thumbs up to respond to questions because he does not speak. LVN G was asked how the resident understood her when the language that he speak was Mandarin/Chinese? LVN G stated that he gives a thumbs up and shakes his head yes or no. LVN G stated that a negative outcome for not utilizing translation services were that Resident #43 wouldn't understand what they were asking. During an interview on 02/06/25 at 09:30 AM CNA L said Resident #43 does not have a communication board. CNA L stated that there has been no education on communication with this resident. CNA L stated that a negative outcome for not being able to communicate with this resident was something could go wrong. During an interview on 02/06/25 at 09:41 AM CNA I stated that Resident #43 does not have a communication board and has not received any education on communication services for Resident #43. During an interview on 02/06/25 at 11:48 AM DON stated that a negative outcome for not being able to communicate with Resident #43 would be that he was not able to communicate his needs. Record review of facility provided policy titled, Care Plans, Comprehensive Person-Centered, revised December 2020 revealed the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan are provided by qualified persons, are culturally-competent and trauma-informed. .7. The care planning process will: a. Facilitate resident and/or representative involvement; b. include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. .8. The comprehensive, person-centered care plan will: . . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . . j. Reflect the resident's expressed wishes regarding care and treatment goals;

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 (Resident #43) of 16 residents reviewed for activities of daily living. The facility failed to work with Resident #43 on using his communication device to communicate effectively. This failure could place residents with communication deficits in danger of being unable to communicate and thereby experiencing a decrease in quality of life. Findings included: Record review of Resident #43's clinical face sheet, dated 02/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 08 indicating moderate cognitive impairment with a diagnosis of, but not limited to, Cerebral infarction (stroke) Aphasia (inability to speak) following cerebral infarction, Dysphasia (difficulty swallowing)following cerebral infarction, Muscle wasting and atrophy, not elsewhere classified, Unsteadiness on feet, lack of coordination, Type 2 diabetes mellitus with unspecified complications, Gastrostomy status, Gastro-esophageal reflux disease without esophagitis, Cellulitis of left finger, Pain, Constipation, disorders of bile acid and cholesterol metabolism, Anxiety disorder, Insomnia, chronic pain, hypertension. The face sheet also states that Resident #43 speaks Mandarin. Record review of Resident #43's MDS dated [DATE] revealed in section A1110-Language A) Resident's preferred language is Mandarin and B) stated that Resident #43 will need/want an interpreter to communicate with doctor or health care staff. Section B-hearing, Speech, and Vision revealed that Resident #43 has unclear speech, and is sometimes understood and usually understands others. In section C-Cognitive patterns under C0200 the repetition of three words revealed that Resident #43 could repeat 3 words after first attempt. Review of Resident #43's Care Plan dated 12/30/2024 revealed the following: Communication: [Resident #43] primary language is Mandarina and has expressive aphasia r/t late effects of CVA. Goal: Will be able to communicate his/her wants, needs. Approach: -Ask simple yes/no questions and allow adequate time to respond, communication board as needed -Do not pretend to understand, request clarification when needed -Speak directly to resident in clear voice facing him/her -ST referral During an observation on 02/04/25 at 08:52 AM revealed Resident #43 lying in bed on his back with covers pulled up to chest. Resident #43 was unable to answer any questions that were asked of him. During an interview on 02/05/25 at 01:20 PM MDS nurse revealed that the SW performs the BIMS for residents. and that Resident #43 should be using a translator to communicate. During an interview on 02/05/25 at 01:22 PM SW stated that Resident #43 used SW's Google translate APP to communicate to Resident #43. SW stated that Resident #43 speaks back to the phone, and it will translate what he says from Mandarin to English. The surveyor asked SW if she could demonstrate how she communicates with Resident #43 using her phone. During an observation on 02/05/25 at 01:26 PM revealed demonstration with Resident #43 and SW using her google translate. SW fumbled quite a bit and had to find the languages to be translated in the APP. The process of communicating with Resident #43 took approximately 25minutes. Resident #43 never spoke to the phone head shaking and thumbs up was his only form of communication. There was no communication board utilized during this demonstration. During an interview on 02/06/25 at 08:44 AM LVN G who was responsible for the care of Resident #43 for the day was asked if a translator was utilized during his care, and LVN G stated that it was not due to the resident answering questions with shaking his head or give a thumbs up to respond to questions because he does not speak. LVN was asked how the resident understood her when the language that he spoke was Mandarin/Chinese? LVN stated that he gives a thumbs up and shakes his head yes or no. LVN G stated that a negative outcome for not utilizing translation services were that Resident #43 wouldn't understand what they were asking. During an interview on 02/06/25 at 09:30 AM CNA L said Resident #43 does not have a communication board. CNA L stated that there has been no education on communication with this resident. CNA L stated that a negative outcome for not being able to communicate with this resident was something could go wrong. During an interview on 02/06/25 at 09:41 AM CNA I stated that Resident #43 does not have a communication board and has not received any education on communication services for Resident #43. During an interview on 02/06/25 at 11:48 AM DON stated that a negative outcome for not being able to communicate with Resident #43 would be that he would not able to communicate his needs. Record review of facility provided policy titled, Care Plans, Comprehensive Person-Centered, revised December 2020 revealed the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan are provided by qualified persons, are culturally-competent and trauma-informed. .7. The care planning process will: a. Facilitate resident and/or representative involvement; b. include an assessment of the resident's strengths and needs; and c. Incorporate the resident's personal and cultural preferences in developing the goals of care. .8. The comprehensive, person-centered care plan will: . . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . . j. Reflect the resident's expressed wishes regarding care and treatment goals; Record review of facility provided policy titled, Residents Rights, revised February 2021, revealed the following: Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . Record review of facility provided policy titled, Accommodation of Needs, revised March 2021, revealed the following: Policy Interpretation and Implementation 1. The resident's individual needs and preferences are accommodated to the extent possible, . 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. .4. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example: a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity; .

Based on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 24 residents (Resident #25) reviewed for physician orders for treatments. In six observations over three days, the facility failed to follow physician orders and apply Resident #25's hearing aid as ordered for Resident # 25. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition. Findings include: Record review of Resident # 25's face sheet printed 02/4/2025 revealed a [AGE] year-old female, admitted on [DATE] with the following diagnoses: moderate intellectual disabilities, cognitive communication deficit, dysphasia, weakness, and generalized anxiety disorder. Record review of Resident # 25's MDS, dated [DATE] revealed a BIMS of 11 indicating no cognitive impairment. Resident #25 required substantial/maximal assistance to complete bathing, toileting, and lower body dressing. Resident # 25 needed partial/moderate assistance with upper body dressing, and supervision or touch assistance with eating and oral hygiene. Record review of Resident #25's Care Plan dated 11/21/24 documented Resident #25 needed the assistance of 1 to 2 staff for ADLs. She was at risk for pain, dry skin and was at risk of not having needs met due to communication issues. Record review of Resident #25's physician's orders dated 2/4/25, documented Apply right hearing aid in right ear every day in am and remove at night at bedtime. Special instructions Resident is to wear right hearing aid in right ear every am and is to be removed every pm at bedtime. Order start date was 11/17/23- open ended. In an observation on 02/4/2025 at 10:40 am, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation on 02/4/2025 at 12:25 pm, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation on 02/4/2025 at 2:15 pm, Resident # 25 was sitting in a wheelchair in her room. There was no hearing aid in her right ear. In an observation and interview on 02/5/2025 at 10:00 am, Resident # 25 was sitting in a wheelchair. There was no hearing aid in her right ear. Resident #25 stated she was supposed to a hearing aid but did not know where they were. Resident # 25 stated staff did not put the hearing aid on her all the time. Resident #25 stated she had not had them on at all this week. In an observation on 02/5/2025 at 3:40 pm, Resident # 25 was sitting in a wheelchair in an activity and there was no hearing aid in her right ear. In an interview on 02/6/2025 at 9:06 am, Resident #25's family member stated she visits resident at least once a month and she had never seen Resident #25 wearing a hearing aid in her right ear. In an interview on 02/6/2025 at 9:31 am LVN F stated she usually works with Resident #25 and is well acquainted with her needs. She stated Resident #25 has an order for a hearing aid in her right ear. When asked why Resident #25 did not have the hearing aid on she stated she just had not had time to get them out of the box yet. She stated everyone on staff knows Resident #25 has a hearing aid and should be wearing them every day. She stated a negative outcome for not having the hearing aid on could be she would not be able to hear. She stated she was trained by the other nurses in the facility. In an interview on 02/6/2025 at 9:40 am, the DON stated she expected all staff follow the physicians' orders. She stated an order would be put into the charting system after it is written by a physician. The order then would be listed on the Treatment Administration Record. The DON stated an order for hearing aids would be listed on the Treatment Administration Record and the system would trigger the staff to put the hearing aids on the resident. The DON stated she expected the nursing staff to put the hearing aids on Resident #25 every day as ordered. She stated she trained the nurses to do their jobs and expects physicians' orders were followed 100 percent for all orders and all residents. She stated the consequences of not wearing the hearing aid would be poor care for the resident. In an interview on 2/6/25 at 10: 55 am, the ADM stated she could not locate any policies on Quality of Care, following physician orders or documentation of treatment administration.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #2) The facility failed to plan for a safe discharge for Resident #2. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. Findings included: Review of Resident #2's Face Sheet dated 12/10/2024 reflected a [AGE] year-old male admitted [DATE] at 2:44 PM. with diagnoses of Unspecified Dementia (a general term for a decline in mental abilities that affects a person's daily life), Major depressive disorder with psychotic symptoms, Essential (Primary) Hypertension (abnormally high blood pressure that not caused by a medical condition), Pain, unspecified (pain that does not have a clear cause or diagnosis), and Major Depressive Disorder (persistent low mood and loss of interest in activities that people enjoy). Resident #2 was discharged on [DATE] at 10:17 AM. Record Review of the Medical Record was completed on 01/22/2025. These records were reviewed to assess the admission process. There was no MDS, Care Plan, Interdisciplinary Discharge Summary, or 30-Day Discharge Letter included in the Medical Record. During a phone interview on 01/22/2025 at 9:52 AM with the complainant, she stated Resident #2's was brought to the ER for a psychiatric evaluation by family member after leaving the nursing facility. The complainant contacted the NF and was told the NF would take Resident #2 back if he was appropriately medicated. The complainant stated Resident #2 was in the ER for 5 days awaiting placement and was placed at an alternative facility. During an interview on 01/22/2025 at 2:33 PM with the DON she reported the Ombudsman was notified of the discharge . During an interview with the facility Administrator on 01/22/2025 at 2:37 PM she reported she was out on vacation at the time of the admission and discharge of Resident #2. Per her report based on her email chain of the situation, Resident #2 came from home after being seen by his primary care provider and was placed on the secure unit. The Interim DON in charge at the time spoke with family upon admission. Based on the email report, Resident #2 was getting acclimated then the next day Resident #2 was trying to get out the window. The Secure Unit Staff were unable to redirect the behavior of Resident #2. Resident #2 was placed on a one to one for elopement risk. The Administrator stated since Resident #2 had not been there for 30 days, the decision was made to discharge him to home . The Administrator confirmed this was a facility-initiated discharge. The Administrator reported she was not in the building and the IDON handled the discharge. Resident #2 was discharged to family. The Administrator reported the facility was contacted to see if Resident #2 could return. The staff at the NF informed the caller that the Resident would have to receive a new referral and assess to see if his needs could be met at the NF. During a phone interview on 01/22/2025 at 2:45 PM with Resident #2's family member, the family member stated staff from the NF called and told her she had to come pick up Resident #2 the day after admission. The caller stated they could not keep him. The family member stated the NF did not give any information on how to further care for Resident #2. The family member further stated she felt it was safe to take Resident #2 home because Resident #2s behavior was always pretty good with her. She reported she did not know what had transpired overnight at the NF. She stated Resident #2 is currently at another NF and was doing well. During an interview on 01/22/2025 at 2:56 PM, the Facility Liaison reported the resident was dropped off at the facility by a neighbor. Resident #2 was referred to the facility by his Primary Care Provider. The Facility Liaison reported Resident #2's family member refused to go with the resident to the secure unit upon admission and this set him off. The staff were struggling to trying to keep Resident #2 calm. Prior to admission, Resident #2's family member reported to the Facility Liaison Resident #2 could be combative. The Facility Liaison reported she went to visit Resident #2 while he was in the ER after he was discharged from the NF. She stated she encouraged Resident #2's family member to take the resident to the ER because more information was needed than what was provided by the resident's primary care provider. During an interview with the Corporate DON on 01/22/2025 at 4:25pm she stated the discharge was not implemented according to the policy of the organization. Record Review of the Medical Record on 01/22/2025 showed the record was lacking the Interdisciplinary Discharge Summary and Physician's orders for discharge. Review of facility's Discharge Summary and Plan policy reflected When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2 of 4 medication carts (Med Cart #1 and Med Cart #2) reviewed for medication storage in that: The facility failed to prevent: Medication Cart #1 being unattended and unlocked in the doorway to dining room on 7/17/2024. Medication Cart #2 being unattended and unlocked across from the nurses' station on 7/17/2024. This failure could allow residents unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 07/17/2024 at 9:10 am revealed, Med Cart #1 sitting near the entrance to the dining room. Med Cart #1 was unsupervised and unlocked. Review of the contents of the cart revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The CMA was approximately thirty yards away with her back turned away from cart. The unlocked computer sitting on top of Med Cart #1 had resident information to other residents, visitors and staff walking past the cart. The ADON approached the cart, reminded the CMA to lock the cart when stepping away, and the ADON secured the cart. Observation on 07/17/2024 at 9:13 am revealed, Med Cart #2 sitting across from nurses' station, up against the wall with the drawer's facing outward. Med Cart #2 was unsupervised and unlocked. Review of the contents of the cart revealed prescription and over-the counter medications and ointments, glucometer supplies, insulin pens, and insulin syringes. The nurse assigned to the cart was not in sight. The ADON approached the cart and asked another staff member sitting in nurses' station to page LVN - A. The ADON secured the cart. Interview on 7/18/2024 at 11:13 am with CMA - A revealed they had been in that position for a year and had received training on the facility's medication policy. She stated the facility trained her for the position. CMA - A stated she left the cart unlocked in the doorway of the dining room. However, she was passing medications at the time, and she was in eyesight of the cart. She stated there were residents in the dining room and others were outside smoking. She identified adverse outcomes for residents as the possibility of a resident taking the wrong medication and experience side effects. She stated the keys to the narcotic box were on her person and residents would not have had access to those medications. Interview attempt on 7/18/2024 at 11:39a m with LVN - A. Called and left a voice message was left requesting a return call. Interview on 7/18/2024 @ 5:20 pm with LVN - B revealed (he/she) had worked at the facility for four months. He said the CMAs and nurses were responsible to lock the med carts. He identified adverse outcomes as the potential for others to steal medication from the cart. Interview on 7/19/2024 @ 9:36 am with CNA - D revealed (he/she) had worked at the facility for eighteen years. She stated it was the CMA's responsibility to lock the med cart, as they are the only ones that had the keys. She said, It was the DON and ADON who ensure it is actually being done. Interview on 7/19/2024 at 9:50 am with LVN - F revealed (he/she) had worked at the facility for six months. She stated the nurses and CMAs were responsible to lock the med carts. She identified adverse outcomes as the potential for residents to take an unprescribed medication and experience adverse reactions. Interview on 7/19/2024 at 10:20 am with the ADON revealed (he/she) had been employed at the facility for five years. She stated it was everyone's responsibility to lock the med carts and face the drawers towards the wall. She identified adverse outcomes as the potential for others to ramble through the cart and take medications or equipment. Interview on 7/19/2024 at 11:00 am with the ADM, she stated her expectation was that the nurses and CMAs locked the med carts.

Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for five of six residents (Residents #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of life/ADL care. The facility failed to ensure nailcare was completed for Resident #1, Resident #2, Resident #3, and Resident #4's and to ensure Resident #5 received a timely response for incontinent care. This failure could place residents at risk for poor hygiene, infections, dignity issues, embarrassment, humiliation, and decreased quality of life. Findings include: 1. Record Review of Resident #1's Face Sheet dated 07/18/2024 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses of Traumatic Brain Injury (a head injury causing damage to the brain), Unspecified convulsions (uncontrollable muscle contractions), Mixed hyperlipidemia (high cholesterol), Seizures (sudden disturbance in the brain that causes behavior, movements, and consciousness), anxiety disorder (intense, excessive worry), and other specified disorders of the brain (diverse group of brain conditions that do not fit in another category). Record review of Resident #1's Quarterly MDS Assessment, dated 06/24/2024, reflected the resident had a BIMS score of 7 which indicated severely impaired cognition. Resident #1 required a one person assist from staff for personal hygiene, dressing, toileting, bathing, and oral hygiene. Record review of Resident #1's Comprehensive Care Plan dated 07/05/2024 reflected Resident #1 was dependent on staff for completion of ADL tasks. Intervention: Resident #1 required extensive assistance for bathing and hygiene. Resident #1 did not receive nail care daily between 6:00am and 2:00pm, per care plan. Interview and observation on 07/18/2024 at 4:14 pm reflected Resident #1 had a blackish/brownish substance underneath all nails on his right and left hand. The residents' nails were about one quarter of an inch past the end of his fingertip. Resident #1 stated he would like his nails trimmed. 2. Record Review of Resident # 2's Face Sheet dated 7/18/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnoses Cerebral infarction, unspecified (stroke), Type 2 diabetes mellitus with unspecified complications (complications from the body's inability to produce insulin), Heart failure, unspecified (reduced blood supply to the heart), Gastrostomy status (feeding tube), Chronic obstructive pulmonary disease (trouble breathing, wheezing), Hypertensive heart disease with heart failure (the heart ceases to function caused by high blood pressure), and Muscle weakness (inability for the muscles to perform). Record review of Resident #2's Quarterly MDS Assessment, dated 06/26/2024, reflected the resident had a BIMS score of 2 which indicated severely impaired cognition. Resident #2 required extensive and total assistance staff for personal hygiene, dressing, toileting, bathing, and oral hygiene. Record review of Resident #2's Comprehensive Care Plan dated 07/10/2024 reflected Resident #2 was dependent on staff for completion of ADL tasks. Intervention: Resident #1 was fully dependent on staff for assistance with ADL's. The care plan did not address nail care for the resident. Interview and observation on 07/18/2024 at 9:07 am reflected Resident #2 had a blackish/brownish substance underneath all nails on her right hand, left hand was not visible. The residents' nails were about one quarter of an inch past the end of her fingertip. Resident did not respond to interview questions. Therefore, she was not interviewed. 3. Record Review of Resident #3's Face Sheet dated 07/18/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnoses of Unspecified Dementia (symptoms that affect memory and daily life), and Chronic Obstructive Pulmonary Disease (persistent breathlessness and cough), Hypertension (high blood pressure). Review of the MDS for Resident #3 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #3 as a resident that could participate in an interview. Record review of Resident #3's Comprehensive Care Plan dated 06/06/2024 reflected Resident #3 required assistance from staff for completion of ADL tasks. Intervention: Resident #3 required extensive assistance for bathing, hygiene, dressing, grooming. Nailcare was not addressed in the care plan for Resident #3. Interview and observation on 07/18/2024 at 4:45 pm reflected Resident #3 had long fingernails exceeding one half inch past the tips of her fingers. Resident #3 stated she would like to have her nails cut back by half the length. Two of the nails had a light brown substance underneath the nails. Resident stated she also had an ingrown toenail. 4. Record Review of Resident #4's Face Sheet dated 07/18/2024 revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Cerebral Infarction (stroke), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis from the stroke), Dysphagia (difficulty swallowing), Asymptomatic human immunodeficiency virus [HIV] (virus affecting the immune system), and Type 2 diabetes mellitus with diabetic polyneuropathy (nerve pain caused by Diabetes). Review of the MDS for Resident #4 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #4 as a resident that could participate in an interview. Record review of Resident #4's Comprehensive Care Plan dated 06/26/2024 reflected Resident #4 was dependent on staff for completion of ADL tasks. Intervention: Resident #4 required extensive assistance for bathing, hygiene, dressing and grooming. Nailcare was not addressed in the Care Plan for Resident #4. Interview and observation on 07/18/2024 at 4:15 pm reflected Resident #4 had a blackish/brownish substance underneath most nails. The resident's nails were more than one half inch past the end of her fingertip. Resident #4 stated she would like her nails trimmed. 5. Review of face sheet dated 7/17/2024 for Resident #5 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Encephalopathy (condition that affects brain structure and function), Hyperlipidemia (high cholesterol),Hypertension (high blood pressure), Congestive Heart Failure (the hearts inability to fill up and pump blood), Bipolar Disorder (mental illness characterized by extreme mood swings), Acquired absence of left leg above knee amputation (no left leg below the knee), and Chronic kidney disease (kidneys cannot filter properly). Review of the MDS assessment for Resident #5 was not available due to international Microsoft issues. Per resident roster provided by the ADM, the facility identified Resident #5 as a resident that could participate in an interview. Review of the Care Plan dated 06/04/2024 for Resident #5 identified a Bowel/Bladder Incontinence problem. The interventions included wearing briefs, Depends, or pantiliners when out of bed, check for incontinence as needed, and keep call light in easy reach. Observation on 07/17/2024 at 10:30 am revealed Resident #5 was sitting in her wheelchair in her room. Resident #5 stated she pressed her call light over three hours ago and no one had come to check on her. A puddle of urine was dripping onto the floor, underneath Resident #5's wheelchair. The resident was tearful and stated, It makes me feel like an invalid. Interview on 7/18/2024 at 5:20pm with LVN - F revealed they had worked at the facility for four months, and stated the nurses and CNAs were responsible to provide nail care to residents. Adverse outcomes were identified as, they could scratch themselves. LVN - F stated, There was no acceptable reason why the resident was left soiled for more than three hours, especially if the nurse is making the required rounds every two hours. Identified adverse outcomes were, Bed sores and red bottoms. Interview on 7/19/2024 at 9:36am with CNA - D revealed they had worked at the facility for eighteen years. CNA - D stated nail care was performed when they gave the residents their showers, and cleaned underneath and clipped their nails. CNA - D stated there was no acceptable reason the resident was left soiled for more than three hours. Identified adverse outcomes were, breakdown, sores, rashes and it will weaken the skin. Interview on 7/19/2024 at 9:50am with LVN - F revealed they had worked at the facility for six months. LVN - F said all nursing staff were responsible to ensure the residents had proper nailcare. The nurses took care of the residents with Diabetes. Adverse outcomes were identified as, Scratch themselves, infection, eat something that's bad for them. LVN - F said residents were checked-on by the CNAs every two hours and those that wet more often, were checked every hour by the CNAs. LVN - F said there was no reason for why the resident was left soiled for more than three hours. Interview on 7/19/2024 at 10:20am with the ADON revealed (he/she) had been employed at the facility for five years. The ADON stated, The nursing staff were responsible to provide nail care to the residents. They should have done nailcare on their assigned shower day, and on Sundays. They should get nails checked every day because they play in their poop. The ADON stated there was no acceptable reason for prolonged wetness. Interview on 7/19/2024 at 11:00am with the ADM, stated the expectation was that each resident had their nails checked every Sunday and as needed. She stated the CNAs and nurses are responsible for providing nail care to ensure residents do not scratch themselves or get infections. The ADM revealed the expectation was that residents were checked every two hours and there was no acceptable reason for why a resident was wet for more than three hours. Record review of the facility policy on Fingernails/Toenails Care, revised in February 2018, reflected the following: Purpose - The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming.

Based on interview and record review, the facility failed to notify the resident representative regarding a change in the resident's condition, for one (Resident #2) of six residents reviewed for changes in condition. , in that: The facility failed to inform Resident #2's Representative (RP) when Resident #2 was found in Resident #1's room on 5/25/2024 while Resident #1 was masturbating behind his curtain . This failure could place residents at risk of not having their Responsible Party notified of changes resulting in a delay in decision making for medical interventions. The findings included: Review of Resident #1's face sheet dated 6/26/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Mood Disorder, Diabetes mellitus (blood sugar regulation disorder), Alcohol abuse, Pulmonary hypertension (a type of hypertension that affects arteries in the lungs and heart) due to lung diseases, Atrial fibrillation (heart rhythm disorder involving the atria of the heart) and Ventricular fibrillation (heart rhythm disorder involving the ventricles of the heart). Review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10 suggesting moderate cognitive impairment. Review of section E - Behavior reflected resident had not had any behaviors related to hallucinations delusions, physical behaviors, verbal behaviors, wandering or rejection of care behaviors. Review of Resident #1's progress note dated 5/25/2024 by LVN A reflected Resident in room with penis out playing with self in front of another resident when staff came in to remove [sic Resident #2] he started yelling and cursing at staff to get out of room. Message left for family and [Nurse Practitioner] made aware. Review of Resident #2's face sheet dated 6/26/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive disease that destroys memory and other important mental functions), unspecified dementia (progressive memory loss disorder), Generalized anxiety disorder, femur head fracture (broken hip), muscle weakness, lack of coordination, Dysphagia (difficulty swallowing), neuropathy (nerve pain), and Hypertension (high blood pressure). Review of Resident #2's quarterly MDS assessment dated [DATE] reflected Resident #2 could not complete the BIMS scoring assessment in Section C. The staff assessment section (C700) was completed and indicated resident had a long-term and short-term memory problem and her decision-making skills were severely impaired. Review of Section E - Behaviors, reflected Resident #2 had wandering behaviors behavior of this type occurred daily Review of Resident #2's progress notes printed 6/26/2024 reflected no entry on 5/25/2024 concerning the incident with Resident #1 or note that Resident #2's RP had been notified of the incident. Review of Resident #2's care plan dated 4/3/2024 reflected Resident #2 had the Problem: Behavioral Symptoms: [Resident #2] disruptive behavior including taking other residents plates, wandering into other residents rooms, and touching other residents personal items. Interventions included convey acceptance of resident during periods of inappropriate behavior, encourage diversional activities, keep environment calm and relaxed, redirect as needed and remove from public area when behavior is unacceptable. During an interview on 6/26/2024 at 2:16 pm, Resident #2's RP stated he does not recall anyone telling him about the incident with Resident #2 and Resident #1 involving anything sexual or Resident #2 being in a room while Resident #1 was masturbating. RP stated the facility has been good about calling him if Resident #2 falls or wanders, or when he needs to know something about Resident #2 - but he does not remember anything like that of a sexual nature. RP stated he was concerned about this because he wondered if there could be other things he does not know that have happened with Resident #2 and he was not notified. During an interview on 6/26/2024 at 3:22 pm, LVN A stated she was working on 5/25/2024 when the incident with Resident #1 took place. She stated on 5/25/2024, Resident #1 was in his room, on his bed masturbating and had the curtain drawn. Resident #2 wandered into Resident #1's room and then laid down on the roommate's bed. Resident #1 did not alert staff and continued his sexual activity with himself. She stated she redirected Resident #2 out of the room and took her to her room. She stated Resident #2 is very confused and she had no way of knowing how or if this affected Resident #2. LVN A stated she thought she had charted in Resident #2's EMR about the incident with Resident #1. She stated she did not remember calling the RP for Resident #2, but she believed he had come up to the facility later that afternoon and she told him in person about the incident. She stated she thought she charted all of this but when she went back to look there was no progress note in Resident #2's chart about the incident or about her telling the RP. She stated in certain areas of the building they have problems with the computers saving and she wondered if that is what could have happened. During an interview on 6/27/2024 at 3:59 pm, the DON stated her expectation of the charge nurse after the incident would have been to complete documentation in the EMR and notify the RP. She stated she was not aware that there was no documentation in the EMR for Resident #2 about the incident or that the RP was not called. DON stated she did review Resident #2's EMR and did not see any documentation on the incident with Resident #1 or notification of the RP. She stated sometimes there were problems with computers saving and she has told staff to just restart the computer and chart again. During an interview on 6/27/2024 at 4:07 pm, the AD stated her expectation of documentation in Resident #2's EMR there should have been a progress note and RP should have been called. AD stated she had not checked the documentation, but her understanding was that it was not there. AD stated Resident #2 had rights and the RP has a right to know what is going on involving the resident. Review of facility policy Change in a Resident's Condition or Status dated 4/20/2023 revealed, Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representatives of changes in the resident medical/mental condition and/or status (e.g., change in level of care, billing/payments, resident rights, etc.)

Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for Resident #1 of 7 residents reviewed for accidents and supervision. The facility failed to ensure Resident # 1 was free from accidents. Resident # 1 eloped from facility on 3/16/2024. Resident # 1 was located two blocks from that facility at a local convenient store that was on busy high traffic road. Resident #1 was found walking in the opposite direction of the facility, disoriented, and confused when facility RN A located her. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/5/202 at 11:30am. The IJ Immediate Jeopardy template was provided to the ADM on 4/5/2024 at 11:30am. While the (IJ) Immediate Jeopardy was removed on 4/8/2024 at 12:00pm, the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on the elopement process and missing resident procedure. This failure placed all residents at risk for accidents and harm. Findings included: On 4/5/2024 during an observation of the facility front door in the lobby area. The facility door was observed to be an egress door that alarmed after holding for 15 seconds. However, the alarm on the door was observed turned off, so the door opened freely without the alarm sounding. Visitors, staff, and residents were observed going in and out the door without the alarm sounding. During this observation there was no staff assigned to monitor the door for who was leaving or coming in the door. Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Unspecified dementia (progressive or persistent loss of intellectual functioning, with impairment of memory and thinking), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During an interview on 4/4/2024 at 12:20pm with Resident #1 revealed that she eloped from the on 3/16/2024. Resident #1 stated she went to the store to get cigarettes. Resident #1 stated she went out the front door of the facility. Resident #1 stated there was no staff at the front desk when she went out the door. Resident # 1 stated she was scared and glad to be alive. Resident # 1 demonstrated how she put her hand up so that the cars would not hit her. Resident # 1 stated she was not going to do that anymore, she showed Surveyor #1 the alarm alert bracelet that had been placed on her ankle. Record review of Resident's #1 quarterly MDS dated [DATE], Section GG functioning reflected Resident #1 had a BIMS score of 2 which indicated severe impairment in cognitive thinking. Record review of Resident #1's care plan reflected prior to 3/20/2024, there was no elopement interventions. On 3/20/2024, after Resident # 1 had eloped from the facility the following care plan and interventions were put into place: Record review of Resident #1 care plan dated 3/20/2024 reflected the care plan had been updated with interventions to address the recent elopement which included the following: roam alert, assess roam alert 1x daily to ensure working properly, elopement assessment will be completed quarterly and with change in condition, document and report any exit seeking behaviors to nursing staff, verify placement of roam alert every shift, and if resident begins to wander provide comfort measures and basic needs for the resident. During an interview on 4/4/2024 at 4:51pm with FM #1, revealed Resident # 1 called her FM to get cigarettes. FM#1 stated she sent FM #2 to the facility to take Resident #1 to the store to purchase some cigarettes, FM#1 stated that was when the facility realized that Resident # 1 had eloped from the facility. FM#1 stated Resident #1 was located at the convenient store across the street walking in the opposite direction of the facility. During an interview on 4/4/2024 via phone at 4:28pm with RN # 1, revealed she was weekend nurse on the day of 3/16/2024. RN #1 stated she was notified by one of the CNA's that Resident # 1 was missing. She stated she and the other staff started searching for Resident # 1 inside and outside the building. RN #1 stated she got in the car with one of the workers and they drove up the street searching for Resident # 1. RN # 1 stated they located Resident # 1 at the convenient store walking in the opposite direction of the facility. She stated they returned Resident # 1 to the facility. RN # 1 stated a head-to-toe assessment was completed once returned and no injuries were noted. During an interview on 4/4/2024 at 5:02pm with the DON, she stated when Resident # 1 admitted to the facility that it was noted that she had wandering behaviors but had not exhibited any elopement or exit seeking behaviors. During an interview on 4/8/2024 at 10:35am with CNA A, revealed that on March 16, 2024, around 12:00pm she was working when Resident # 1 eloped from the facility. CNA A stated she had seen Resident # 1 earlier when the other residents went outside on a smoke break around 11:30am, but stated she came back in the facility. CNA A stated she thought Resident # 1 was displaying exit seeking behaviors early in the day. CNA A stated Resident # 1 continued to walk back and forth to the front door and stated Resident # 1 then sat down in the front by the front door. CNA A stated Resident #1 waited until there was no staff around and went out the front door. CNA A stated she advised the nurses that Resident # 1 had left the building when the FM showed up and was looking for Resident # 1. CNA A stated Resident #1 had never exhibited those behaviors before and stated she had never attempted to leave the facility, so she was surprised when she found out that Resident #1 had eloped. Record review of facility progress report dated 3/16/2024 at 1:44pm, completed by LVN A reflected, on 3/16/2024 the facility was unable to locate Resident #1 when FM came to facility looking for her. The progress report reflected Resident # 1 was found at the convenient store and returned to the facility around 1:00pm. Record review of facility elopement policy dated 9/1/2023, reflected the following: The facility will ensure that all residents who exhibit wandering behavior and or are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of service. An (IJ) Immediate Jeopardy was identified on 4/5/2024 at 11:30am., due to the above failures. The ADM was notified on 4/5/2023. The ADM was provided with the (IJ) Immediate Jeopardy template on 4/5/2023 at 11:30am, and a Plan of Removal (POR) was requested. A Plan of Removal was first submitted by the ADM on 4/5/2024 at 1:17pm. The Plan of removal accepted on 4/7/2024 at 1:29pm Plan of Removal Date Initiated: 4/5/2024 and accepted on 4/7/2024 The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. This failure placed Resident # 1 in danger and has the potential for other residents at risk of elopement from the facility. With a change in condition the facility could have performed another elopement risk assessment. Residents at risk for elopement could be affected by this deficient practice. Action: Residents residing outside of the secured unit will be educated over signing out prior to leaving the building via a council meeting and/or 1:1(person- to person contact) education. The center will place a sign on the door stating, residents must sign out prior to exiting the doors. The center will add in the admission paperwork, Residents wishing to leave the center must sign out. Person(s) Responsible: Administrator and/or Designee Date: 4/6/2024 by 1PM Action: The facility will place an alarm on the door. All staff will know to respond to the door when it alarms. When the door alarms and staff respond they will check the elopement binder to see if the resident attempting to leave is at risk for elopement and should not leave unattended. Additionally, the staff will check to ensure the resident has signed out to avoid an elopement situation. All of this will be educated on, and all staff will be educated prior to working their next shift. Person(s) Responsible: Administrator and/or Designee Date: 4/7/2024 by 12PM Action: The facility will review residents with change in condition in clinical meeting and the IDT (Interdisciplinary Team) and/or Doctor will determine what the change in condition will trigger, such a new elopement risk assessment being completed. If the change in condition occurs over the weekend the nurses will know to notify the MD and Director of Nursing and/or Assistant Director of Nursing immediately so assessments can be completed, and interventions can be put in place. Nurses will know to notify the DON and/or ADON & MD through education. Person(s) Responsible: Director of Nursing and/or Assistant Director of Nursing, and/or Designee Date: 4/6/2024 by 3PM Action: All residents received an elopement assessment. 24 people are at risk for elopement. No new elopement risks that were not previously identified. New admissions will receive an elopement assessment upon admission, quarterly, and as needed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 4/5/2024 by 3PM Action: All residents triggering as an elopement risk will have a care plan and person-centered interventions in place. New admission that are identified as elopement risks in the above assessment will have a person-centered care plan initiated. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, MDS Coordinator, and/or Designee Date: 4/5/2024 by 3PM Action: All staff will be educated over wandering/elopement/missing resident. Test will be completed for comprehension. All staff will be educated prior to working their next shifts. Person(s) Responsible: Administrator and/or Designee Date: 4/5/2024 by 8PM Action: All doors was checked for functionality on 4/5/2024 with no concerns. Door functionality was checked weekly and as needed by Maintenance Director and/or Designee. Person(s) Responsible: Maintenance Director and/or Designee Date 4/5/2024 by 3PM Action: Ad hoc QAPI (specifically done for Quality Assurance performance improvement) to review the template and plan to remove the immediacy. Person(s) Responsible: Administrator and/or Designee Date: 4/5/2024 by 3PM Monitoring on 4/8/2024 included the following: 9:10am - Entrance in facility. Observation made on 4/8/2024 at 9:10am- of the entry door, the facility has set up a desk that was always monitored by staff. There was a sign-in and out book for the resident if they are going out for fresh air, there is a separate book for those residents who are signing out leaving the property. Each book has a different sign -in and out sheet for each day. Each day they start a new sign-in and out sheet. Observation made on 4/8/2024 at 9:10am of sign posted on front of facility front door alerting all residents of the sign-in and out process. Observation of table set up at front door with sign-in and out books for fresh air and for leaving the facility property. On 4/8/2024 in an interview at 9:15am with AA who revealed she worked 8am- 5pm Monday through Friday. The AA stated she had been trained on the elopement process, stated the code was Pink if they had a missing resident. Stated she was would her immediate supervisor know, then they would start searching for the resident, notify the family or RP, the DON, administrator, and police. The AA stated she had also been trained on abuse/neglect and stated the administrator was the abuse/neglect coordinator. She stated the protocol to let her know immediately if she is not available the DON, and the next person in charge. Stated she had never seen or suspected abuse/neglect at this facility. On 4/8/2024 in an interview at 9:20am with RN B, revealed she worked the 6am to 2pm shift. RN b stated the facility had implemented the new sign-in and out sheet and the front door was going to be always monitored for now during all shifts. RN B stated she had been trained on abuse/neglect and the process. Stated she had also been trained on the elopement process and that the code was Pink if they had a missing resident. RN B stated all the residents had been in-serviced on the new sign-in and out process and stated some were upset that they had to do it that way now. Record review of the Elopement risk assessments completed from 4/6/2024-4/8/2024 for all residents- 83 assessments completed all residents assessed. Record review of the Competency elopement test dated 4/6/2024 -4/8/2024 completed by - 83 staff that covered the elopement process if a resident was missing the code to call and the steps to take. Review of Wandering and Elopement policy in-service dated 4/5/24-completed by 100% of staff. Review of Emergency Procedure - Missing resident in-service -dated 4/5/2-24 - completed by 100% of staff. Review of the QAPI - dated 4/5/2024 addressed the elopement process and procedures. Observation made on 4/8/2024 at 11:00am- 1:00pm of alarm alerts going off through the day each time a resident with an alarm alert was within so many feet of the front door. During an interview on 4/8/2024 at 9:59am via phone with LVN A revealed she worked the 10pm- 6am shift. LVN A stated she had been trained on abuse/neglect. She stated the abuse/neglect coordinator was the Admin. and the protocol was to stop the abuse/neglect first ensure the safety of the resident and then make all notifications. LVN A stated she had also been trained on the elopement process and procedures. She stated the code for a missing resident was code Pink LVN A stated once the code Pink was called then a head count would be completed, and the search would be started by all staff. During an interview on 4/8/2024 at 10:31am with LVN C revealed she worked the 6am-2pm shift. LVN C stated she had been trained on abuse/neglect and the elopement process and procedure. She stated the abuse/neglect coordinator was the Admin. and the protocol was to stop the abuse/neglect first ensure the safety of the resident and then make all notifications. She stated the code for a missing resident was code Pink LVN C stated once the code Pink was called they would start search inside and outside the building and if the resident was still not able to be located then they would contact the police. During an interview on 4/8/2024 at 11:00am with the Maintenance supervisor, who stated he checked all exit doors to ensure working properly. He stated he was educated on the elopement process and that the elopement code was Pink. The Maintenance supervisor stated the abuse/neglect coordinator was the Admin. and he needed to report immediately if he saw or suspected abuse/neglect, he stated he had never seen or suspected abuse/ neglect at this facility. During an interview on 4/8/2024 at-11:10am with CNA D and CNA E revealed they both worked the 6am- 2pm shift. CNA D and CNA E both stated they were trained on abuse/neglect and the elopement process and procedures. They stated the code when there was a missing resident was code Pink. They reported the process was to notify the nurse immediately, call the code Pink and everyone would start searching inside and outside the building looking for the missing resident. CNA D and CNA E reported that the abuse/neglect coordinator was the Admin., and the protocol was to report immediately to management if they saw or suspected abuse/neglect. They both stated that they had never seen or suspected abuse/neglect at this facility. During an interview on 4/8/2024 at 11:05am with Resident # 30 revealed he was educated on the sign-in and out process and stated he was started following the process. During an interview on 4/8/2024 at 11:20am with the DON revealed she and other designated staff completed elopement assessments on all residents. She stated all staff were trained on the elopement process and emergency process. Stated any agency staff will be in-serviced before starting their shift by herself or someone from nursing would in-service. The DON stated only facility staff were working at facility at this time. The DON stated the sign-out book was placed at the front door and the front door would be monitored 24/7 (24 hours 7 days a week) and the sign-in and out sheet would be changed daily. She stated all exit doors were checked to ensure they were functioning properly. The DON stated all residents were educated on the sign-in and out procedure moving forward. During an interview on 4/8/2024 at11:30am with Admin revealed, all staff were in-serviced over the elopement process and emergency procedures. She stated it was her expectation that staff follow all the steps when they had a missing resident. The Admin. stated all the residents were educated on the sign-in and out procedure, she stated a lot of the residents were upset that they had to do it this way. The admin stated it was her expectation that staff stop any abuse/ notify her or the DON immediately and ensure that the resident was safe. The Admin. stated they added the sign-in and out process to the admission packet for any new residents. During an interview on 4/8/2024 at 11:45am with the following residents who were on a smoke break outside included: Resident # 3, Resident # 8, Resident #9, and Resident # 10 who all stated they were educated on the sign-in and out policy. It was said they were required to sign-out when going out for fresh air on the front porch. They also stated that they had to check with a nurse prior to signing -out if they were going to the store or leaving the facility for any reason. Review of facility elopement policy undated reflected the following: The facility will ensure that residents who exhibit wandering behavior and /or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. On 4/8/2023 at 12:00pm., the ADM was informed the (IJ)immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/8/2024 at 12:00pm, the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had been trained on the elopement process and missing resident procedure.

Based on observation, interview and record review, the facility failed to follow their policy and ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 20 residents reviewed for pain management. (Resident #21) LVN B failed to stop wound care and notify the physician and/or receive an order for [REDACTED]. This facility failure could affect all residents on a pain management program placing them at risk for unnecessary pain, discomfort and decreased quality of life. Findings include: Review of Resident #21's Face Sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Doctor's assessment dated [DATE] revealed Resident #21's sacrum pressure ulcer was classified as Category/Stage IV. Review of the Physician order [REDACTED].#21 received the following PRN medication every 12 hours [MEDICATION NAME] 400 mg/tablet ordered on [DATE]. Physician order [REDACTED].#3 300-30mg 2 tablets by mouth at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM, ordered on [DATE]. an order for [REDACTED].#21's Sacral wound. Review of the most recent Quarterly MDS assessment dated [DATE] revealed Resident #21's cognition was severely impaired. Resident #21 received scheduled pain medication. Review of the Care Plan dated 4/18/19 revealed Resident #21 was at risk for pain related to [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. During an observation on 6/11/19 at 10:43 AM, LVN B provided wound care with assistance from CNA B to Resident #21's stage IV Sacral region (buttocks) wound. LVN B did not assess pain prior to starting wound care for Resident #21. The old dressing had been removed prior when resident received a shower. CNA B rolled resident to her right side with no complaints from resident or aggressive behavior. Resident #21 was talking calmly with both LVN B and CNA B while she was positioned for wound care. When LVN B applied a normal saline soaked 4x4 gauze to Resident #21's wound, Resident #21 started to scream and yelled that hurts, quit it, stop it now. Resident #21 struck CNA B several times with her left fist. Resident #21's legs became fully extended and grimacing was observed as she yelled. LVN B did not assess or stop treatment to address Resident #21's pain. When surveyor asked LVN B if she had been medicated prior to treatment she stated, she had her scheduled this morning, but she doesn't get anything for wound care. Interview with Resident #21 on 6/11/19 at 10:50 AM revealed that when asked if she was in pain she stated, my butt hurts. Interview with LVN B on 6/11/19 at 10:53 AM revealed that Resident #21 had received her scheduled Tylenol-[MEDICATION NAME] #3 at 7:00 AM that morning but did not have anything else scheduled for pain till 12:00 PM. She stated that Resident #21 always acts that way during wound care and did not realize Resident #21 was in pain. Observation on 6/11/19 at 10:56 AM revealed CNA B reporting to CNA C that Resident #21 was screaming because she just received wound care. Interview with CNA C on 6/11/19 at 10:54 AM revealed that he believed Resident #21 could say when she was in pain. Interview with DON on 6/11/19 at 11:05 AM revealed she had expected LVN B to stop wound care and assess pain if the resident is yelling or stating, that hurts. She stated she then expected LVN B to stop wound care when pain was assessed and to notify doctor for a PRN order to address break-through pain. She stated her expectations were for nurses to always assess pain prior to performing wound care and anytime during treatment when pain is suspected. Review of a current facility policy (undated) and titled Core Principles of Pain Treatment revealed the following elements: 3. Follow the principles of pain assessment. Pain is subjective experience; the resident is the best judge of his or her own pain, and the expert on each pain treatment's effectiveness on him/herself. Review of current facility policy dated 8/3/18 and titled Pain Management Program Quality of Life Series revealed the following elements: Acute Pain-Acute pain is the abrupt onset and limited duration. Acute pain follows an injury to the body and generally disappears when the injury heals. (p. 3) Non-Specific Symptoms-Additional non-specific signs and symptoms that may suggest the presence of pain include: (p. 5) Vocal (crying, moaning, groaning) Facial Expressions (wincing, frowning, grimacing, grinding teeth) Bracing (clutching, tense) Rubbing (body guarding) Verbal Complaints Striking out (recurring agitation) Eating poorly Sleeping poorly Decreased activity level Change in gait Change in behavior Loss of function Restlessness Anticipating Pain-if a resident has had a recent musculoskeletal surgery, has an open wound requiring treatment, or is cognitively impaired with periods of agitation, and the resident does not have pharmacological interventions in place, contact the attending physician or NP to start routine [MEDICATION NAME] until a more comprehensive evaluation is completed. (p.6)

Based on observation, interview and record review, the facility failed to: 1. assess for pain and provide pain relief during a pressure ulcer dressing removal and subsequent pressure ulcer wound treatment; and 2. care plan interventions for pain management prior to, during and/or after pressure ulcer wound treatment for one (Resident #6) of four residents observed during wound care. Resident #6 received no pain mediation prior to assessment and treatment of a Stage III pressure ulcer on one ankle by LVN C and LVN E. The resident continuously cried out in pain and asked the nurses to stop the procedure, but the nurses continued the care and treatment of the wound. As a result, Resident #6 suffered avoidable, excruciating pain. An Immediate Jeopardy (IJ) was identified on 12/15/14. While the IJ was removed on 12/18/14, the facility remained out of compliance at a severity level of " actual harm" that is not immediate jeopardy," and at a scope of "pattern" as the facility was continuing to monitor the effectiveness of their plan of removal. LVN C and LVN E were assigned to hall 3, however the LVN ' s both stated they floated and worked on all halls in the building. Hall 3 had three residents who required wound treatment; thus, all three residents (Resident #6 and two additional residents) as well as the other 26 residents on pain management, were placed at risk of not receiving appropriate pain management with resulting avoidable pain during wound care. Findings Included: Observation of Resident #6 on 12/15/14 at 9:45 AM, during initial tour, reflected LVN C removed the dressing to Resident #6's right ankle for the surveyor's observation of the pressure ulcer. Resident #6 complained of pain during the entire observation, yelling repeatedly, " That hurts. That really hurts. " LVN C did not stop the undressing of the pressure ulcer, she did not stop the assessment of the pressure ulcer, she did not inquire as to the level of pain he was experiencing nor did she offer to get Resident #6 any pain medication so the assessment could continue after Resident #6 received relief from the pain he was experiencing during the procedure. Resident #6's (undated) Admission Record reflected he was a [AGE] year-old male with an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #6's MDS assessment dated [DATE], reflected Resident #6 had clear speech, was understood, and understood others; scored 15 on the BIMS (Brief Interview for Mental Status)(score of 0-15 with 15 being completely oriented and able to recall all items asked), exhibited no behaviors and required supervision of one person for eating, extensive assistance of one person for movement on /off the unit, toileting and personal hygiene, extensive assistance of two persons for bed mobility and total dependence of two persons for transfers and bathing. Resident's #6 was always incontinent of bowel and bladder, had pain occasionally with a level of " 6 " (0-10 scale), received scheduled pain medications and also PRN pain medications. The MDS revealed he was at risk for developing pressure ulcers and had a Stage III pressure ulcer measuring 2.0 cm X 1.3 cm X 0.1 cm. The tissue type of the pressure ulcer was listed as " slough - yellow or white tissue that adheres to the ulcer bed ... " Observation on 12/15/14 at 2:15 PM revealed wound care being provided on Resident # 6. LVN C and LVN E went to Resident #6's bed and began to shift Resident #6 from his right side to his left side. LVN E elevated Resident #6 ' s right leg as LVN C assessed the wound (measuring) and then began to perform wound care on his right ankle. Resident #6 repeatedly yelled to LVN C that she was hurting him, stating " Yeah it hurts " , " Really hurts now " , " Stop, stop " , " Oh no, no, no " and "feels like my leg is being crushed back, stop, it hurts", all stated while LVN C was measuring the right ankle pressure ulcer. Neither LVN C nor LVN E stopped the wound assessment/care to assess his pain and administer pain medication. Upon completion of the wound care at 2:45 PM, LVN E stated she would " see if we can get some pain meds. " During an interview on 12/15/14 at 2:55 PM with LVN C, the surveyor asked LVN C what pain interventions she conducts/provides if a resident complains about pain during wound care. LVN C stated she " usually will complete a pain assessment. " The surveyor asked LVN C, if she completed a pain assessment during wound care with Resident #6 today and LVN C stated, "No I didn't." During an interview on 12/15/14 at 2:56 PM with LVN E, the surveyor asked LVN E what she does during wound care if a resident complains of pain. LVN E stated that she will give medication to the resident. LVN E stated " I will go now and tell the Medication Aide to give the Resident some pain medication for his pain. " Observation on 12/15/14 at 2:57 PM, in Resident #6 room, MA E gave Resident #6, 2 tablets for his pain (unwitnessed pouring of medication by the surveyor). Resident #6's plan of care, onset date of 11/14/14, reflected a problem of an open area to the right outer ankle with interventions including treatment as ordered by the M.D. No interventions for pain management prior to, during and/or after pressure ulcer wound treatment were documented. No care plans were located for pain management during pressure ulcer wound treatments. Resident #6's physician's orders [REDACTED]. Additional physician's order [REDACTED]. Resident #6 ' s Treatment Flowsheet dated for 11/01/14 through 11/30/14 revealed an entry for " Assess for Pain Q Shift, if pain indicated then utilize pain management flow sheet. Q Shift - Every Shift " with spaces for daily entries on Shift 1, 2 and 3. Shift 1 had 29 of 30 spaces initialed as having been assessed, but no indication of Resident #6 ' s pain level was documented. Shift 2 had 29 of 30 spaces initialed as having been assessed, but no indication of Resident #6 ' s pain level was documented. Shift 3 had 30 of 30 spaces initialed as having been assessed, with " 0 " written in to indicate Resident #6 ' s pain level on 9 of 30 assessments. Resident #6 ' s Medication Flowsheet dated for 11/01/14 through 11/30/14 revealed an entry for " [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) Schedule III tablet; 5-325 mg; 1 tab; oral TID - Three Times a Day (DX: Inj brain NEC w/o opn wnd unspc LOC) " , with scheduled times at 8AM, 2PM and 8PM. All 90 scheduled opportunities were initialed as administered. An additional entry for " [MEDICATION NAME] (OTC) tablet; 325 mg; Amount to Administer:2 tab Q4 hr for pain/temp; Oral PRN- As Needed " was initialed as being administered twice on 11/04/14 and 11/22/14. No documentation was located to indicate what time the medication was administered, what the pain level was at that time or what the specific complaint was for the administration of the PRN medication. No documentation was located to indicate when during the shift the scheduled pain assessment was completed or if it was completed to coincide with the routine administration of [MEDICATION NAME]. Review of Resident #6 ' s Treatment Flowsheet dated for 12/01/14 through 12/31/14 on 12/15/14 revealed an entry for " Assess for Pain Q Shift, If pain indicated then utilize pain management flow sheet. Q Shift - Every Shift " with spaces for daily entries on Shift 1, 2 and 3. Shift 1 had 15 of 15 spaces initialed as having been assessed, but no indication of Resident #6 ' s pain level was documented. Shift 2 had 14 of 15 spaces initialed as having been assessed, but no indication of Resident #6 ' s pain level was documented. Shift 3 had 15 of 15 spaces initialed as having been assessed, with " 0 " written in to indicate Resident #6 ' s pain level on 4 of 15 assessments. Review of Resident #6 ' s Medication Flowsheet dated for 12/01/14 through 12/31/14 on 12/15/14 revealed an entry for " [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) Schedule III tablet; 5-325 mg; 1 tab; oral TID - Three Times a Day (DX: Inj brain NEC w/o opn wnd unspc LOC) " , with scheduled times at 8AM, 2PM and 8PM. All 44 scheduled opportunities were initialed as administered. An additional entry for " [MEDICATION NAME] (OTC) tablet; 325 mg; Amount to Administer: 2 tab Q4 hr for pain/temp; Oral PRN- As Needed " was initialed as being administered once on 12/15/14. Documentation reflected the medication was administered at 2:50 PM for complaints of pain. No documentation was located to indicate what the pain level was at that time or what the specific complaint was for the administration of the PRN medication. No documentation was located to indicate when during the shift the scheduled pain assessment was completed or if it was completed to coincide with the routine administration of [MEDICATION NAME]. Review of Resident #6 ' s clinical record did not reveal any documentation could be located to indicate the facility staff had contacted Resident #6 ' s physician for any additional pain medication orders, specifically to coincide with pressure ulcer treatments. Record Review on 12/15/14 at 2:59 PM of the facility's undated Pain Management Policy, revealed " ...Optimizing pain assessments and management can alleviate many of these conditions and can improve quality of life ...Residents with pain will be assessed and monitored daily ...Assessments for pain will be done anytime a resident complains of pain or indicates non -verbally that they are experiencing pain ...Pain Management will be documented on the back of the Pain Assessment Form...The Pain Assessment Form includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor response to pain management interventions. It also attempts to target the site of pain ...Pain refer to any type of physical pain or discomfort in any part of the body ... It may be acute or chronic, continuous or intermittent, or occur at rest or movement. The pain experience is very subjective; pain is whatever the resident says it is. A full assessment for pain includes: Origin, Location, Severity, Alleviating, Exacerbating factors ? Current treatment and response to treatment ...Procedure: Ask if they have experienced any pain ...If they state they have pain, take their word for it Pain is subjective experience. Ask to describe the pain. Observe for indicators for pain: Moaning, crying and other vocalizations, Wincing or frowning and other frowning and other facial expressions ... " Review of Perry and Potter Clinical Nursing Skills & Techniques, 7th Edition, page 983, Procedural Guideline 38-1 Performing a Wound Assessment revealed " ...Procedural Steps ...2 Assess comfort level or pain on a scale of 0 to 10, and identify symptoms of anxiety ...10 Reassess patient ' s pain and level of comfort ... " An IJ was identified on 12/15/14. On 12/15/14 at 3:30 PM, the Administrator and DON were notified an IJ had been identified in the area of Quality of Care. A Plan of Removal was requested at that time. The Plan of Removal was accepted on 12/16/14 at 12:24 PM. The Plan of Removal reflected the following: Employee Memorandum on 12/15/14 at 5:48 PM, revealed LVN C and LVN E received a written warning for failing to follow appropriate policy and or procedures resulting in harm or potential harm to a resident ... "When resident c/o pain during a skin treatment this nurse continued with treatment " . "Nurse should assess for pain before and during treatment and if pain occurs- stop treatment and notify physician ..." Variance to Standard Facility staff failed to assess the pain and provide interventions during the performance of a wound care treatment. Corrective Action Steps Date Started 12/15/14 Target Date 12/15/14 Staff Responsible DON, ADON and Administration. 1. Pain assessments will be done on admission, re-admission, with significant change of condition (i.e. altered mental status, vital sign changes, injury), quarterly, daily, and with c/o pain before and after pm pain meds. Licensed nurses will assess 30 minutes before for pain before treatments. If residents complain of pain during treatments staff will stop the treatment immediately and medicate as needed and/or notify the MD. 2. Licensed staff will assess residents for pain and respond immediately if c/o are made with non-pharmacologic measures to promote physician comfort such as positioning, turning, applications of heat or cold (per MD order). Administer [MEDICATION NAME] as ordered, on time and titrate the medication dosage/frequency within prescribed guidelines. 3. Licensed staff will provide measures for distraction- relaxation, diversional, activities, music therapy, etc. 4. Obtain referrals for physical therapy, or occupational therapy as needed. 5. Licensed staff will assess residents for adequate bowel and bladder function (i.e. does the resident need to use the restroom, is the resident constipated or having loose stools). 6. Pain management will be documented on the Pain Assessment Form which will include frequency, intensity of signs and symptoms of pain and can identify indicators of pain as well as to monitor response to pain management interventions. It will include the target site of the pain, origin, location, severity, and alleviating and /or exacerbating factors. It will include treatment and response to treatment for pain. 7. Licensed staff will notify the physician if pain management regimen for a resident is noted to be inadequate to control the resident's pain as determined by the residents target pain level. 8. All licensed staff will be in serviced by the DON or ADON on Pain Assessment and Management within the next 24 hours starting at 12/15/14 at 4 PM. 9. The two identified LVN's will undergo written counseling for failure to follow facility policy regarding pain assessment and management on 12/15/14. Both identified nurses will receive one on one re-training on pain assessment and management by the DON and/ or ADON 12/15/14. 10. DON, ADON or designated Administrative RN will monitor residents with pain symptoms daily for 1 week then 3x wk for two months to insure compliance with this plan of action. 11. Medical Director and/ or designated physician extender will evaluate plan of action for compliance on an ongoing basis. Resident #6 ' s physician was notified on 12/15/14 after the IJ was called, and new orders were received (untimed) to change Resident #6 ' s pain medication to [MEDICATION NAME] 25 mcg/hr patch, apply topically every 72 hours; [MEDICATION NAME] 15 mg tablet, give 1 or 2 tablets 1 hour prior to dressing change and every 4 hours PRN pain and to discontinue [MEDICATION NAME] when other pain meds arrive. During an interview on 12/16/14 at 10:35 AM, the Medical Director stated he was aware of the IJ. The Medical Director stated the "the DON had just in-serviced and trained the staff regarding pain and pain assessments about two weeks ago. They should have known to conduct pain assessment or stop treatments if the resident was in pain." During an interview on 12/16/14 at 12:55 PM, the DON confirmed her understanding of the Immediate Jeopardy action. The DON stated " it was because LVNs got scared during treatment. The Resident has hit staff before and maybe they were scared he was going to hit them again. " During an interview on 12/16/14 at 12:40 PM, the Administrator stated the IJ occurred because Resident #6 was in pain and staff failed to assess/evaluate the level of pain and provide pain management. During an interview on 12/16/14 at 2:10 PM LVN F stated that she had been in-serviced on pain assessment during wound care and pain assessment in general. She stated that a resident should be assed for pain before wound care and medicated, and if the resident complains of pain during wound care, the care should be stopped. The resident should then be reassessed for pain management. During an interview on 12/16/14 at 2:15 PM, LVN C stated she had been in-serviced on pain management and counseled on pain management and wound care. She stated that she should stop if the resident complains of pain and assess him, notify physician if pain medication is not working for the resident. During an interview on 12/17/14 at 8:05 AM, LVN B stated that he had been in-serviced on pain management and wound care. He stated that the resident should be assessed for pain before, during, and after wound care. He stated that pain assessments should be an on-going task throughout the day. According to the CMS Form 672, Resident Census and Conditions of Residents, completed by the DON on 12/15/14, there were 26 residents on pain management.

Based on interview and record review the facility failed to ensure the consultant pharmacist identified and reported drug regimen irregularities for 5 of 13 residents reviewed for medications (Resident #'s 3, 6, 7, 9 and 16) when: A. Resident #16 received [MEDICATION NAME] (medication used to treat depression) every day since 1/18/11, [MEDICATION NAME] (an Antipsychotics used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disease) every morning, noon and at bedtime since 2/4/10 and [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and panic attacks) three times per day since 2/4/10. The consultant pharmacist did not identify the need for a dose reduction. B. Resident #3 received four (4) anti-[MEDICAL CONDITION] medications ([MEDICATION NAME], and [MEDICATION NAME]). The Consultant Pharmacist did not identify duplicate medication therapy, or the need for monitoring for side effects of anti-[MEDICAL CONDITION] medications, including incoordination. Resident #3 experienced 12 falls between 4/15/11 and 12/29/11. Resident #3 is also on an anti-pshycotic and anti-depressant. The facility failed to address gradual dose reductions, and monitor effectively for side-effects of these medications. C. Resident #6 received [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] and nerve pain) 600 milligrams (mg) 1 (one) PO (by mouth) QD (daily). There is no [DIAGNOSES REDACTED]. D. Resident # 6 received an increase in dosage of [MEDICATION NAME] XR (an extended release Antipsychotic used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disease) from 150 mg per day to 200 mg per day on 1/3/12 without documentation of a need on the Behavior Monitoring Sheets. E. Resident #7's physician orders [REDACTED]. The consultant pharmacist did not identify the need for a dose reduction. F. Resident #9 received [MEDICATION NAME] 25 mg 1 PO TID (three times a day). The facility did not monitor for adverse side effects for Malignant Neuorpleti[DIAGNOSES REDACTED] (a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs). This deficient practice placed 5 residents at risk of receiving unnecessary medications and could affect an additional 8 residents due to failure to monitor behaviors, side effects, efficacy or recommend a gradual dose reduction. Findings include: The administrator was informed on 1/12/12 at 4:10 PM that substandard quality of care had been identified in the area of accidents. A. Review of Resident #16's physician orders [REDACTED]. His diagnoses included [MEDICAL CONDITION] 1 Disorder, [MEDICAL CONDITIONS], Unspecified [MEDICAL CONDITION] and Dementia with Behavioral Disturbances. Further review of physician orders [REDACTED]. Review of Resident #16's care plan dated 10/14/11 and reviewed 10/20/11 and 1/5/11 reflected Resident #16 was receiving [MEDICAL CONDITION] medications with a goal that he will not experience adverse side effects over the next ninety days. Approach # 5 reflected that the medications would be reviewed every three months for possible dose reduction. Review of the Consultant Pharmacist reports from January through December 2011 reflected no recommendation for a dose reduction for Resident #16. B. Review of Resident #3's face sheet revealed he was admitted to the facility on [DATE] with diagnoses of Other Forms of [MEDICAL CONDITION] and Recurrent [MEDICAL CONDITIONS] not Elsewhere Classified, Unspecified [MEDICAL CONDITION], and Other Persistent Mental Disorders due to Condition. Review of Resident #3's physician orders [REDACTED]. 1) [MEDICATION NAME] (anti-convulsant used to treat [MEDICAL CONDITION]) 300 milligrams (mg), give 3 tablets to equal 900 mg BID (two times a day), ordered 12/31/10 2) [MEDICATION NAME] (anti-convulsant)100 mg., one by mouth two times a day, original order on 7/19/11, and increased on 12/30/11 to: [MEDICATION NAME] (anti-convulsant) 100 mg, give 1 tablet every morning, and 1 and 1/2 tablets (150 mg) by mouth every hour of sleep. 3) [MEDICATION NAME] (anti-convulsant) 100 mg, give 1 capsule by mouth BID, ordered 11/15/11. 4) [MEDICATION NAME] (anti-convulsant) 100 mg, give 6 capsules to equal 600 mg by mouth every hour of sleep on Monday, Tuesday, Wednesday, Thursday, Friday, and: [MEDICATION NAME] (anti-convulsant) 100 mg, give 5 capsules to equal 500 mg by mouth every hour of sleep on Saturday, Sunday, ordered 8/22/11. Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for [MEDICATION NAME]: Central Nervous System: Fatigue, feeling abnormal, abnormal gait, abnormal co-ordination, confusion, anxiety, amnesia, aggravated [MEDICAL CONDITION], impaired concentration. Musculoskeletal: Muscular weakness. Review of manufacturer's specifications reflected the following adverse reactions for [MEDICATION NAME]: Patients should be advised that [MEDICATION NAME] may cause dizziness, ataxia (defective muscular coordination), and [MEDICAL CONDITION] (transient loss of consciousness, [MEDICAL CONDITION]). The most common adverse reactions were dizziness, headache, nausea, and diplopia (double, blurred vision). Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for [MEDICATION NAME]: Central Nervous System: Headache, dizziness, confusion, mental slowing, anxiety, nervousness, fatigue, incoordination. Other: Flulike syndrome, accidental injury. Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for [MEDICATION NAME]: Central Nervous System: Dizziness, nervousness, headache, mental confusion, decreased coordination. During an interview on 01/11/12 at 9:10 AM, the Occupational Therapy Assistant stated, "We started Resident #3 on physical therapy and occupational therapy mid November, 2011, due to multiple falls in October. We are unsure if they are [MEDICAL CONDITION] related, and think some are due to balance. He is not safe. He continues to get headaches and gets fatigued easily." Review of Resident #3's Individual Incident Tracking/Trending Report revealed he had 10 falls during 2011 (4/15, 5/5, 7/4, 7/12, 7/20, 9/13, 10/1, 10/31, 10,31, and 12/29), and nurse's notes for that period revealed an 2 additional falls (10/15 and 12/9) for a total of 12 falls. He sustained a fractured nasal bone as a result of the fall on 12/9/11, and required seven staples to a laceration to the back of his head which he sustained as a result of the 12/29/11 fall. Review of the facility Consultant Pharmacists' Medication Regimen Reviews for January through November, 2011 revealed no documentation to suggest a review for duplicate anti-[MEDICAL CONDITION] medications therapy, nor the potential for increased incidence of side effects (including decreased coordination) which may have contributed to the Resident's numerous falls. Review of Resident #3's physician orders [REDACTED]. Antipsychotics: [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION] and Manic episodes) 0.5 mg, 1 tablet by mouth BID. Started 12/31/10. Antidepressants: [MEDICATION NAME] 60 mg every day. Started 12/31/10. Review of the facility Consultant Pharmacist's Medication Regimen Reviews for January through November, 2011 revealed no request for gradual dose reduction of his anti-psychotic (Rispersdal) or anti-depressant ([MEDICATION NAME]) for the first 11 month he was a resident and the following notation for each month: No recommendation specified. No recommendation. Review of a Note to Attending Physician/Prescriber from the facility Consultant Pharmacist dated 12/29/11 regarding Medication Regimen Review for Resident #3 revealed the following: This resident receives [MEDICATION NAME] (anti-depressant) 60 mg everyday and [MEDICATION NAME] 0.5 mg BID with diagnoses of depression and ETOH ([MEDICAL CONDITION]) on chart. 1) Please indicate [DIAGNOSES REDACTED]. Signed: Consultant Pharmacist Physician/Prescriber Response: I disagree with recommendation. Handwritten note: 'Has been on for months and is stable - will defer to psych (psychiatric) team. Signed: Nurse Practitioner Date: 01/04/12 Review of Resident #3's clinical record revealed no referral to, or progress note from a psychiatric team which the nurse practitioner deferred to make judgement on continued need for anti-depressant and anti-psychotic medications. During an interview on 01/11/12 at 8:30 AM, Licensed Vocational Nurse (LVN) G stated, "I reviewed Resident #3's chart and pulled his thinned records. I did not find a referral for a psych consult, nor any progress notes that he has had psych visits." Review of Resident #3's Behavior monitoring Form for Anti-Psychotic Medications dated December, 2011 revealed the following: Resident #3 received [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Review of Resident #3's Behavior Monitoring Form for the month of December, 2011 revealed no specific behaviors listed or monitored, i.e. auditory versus visual hallucinations. Review of Resident #3's Behavior Monitoring Forms for the months of October, November and December, 2011 revealed he was monitored daily for Side Effects (including [MEDICAL CONDITION] and Headaches) of [MEDICATION NAME], and [MEDICATION NAME]. The daily entries on the Behavior Monitoring Forms above for those side effects reflected all zeros (0's), indicating that side effects were not observed. Review of a facility Individual Incident Tracking/Trending log for Resident #3 reflected the following information: 07/04/11 Fall Comments: [MEDICAL CONDITION] Activity, Light Headed. 07/12/11 Fall Comments: [MEDICAL CONDITION] Activity. 07/20/11 Fall Comments: [MEDICAL CONDITION] Activity. 09/13/11 Fall Comments: Possible [MEDICAL CONDITION]. 10/01/11 Fall Comments: [MEDICAL CONDITION] Activity. 10/31/11 Fall Possible [MEDICAL CONDITION] Activity. 10/31/11 Fall [MEDICAL CONDITION] Activity. Review of nurses notes for Resident #3 for the months of October, November and December 2011 revealed the following: 10/01/11 at 10:30 PM. Resident complained of bad Migraine headache. At 5:45 PM, another resident stated Resident #3 having a [MEDICAL CONDITION]. 10/31/11 at 11:45 PM. Reported [MEDICAL CONDITION] approximately 7:20 PM, [MEDICATION NAME] approximately 7 minutes on the smoking porch at facility 11/23/11 at 12:20 PM. Complained of headache, which are prodromal signs of his [MEDICAL CONDITION]. 11/27/11 at 2:15 PM. Family reported that resident had a [MEDICAL CONDITION] earlier today. 12/30/11 10:20 AM Resident observed this AM with [MEDICAL CONDITION] activity during physical therapy. Review of the facility Consultant Pharmacist's Medication Regimen Reviews for January through November, 2011 (first eleven months of resident's admission) revealed no attempt at gradual dose reduction of his anti-psychotic medication ([MEDICATION NAME]) and the following notation for each month: No recommendation specified. No recommendation. During an interview on 1/13/12 at approximately 9:00 AM, The Consultant Pharmacist stated "If the resident is on Ambien, I will do a gradual dose reduction until the doctor says no. If the resident is on anti-psychotic with a [DIAGNOSES REDACTED]. If an anti-psychotic is for dementia, we must do quarterly dosage reduction recommendations two times. If the doctor says no, then only need to request a yearly dosage reduction. If the resident is on multiple [MEDICAL CONDITION] medications and still having [MEDICAL CONDITION], its just common practice to add other [MEDICAL CONDITION] medications." C. Review of Resident #6's physician orders [REDACTED]. His diagnoses [MEDICAL CONDITION], [MEDICAL CONDITIONS], Muscle Weakness, Muscle Wasting, Mental [MEDICAL CONDITION], Convulsions, Hypertension, [MEDICAL CONDITIONS] joint Disease, Acute Pharyngitis, [MEDICAL CONDITION], Dysarthria, Abnormality of gait, [MEDICAL CONDITION]. Further review of physician orders [REDACTED]. Review of the Consultant Pharmacists' Medication Regimen Review sheet back through 7/1/11 did not reveal the Consultant Pharmacist had requested a [DIAGNOSES REDACTED]. Review of Resident #6's care plan dated 10/14/11 and reviewed 10/20/11 and 1/5/11 reflected Resident #6 was receiving [MEDICAL CONDITION] medications with a goal that he will not experience adverse side effects over the next ninety days. Approach #5 reflected that the medications would be reviewed every three months for possible dose reduction. Review of the consultant pharmacist reports from January through December 2011 reflected no recommendation for a [DIAGNOSES REDACTED]. D. Review of Resident #6's prescribed medications reflected resident had been prescribed [MEDICATION NAME] XR 50 mg one (1) TID(three times daily) on 9/30/11. On 1/3/12 resident's [MEDICATION NAME] XR was increased to 50 mg two (2) BID(twice a day). This was an increase from a total of 150 mg a day to 200 mg a day. Review of resident's Behavior Monitoring Form-Anti-Psychotic medications for [MEDICATION NAME] revealed no behaviors of cursing or combativeness for the month of December 2011. Review of physician progress notes [REDACTED]. Reflected in the 1/3/12 physician progress notes [REDACTED]. aggression, kicked someone in the facility. " The documentation on Resident #6's Behavior Monitor Forms did not reflect the same documentation by the Nurse Practioner for Resident #6's behaviors for increasing the [MEDICATION NAME] dosage. E. Review of Resident #7's Physician order [REDACTED]. Review of Resident #7's Physician order [REDACTED]. Review of the facility Monthly Summary Assessment for Resident #7 revealed the following: Date: 12/27/11 Section V - Mood and Behavior All behavior symptoms were blank and the rejection of care was none. Review of Resident #7's Behavior Monitoring Log for October, 2011 and December, 2011 did not reveal any documented behaviors. Review of the consultant pharmacist reports from January through December 2011 reflected no recommendation for a dose reduction for [MEDICATION NAME]. F. Review of Resident #9's Physicians Orders (recap) dated 1/10/12 through 1/31/12 revealed the following Diagnoses: [REDACTED]. Review of Resident #9 ' s Physician order [REDACTED]. Review of Resident #9's Behavior Monitoring form - Anti-Psychotic Medications dated November, 2011 and December, 2011 revealed the following Medication Side Effect monitoring: A. Sedation B. Drowsiness C. Dry Mouth D. Blurred Vision E. [MEDICAL CONDITION] F. Constipation G. Weight Gain H. [MEDICAL CONDITION] I. Extrapyramidal Reaction J. Tardive Dyskinesia K. Cognitive Behavior Impairment L. Akathisia M. Orthostatic [MEDICAL CONDITION] O. Pseudo Parkinsonism Review did not reveal monitoring for [DIAGNOSES REDACTED] (NMS) is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. It generally presents with muscle rigidity, fever, autonomic instability and cognitive changes such as [MEDICAL CONDITION]. Review of the [MEDICATION NAME] manufacturer's website (www1.astrazeneca-us/pi/ [MEDICATION NAME].pdf) revealed the following: "Elderly patients with dementia-related [MEDICAL CONDITION] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death. [MEDICATION NAME] XR and [MEDICATION NAME] are not approved for treating these patients. Stop [MEDICATION NAME] XR or [MEDICATION NAME] and call your doctor right away if you have some or all of the following symptoms: high fever; stiff muscles; confusion; sweating; changes in pulse, heart rate, and blood pressure. These may be symptoms of [DIAGNOSES REDACTED] (NMS), a rare and serious condition that can lead to death What is the most important information I should know about [MEDICATION NAME]? [MEDICATION NAME] may cause serious side effects, including: 1. Risk of death in the elderly with dementia 2. Risk of suicidal thoughts or actions 3. High blood sugar ([MEDICAL CONDITION]) 4. High fat levels in your blood (increased cholesterol and triglycerides) 5. Weight gain" During an interview on 1/10/12 at 2:55 PM, Corporate RN P stated that the facility did not have to try a gradual dose reduction for antipsychotic medications if the resident had a [DIAGNOSES REDACTED]. Review of the current facility Nursing Guidelines (undated) reflected the following elements: 3. Determining the need for Dose Reduction a. When the resident's behavior pattern is stable, that is, there are no instances of behaviors documented during the course of a two-month period consecutively, the consultant pharmacist will send a recommendation the the resident's physician noting this fact, and recommending a dose reduction of the Antipsychotics medication. b. The physician can order the dose reduction suggested, order an alternative dosage reduction schedule, or state that it is clinically contraindicated to adjust the dosage, with justification for this determination. c. At least once every six months, if no dosage reduction is implemented, the consultant pharmacist will send a recommendation to the residents physician noting the current dose and the behavior pattern of the resident for their review. The facility completed CMS 672 form reflected 42 residents receiving psychoactive medications. Corporate RN O provided a list of 22 residents who receive [MEDICAL CONDITION] medications.

Based on observation, interview and record review, the facility failed to ensure 4 (Resident #'s 3, 6, 8 and 12) of 13 residents reviewed for accidents/falls received adequate supervision, assistance and interventions to prevent injury when: A. Resident #3 had 12 falls between 4/15/11 and 12/29/11. The two most recent (12/9/11 and 12/29/11) resulted in a nasal bone fracture and 7 staples to the back of his head, respectfully. Although the resident had a history of [REDACTED]. B. Resident #8 had 14 falls between 2/10/11 and 12/3/11. The fall on 12/1/11 resulted in the resident having 5 sutures to the back of his head. The facility plan of care was not updated after each fall for new approaches to prevent falls and the investigation reports did not reveal that his seizure medication was reviewed for contributing to the residents falls. C. Resident #6 sustained falls on 3/1/11, 4/28/11, 10/26/11, 12/26/11 and 1/9/12. D. Resident #12 sustained falls on 10/21/11, 10/28/11,11/3/11, 11/17/11, 11/26/11, 11/28/11, 11/29/11, 12/17/11, 1/1/12, 1/3/12,1/9/12 and 1/8/12. This deficient practice caused injury to Resident #3 and Resident #8, and could have contributed to multiple falls for Resident #6 and 20 and could contribute to falls with injuries to the additional 9 residents. Findings include: The administrator was informed on 1/12/12 at 4:10 PM that substandard quality of care had been identified in the area of accidents. A. Review of Resident #3's Record of Admission revealed the following information: Resident #3 is a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's physician orders [REDACTED]. 1) Trileptal (anti-convulsant used to treat seizures) 300 milligrams (mg), give 3 tablets to equal 900 mg BID (two times a day), ordered 12/31/10 Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for Trileptal: Central Nervous System: Fatigue, feeling abnormal, abnormal gait, abnormal co-ordination, confusion, anxiety, amnesia, aggravated seizures, impaired concentration. Musculoskeletal: Muscular weakness. 2) Vimpat (anti-convulsant)100 mg., one by mouth two times a day, original order on 7/19/11, and increased on 12/30/11 to: Vimpat (anti-convulsant) 100 mg, give 1 tablet every morning, and 1 and 1/2 tablets (150 mg) by mouth every hour of sleep. Review of manufacturer's specifications reflected the following adverse reactions for Vimpat: Patients should be advised that Vimpat may cause dizziness, ataxia (defective muscular coordination), and syncope (transient loss of consciousness, fainting). The most common adverse reactions were dizziness, headache, nausea, and diplopia (double, blurred vision). 3) Zonegran (anti-convulsant) 100 mg, give 1 capsule by mouth BID, ordered 11/15/11. Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for Zonegran: Central Nervous System: Headache, dizziness, confusion, mental slowing, anxiety, nervousness, fatigue, incoordination. Other: Flulike syndrome, accidental injury. 4) Dilantin (anti-convulsant) 100 mg, give 6 capsules to equal 600 mg by mouth every hour of sleep on Monday, Tuesday, Wednesday, Thursday, Friday, and: Dilantin (anti-convulsant) 100 mg, give 5 capsules to equal 500 mg by mouth every hour of sleep on Saturday, Sunday, ordered 8/22/11. Review of Lippincott Nursing Drug Handbook (2006) reflected the following adverse reactions for Dilantin: Dizziness, nervousness, headache, mental confusion, decreased coordination. Review of Resident #3's Individual Incident Tracking/Trending Report revealed he had 10 falls during 2011 (4/15, 5/5, 7/4, 7/12, 7/20, 9/13, 10/1, 10/31, 10,31, and 12/29), and Resident #3's nurse's notes for that period revealed 2 additional falls (10/15 and 12/9) for a total of 12 falls between 4/15/11 and 12/29/11. Review of the fall on 12/09/11 revealed injuries including a fractured nasal bone, abrasions and bruises. Review of the fall on 12/29/11 revealed injuries including 7 staples to a laceration to the back of the resident's head. Review of Resident #3's Care Plan dated 12/9/11 for History of Falls was updated to reflect the falls on 12/9/11 and 12/29/11, but no new interventions or approaches were addressed in an effort to identify or reduce contributing factors for falls and future falls. Review of each Resident Incident/Accident Report revealed a space for documentaion and Review of Medications. The boxes were checked indicating Resident #3 was on Anti-Depression and Behavior Medications. The space for medication review had no documentation of the (4) anti-seizure medications, nor documentation to indicate observation for side effects that could contribute to falls. Review of facility Individual Tracking/Trending log and Incident and Accident Reports revealed Resident #3 experienced falls as follows: 04/15/11 Fall Tripped on chair when standing. 04/15/11 at 11:50 AM. Tripped on table. Abrasions to left side of face. Abnormal labs: Sodium level low secondary to Trileptal. 05/05/11 Fall Fall after smoking and standing up. 05/05/11 at 11:30 AM. Started shaking and legs and body fell and hit left side of head on patio table and then hit head on concrete. Lost Leg Support. Resident observed laying on concrete back patio with abrasion, hematoma (bruising) to left side of forehead, unresponsive for 1 minute, 911 called for transport. 07/04/11 Fall Seizure Activity, Light Headed. 07/04/11 at 08:45 AM. Resident found sitting on floor at bedside. States became lightheaded and went to floor. Observed abrasion to left side of face with hematoma to forehead. 07/12/11 Fall Seizure Activity. 07/12/11 at 01:45 PM. Resident stated had seizure and fell and hit head. Bump on right front head. New medication started: Vimpat 100 mg, one by mouth BID. Review of Resident #3's Care Plan dated 9/27/11 and updated 12/1/11 revealed the following: Problem: Resident has history of seizures. Goal: Safety will be maintained with the occurrence of any seizure over the next 90 days. Approach: Monitor for warning signs to prevent seizures. Assure direct care staff are aware of resident's history. During an interview on 01/13/12 at 10:00 AM, Certified Nurse Aide (CNA V) stated, "Resident #3 is really pretty much independent. We just supervise him in the shower, but he does everything for himself. I had been taking care of him for a few months, before anyone told me about his seizures. Apparently, he just blacks out when he has a seizure. Nobody told me he had seizures, or what to watch for, or what to do before that fall (12/29/11) happened. If I had known about his seizures, I would have watched him more closely." 07/20/11 Fall Seizure Activity. 09/13/11 Fall Possible Seizure. Possible seizure activity on 09/13/11 at approximately 9:10 PM. Found Resident #3 lying on right side of concrete floor on smoking porch. Cleaned and steri-stirpped small 1/2 inch laceration to right forehead. 10/01/11 Fall Seizure Activity. 10/01/11 at 05:45 PM. Found on left side on floor in room. States "just fell over when I stood up, caught myself with my hands and laid down on floor." New order: Check Dilantin levels every 3 months, monitor levels on consistent basis. This was the first time Dilantin levels had been ordered on a routine basis. 10/15/11 (time left blank). Nurse notified that resident out side on smoke patio with blood all over his face. Puddle of blood found in room. Resident states, "does not remember falling". Laceration (skin cut) to left forehead. 10/31/11 Fall Possible Seizure Activity. 10/31/11 at 11:00 AM. Found sitting up in his bathroom floor. Appears he did have a seizure and fell in bathroom. Nurse received order for Zonegran 100 mg by mouth everyday times 2 weeks, then 100 mg BID thereafter. 10/31/11 Fall Seizure Activity. 10/31/11 at 07:20 PM. Reported that Resident #3 was lying on the smoke porch, having a seizure for 7 minutes. No apparent injuries. Review of Resident #3's Care Plan dated 10/1/11 and updated 12/1/11 revealed the following: Problem: I had a fall and at risk for further falls. 10/1/11: Seizure Activity causes falls. 10/31/11 Found in floor, did not know what happened. 10/31/11 Found outside on patio, reports resident had seizure. New Approaches: Prescriptions per order for seizures. Educate resident on warning signs of seizure. Tell nurse when you have a headache. Notify Neurologist as needed. During an interview on 01/10/12 at 5:00 PM, Resident #3 stated, "The last time I fell , the only thing I can figure is that I had one of my seizures. My seizures are pretty much contained; I don't have any pre-warning. I never know when a seizure will hit." During an interview on 01/11/12 at 9:10 AM, the Occupational Therapy Assistant stated, "We started Resident #3 on physical therapy and occupational therapy mid November, 2011, due to multiple falls in October. We are unsure if they are seizure related, and think some are due to balance. He is not safe. He continues to get headaches and gets fatigued easily." During an interview on 01/11/12 at 4:20 PM, Resident #3's PCP stated, "Resident #3 has seizures without warning. He has no aura or warning, so that staff would know to try to get him to a position of safety. Maybe general training regarding seizures may be of benefit to alert staff to intervene, to get him protected. Most of his episodes are unwitnessed. As far as his medications, and the side effects (incoordination) of the anti-seizure medications, we leave that up the neurology specialist." During a telephone interview on 01/10/12 at 4:00 PM, Resident #3's neurologist's office stated, "He was last seen in the clinic on 7/12/11 for seizures and to check his levels (therapeutic blood levels of anti-seizure medication). We recommended another appointment in 3 months. The appointment was scheduled three different times, but the patient, or family canceled twice, and the 3rd time, he just didn't show up." B. Review of Resident #8's facility Individual incident Tracking/Trending revealed the following falls: 12/24/11 Found sitting on floor Skin Tear to right forearm self-transfers 12/30/11 Found sitting in floor Laceration to right brow 1/5/12 Found on floor in room No injuries Further review of the Individual Incident Tracking/Trending revealed the resident had fallen twelve (12) times between 2/10/11 and 12/3/11 (2/10/11, 4/18/11, 7/8/11, 2 falls on 8/6/11, 8/8/11, 8/12/11,9/5/11, 9/7/11, 9/23/11, 10/4/11, 11/29/11, 12/3/11. Review of Resident #8's incident/accident report dated 12/1/11 revealed the following: "Resident found sitting on floor in room beside dresser calling for help. states "I just fell ". Resident was sent to ER. Received 5 sutures to right scalp laceration". The incident/accident report did not list his anti-seizure medication, Dilantin, when medications where reviewed for the incident. Review of a Lippincott Nursing Drug Handbook 2010 revealed the following adverse effects for Dilantin (Phenytoin-anticonvulsant medication): Ataxia (lack of coordination), decrease coordination, mental confusion, slurred speech, dizziness, headache, insomnia, nervousness, and twitching. Review of facility Incident/Accident Reports for the falls on 2/10/11, 4/18/11, 7/8/11, 2 falls on 8/6/11, 8/8/11, 9/5/11, 9/17/11, 9/23/11, 10/7/11, 11/29/11, and 12/3/11 did not reveal that the anticonvulsant medication was reviewed to see if it contributed to his falls. Anti-convulsant's are not listed on the report and not written in the blanks. Review of Resident #8's incident/accident report dated 12/3/11 revealed Resident #8 was found sitting in recliner bleeding from a skin tear to his right forearm. When asked if fell , states " yeah " . Review of Resident #8's Comprehensive Plan of Care dated 12/3/11 with a follow-up date of 12/15/11 did not reflect the falls on 12/24/11, 12/30/11, and 1/5/12. The Care Plan revealed the following approaches: 12/3/11 Problems/Needs: I had a fall and I am at risk for further falls. Found on floor by recliner. Approaches: I need the nurses to: 1. Allow me to do the things I can but to realize when I cannot do something for myself and help me with that task. some days I may be able to do more than others. 2. Make sure my call light is in my reach and come to my room quickly when I need them. 3. Anticipate when I might need something from you 4. Keep my room clean, no trash in the floor that I might fall over 5. Help me with dressing, showering, getting into and out of my chair. 6. Let therapy know if there is a change in my abilities so that they can help me to maintain strength and abilities as long as possible 7. Let my Dr. know if there is a major change in my abilities. 8. Review and update interventions on my careplan if I have a repeat fall. 9. Educate use of call light 10. Teach use of recliner lift chair. 11. Alarm to chair or bed. The Comprehensive Plan of Care(for Resident #8) dated 12/3/11 revealed the following approaches with a date of the survey exit of 1/13/12: Sensory pad alarm applied to recliner, wheelchair and bed. Physician to review medications regimen. Review of facility Incident Investigation Report dated 9/17/11 for Resident #8 revealed the following: List interventions in Place to Prevent Incident: CL (Call Light) in reach (although resident unable to use) Staff making frequent checks List Interventions Needed to Prevent Recurrence: Care plan Initiated/Modified Checked Try educate resident to use call light Chair Alarm for Wheelchair and Recliner, Side rails for Bed to deter self-transfers Review of facility Incident Investigation Report dated 12/3/11 revealed the following: List interventions in Place to Prevent Incident: Frequent checks on resident due to frequent falls Wheelchair mobility List Interventions needed to prevent recurrence: Counsel Staff Checked Care plan Initiated/Modified Checked Continue checks, Chair alarm to alert staff to self-transfers Review of Resident #8's Comprehensive Plan of Care dated 9/14/11 with a reviewed date of 12/15/11 revealed the following: Resident is in a Restraint Free Environment as Evidenced by: The Bed Alarm is marked as in use; however, the Chair Alarm is not marked as in use. C. Review of an incident/accident report for Resident # 6,dated 10/26/11, reflected the following: Clinical Assessment of Occurrence: He was in his room in wheelchair playing with his cards. Cards on floor and apparently fell when he went to pick up the cards. He doesn't use the call light. List interventions needed to prevent recurrence: Place a wheelchair alarm. Possibly place the things that he plays with on a table that doesn't move. Review of the facility incident/accident report for Resident # 6, dated 12/27/11, reflected the following elements: Clinical Assessment of Occurrence: Unknown, but possibly hit hand when striking out at someone.. List interventions needed to prevent recurrence: Document all behaviors of striking out at staff. Be patient with resident when he is upset. Review of the incident/accident report dated 1/9/12 reflected the following element: Clinical Assessment or occurrence: blank, no assessment List interventions needed to prevent recurrence: blank, no new interventions Review of Resident #6's care plan, reviewed on 9/26/11, 10/1/11, and 10/26/11 for falls did not reflect a chair alarm was placed on Resident #6's wheelchair as indicated on the list of interventions on the incident/accident report dated 12/17/11. It further did not address the fall on 1/9/12 or list new approaches to prevent falls. D. Review of the facility Individual Incident Tracking/Trending log for Resident #12 revealed resident sustained [REDACTED]. Review of an incident/accident report for Resident #12,dated 10/21/11, reflected the following: Clinical Assessment of Occurrence: Patient noted by staff nurse sliding until he slid from geri chair; he appeared to do so purposely. List interventions needed to prevent recurrence: Careplan Initiated/Modified-checked Since this seems to be one of the behaviors he periodically is prompted re-directed not to do he may need Care Plan in place for this behavior. Review of an incident/accident report for Resident # 12,dated 10/28/11, reflected the following: Clinical Assessment of Occurrence: Resident found in dining room on floor laying on Left side on floor in front of geri chair. List interventions needed to prevent recurrence: Careplan Initiated/Modified-checked. No intervention listed to prevent recurrence. Staff available to meet needs. Resident kept in eye sight of staff. Review of an incident/accident report for Resident # 12,dated 11/03/11, reflected the following: Clinical Assessment of Occurrence: Report resident slid out of geri chair with involuntary movements. Denies injury or pain. Witness reports that he did not hit his head. No apparent injuries. List interventions needed to prevent recurrence: Careplan Initiated/Modified-not checked. Offer assist as needed. Patient education given to ask for assistance when needed. Monitor for proper positioning. Added Depon under geri chair cushioning to prevent slipping. Review of an incident/accident report for Resident # 12,dated 11/17/11, reflected the following: Clinical Assessment of Occurrence: Resident found sitting up right on floor in front of restroom yelling, " Hey, hey, I ' m ready to eat. " Denies falling, denies hitting head. No signs/symptoms of any injuries. List interventions needed to prevent recurrence: Careplan Initiated/Modified-not checked. No intervention listed to prevent recurrence. Review of incident/accident report for Resident # 12, dated 11/26/11, reflected the following: Clinical Assessment of Occurrence: fell off geri chair by nurses ' station. Brief waist restraint loosely intact. List interventions needed to prevent recurrence: Careplan Initiated/Modified-Counsel Staff. Offer toileting Q (every) 2 hours and PRN (as needed). PRN prescription for anxiety. Ensure proper positioning of brief waist restraint when getting up in chair. Review of incident/accident report for Resident # 12, dated 11/28/11, reflected the following: Clinical Assessment of Occurrence: Resident was seen in hallway. When staff went to get resident, resident scooted back into room per report. List interventions needed to prevent recurrence: Counsel Staff When resident awake, have out of room for observation. Offer toileting Q2 hours and PRN. Review of incident/accident report for Resident # 12, dated 11/29/11, reflected the following: Clinical Assessment of Occurrence: Resident slid out of geri chair, observed light impact of chair to residents back. Chair did " topple " over with resident. No injuries. List interventions needed to prevent recurrence: Careplan Initiated/Modified checked. No intervention listed to prevent recurrence. Review of incident/accident report for Resident # 12, dated 12/10/11, reflected the following: Clinical Assessment of Occurrence: Resident has continuous spastic involuntary movement that becomes severe when patient is agitated or upset. List interventions needed to prevent recurrence: Monitored closely by the nurses ' station. Medications given to calm him down like Ativan and Roxinal. List interventions Needed to Prevent Recurrence: Careplan Initiated/Modified checked. No intervention listed to prevent recurrence. Review of incident/accident report for Resident # 12,dated 12/17/11, reflected the following: Clinical Assessment of Occurrence: No Clinical assessment of Occurrence recorded.. List interventions needed to prevent recurrence: Pelvic restraint. List Interventions Needed to Prevent Recurrence: Nothing Checked. No intervention listed to prevent recurrence. Review of Resident #12's care plan, reviewed on 10/14/11, 10/15/11, 10/25/11, 10/28/11, 11/3/11 and 11/8/11 for falls was updated on 10/15/11, 10/25/11 and 11/8/11. Care plan was not updated, on 10/21/11,10/28/11,11/26/11 and 11/28/11 as checked on Incident Investigation forms under " Careplan Initiated/Modified. " On Incident Investigation forms under " List Interventions Needed to Prevent Recurrence: Careplan Initiated/Modified was not checked and no Interventions were documented to prevent recurrence on incidents that occurred on 11/17/11 and 12/17/11. During an interview on 1/10/12 at 2:55 PM, Corporate Nurse, RN P stated that the facility has a Standards of Care meeting weekly and discuss falls and recommendations to prevent the falls. The Standards of Care minutes were not offered to the surveyors for review. RN P stated that someone from the facility reports to her the interventions (approaches) to use for falls and she approves them. Thirteen (13) residents were reviewed for falls and accidents.