Every finding on record at Avir at Kaufman

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) observed for infection control. The facility failed to ensure the Treatment Nurse wore a gown when providing wound care to Resident #1. This failure could place residents and staff at risk for MDROs, cross-contamination, spread of infection and could potentially affect all others in the building.Findings Include:1. Record review of the face sheet dated 2/9/26 indicated Resident #1 was [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including stage IV pressure ulcer (severe, full-thickness wound extending through the skin to expose muscle, bone, , tendon, or fascia and high infection risk), diabetes, osteoarthritis (chronic degenerative joint disease where the cartilage breaks down, causing pain, stiffness, and reduced-mobility), and coronary atherosclerosis (hardening of the coronary arteries due to plaque build-up). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 had 1 stage IV pressure ulcer that was present on admission. Record review of the undated care plan indicated Resident #1 had a stage IV pressure ulcer to his left calf that was present on admission. The care plan indicated Resident #1 was on EBP, and staff must use a gown and gloves during high-contact resident care activities that could possibly result in transfer of MDROs to hand and clothing of staff. During an observation on 2/9/26 at 10:33 a.m. the Treatment Nurse performed wound care on Resident #1. PPE for EBP observed outside Resident #1's door. Treatment Nurse knocked on Resident #1's door, explained she was there to perform wound care, performed hand hygiene, opened supplies, put on clean gloves, and did not put on a gown. The Treatment Nurse removed dressing from Resident #1's wound to his left lateral calf, changed gloves, and performed hand hygiene. The Treatment Nurse cleansed the wound to Resident #1's left lateral calf, changed gloves, and performed hand hygiene. The Treatment Nurse applied Xeroform (a sterile, non-adhering, petroleum-based gauze dressing) to Resident #1's left lateral calf wound, covered with a clean dressing, disposed of trash, removed gloves, and performed hand hygiene. During an interview on 2/9/26 at 10:40 a.m. the Treatment Nurse said residents with wounds required EBP including gowns and gloves. The Treatment Nurse said she did not wear appropriate PPE (a gown) during Resident #1's wound care because it slipped her mind. The Treatment Nurse said the importance of adhering to the proper EBP was for infection control and to prevent spreading infection or germs to other residents. During an interview on 2/9/26 at 1:52 p.m., the DON said EBP was required for residents with indwelling medical devices and chronic wounds. The DON said EBP for wound care included PPE of a gown and gloves always and goggles or face shield if there was a risk for splashing of exudate (drainage that seeps out of wounds). The DON said the importance of EBP was to prevent the spread of MDROs and to protect the residents from infections. Record review of the facility's Enhanced Barrier Precautions policy revised February 2025 indicated, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident activities.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. The facility did not ensure:1. Food items were labeled and dated.2. The microwave was clean and free of food debris.3. The juice machine spigot was free from a red gooey substance where the juice was dispersed4. The cups, bowls and plate domes were stacked with water pooled between them. 5. The outside of the ice machine was clean. 6. Ice scoop holder was clean. 7. eggs were pasteurized.8. Drinks and food temps not taken after heating or reheating. 9. The Dietary Manager checked the chlorine level in the correct dishwasher cycle. These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 01/05/26 beginning at 10:54 a.m. the following was revealed: 1. Clear container of cherries that was identified by the Dietary Manager unlabeled and undated. 2. Clear container of fruit loops that was identified by the Dietary Manager unlabeled and undated. 3. A pitcher of orange juice that was identified by the Dietary Manager unlabeled and undated. 4. A pitcher of cranberry juice that was identified by the Dietary Manager unlabeled and undated. 5. A pitcher of tea that was identified by the Dietary Manager unlabeled and undated. 6. (8) loaves of wheat bread with no received date. 7. (4) packages of hamburger buns with no received date. 8. (1) package of tortillas with no open date. 9. A box of tea filter pouches with no open date. 10. A box of 108 eggs that were unpasteurized. 11. Inside the microwave had a yellow buildup. 12. The juice machine spigot with a thick gooey red substance. 13. The cups, bowls and plate domes were stacked and remained wet with water pooled in between. 14. Ice machine with a white substance. 15. The bottom of the ice machine scoop holder had a wet brownish gooey substance. 16. During an observation on 01/05/26 at 11:15 a.m., the Dietary Manager ran a cycle in the dishwasher to heat up the water. After the cycle completed she tested the chlorine which read less than 10 ppm. The Dietary Manager placed the dirty dishes in the dishwasher and started the cycle. During an interview on 01/05/26 at 12:40 p.m., Resident #26 stated 99.5% of the time she ate scrambled eggs. Resident #26 stated she rarely asked for a fried egg. 17. During an observation on 01/06/26 at 11:27 a.m., the Dietary Manager prepared the pureed beef stroganoff, noodles, green beans, and a roll and placed them on a divided plate. The Dietary Manager placed the plate in the microwave for one minute. The Dietary Manager then removed the divided plate from the microwave and checked the temperature of the beef stroganoff, which revealed a temperature of 125. The Dietary Manager placed the plate back in the microwave for another minute and rechecked the stroganoff, which revealed a temperature of 140, and placed the plate on the steam table. The Dietary Manager never checked the temp the noodles, green beans, or the roll. 18. During an observation and interview on 01/06/26 at 11:44 a.m., Dietary Aide N placed Resident #13's glass of sweet tea that was identified by Dietary Aide N in the microwave to be heated for one minute. Dietary Aide N did not temp the tea before handing it to Resident #13. Dietary Aide N stated he was taught by the Dietary Manager to heat up the beverage for no more than one minute but was never told to check the temperature before serving it to the resident. Dietary Aide N stated he did not know the temperature on how hot the beverage could be. Dietary Aide N stated it was important to tempt the beverage to prevent burns. During a telephone interview on 01/08/26 at 9:58 a.m., the Sale Service Representative for the dishwasher stated he came in on Monday (01/05/26) and showed the Dietary Manager what cycle to check the chlorine. The Sale Service Representative stated the chlorine should be checked during the second cycle and the test strip should be read between 50-100 ppm. The Sale Service Representative stated it was important to ensure the chlorine was checked at the right cycle to prevent potential food hazards. During a telephone interview on 01/08/26 at 10:27 a.m., the Dietician stated she was in another facility and would call the state surveyor back. The Dietician did not return the state surveyor call. During an interview on 01/08/26 at 12:39 p.m., Dietary Aide M stated all staff were responsible for labeling and dating. Dietary Aide M stated the aides were responsible for cleaning the microwave every two days and the cooks were responsible for cleaning the juice nozzle. Dietary Aide M stated cups, bowls and dome covers should be air dried first before stacking. Dietary Aide M stated the aides were responsible for cleaning the ice scoop holder after every meal. Dietary Aide M stated the chlorine should be checked in the dishwasher after the second cycle and the test strip should read 50-100 ppm. Dietary Aide M stated he was taught by the previous Dietary Manager how to check the chlorine when running the dishwasher. Dietary Aide M stated these failures put residents at risk for food borne illness and cross contamination. During an interview on 01/08/26 at 12:47 p.m., [NAME] O stated all staff were responsible for labeling and dating. [NAME] O stated all staff were responsible for cleaning the microwave and juice nozzle dispenser after every use. [NAME] O stated cups, bowls and dome covers should be air dried first before stacking. [NAME] O stated the aides were responsible for cleaning the ice scoop holder daily. [NAME] stated these failures could possibly cause food borne illness and cross contamination. During an interview on 01/08/26 at 1:01 p.m., the Dietary Manager stated cleanliness was important in the kitchen, so staff were not spreading germs or contaminating anything. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately. The Dietary Manager stated all food should be labeled and dated by the date received and the date it was opened. The Dietary Manager stated all staff were responsible for cleaning the microwave and juice nozzle. The Dietary Manager stated she did not know the eggs were unpasteurized until the state surveyor intervention. The Dietary Manager stated Resident #26 sometimes asked for her eggs medium sunny side up. The Dietary Manager stated she could not remember the last time she requested them. The Dietary Manager stated cups, bowls and dome covers should be air dried first before stacking. The Dietary Manager stated the aides should clean the ice scoop holder every day. The Dietary Manager stated the sales representative came in and ensured she knew when to check the chlorine. The Dietary Manager stated she did check the chlorine on the second cycle whenever she runs the dishwasher but was nervous on 01/05/26 when the state surveyor was present. The Dietary Manager stated the Maintenance Supervisor was responsible for cleaning the outside of the ice machine. The Dietary Manager stated she should have checked the temp of the noodles, green beans, and the roll after she heated it up the first time. The Dietary Manager stated she was unaware that she should have reheated the food on a constant heat source such as the stove or oven for 15 seconds to get a temperature of 165 before serving. The Dietary Manager stated Dietary Aide N should have check the temp of the beverage and ensure the temperature was 140. The Dietary Manager stated it was important to ensure the beverages and food was the correct temp to prevent hot spots. The Dietary Manager stated she was responsible for monitoring and overseeing daily walk throughs and when there was an isolated issue that staff were verbally in service and if a widespread issue a paper in service was completed. The Dietary Manager stated these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 01/08/26 at 1:45 p.m., the Maintenance Supervisor stated him, and the dietary staff were responsible for cleaning the outside of the ice machine. The Maintenance Supervisor stated he cleaned it weekly. The Maintenance Supervisor stated he cleaned it on Monday after surveyor intervention but could not recall the exact date before that. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated food items should be labeled and dated. The Administrator stated kitchen equipment should be cleaned daily for sanitization purposes. The Administrator stated eggs should be pasteurized. The Administrator stated dietary staff should check the temperature after heating and reheating beverage or food. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator stated these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Food Preparation and Service revised 11/2022 reflected. Food and nutrition services employees prepare, distribute, and service food in a manner that completed with safe food handling practices. 2. Potential Hazardous Food. Unpasteurized eggs. Food Preparation, Cooking and Holding Time/Temperatures.5. Food thermometers used to check food temperatures. 9. Previously cooked food was reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds before for hot service. Record review of the facility's policy titled, Food Receiving and Storage revised 11/2022 reflected. Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage. 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated . Record review of the undated facility's policy titled, Cleaning Dishes/Dish Machine . All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Procedure (1). Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified.

Based on observations, interviews, and record review, the facility failed to establish and 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 6 of 6 residents (Resident #'s 27, #36, #15, #9, #41 and #13) reviewed for infection control.1. The facility failed to ensure CNA K performed hand hygiene while providing incontinent care for Resident #27 on 01/06/26.2. The facility failed to ensure CNA N and CNA L wore PPE when providing care for Resident #36.3. The facility failed to ensure CNA G and CNA H performed hand hygiene while providing incontinent care for Resident #15 on 01/06/26.4. The facility did not ensure RN B performed hand hygiene prior to administering Resident #9's medications.5. The facility did not ensure MA C cleaned the glucometer between Resident #41 and Resident #13's blood pressure. This failure could place residents at risk for cross-contamination and the spread of infection.Finding included: 1.Record review of Resident #27's face sheet, dated 01/08/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include rhabdomyolysis ( the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood), dementia (a loss of mental functioning such as, thinking, memory, mood and behavior), and diabetes (high blood sugars). Record review of Resident #27's quarterly MDS assessment, dated 11/24/25, indicated Resident #27 understood and was usually understood by others. Resident #27's BIMS score was 05, which indicated her cognition was severely impaired. The MDS indicated Resident #27 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was incontinent of bowel and bladder. Record review of Resident #27's comprehensive care plan, revised on 10/06/25, indicated that Resident #27 had an alteration in ADL function related to rhabdomyolysis and weakness. The intervention was for 1 staff member to assist with toileting. During an observation on 01/06/26 at 9:11 a.m., CNA K provided incontinence care for Resident #27. CNA K wiped Resident #27's peri area and then assisted to turn her on her left side without hand hygiene or changing her gloves. CNA K wiped her buttocks using the same wipe and wiping side to side, then applied a clean brief with the same gloves on. CNA K then changed her gloves but did not perform hand hygiene, assisted in turning Resident #27 to her back, touching her stuffed animal and linen without hand hygiene. During an interview on 01/06/26 at 9:25 a.m., CNA K said she did not perform hand hygiene or change her gloves after wiping Resident #27, then touching the resident, clean brief, stuffed animal, and linen with dirty gloves. She said she knew that without hand hygiene or removing dirty gloves could cause cross-contamination and infection. During an interview on 01/07/26 at 1:00 p.m., LVN A said she was Resident #27's nurse. She said she expected staff to provide incontinent care to keep the residents clean. She said she expected them to practice hand hygiene and change gloves when soiled. She said without proper hand hygiene, wiping the correct way, and touching other objects could cause infection and or bacteria. She said Resident #27 did not have signage or a cart placed on her door or outside her room. She said Resident #27 was on EBP. She said if staff were not wearing proper PPE (gown and gloves), it could cause infection and or bacteria. She said that after the staff told her they were going to provide incontinent care, she went and told management about the signage and cart for Resident #1. 2. Record review of Resident #36's face sheet, dated 01/08/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, also called COPD (is a progressive lung disease that causes restricted airflow and breathing problems), kidney failure, also known as renal failure or end-stage renal disease (ESRD), (a medical condition in which the kidneys can no longer adequately filter waste products from the blood), and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs such as: euphoria, to depressive lows such as: sadness, significantly impacting daily functioning, work, and relationships). Record review of Resident #36's admission MDS assessment, dated 10/15/25, indicated Resident #36 understood and was usually understood by others. Resident #36's BIMS score was 09, which indicated her cognition was moderately impaired. The MDS indicated Resident #36 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was incontinent of bowel and bladder. Record review of Resident #36's comprehensive care plan, dated 09/24/25, indicated, Resident #36 had dialysis related to ESRD. The intervention for staff was to provide enhanced barrier precautions related to the dialysis port. Record review of Resident #36's comprehensive care plan, dated 09/24/25, indicated, Resident #36 had altered ADL function and was incontinent of bowel and bladder. The intervention was for one staff member to assist with toileting. Record review of Resident #36's Physician order dated 11/21/25 indicated Hemodialysis to the left subclavian Quinton catheter (involves surgically implanting a port under the skin in the chest, with the catheter tunneled into the left subclavian vein). Record review of Resident #36's Physician order dated 11/21/25 indicated dialysis performed on Monday, Wednesday, and Friday with a chair time of 5:30 pm till 9:30 pm. During an observation and interview on 01/06/26 at 10:45 a.m., Resident #36 had an EBP sign on her door, but no PPE (gown or gloves) was noted in the bins outside of the room. Resident #36 said she went to dialysis. Resident #36 said the staff does not wear gowns when they provide incontinent care. During an interview on 01/07/26 at 8:24 a.m., CNA N said she was Resident #36's aide at times. She said when she provided care, she wore gloves and a mask but no gown. She said she was not aware she needed to wear gowns for Resident #36. She said she had been trained on the EBP on an unknown date. During an interview on 01/07/26 at 1:07 p.m., CNA L said she was Resident #36's aide. She said she was not aware that Resident #36 required PPE when providing care. She said she was usually aware if someone required a certain type of PPE by a sign on the door and the bin outside the room. CNA L and the state surveyor went to Resident #36's door and identified a sign for EBP on the door, and CNA L read the sign and said she was supposed to wear a gown and gloves when caring for Resident #36. She said that since she had not worn PPE (gown), she placed the resident at risk of infection. During an interview on 01/07/26 at 2:10 p.m., LVN A said she was Resident #36's charge nurse. She said she was aware Resident #36 was on EBP. She said she usually gave in report if a resident was on EBP or any changes. She said the staff was aware Resident #36 was on EBP precautions. She said that without the proper PPE, it could cause an infection for the residents. During an interview on 01/08/26 at 1:08 p.m., the ADON said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between dirty to clean and use hand hygiene between glove changes. She said she and the DON oversaw the infection control process. She said she was not aware that Resident #36's bin was not filled on 01/05/26. She said staff should change gloves, practice hand hygiene, and wear proper PPE (gown and gloves) when caring for residents on EBP to prevent infection and cross-contamination. She said they had quarterly in-services on hand hygiene and EBP. During an interview on 01/08/26 at 2:11 p.m., the Administrator said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with care. He said if a resident required EBP he expected them to wear gown and gloves. The Administrator said the DON and nurse management were responsible for ensuring staff were trained on incontinent care, hand washing, EPB, and infection control. He said improper hand hygiene and not wearing the proper PPE (gown and gloves) could place residents at risk for cross-contamination or potential infection. Record review of the competency check-off reflected that CNA K had completed her training for hand washing and incontinence care on 12/16/25. Record review of in-service on hand hygiene and EBP was dated 12/21/25. 3.Record review of a face sheet dated 01/08/26 indicated Resident #15, a [AGE] year-old female, was admitted on [DATE] and readmitted on [DATE] with the diagnosis of cerebral infarction due to occlusion or stenosis of small artery (stoke because a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). Record review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 required depended assistance toileting hygiene, including perineal hygiene before and after voiding or bowel movement and was always incontinent of bowel and bladder. Record review of Resident #15's care plan dated 09/18/25 revealed Resident #15 was fed via PEG tube and on enhanced barrier precautions, with staff instructed to monitor the PEG tube/g-tube site for signs and symptoms of infection. During an observation on 01/06/26 at 9:39 a.m., incontinent care was provided for Resident #15 by CNA G and CNA H. CNA G failed to perform hand hygiene and change gloves when hands were visibly soiled. CNA H used the same gloves to clean both the front and back perineal areas following a bowel movement. During an interview on 01/06/26 at 9:50 a.m., CNA G stated proper hand hygiene and glove changes are necessary to prevent infection and stated she should have changed gloves and performed hand hygiene between care tasks. CNA G reported she did not recall the most recent in-services on hand hygiene or incontinent care. During an interview on 01/06/26 at 9:55 a.m., CNA E stated this is my first day on the job and training and acknowledge the risk to resident when proper hand hygiene is not performed. During an interview on 01/08/26 at 2:13 p.m., the ADON stated she expects all care staff to follow enhanced barrier precautions, including use of appropriate PPE (gloves, mask, and gown) when providing care for Resident #15. The ADON confirmed PPE is required to prevent the spread of infection and acknowledged responsibility of infection preventionist activities along with the DON. The ADON reported conducting routine quarterly hand washing audits when delegated by the DON. During an interview on 01/08/26 at 2:28 p.m., the Administrator stated staff are expected to wear EBP when proving care and perform hand hygiene before and after care and when hands are soiled. The Administrator reported that nursing administration conducts quarterly audits and in-services to PPE and hand hygiene. 4. During an observation and interview on 01/05/26 at 3:16 p.m., RN B put on a gown outside the room, entered Resident #9's room, applied a mask and gloves and grabbed the IV medication and started preparing for administration. RN B did not perform hand hygiene prior to applying the mask. RN B stated she should have performed hand hygiene before touching the mask. RN B stated she was nervous due to the state surveyor being present. RN B stated it was important to perform proper hand hygiene to prevent the spread of infection. 5. During an observation and interview on 01/06/26 at 8:45 a.m., MA C used the automatic wrist blood pressure monitor to check Resident #41's blood pressure. After using the blood pressure monitor, MA C placed the blood pressure monitor on top of the medication cart without disinfecting it. MA C administered Resident #41's medications. MA C then took the automatic wrist blood pressure monitor and checked Resident #13's blood pressure. After using the monitor, MA C placed the monitor back on the medication cart without disinfecting it. MA C stated she should have sanitized the blood pressure monitor between each resident. MA C stated she was nervous because the state surveyor was present. MA C stated it was important to disinfect between each use to prevent cross contamination. During an interview on 01/08/26 at 1:54 p.m., the RNC stated prior to the nurse donning (on) full PPE hand hygiene should have been performed. The RNC stated his expect staff that utilized reusable equipment to be sanitized before and after use between each resident. The RNC stated the DON or designee were responsible for monitoring and overseeing infection control compliance, policy and procedures. The RNC stated it was important to ensure infection control practices were followed to prevent cross contamination between residents when providing care. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he expected hand hygiene to be performed after entering the room and sanitize the blood pressure [NAME] between residents. The Administrator stated the nursing administration was responsible for monitoring infection control compliance by spot checks. The Administrator stated it was important to ensure infection control practices were followed to prevent the spread of infection. Record review of a Handwashing competency check off reflected that RN B had completed her training for hand washing on 12/13/25. Record review of the facility's policy titled Handwashing/Hand Hygiene last revised on 01/2025, reflected. This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. 1. All personal are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practice to help prevent the spread of infections to other personnel, residents. Indications for hand hygiene (1) Hand Hygiene is indicated: b. before performing an aseptic task. e. after touching the resident's environment. Record review of the facility's policy titled Standard Precautions last revised on 09/2022, reflected. Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or conformed infection status. Standard precautions include the following practices: 5. Resident-Care Equipment. b. reuseable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 of 5 residents (Residents #11, # 36, #27, and #15) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was set at 2 liters per nasal cannula as ordered on 12/18/25. 2. The facility failed to have Resident #36's oxygen sign outside the door and the oxygen tube dated on 01/05/26 and 01/06/26. 3. The facility failed to have Resident #27 and Resident #15's nebulizer dated or bagged on 01/05/26 and 01/06/26. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included: 1. Record review of Resident #11's face sheet, dated 01/08/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), anxiety (a feeling of fear, dread, and uneasiness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life) and stroke. Record review of Resident #11's quarterly MDS assessment, dated 12/04/25, indicated Resident #11 usually understood and was usually understood by others. Resident #11's BIMS score was 05, which indicated she was severely impaired. The MDS indicated Resident #11 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up/supervision for eating. The MDS during the 7-day look-back period did not indicate Resident #11 was receiving oxygen. Record review of Resident #11's physician orders dated 12/18/25 indicated oxygen at 2-4 liters per minute via nasal cannula continuously. Record review of Resident #11's care plan revised date of 10/20/25, did not indicate she required oxygen. During an observation on 01/05/26 at 12:55 p.m., Resident #11 was in her bed with no oxygen in her room. No distress noted. During an observation and attempted interview on 01/06/26 at 8:15 a.m., Resident #11 was in her bed without any oxygen on. Resident #11 did not answer when asked if she wore oxygen. During an observation and interview on 01/07/26 at 2:10 p.m., LVN A said Resident #11 had an order for oxygen, but did not have any oxygen in her room. She said Resident #11 often refused oxygen, but since she had an order for oxygen, it should be in her room and applied as ordered. 2. Record review of Resident #36's face sheet, dated 01/08/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, also called COPD (a progressive lung disease that causes restricted airflow and breathing problems), kidney failure, also known as renal failure or end-stage renal disease (ESRD), (a medical condition in which the kidneys can no longer adequately filter waste products from the blood), and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs such as: euphoria, to depressive lows such as: sadness, significantly impacting daily functioning, work, and relationships). Record review of Resident #36's comprehensive care plan, dated 09/24/25, indicated, Resident #36 had oxygen related to the diagnosis of COPD. The intervention for staff was to provide oxygen as needed and change oxygen tubing, cannula/mask once a week on Sunday. Record review of Resident #36's admission MDS assessment, dated 10/15/25, indicated Resident #36 understood and was usually understood by others. Resident #36's BIMS score was 09, which indicated her cognition was moderately impaired. The MDS indicated Resident #36 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated during the 7-day look-back period, she was receiving oxygen. Record review of Resident #36's Physician order dated 11/21/25 indicated oxygen at 2-4 liters via nasal cannula as needed for shortness of breath. During an observation on 01/05/26 at 11:26 a.m., Resident #36 had oxygen on at 2 liters per nasal cannula, but the oxygen tubing was not dated and not bagged. The oxygen tubing was lying on the floor. No oxygen sign was noted outside her door. During an observation on 01/06/26 at 10:19 a.m., Resident #36 was not in her room but had oxygen on at 2 liters per nasal cannula. The oxygen tubing was lying on the bed, not dated, or bagged. Resident #36 did not have an oxygen sign outside her door. During an interview on 01/06/25 at 10:20 a.m., Resident #36 said she wore oxygen. During an observation and interview on 01/06/26 at 10:22 a.m., CNA K said she was aware that the resident wore oxygen by the oxygen sign outside the door. She said Resident #36 wore oxygen. CNA K and the surveyor went to Resident #36's door, and CNA K said she did not see an oxygen sign. CNA K then walked into Resident #36's room and verified her oxygen tubing was on the floor and not dated or in a bag. She said the staff who assisted Resident #36 to get up for the day should have ensured the oxygen was in a bag. She said the oxygen was kept in a bag for infection reasons. CNA K went and placed an oxygen sign on the door. 3. Record review of Resident #27's face sheet, dated 01/08/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include rhabdomyolysis ( the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood), dementia (a loss of mental functioning such as, thinking, memory, mood and behavior), and diabetes (high blood sugars). Record review of Resident #27's quarterly MDS assessment, dated 11/24/25, indicated Resident #27 understood and was usually understood by others. Resident #27's BIMS score was 05, which indicated her cognition was severely impaired. The MDS indicated Resident #27 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS did not indicate she received nebulizer treatments. Record review of Resident #27 's comprehensive care plan, revised on 10/06/25, did not indicate any nebulizer treatments. Record review of Resident #27's physician order dated 12/18/25 indicated Ipratropium-Albuterol Solution 0.5-2.5 (3milligram/3 milliliter) give 1 Vial inhalation orally every 8 hours as needed for shortness of breath or wheezing. Record review of Resident #27's MAR dated 01/03/26 indicated she received a breathing treatment of Ipratropium-Albuterol Solution. During an observation and interview on 01/05/26 at 12:50 p.m., Resident #27 had a hand-held nebulizer with tubing on her nightstand, not bagged, or dated. Resident #27 said she had a breathing treatment the other night. During an observation on 01/06/26 at 8:16 a.m., Resident #27 had a hand-held nebulizer with tubing on her nightstand, not bagged, or dated. During an observation and interview on 01/06/26 at 8:17 a.m., CNA K verified Resident #27 had a nebulizer tubing not dated or in a bag. She said the tubing should be bagged for infection reasons. During an interview on 01/07/25 at 2:10 p.m., LVN A said she was the charge nurse for Resident #36 and Resident #27. She said oxygen and nebulizer tubing should be dated and bagged when not in use for infection reasons. She said an oxygen sign should be placed outside of residents' rooms who require oxygen. During an interview on 01/08/26 at 1:08 p.m., the ADON said oxygen and nebulizer tubing should be dated and bagged when not in use. She said the charge nurses were responsible for dating and bagging tubing when not in use. She looked at Resident #27's medication administration record and verified; she had given her a breathing treatment on 01/03/26. She said she could not recall if the nebulizer tubing was dated, but was sure she placed it in a bag. She said it was important to date and store tubing in a bag when not in use to prevent infection. During an interview on 01/08/26 at 2:11 p.m., the Administrator said all residents who require oxygen should have an oxygen sign on the door. He said he was not sure of all the details, but if they had an order for oxygen, he expected it to be set at the correct rate. He said he knew the nurses should make sure the tubing was dated and bagged, and the nurse administration should follow up and ensure it was bagged for infection reasons. He said they also did room rounds. He said if a resident required oxygen but was not wearing it, it could cause their oxygen intake to be compromised. During an interview on 01/08/26 at 2:33 p.m., the BOM said she was responsible for room rounds for Residents #27 and #36. She said she made room rounds on Monday (01/08/26),but did not look at the oxygen or nebulizer tubing. She said she usually did, but since the state surveyors were in the building, she focused on ensuring their call lights were in reach, and they had water at the bedside. She said when she did room rounds, she would look at the tubing and if it were not dated or bagged, she would notify the nurse. 4.Record review of a face sheet dated 01/08/26 at 10:21 a.m., indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke; a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). Record review of Resident #15's quarterly MDS dated [DATE] did not identify any breathing problems or shortness of breath. Record review of Resident #15's care plan dated 09/18/25 revealed she required assistance with activities of daily living. Record review of order summary dated 01/08/26 at 10:21 a.m., revealed an order for nebulization treatment of Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML one vial via nebulizer every eight hours as needed for shortness of breath or wheezing. During an observation on 01/08/26 at 2:30 p.m., revealed Resident #15's facemask was observed on the bedside table without being bagged and dated. During an interview on 01/05/26 at 2:40 p.m., LVN F revealed Resident #15 had recently received a nebulizer treatment and LVN F failed to return the facemask to the storage bag, stating she had been busy. LVN F acknowledged the purpose of bagging the facemask is to prevent contamination and bacteria spread. During an interview on 01/05/26 at 2:45 p.m., Resident #15 said she had just had a nebulizing treatment and required staff assistance with applying and storing the facemask. During an interview on 01/08/26 at 2:10 p.m., the ADON stated nursing staff are expected to check nebulizer equipment during rounds that occur every two hours and ensure nebulizer facemasks are properly stored. The ADON reported nebulizer supplies are changed weekly and stated proper storage is required to prevent contamination. During an interview on 01/08/26 at 2:25 p.m., the Administrator stated all supplies are expected to be properly secured and stored to prevent illness. The Administrator stated department heads conduct daily safety rounds and nursing staff are responsible for ensuring supplies are properly stored after treatment administration. Record review of the facility's policy titled Oxygen Administration, revised date of October 2010, indicated, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: # 1. Verify that there is a physician's order for this procedure. Review the physician's orders and facility protocol for oxygen administration. Equipment and Supplies:.#4. No Smoking/Oxygen in Use signs.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 3 residents (Residents #16, #15 and #41) reviewed for pharmacy services and 2 of 5 (100 and 200 Hall) medication carts reviewed for storage of medications. The facility to ensure: 1. Resident #15's Amlodipine (blood pressure medication), Potassium Chloride (medication to treat low levels of potassium) label from the pharmacy matched the orders placed in the electronic charting system and was free from medications at bedside. 2. Resident #16's Lorazepam (antianxiety medication) was secured behind two locks.3. Resident #41's Amlodipine label from the pharmacy matched the orders placed in the electronic charting system. 4. RN B did not ensure a tube of hydrogel wound gel was properly and secured in the treatment cart. 5. The treatment medication cart and keys for Hall 100/200 was locked and secured while not in use on 01/05/26. MA C locked the Hall 200 medication cart while administering medication on 01/06/26.These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.Findings included: 1. Record review of Resident #16's face sheet, dated 01/08/26, reflected Resident #16 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included seizures (sudden, uncontrolled electrical disturbance in the brain), and anxiety. Record review of Resident #16's physician order summary report, dated 01/08/26, reflected an active physician's order for: Lorazepam 2 mg/ml; inject 0.5 ml sub-Q every 2 hours as needed for seizure active with a start date 11/21/25. Record review of Resident #16's quarterly MDS, dated [DATE], reflected Resident #16 usually made himself understood and usually understood others. Resident #16's BIMS score was a 10, which reflected his cognition was moderately impaired. Record review of Resident #16's comprehensive care plan, dated 08/29/25, reflected Resident #16 had seizures related to seizure disorder. The care plan interventions included administering PRN medications as ordered for prolonged seizure. During an observation and interview on 01/06/26 at 5:25 p.m., there was a small black refrigerator with a locking device but unlocked in the Hall 100/200 medication storage room. Inside the refrigerator there was a black lock box with 2 sealed vials of lorazepam 2 mg/ml with Resident #16's name on the label. RN B stated she did not have the key to the lock box, or the refrigerator RN B stated the back hall nurse was responsible for ensuring the medication was secured behind two locks. RN B stated she did not reconcile the medication upon start of her shift, but RN B reconciled at that time with the surveyor. RN B stated the risk not having the medication secured was someone could take the medication. During an interview on 01/06/26 at 5:40 p.m., LVN F stated she had not seen the lock box today and was unaware it was open and unlocked. LVN F stated she was responsible for ensuring the medication was locked and secured behind two locks. LVN F stated she failed to reconcile with the previous nurse today. LVN F stated it was important that the mediation was locked and secure to prevent drug diversion. 2. Record review of Resident #15's face sheet, dated 01/08/26, reflected Resident #15 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support, essential hypertension (high blood pressure), and hypokalemia (low potassium). Record review of Resident #15's physician order summary report, dated 01/08/26, reflected an active physician's order for: amlodipine besylate 10 mg: 1 tablet enterally in the morning related to essential hypertension with a start date 11/13/25. Record review of Resident #15's physician order summary report, dated 01/08/26, reflected an active physician's order for: Potassium Chloride ER 20 meq: 1 tablet enterally in the morning two times a day related to hypokalemia with a start date 11/13/25. Record review of Resident #15's quarterly MDS assessment, dated 10/16/25, reflected Resident #15 rarely/never made herself understood, and sometimes understood others. Resident #15's BIMS score was 7, which indicated his cognition was severely impaired. Resident #15 was dependent with eating and had a feeding tube while a resident of the facility and within the last 7 days. Record review of Resident #15's comprehensive care plan, edited on 10/06/25, reflected Resident #15 required the use of a gastrostomy tube for nutrition s/p CVA with dysphagia (difficulty swallowing). The care plan interventions included observe peg tube/g-tube site for s/sx of infection/irritation, NPO, and oral hygiene at least every shift. Record review of Resident #15's MAR, dated 01/01/26-01/31/26, reflected Resident #15 received Amlodipine and Potassium Chloride per the physician's orders on 01/07/26. During an observation on 01/07/26 at 9:30 a.m., LVN A prepared Resident #15's medication for administration via g-tube. The amlodipine and potassium chloride medication label from the pharmacy stated, by mouth. During an interview on 01/07/26 at 1:44 p.m., LVN A stated the person administering medications usually looked at the order in the computer on the MAR and compared it to the card. LVN A stated she should have noticed the card did not match the order. LVN A stated that was something she was supposed to check for. When asked if she noticed the card stated, by mouth LVN A stated she would like to go consult with the regional nurse before she answers. After consulting with the regional nurse, she stated she did not know the label stated, by mouth until the state surveyor intervention. LVN A stated she should have contacted the pharmacy and requested a new label, and a change of directions sticker should have been placed on the card. LVN A stated it was important to ensure the pharmacy labels matched the orders in the electronic charting system to prevent a medication error. If someone did not know Resident #15 and administered her medications by mouth, it could have caused aspiration or choking. 3. Record review of Resident #41's face sheet, dated 01/08/26, reflected Resident #41 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included essential hypertension (high blood pressure). Record review of Resident #41's physician order summary report, 01/08/26, reflected an active physician's order for: amlodipine besylate 10mg: 1 tablet by mouth one time a day with a start date 11/14/25. Record review of Resident #41's quarterly MDS assessment, dated 12/09/25, reflected Resident #41 usually made herself understood, and usually understood others. Resident #41's BIMS score was 9, which reflected cognition was moderately impaired. Record review of Resident #41's comprehensive care plan, edited 09/08/25, reflected Resident #41 received diuretic medication related to chronic kidney disease and hypertension. The care plan interventions included: monitor blood pressure and report signs of hypotension. Record review of Resident #41's MAR, dated 01/01/26-01/31/26, reflected Resident #41 received Amlodipine per the physician's orders on 01/06/26. During an observation and interview on 01/06/26 at 8:45 a.m., MA C prepared Resident #41's medication for administration and placed two 5 mg tablets in the medication cup. The Amlodipine medication label from the pharmacy stated, amlodipine 5 mg 1 tablet by mouth once daily. MA C stated the nurse was responsible for ensuring a new label was requested by the pharmacy and a change of direction sticker was placed on the card. MA C stated she had reported to the charge nurse that the direction was incorrect but could not recall the nurse's name. MA C stated she administered Resident 41's medications Monday-Friday and knew to administer 2 tablets of the 5 mg until the new packet came in. MA C stated it was important to ensure the pharmacy labels matched the orders in the electronic charting system to prevent a medication error. If someone did not know Resident #41 and administered her one 5 mg tablet instead of two would put her at risk for hypertension. 4. During an observation and interview on 01/05/26 at 12:09 p.m., Hall 100/200 treatment cart with keys in lock was opened. RN B was found by another surveyor while another surveyor remained with the cart. RN B stated this cart was a shared cart and was unsure who left it open but should have been locked because residents or staff could get into the open cart. During an observation on 01/06/26 at 5:10 p.m., a tube of hydrogel wound gel was on top of Hall 200 nurses' cart with no nurse staff available. During a telephone interview on 01/07/26 at 3:46 p.m., RN B stated the hydrogel wound gel should have been stored in the treatment cart after use. RN B stated she got busy and pulled away from the cart before she could store it back in the treatment cart. RN B stated it was important to ensure medications were properly stored for resident safety. During an observation and interview on 01/06/26 at 8:45 a.m., MA C left the Hall 200 medication cart unlocked and out of sight, facing Resident #41's room, while administering Resident #41's medication. MA C stated she should have locked the medication cart prior to going in Resident #41's room. MA C stated she was nervous with the state surveyor being present. MA C stated this failure allowed residents, staff, and visitors access to other residents' medication. During a telephone interview on 01/08/26 at 11:30 a.m., the Pharmacist Consultant stated she comes to the facility once a month. The Pharmacist Consultant stated during the visit she watched a medication pass, looked at medication rooms/cart, and drug destruction. The Pharmacist Consultant stated her last audit was on 12/15/25 and there were no issues. The Pharmacist Consultant stated medication/treatment carts should always be locked unless the nurse was standing in front of it. The Pharmacy Consult stated the lorazepam should have been locked in the black box and the refrigerator should have been locked. The Pharmacist Consultant stated until the nurse or MA received the new bubble pack from the pharmacy a sticker to identify the change of direction of the medication should be placed on the medication. The Pharmacy Consultant stated these failures could potentially cause a medication error or others such as residents and staff having access to it. During an interview on 01/08/26 at 1:54 p.m., the RNC stated his expectation was that if the medication blister pack verbiage stated incorrect information from how it was ordered that staff would contact the pharmacy to receive a change of direction sticker to place on the blister pack. The RNC stated narcotics should be stored behind two locks for storage to prevent the risk of potential drug diversion. The RNC stated that all medications or biologicals would be stored in a medication cart or in a medication room. The RNC stated all keys to medication or treatment carts should be kept on the nurses to ensure safe storage and lock the cart prior to entering the room. The RNC stated the DON or designee were responsible for monitoring and overseeing by routine rounding. The RNC stated it was important to ensure that no residents or staff members have access to medications and prevent medication errors. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he expected nursing staff to ensure medication labels from the pharmacy matched the orders placed on the computer. The Administrator stated the charge nurses, then nursing management were responsible for monitoring to ensure medication labels from the pharmacy matched the orders in the electronic charting system. The Administrator stated there should have been something in place to indicate there was a change in the order. The Administrator stated the nursing management was responsible for monitoring and overseeing by rounding. The Administrator stated medications and medication carts should be secured and always locked to prevent residents, staff or visitors from having access to them or prevent a medication error. During a record review of a face sheet dated 01/08/2026 10:21 AM, indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke due to a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). During a record review on 01/08/2026 at 10:27 AM, Resident #15's care plan revealed she was care planned for medications to be administered to her safely. During a record review on 01/08/2026 at 10:30 AM, Resident #15 quarterly MDS assessment dated [DATE] revealed she is dependent on staff to receive medication administration. During an observation on 01/05/2026 at 11:25 AM, revealed an unlabeled medication cup containing a cloudy, slightly transparent cream was observed on Resident #15 bedside table, along with opened oral swabs. The substance was not labeled or secured. During an interview on 01/05/2026 11:21 AM, Resident #15 stated the substance belongs to her and was used on her lips. The resident reported she did not ingest the substance and demonstrated applying it topically. During an interview on 01/05/2026 at 2:31 PM, LVN F stated the substance in the medication cup was believed to be Vaseline but acknowledged she did not place it there and could not verify when or by whom it was provided. During a follow-up interview on 01/05/2026 at 2:48 PM, LVN F stated the night staff had been providing the resident petroleum jelly but acknowledged the facility had run out of gasoline and it was not available on the medication cart. LVN F was unable to identify risks associated with leaving the substance at the bedside and acknowledged that medications are not to be kept at bedside due to risk of inappropriate consumption. During an interview on 01/08/2026 at 2:10 PM, the ADON stated medications are to be secured in the medication cart, during treatment nursing staff are expected to monitor resident rooms for medications during rounds. The ADON acknowledged residents are at risk of harm when medications or creams are left at bedside. During an interview on 01/08/2026 at 2:27 PM, the Administrator confirmed department heads conduct daily safety rounds and stated medications and creams are not permitted to be stored at the bedside due to safety concerns of consumption. During a record review of an order summary dated 01/08/2026 indicated Resident #15 had an active order for oral care every shift beginning 11/13/2025 with no end date and an order for diet of nothing by mouth, there was not an order for Vaseline or petroleum jelly. Record review of the facility's policy titled Medication Labeling and Storage last revised on 02/2023, indicated. the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. Medication Storage 2. The nursing staff is responsible for maintaining medication storage.4. Compartments (including, but not limited to. refrigerators, carts) containing medications and biologicals are locked when not in use. or carts used to transport such items are not left unattended if open or otherwise potentially available to others.Medication Labeling 2. The medication label includes, at a minimum: b. prescribed dose. f. route administration. 12. The nursing staff must inform the pharmacy of any changes in physician orders for a medication.

Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents (Resident #32 and 9 confidential residents) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 01/06/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.Findings included: During a confidential resident group meeting 9 residents stated the food could be warmer. During an interview on 01/05/26 at 12:09 p.m., Resident #32 stated the food was not too good. Resident #32 would not go into detail on how the food was not good. During an observation and interview on 01/06/26 at 12:44 p.m., lunch tray was sampled by the Dietary Manager and 4 surveyors. The sample tray consisted of beef stroganoff which was lukewarm, a mushy texture, and overpowered garlic flavor; green beans were cold and bland; and the overall appearance was soggy and greasy. The Dietary Manager stated the beef stroganoff could have been warmer and the noodles were overdone; green beans were bland, below room temperature and the food could have been separated more. During an interview on 01/08/26 at 9:15 a.m., CNA D stated residents had stated the food was cold. CNA D stated she was unable to recall the resident's name. CNA D stated when they complained about the food being cold, she would reheat their food in the employee breakroom. CNA D stated she did not take the temp of the food after reheating and has never been told too. CNA D stated she was told by staff that she could reheat their food but unable to recall the staff name. CNA D stated she did not report the complaints to anyone. CNA D stated residents not eating their food could potentially cause weight loss. During an interview on 01/08/26 at 9:21 a.m., CNA E stated residents randomly complained about the food not being good overall. CNA E stated she was unable to recall the resident's name. CNA E stated she would offer the residents an alternative. CNA E stated all food complaints would be reported to the dietary staff. CNA E stated residents not eating their food could potentially cause weight loss. During an interview on 01/08/26 at 10:21 a.m., RN B stated at times residents do complain about the food being cold or bland. RN B stated there was not a specific resident she could recall. RN B stated she would offer the residents an alternative and report to the dietary staff. RN B stated it was important to ensure food was palatable and had an appetizing temperature to maintain their adequate weight and proper nutrition for healing. During an interview on 01/08/26 at 1:01 p.m., the Dietary Manager stated she had not had any complaints regarding food being cold or tasting bland in the last several months. The Dietary Manager stated if food complaints were brought to her an alternative would be offered. The Dietary Manager stated she monitored meal service daily, including sampling trays a few times a week, especially a new meal. The Dietary Manager stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he expected food to be at the appropriate temperature and seasoned for palatability. The Administrator stated he has not had any complaints about food being cold or bland. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing meal service. The Administrator stated he has not experienced a test tray that was not palatable including temperature. The Administrator stated it was important to ensure food was palatable and had an appetizing temperature to prevent weight loss. Record review of the facility's policy titled, Food and Nutrition Services revised 10/2017 reflected. each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional. needs.

Based on observations, interviews, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 of 4 residents (Resident #15) reviewed for privacy and confidentiality. The facility did not ensure LVN A closed Resident #15's EMR before entering her room to administer her medications on 01/07/26. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration record being accessible to others.Findings included: Record review of Resident #15's face sheet, dated 01/08/26, reflected Resident #15 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). Record review of Resident #15's quarterly MDS assessment, dated 10/16/25, reflected Resident #15 rarely/never made herself understood, and sometimes understood others. Resident #15's BIMS score was 7, which indicated his cognition was severely impaired. Resident #15 was dependent with eating and had a feeding tube while a resident of the facility and within the last 7 days. Record review of Resident #15's comprehensive care plan, edited on 10/06/25, reflected Resident #15 required the use of a gastrostomy tube for nutrition s/p CVA with dysphagia (difficulty swallowing). The care plan interventions included observe peg tube/g-tube site for s/sx of infection/irritation, NPO, and oral hygiene at least every shift. During an observation on 01/07/26 at 9:30 a.m., revealed the Hall-400 medication cart laptop with the screen open to Resident #15's information facing into the hall. Staff, residents, visitors, and surveyors were observed to be walking next to the medication cart. During an observation on 01/07/26 at 10:07 a.m., the ADON closed the screen when this surveyor brought to her attention that Resident #15's personal health information was showing. During an interview on 01/07/26 at 1:44 p.m., LVN A stated she should have locked the screen when she walked away from the cart. LVN A stated she was nervous due to the surveyor being present. LVN A stated it was important to ensure the residents' information was kept confidential to prevent HIPPA violation. During an interview on 01/08/26 at 1:54 p.m., the RNC stated his expectation was the computer screen was locked if the nurse was not utilizing it. The RNC stated the DON or designee was responsible for monitoring and overseeing compliance by routine rounding. The RNC stated it was important to ensure the residents' information was kept confidential to prevent personal health information being viewed by others. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated the computer screen should be locked or closed prior to entering a resident's room. The Administrator stated the department heads did random rounds to ensure compliance. The Administrator stated it was important to ensure the resident's information was kept confidential to prevent HIPPA violation. Record review of the facility's policy Protected Health Information (PHI), Uses and Disclosures of reviewed 03/2014, reflected. Protected health information will not be used or disclosed except as permitted by law.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 10 residents (Resident #15) reviewed for a homelike environment. The facility failed to ensure Resident #15's room had wall trim in good repair. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.Findings Included: During an observation on 01/05/2026 at 11:21 AM, Resident #15's room wall trim along the lower portion of the wall was lifting and jagged. The trim was observed to be uneven with sharp edges exposed. During an observation on 01/08/2026 at 8:17 AM, the damaged trim had been removed leaving the interior wall exposed. The exposed area was unfinished and did not have replacement trim or protective covering installed. During an interview on 01/05/2026 at 11:25 AM, Resident #15 stated she was scared she would get injured by the missing trim that was jagged when the resident is propelling in the wheelchair. During interview on 01/08/2026 at 12:44 PM, the facility maintenance director acknowledged awareness of the damaged trim and stated the trim had been removed, however the area had not been restored to a finished residential condition at the time of observation. Reported it has been that way a month or more. Yesterday I cut the hanging trim off so now it has to be fixed. The Maintenance director could not recall who reported the hanging trim to him. During interview on 01/08/2026 at 1:44 PM, CNA E reported that she had noticed the trim coming off the wall in Resident #15's room. CNA E stated Resident #15's wheelchair would catch the hanging trim when moving passed the trim. CNA E said she had verbally reported the broken trim to the maintenance director several weeks ago but could not recall an exact date or time. During an interview with the ADON on 01/08 2026 at 1:57 PM, said all staff are responsible for ensuring rooms are safe and have a homelike appearance. The ADON stated the loose trim was a tripping hazard. During an interview with the administrator on 01/08/2026 at 2:19 PM, the Administrator stated he was not aware of the missing trim; however, the maintenance director was responsible for all repairs. The facility used a computerized tracking system and the staff was instructed to report all needed repairs to the maintenance director. Record review of Homelike Environment policy revision date February 2021 revealed the policy statement of residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.Clean, sanitary and orderly environment.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 6 residents (Resident #36) reviewed for PASRR. The facility failed to ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #36, who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of Resident #36's face sheet, dated 01/08/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs such as: euphoria, to depressive lows such as: sadness, significantly impacting daily functioning, work, and relationships), and anxiety (a feeling of fear, dread, and uneasiness). Record review of the PASRR Level 1 Screening form, dated 06/23/25, reflected Resident #36 had no evidence or indicator of dementia or a mental illness (negative PL1). No PASRR evaluation had been completed. Record review of Resident #36's comprehensive care plan, dated 09/24/25, indicated, Resident #36 had an alteration in affect/mood requiring the use of an anticonvulsant for mood stabilization related to the diagnosis of bipolar disorder and anxiety. The intervention was for staff to give medication as ordered. Record review of Resident #36's quarterly MDS assessment, dated 10/21/25, indicated Resident #36 understood and was usually understood by others. Resident #36's BIMS score was 09, which indicated her cognition was moderately impaired. The MDS indicated Resident #36 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS reflected Resident #36 had an active diagnosis of bipolar disorder. Record review of Resident #36's Physician order dated 11/21/25 indicated Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium), give 1 tablet by mouth two times a day, related to bipolar disorder and . Buspirone HCl oral tablet 7.5 MG (Buspirone HCl), give 1 tablet by mouth two times a day, related to anxiety disorder. During an interview and record review on 01/08/26 at 9:50 a.m., the MDS Coordinator said she was responsible for ensuring the PASRR Level 1 was entered into the system prior to the resident being admitted . She said she input the information that the hospital sent to the facility. The MDS Coordinator said it was important for the residents to be screened for PASRR to ensure they were evaluated for eligibility and services. The MDS Coordinator and the state surveyor reviewed the PASRR Level 1 done on 06/03/25 and Resident #36's diagnosis list and saw where Resident #36 had an admitting diagnosis of bipolar, which was a form of mental illness, and no diagnosis of dementia (memory loss). The MDS Coordinator said she was aware Resident #36 had a diagnosis of bipolar but did not consider bipolar as a mental disorder. She said even after being aware of the bipolar diagnosis, she entered the correct information for the PASRR Level 1 Screening. During a phone interview on 01/08/26 at 10:22 AM, the Local Authority stated Resident #36 had a PL1 that was negative in 2025. The Local Authority said there was no PASRR evaluation completed because her PL1 screening was negative. The Local Authority said the screening was negative because in Section C of the PASRR Level 1 Screening was marked No, indicating Resident #36 had no indicators of mental illness. The Local Authority said bipolar disorder should have constituted a positive PL1 screening if her primary diagnosis was not dementia (memory loss). During an interview on 01/08/26 at 1:08 p.m., the ADON said she was not aware of the PASRR process but expected the MDS Coordinator to complete the necessary paperwork for the process. During a telephone interview on 01/08/25 at 1:44 p.m., the Director of MDS said if the PASRR Level 1 was filled out incorrectly or a diagnosis was not added previously, she expected a Form 1012 to be completed so the resident could be reevaluated for services. The Director of MDS said the purpose of Form 1012 was to alert the local authority that the residents required a PASRR evaluation or level 2 screening because of a qualifying diagnosis. The Director of MDS said the MDS Coordinator was responsible for ensuring the PASRR Level 1 was completed correctly. The Director of MDS said it was important for the residents to be screened for PASRR, so the residents had an opportunity to receive the care they needed. During an interview on 01/08/26 at 2:11 p.m., the Administrator said the MDS was responsible for the PASRR Level 1 Screening, and he was the overseer. He said he expected the MDS Coordinator to fill out the PASRR Level 1 Screening accurately. He said the PL1 form was completed to see if the residents would be positive or negative for mental health. He said if they were positive, then the residents would qualify for services that could benefit them. Record review of the facility's undated policy titled PASRR dated 07/09/25, indicated, Purpose: The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. Procedure: 1. admission Process: C). Preadmission happens when a person comes from the community (psychiatric hospital, home, group home, jail, assisted living, etc.). This includes anywhere other than a medical acute care hospital or another nursing facility. The person, coming from the community, with a PASRR. Level 1 that indicates suspicion of IDD, and/or mental illness, must also have a completed PASRR Evaluation submitted before they can be admitted to a nursing facility. This process must be followed to ensure people coming from a community setting can receive education about other placement alternatives before nursing facility admission. D). Negative indicates the person has a negative PL1 screening, and is not suspected of having an intellectual disability, developmental disability, and/or mental illness.2. Screening Process: A). Level I Screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission. B). Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 3 newly admitted residents reviewed. (Resident #53) The facility failed to develop a baseline care plan assessment for Resident #53. This failure could affect residents who are admitted to the facility with specialized needs and result in residents not receiving necessary care and services. Findings Included: During a record review on 01/08/2026 at 10:45 AM, the face sheet revealed Resident #53 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of pneumonia (infection of the lungs). During a record review on 01/07/2026 at 9:30 AM, Resident #53's electronic medical record indicated the baseline care plan was not opened or initiated and remained highlighted in red with the due date (meaning past due). During a record review on 01/07/2026 at 9:35 AM, Resident #53's electronic medical record indicated the admission MDS or the comprehensive care plan had not been completed. During an interview with Resident #53 on 01/05/2026 at 12:13 PM, revealed the resident had not yet had a care plan meeting with the facility. Resident #53 reported he had not yet had an explanation of plan of care for pneumonia (infection of the lungs). Resident #53 also reported he had a fall within his stay within the facility on 01/03/2026 prior to 48-hour timeframe required for completed care plan. During an interview on 01/06/2026 at 2:40 PM, the ADON said the resident was newly admitted and said the baseline care plan had not been completed within 48 hours of admission. Staff was unable to provide documentation demonstrating that a baseline care plan was in place during the required timeframe. The ADON reported an RN is responsible for initiating the baseline care plan assessment which can be completed by an RN or LVN. The ADON reported the DON is responsible for overseeing and ensuring all assessments are completed in the required timeframe. The ADON reported residents are at risk of not receiving care when the baseline care plan assessment is not completed within 48 hours. During an interview with RN B on 01/08/2026 at 1:31 PM, revealed she did not admit the resident to the facility; however, she did initiate the baseline care plan assessment as of 01/08/2026 but had not completed it. RN B said the risk is the resident not receiving the care required. During an interview on 01/08/2026 at 2:02 PM, the ADON revealed the DON oversees assessments to ensure they are completed. The ADON said only an RN can initiate the baseline care plan assessment. The ADON reported I had the RN on duty today start the baseline care plan assessment this morning. The ADON reported baseline care plans are to ensure person-centered care is addressed the initial needs, preferences, and goals. During an interview on 01/08/2026 at 2:22 PM, the administrator said the risk to residents not having a completed baseline care plan was the residents may not to receive the care admitted to the facility for. Record review of the new admission matrix revealed Resident #53 was newly admitted to facility on 01/02/2026. Record review of user defined assessment documentation showed the facility did not complete a baseline care plan assessment within 48 hours of admission, as required for Resident #53. Record review of Care Plans - Baseline revised March 2022 policy revealed: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident/representative; Physician orders; Dietary orders; Therapy services; Social services; and PASARR recommendation, if applicable. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed. A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 2 of 4 (Resident #11 and Resident #27) residents reviewed. The facility failed to care plan Resident #11's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. The facility failed to care plan Resident #27's nebulizer treatments (which uses a machine to turn liquid medicine into a fine mist, inhaled through a mask or mouthpiece, to deliver medication deep into the lungs for respiratory conditions). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.The findings included:1. Record review of Resident #11's face sheet, dated 01/08/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease also known as COPD (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction), anxiety (a feeling of fear, dread, and uneasiness), and stroke.Record review of Resident #11's quarterly MDS assessment, dated 12/04/25, indicated Resident #11 usually understood and was usually understood by others. Resident #11's BIMS score was 05, which indicated she was severely impaired. The MDS indicated Resident #11 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up/supervision for eating. The MDS during the 7-day look-back period did not indicate Resident #11 was receiving oxygen.Record review of Resident #11's physician orders dated 12/18/25 indicated oxygen at 2-4 liters per minute via nasal cannula continuously.Record review of Resident #11's care plan revised date of 10/20/25, did not indicate she required oxygen. During an observation and attempted interview on 01/06/26 at 8:15 a.m., Resident #11 was in her bed without any oxygen on. Resident #11 did not answer when asked if she wore oxygen. No distress noted.During an observation and interview on 01/07/26 at 2:10 p.m., LVN A said Resident #11 had an order for oxygen but did not have any oxygen in her room. She said Resident #11 often refused oxygen, but since she had an order for oxygen, it should be in her room and applied as ordered.2.Record review of Resident #27's face sheet, dated 01/08/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include rhabdomyolysis ( the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood), dementia (a loss of mental functioning such as, thinking, memory, mood and behavior), and diabetes (high blood sugars).Record review of Resident #27's quarterly MDS assessment, dated 11/24/25, indicated Resident #27 understood and was usually understood by others. Resident #27's BIMS score was 05, which indicated her cognition was severely impaired. The MDS indicated Resident #27 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS did not indicate she received nebulizer treatments.Record review of Resident #27 's comprehensive care plan, revised on 10/06/25, did not indicate any nebulizer treatments. Record review of Resident #27's physician order dated 12/18/25 indicated Ipratropium-Albuterol Solution 0.5-2.5 (3milligram/3 milliliter) give 1 Vial inhalation orally every 8 hours as needed for shortness of breath or wheezing. Record review of Resident #27's MAR dated 01/02/26 at 8:53 p.m., indicated she received a breathing treatment of Ipratropium-Albuterol Solution.During an observation and interview on 01/05/26 at 12:50 p.m., Resident #27 had a hand-held nebulizer with tubing on her nightstand, not bagged, or dated. Resident #27 said she had a breathing treatment the other night.During an interview and observation on 01/08/26 at 1:08 p.m., the ADON said the DON was responsible for completing the care plans. The ADON said she was unaware that Resident #11's oxygen and Resident #27's nebulizer treatment had not been care planned. She said if Resident #11 had a routine order for oxygen, then she should be wearing her oxygen, and it should be care planned. The ADON looked at Resident #27's MAR and verified that she had given her a breathing treatment on 01/03/26 and said the nebulizer treatments should be care planned. She said the care plan was generated to guide staff and others in the care the resident should receive. During an interview on 01/08/26 at 2:11 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the DON and nurse management were the overseers. He said care plans were generated to guide staff on the residents' care. Record review of the facility policy titled Care planning, dated 12/2024, indicated Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation:1. Resident care plans are developed according to the timeframes and criteria established by S483.21. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).4. The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #17) reviewed for smoking-related accidents and hazards of 1 of 1 smoking areas. 1.The facility failed to ensure Resident #17 did not smoke near a grill with propane gas attached.2. The facility failed to ensure that no trash was in the red cigarette butts' canisters.3. The facility failed to ensure that no cigarette butts were on the ground or near the oxygen storage area.This failure could place residents at risk for injury.Findings included:Record review of a face sheet dated 01/08/26 indicated Resident #17 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with the diagnoses of Multiple sclerosis, also known as MS (a condition that affects nerves in your central nervous system), anxiety (a normal feeling of worry or fear in response to stress), and muscle weakness.Record review of a quarterly MDS dated [DATE] indicated Resident #17 usually understood and was usually understood by others. The MDS indicated Resident #17's BIMS score was a 07, which indicated he had moderate cognitive impairment. The MDS did not indicate he was a smoker.Record review of a comprehensive care plan dated 09/08/25 indicated Resident #17 was a smoker. The intervention was for staff to inform the residents and representatives of the risks associated with smoking and provide supervision while smoking.Record review of a Smoking Risk assessment dated [DATE] indicated Resident #17 was a supervised smoker.During an observation on 01/05/26 at 4:07 p.m., the gas grill on the smoking patio had a propane bottle attached. There was about five other residents who were smoking in the area, Resident #17 was sitting next to the propane tank, smoking. Also observed trash in the red cigarette butt bin and cigarette butts on the grounds next to the oxygen storage area.During an interview on 01/05/26 at 4:12 p.m., the maintenance supervisor said he bought the propane tank last month and set it outside next to the grill in the smoking area. He said it was a full tank because he had not used it since he purchased it. He said he was responsible for checking on safety and cleanliness issues throughout the facility. He said he realized it was a smoking hazard when questioned by the state surveyor and said he would move it. He said no trash should be in the cigarette butt bin, and no cigarette butts should be on the ground or near the oxygen storage because they could start fires. During an observation on 01/05/26 at 5:00 p.m., the propane tank had been removed from the smoking area.During an interview on 01/07/26 at 8:40 a.m., DA M said he was assigned to smoke the residents during smoking times. He said he was aware of the propane tank sitting in the smoke area and had told the maintenance supervisor about it at an unknown date and time, but because he did not remove it, he felt it was okay. He said he did not think about telling the Administrator. DA M verified that trash was in the cigarette butt' trash bin and cigarettes were on the ground. He said no trash should go in the cigarette bins; it should go in the regular trash, and no cigarette butts should be on the ground or near the oxygen storage area. He said they both could cause fires. During an interview on 01/08/26 at 1:55 p.m., the ADON indicated the maintenance supervisor was responsible for ensuring the propane tank was not in the smoking area, the smoking area did not have butts on the ground, or trash paper in the cigarette bin. She said she was not aware that the propane tank was in the smoking area. She said having a full propane tank in the smoking area, cigarette butts on the ground, and trash paper in the cigarette bins could lead to a potential fire hazard. During an interview on 01/08/26 at 2:00 p.m., the Administrator indicated he was made aware of the propane tank being outside in the smoking area. He said the maintenance supervisor was responsible for ensuring it was not in the smoking area, but he was the overseer. He said he knew the full propane tank could lead to a fire hazard. He said the maintenance supervisor had moved it. He said he had seen the propane tank sitting outside but did not think about it being in the smoking area. He said she was not aware of the trash in the cigarette butt can or cigarette butts on the ground, but they could also lead to fire hazards.Record review of a Fire Safety and Prevention policy dated May 2011 indicated, Policy Statement: All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. Policy Interpretation and Implementation: #1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public. #2. Whoever identifies a fire hazard or other conditions that could develop into a fire hazard must report the situation to the department director or maintenance director as soon as practical. Flammable Items: a. Smoke only in designated areas. b. Do not put cigarettes in trash cans.#4. All personnel must report observations of: A. accumulation of trash and rubbish; B. unusual odors or conditions; C. smoking in unauthorized areas; F. any unusual incidents; H. violation of fire safety rules. #5. The safety coordinator will be responsible for the prompt investigation of such conditions. Hazardous conditions must be corrected as soon as practical. Appropriate departments, such as building engineers/maintenance, etc., shall be responsible for the prompt correction of electrical, plumbing, or structural hazards.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary infections for 1 of 2 residents (Resident #15) reviewed for incontinent care. The facility failed to ensure CNA G and CNA H properly cleaned the perineal/genital areas for Resident #15 during incontinent care. These failures could place residents at risk for urinary tract infections.During a record review of a face sheet dated 01/08/2026 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke because a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). During a record review of Resident #15's quarterly MDS assessment dated [DATE] after a recent readmission to the facility revealed resident #15 toileting hygiene ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement was chart coded as 01: Dependent. Always incontinence of urinary and bowel. During a record review of Resident #15's care plan dated 09/18/2025 it was revealed she was care planned for activities of daily living (ADLs). Resident #15 also was care planned to keep skin clean and dry as possible to minimize skin exposure to moisture due to occasional moisture associated with skin damage to buttocks and skin folds. Record review of physician progress notes dated 12/27/2025 indicated Resident #15 has a past medical history of urinary tract infections. During an observation on 01/06/2026 at 9:39 AM, Resident #15 was provided incontinent care by CNAs G and H. The incontinent care revealed CNAs G and H used the same visibly soiled gloves throughout the entire care provided for Resident #15 with a bowel movement. CNA G and CNA H failed to change their gloves and failed to perform hand hygiene before, during and after the incontinent care. During an interview on 01/06/2026 at 9:50 AM, CNA G stated that she failed to change gloves and perform hand hygiene during Resident #15's perineal care provided by her and one other staff member (CNA H). CNA G acknowledged Resident #15 was on enhanced barrier precautions. CNA G said proper perineal care was provided to residents to prevent urinary infections. During an interview on 01/06/2026 at 9:55 AM, CNA H revealed it was her first day on the job and she had not completed incontinent care skills check-off. During an interview on 01/08/2026 at 2:06 PM, the ADON revealed that nursing administration are responsible for conducting check-off prior to allowing nursing staff to work independently. The ADON reported they have hand washing audits quarterly. The ADON stated the risk of incorrect incontinent care can cause urinary tract infections. During an interview on 01/08/2026 at 2:24 PM, the Administrator reported nursing staff was responsible for performing incontinent care. The Administrator said procedure check offs were done on hire and annually. He said he expected the DON and ADON to ensure skills are performed properly and skills are checked off prior to working independently. The Administrator reported residents are at risk for infection when incontinent care is not performed correctly. The Administrator reported the ADON and DON perform hand washing audit and annual skill check off to ensure compliance. During a record review on 01/08/2026 at 10:26 PM of Perineal Care policy dated February 2018 revealed the purpose of this procedure is to provide cleanliness and comfort to the residents, to prevent infections and skin irritation, and to observe the resident's skin condition.Wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely. Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens / adult brief.

Based on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. 1. The facility did not update the facility assessment to include Resident #15's gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). 2. The facility did not update the facility assessment to include Resident #36's oxygen and dialysis. These failures could affect residents by not having the necessary resources to ensure appropriate care is provided. Findings included: 1. Record review of Resident #15's face sheet, dated 01/08/26, reflected Resident #15 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). Record review of Resident #15's quarterly MDS assessment, dated 10/16/25, reflected Resident #15 rarely/never made herself understood, and sometimes understood others. Resident #15's BIMS score was 7, which indicated his cognition was severely impaired. Resident #15 was dependent with eating and had a feeding tube while a resident of the facility and within the last 7 days. Record review of Resident #15's comprehensive care plan, edited on 10/06/25, reflected Resident #15 required the use of a gastrostomy tube for nutrition s/p CVA with dysphagia (difficulty swallowing). The care plan interventions included observe peg tube/g-tube site for s/sx of infection/irritation, NPO, and oral hygiene at least every shift. 2. Record review of Resident #36's face sheet, dated 01/08/26, reflected Resident #36 was a [AGE] year-old female, originally admitted to the facility on [DATE] with a diagnosis which included dependence of renal dialysis (treatment that filters waste, toxins, and extra fluid from your blood when your kidneys fail), COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and shortness of breath. Record review of Resident #36's quarterly MDS assessment, dated 10/21/25, reflected Resident #36 made herself understood, and usually understood others. Resident #36 BIMS score was a 9, which indicated her cognition was moderately impaired. The assessment indicated Resident #36 was receiving oxygen therapy and dialysis. Record review of Resident #36's comprehensive care plan, edited 09/24/25, reflected Resident #36 required PRN oxygen therapy related to COPD. The care plan interventions included administer oxygen via nasal canula (PRN): O2 at 1-4 LPM. The care plan reflected Resident #36 required dialysis due to dialysis. The care plan interventions included hemodialysis performed on Monday, Wednesday and Friday. During an interview on 01/08/26 at 2:47 p.m., the Administrator stated he was responsible for completing and updating the facility assessment. The Administrator stated those things that were mentioned above should have been reflected in the assessment. The Administrator stated it was important to update the facility assessment to prevent the proper focus on the residents that needs particular care. The Administrator stated the risk associated with not updating the assessment was residents not receiving the proper care. During an interview on 01/08/26 at 2:11 p.m., the RNC stated there was not a policy and procedure regarding facility assessment.

Based on observation, interview, and record review, the facility failed to establish policies in accordance with applicable Federal, State and local and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 4 residents (Resident #17 and Resident #36) reviewed for smoking.The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #17 and Resident #36. This failure could place residents at risk of unsafe smoking and injury.Findings included:1.Record review of a face sheet dated 01/08/26 indicated Resident #17 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with the diagnoses of Multiple sclerosis, also known as MS (a condition that affects nerves in your central nervous system), anxiety (a normal feeling of worry or fear in response to stress), and muscle weakness.Record review of a quarterly MDS dated [DATE] indicated Resident #17 usually understood and was usually understood by others. The MDS indicated Resident #17's BIMS score was a 07, which indicated he had moderate cognitive impairment. The MDS did not indicate he was a smoker.Record review of a comprehensive care plan dated 09/08/25 indicated Resident #17 was a smoker. The intervention was for staff to inform the residents and representatives of the risks associated with smoking and provide supervision while smoking.Record review of Resident #17's Smoking Screen Assessment, which was last dated 09/27/24, revealed he was a supervised smoker.During an observation on 01/05/26 at 4:07 p.m., Resident #17 was outside smoking with other residents and staff. 2. Record review of Resident #36's face sheet, dated 01/08/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, also called COPD (is a progressive lung disease that causes restricted airflow and breathing problems), kidney failure, also known as renal failure or end-stage renal disease (ESRD), (a medical condition in which the kidneys can no longer adequately filter waste products from the blood), and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity levels, ranging from manic highs such as: euphoria, to depressive lows such as: sadness, significantly impacting daily functioning, work, and relationships). Record review of Resident #36's admission MDS assessment, dated 10/15/25, indicated Resident #36 understood and was usually understood by others. Resident #36's BIMS score was 09, which indicated her cognition was moderately impaired. The MDS indicated Resident #36 required assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. Record review of Resident #36's comprehensive care plan, dated 09/24/25, indicated, Resident #36 was a smoker. The intervention was for staff to do a safe smoking screen to be completed upon my admission and as needed and inform the resident and her representative of the risks associated with smoking.Record review of Resident #36's Smoking Screen Assessment, which was last dated 09/06/25, revealed she was a safe smoker but required a smoking apron.During an observation and interview on 01/07/26 at 8:38 a.m., Resident #36 was outside smoking with a smoking apron. Resident #36 said the staff always kept her smoking supplies, and she wore her apron when smoking.During an interview on 01/08/26 at 12:52 p.m., LVN A said the nurses was responsible for completing the smoking assessments. She said she was not aware of what the smoking policy said about how often smoking assessments needed to be completed, but she completed them as they populated on her user-defined assessments screen. She said the smoking assessment was to assess the resident for safety while smoking. She said if the smoking assessments was not done, then a resident might not be safe to smoke, which could place them at risk for burns or injuries. During an interview on 01/08/26 at 1:08 p.m., the ADON said she was not sure about the time frame of the smoking assessments. She said the nurses was responsible for doing the smoking assessments, and she and the DON were the overseers. She said it had been brought to her attention that the smoking assessments were not populated on the user-defined assessment system, and they fixed the issue on Tuesday (01/06/26). She said she knew the smoking assessments were done to ensure the residents were safe to smoke. She said that since the smoking assessment was not being done, it could place the residents at risk for burns or injuries. During an interview on 01/08/26 at 2:11 p.m., the Administrator said the nurses was responsible for completing the smoking assessment, and nurse management was the overseer. He said smoking assessments was done for the safety of the residents.Record review of the facility's Policy titled Smoking Policy-Residents, revised date of 10/22, indicated, This facility shall establish and maintain safe resident smoking practices. #8 The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the smoking assessment. #9 A residents' ability to smoke or chew tobacco safely will be reevaluated quarterly, upon a significant change, and as determined by the staff.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure the can opener blade was free a black substance and a rusty-like material. 2. The facility failed to ensure 2 skillets, 5 large sheet pans, 3 small sheet pans, and 6 muffin pans were free from carbon build up on the cooking surface of the pan. 3.The facility failed to ensure the microwave was free from a thick, hard yellow substance, and a brownish substance resembling rust material on the inside top surface. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour on 10/07/2024 at 11:02 a.m. - 11:55 a.m., the following was observed: 2 large skillets with black carbon build up on the inside cooking surfaces. 5 large sheet pans with black carbon build up on the outside pan surfaces, and on the sides of the inside pan surfaces. 3 small sheet pans with black carbon build up on the outside pan surfaces, and on the sides of the inside pan surfaces. 6 muffin pans with black carbon build up on the entire top surface. The microwave had a thick yellow hard substance and a brownish substance resembling rust material on the inside top surface. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with attachment dated 5/13/2024 indicated the Dietician found there were no cleaning schedules posted and followed to indicate routine cleaning of equipment, and the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with an attachment dated 6/17/2024 indicated the Dietician found there were no cleaning schedules posted and followed to indicate routine cleaning of equipment, and the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. The attachment indicated the pans had carbon buildup. Record review of a Quality Assurance Monitor 1 Kitchen/Food Service Observation with an attachment dated 9/16/2024 indicated the Dietician found the equipment, drawers, shelves, worksurfaces, cutting boards, utensils, pots, pans, can opener, microwave, toaster, robot coupe mixer, over, plate warmer, fryer, juice gun, steam table and other equipment was not clean. During an interview on 10/09/2024 at 9:53 a.m., the Dietary Manager said she was aware of the pans and had tried to clean them with a chemical for removing carbon but was unsuccessful. The Dietary Manager said they would have to purchase new pans. The Dietary Manager said the microwave should be cleaned after each use and was unsure what the material was inside on the top surface. The Dietary Manager said the can opener should be clean and free of rust. The Dietary Manager said the can opener having the material on the blade could fall in the food items when opening. The Dietary Manager said kitchen sanitation was important, so residents did not get sick. The Dietary Manager said kitchen sanitation monitoring was her responsibility. During an interview on 10/09/2024 at 2:33 p.m., the DON said she expected the kitchen equipment and dishware to be clean to prevent food borne illness from cross contamination. The DON said the Dietary Manager was responsible for the dietary department. During an interview on 10/09/2024 at 3:05 p.m., the Administrator said the staff had tried using the carbon removing product but was unsuccessful. The Administrator said the Dietary Manager was responsible for ensuring the equipment and dishware was clean to prevent food borne illness. Record review of an undated Kitchen Sanitation and Cleaning Schedule policy indicated all surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. Ceilings, vents, light fixtures, pipes, and any other potentially contaminated surfaces will be cleaned as needed. All equipment must be thoroughly washed and sanitized between uses, in different food preparation tasks and anytime contamination occurs or is suspected . https://www.fda.gov/media/164194/download?attachment FDA Food Code 2022 on 10/09/2024 indicated: Chapter 4. Equipment, Utensils, and Linens Multiuse 4-101.11 Characteristics. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment. Cleanability 4-202.11 Food-Contact Surfaces. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The requirement for easy disassembly recognizes the reluctance of food employees to disassemble and clean equipment if the task is difficult or requires the use of special, complicated tools. 4-202.15 Can Openers. Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement.

Based on observations, interviews, and record reviews, 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 2 of 14 residents (Resident #24 and Resident #36) and 1 laundry room reviewed for infection control practices and transmission-based precautions. 1) The facility failed to ensure LVN C provided proper hand hygiene during wound care to Resident #24's sacrum/coccyx area of the buttocks. 2) The facility failed to ensure the laundry staff were using a barrier when sorting contaminated linens. 3)The facility failed to ensure enhanced barrier precautions were initiated for Resident #36. These failures could place residents at increased risk for serious complications from a communicable disease that could diminish the resident's quality of life. Findings included: 1)Record review of Resident #24's face sheet dated 10/09/24 indicated she was a [AGE] year-old female who readmitted to the facility on [DATE] with the diagnoses dementia (loss of cognitive functioning), diabetes (a chronic condition that affects the way the body processes blood sugar), high blood pressure, major depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act), and a stage 4 pressure ulcer to sacrum. Record review of Resident #24's significant change MDS assessment dated [DATE] indicated she understood others and usually made herself understood. The MDS indicated she had a BIMS score of 2 which means she was severely cognitively impaired. The MDS also indicated she required total assistance from staff for transfers, bed mobility, toileting, eating, and bathing. Record review of Resident #24's care plan dated 4/18/24 indicated she had a stage 4 pressure ulcer to her coccyx with a goal for the wound to not increase in size and to not exhibit signs of infection. The interventions for the wound included providing wound treatments as ordered. During an observation on 10/08/24 at 03:32 PM, LVN C provided wound care to Resident #24's sacrum/coccyx area of the buttocks. LVN C cleaned the dirty wound and then failed to use hand hygiene and change gloves prior to applying the gentamycin ointment, calcium alginate with silver, and the clean dressing to Resident #24's wound. During an interview on 10/08/24 at 04:09 PM, LVN C said after she cleaned Resident #24's wound to her sacrum, her hands were considered dirty, and she should have changed her gloves and used hand sanitizer in between. She said she was nervous. LVN C said the failure placed Resident #24 at risk for infection. During an interview on 10/09/24 at 02:59 PM, the ADON said she expected the wound care to be performed properly when providing wound care. She said the DON was the infection preventionist and she completed the proficiency checks offs for nurses upon hire and quarterly to ensure the nurses were competent. The ADON said the failure placed a risk of infection being passed to Resident #24 and the risk for the wound not healing properly. During an interview on 10/09/24 at 03:04 PM, the DON said her expectation was to correctly provide wound care. She said LVN C was very anxious and nervous. The DON said LVN C's gloves should have been changed by her after the cleaning of the wound, hand sanitizer should have been used, and new gloves put on. She said she was responsible for ensuring the nursing staff could properly perform treatments, and she said she checked the nurses off for wound care proficiency twice yearly. The DON said the failure placed a risk for cross contamination and infection for Resident #24. During an interview on 10/09/24 at 03:23 PM, the Administrator said her expectation was for the nurses to follow the proper protocol for wound care. She said nursing administration (which was the DON and ADON) were responsible for ensuring the nurses properly provided wound care. The Administrator said the failure placed Resident #24 at risk for potential infection. 33249 2)Record review of a face sheet dated 10/08/2024 indicated Resident #36 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of urinary tract infection. Record review of the Quarterly MDS dated [DATE] indicated Resident #36 understood and was understood by other. The MDS indicated Resident #36's BIMS score was 7 indicating Resident #36 had severe cognitive impairment. The MDS indicated Resident #36 was dependent for toileting and showering/bathing, required partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing, and touching assistance with personal hygiene. The MDS indicated Resident #36 was always incontinent of bowel and bladder. Record review of the comprehensive care plan dated 10/01/2024 and edited on 10/07/2024 indicated Resident #36 received IV medications. The goal of the care plan indicated Resident #36 would not exhibit signs of complications from the IV (localized infection, systemic infection, .) The care plan interventions indicated initiated enhanced barrier precautions related to midline placement dated 10/07/2024. The care plan interventions dated 10/01/2024 included assess for complications from the IV, follow regimen when caring for the IV site, and the midline placement by an outside vendor. Record review of the Consolidated Physician's Orders dated October 2024 indicated on 10/01/2024 Resident #36 was ordered Mid-line (a long-erm central venous catheter inserted in the upper limb for medium-term treatments) for IV (intravenous) for intravenous therapy and to change the Mid-line IV dressing and clean insertion site every 7 days. During an observation and interview on 10/07/2024 at 12:55 p.m., Resident #36 was lying in her bed. Resident #36 said she had a device in her right upper arm. Resident #36 held up her arm revealing a mid-line catheter. Resident #36 said she had a urinary tract infection and was receiving antibiotics. Resident #36's door or outside wall had no signage indicating enhanced barrier precautions or any other precautions. CNA B said she was unaware if Resident #36 had an infection and was unaware of a need for the use of PPE or any special precautions related to Resident #36's care. During an interview and observation on 10/07/2024 at 3:36 p.m., CNA B came to ask the surveyor to go to Resident #36's room where CNA B revealed signage had been placed on Resident #36's door indicating she was on enhanced barrier precautions. CNA B said because of the IV line and Resident #36's urinary tract infection, staff could spread germs. 3)During an observation and interview on 10/07/2024 at 3:15 p.m., Laundry Aide and the Housekeeping Supervisor provided the tour to the laundry room. The Laundry Aide and Housekeeping Supervisor said they wore gloves when sorting the dirty clothes/linen but there were no aprons or any goggle/shields available nor had they used them when sorting the contaminated laundry. The Housekeeping Supervisor said there were residents on transmission-based precautions. The Housekeeping Supervisor said they could spread germs if the dirty clothes/linens touched their personal clothing. During an interview on 10/09/2024 at 1:53 p.m., the ADON said she was one of the infections preventionists of the facility. The ADON said when sorting clothes, the staff should prevent their personal clothing from coming in contact with contaminated linen. The ADON said the facility currently had residents on transmission-based precautions and there was a risk to spread infection. The ADON said Enhanced Barrier Precaution signage should be placed when a resident initiated the use of a device or has an infection. The ADON said she was unsure how Resident #36's enhanced barrier precautions sign was missed. The ADON said when proper precautions were not taken germs could spread. During an interview on 10/09/2024 at 2:39 p.m., the DON said she had not placed Resident #36 on enhanced barrier precautions because she believed the mid-line was not a central line and therefore was not required to have the precautions. The DON said when referring to the facility's policy concerning the use of enhanced barrier precautions with devices such as central lines e.g. she indicated she believed it was based on an individual's interpretation. The DON said she believed contamination of the laundry personnels personal clothing when not using a form of PPE would be dependent upon the technique of the person handling the laundry. During an interview on 10/09/2024 at 3:07 p.m., the Administrator said she would have to research the use of PPE when sorting laundry, and the use of enhanced barrier precautions with a mid-line. Record review of the Infection Prevention and Control Program dated July 2024 indicated an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections 2. The program is based on accepted national infection prevention and control standards. Record review of an Enhanced Barrier Precautions policy dated 4/01/2024 indicated it was the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. Definition: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employes targeted gown and gloves use during high contact resident care activities. 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism) 4. High-contact resident care activities include: .g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. 9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Record review of a Laundry and Bedding, Soiled policy dated April 2020 indicated soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Handling: 1. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. A. Soiled laundry and bedding contaminated with blood or other potentially infectious material is handled as little as possible and with minimum of agitation .Personal Clothing 1. Personal clothing that becomes soiled with blood or body fluids is covered (e.g., with a gown) or removed and immediate laundered before leaving the work area.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible 1 of 14 resident (Resident #36) reviewed for quality of care. The facility failed to maintain resident use hot water at safe and comfortable temperature between 100 to 110 on Hall/Room where the hot water temperatures was 122 F on 10/09/2024. This failure could place residents at risk for sustaining scalding injuries when using resident accessible hot water. The findings include: Record review of the face sheet, dated 10/09/2024, revealed Resident # 36 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), venous insufficiency (a condition that occurs when the veins in the legs have difficulty returning blood to the heart). Record review of the MDS assessment, dated 08/06/2024, revealed Resident # 36 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #36 needed partial assistance from another person to complete bathing, dressing, toileting, or eating. Record review of the comprehensive care plan, revised on 05/14/2024, revealed Resident #36 required one person assist with dressing and grooming. During an observation on 10/09/2024 at 09:00 a.m., the surveyor observed water temperature at 125 F with a digital thermometer in Resident #36's bathroom sink. During an interview and observation 10/09/2024 at 09:25 a.m., the Maintenance Supervisor checked the hot water with a digital thermometer in Resident #36's bathroom and the temperature was 122 F. The Maintenance Supervisor stated it was his responsibility to maintain the correct water temperature. The Maintenance Supervisor stated the water temperature should be between 100 and 110 F. The Maintenance Supervisor stated the risk to the resident with a water temperature of 122F was someone could get scolded. During an interview on 10/09/2024 at 1:46p.m., the DON stated it was the Maintenance Supervisor's responsibility to make sure the water temperature was correct. The DON stated it was important for the water temperature was correct so no one would get scolded. The DON stated the harm would be if someone was to get burned. During an interview on 10/09/2024 at 2:05 p.m., the Administrator stated maintenance was responsible for maintaining the correct water temperature. The Administrator stated it was important to keep the water temperature at 110 to prevent scolding. The Administrator stated the water temperature would be monitored daily by maintenance. Record review of facilities undated policy Maintenance Policies & Procedures revealed .Regulations require that hot water temperature be maintained at not less than100 degrees F (38 degrees C) and not more than 110 degrees F (43 degrees C) for all hot water used by residents.

Based on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 14 residents (Resident #30) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident #30's medications when she left Resident #30's medications on the top of the medication cart unattended. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: Record review of a face sheet dated 10/08/2024 indicated Resident #30 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of chest pain, eye pain, and lower abdominal pain. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and understood others. The MDS indicated Resident #30 was cognitively intact with a BIMS score of 13. Section J-Health Conditions of the MDS indicated Resident #30 received scheduled pain medications. Record review of the comprehensive care plan dated 6/19/2024 indicated Resident #30 had pain and the goal of the care plan was Resident #30 would be as comfortable as possible. The interventions for the care plan were administer pain medications as needed, monitor pain, and use non-drug interventions. Record review of the consolidated physician's orders dated 10/07/2024 - 10/08/2024 indicated Resident #30 on 9/13/2024 was ordered aspirin 81 milligrams one time daily, and on 6/21/2024, she was ordered acetaminophen-codeine-Schedule lll tablet 300-60 milligrams one tablet every 6 hours as needed for pain. During an observation and interview on 10/08/2024 at 8:21 a.m., on the top of the Hall 300 medication cart, there was a paper medication cup with two medication tablets inside the cup. The medication cart was unattended. At 8:26 a.m., MA A walked up to the medication cart. MA A said she had a personal emergency and thought she had locked the medications belonging to Resident #30 inside the cart. MA A said the medications in the cup was an acetaminophen with codeine 300-60 milligram and an aspirin 81 milligrams. MA A said another resident could have taken this medication and the medication could have been harmful to them. During an interview on 10/09/2024 at 1:50 p.m., the ADON said the instance where MA A left medications unattended should have never happened. The ADON said she monitored forthat type of error with rounds, random checks, and competencies. The ADON said the facility had residents who wandered and there was a risk for another resident taking Resident #30's medications. During an interview on 10/09/2024 at 2:28 p.m., the DON said she expected MA A to administer the medications right away when she prepared them. The DON said MA A should have given the medications to her nurse when the personal emergency occurred. The DON said she monitored each shift, different times and different days, to ensure compliance with medication management. The DON said they had residents who wandered but not on Hall 300 in particular. The DON said there was a risk another resident could have taken Resident #30's medication. During an interview on 10/09/2024 at 3:03 p.m., the Administrator said she expected the medications to be administered; not left sitting around where someone else could have gotten them. The Administrator said monitoring included rounds by the nurse managers. The Administrator said the nursing mangers were responsible for monitoring. Record review of the Medication Storage in the Facility policy dated 6/01/2022 indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for elopement risk. The facility failed to ensure Resident #1did not elope from the facility and cross a four-lane highway 04/24/2024. The noncompliance was identified as PNC. The IJ began on 04/24/2024 and ended on 04/24/2024. The facility had corrected the noncompliance before the survey began. This failure could place all 5 residents who used a wander guard at risk for serious injuries. The findings included: Record review of the face sheet, dated 08/06/2024, revealed Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a general term for impaired ability to remember, think, or make decisions), altered mental status (a change in mental function), cognitive communication deficit (trouble reasoning and making decision while communicating). Record review of the comprehensive care plan dated 03/08/2024, revealed Resident #1 was a risk for elopement due to his diagnosis of unspecified dementia. The care plan goal, initiated on 03/09/2024 I will not elope from the center in the next 90 days. The care plan inventions included, When I begin to wander, provide comfort measures for my basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). Problem start date 04/24/2024 edited on 04/24/2024, I have had an elopement event. The care plan goal, I will not elope from the center in the next 24 hours, at which time I will be transferred to secure unit facility. The care plan inventions included staff will monitor me 1:1 until I am transferred to the secure unit facility. Record review of the MDS assessment, dated 03/11/2024, revealed Resident # 1 had a BIMS score of 06, indicating severe cognitive impairment. MDS assessment for wandering behaviors coded as a 1, indicating Resident #1 had the potential to wander. MDS assessment did not address transfer to secure facility on 04/24/2024. Record review of the order summary dated 03/01/2024, revealed Resident # 1 had an order for a wander guard and verify placement every shift with a start date 03/09/2024 and end date 04/24/2024. Record review of the Elopement assessment, dated 03/09/24, revealed Resident #1 was at risk for elopement at this time. Proceed to potential interventions and care plan. Record review of the progress notes dated 04/24/2024, by DON revealed Resident #1 was placed on 1:1 observation at 7:20 a.m. after elopement. Resident # 1 sitting on couch in common area watching a movie. Resident #1 stated he had no pain. Resident #1 was smiling and laughing with staff. Resident #1's wander guard was on and in working order. Resident # 1 was taken to his room for head-to-toe assessment by floor nurse and returned to the couch in common area per his request to watch a movie. Resident #1 continued with 1:1 observation. 8:25 a.m. Resident #1 had continued 1:1 observation since return to the facility. Resident #1 continues to deny pain and no apparent injury. Progress notes did not address transfer to secure facility on 04/24.2024. Observation of the facility grounds on 08/05/2024 at 10:15 a.m., revealed the facility was located along side and facing a two-lane farm to market road. Observation upon approaching the facility revealed the front door to be locked and a keypad present without an access code posted. Surveyor rang the doorbell and was let inside by staff member. The front door had a delayed egress bar, keypad and a wander guard system. Observations of the facility on 08/05/2024 at 3:47 p.m., revealed exit doors at the end of each of the 4 hallways had a delayed egress bar, STOP alarm box in the armed position and a code alert box. A sign was on the door stating the alarm will sound for 15 seconds then door will open. Exit door alarms sounded when the surveyor pressed on the delayed egress bars at all exit doors. Surveyor observed signs posted on each of the 4 doors, door not in use. Observation on 08/05/2024 at 4:15 p.m. of the facility grounds and route Resident #1 traveled to exit the facility to the location he was found, revealed Resident #1 walked approximately 0.6 miles from the exit door, through the parking lot and across the highway where he was found at a convenience store. During an interview on 08/5/2024 at 1:04 p.m., Resident #1's family member stated the facility called 04/24/2024 after 9:00 a.m. stating Resident# 1 had gone outside by himself, and the police found him at the convenience store. Resident #1's family member stated the facility told her he got out before breakfast and went to the convenience store. Resident #1 family member stated she did not know how he got out with the bracelet on his ankle. Resident #1 family member stated she agreed Resident #1 needed to be transferred to a secure facility and the facility had him 1:1 one until he was transferred to another facility with a locked unit that day. During an interview on 08/5/2024 at 5:15 p.m., CNA A stated upon arriving to the facility on [DATE] at 7:01 a.m. she received a call from the sheriff's department stating Resident #1 was at the convenience store. CNA A stated she got into the van and went to get Resident # 1 and was back at the facility by 7:20 a.m. CNA A stated she notified the Administrator immediately. CNA A stated it was everyone's responsibility to make sure the resident did not elope. CNA A stated it was important to prevent elopement for the safety of the residents. CNA A stated the harm was the residents could get injured. CNA A stated she was in-serviced on missing residents, elopement and not to use the side doors for an exit 04/24/2024. During an interview on 08/05/2024 at 6:11 p.m., LVN B stated Resident #1 would wander the halls but was easy to redirect. LVN B stated she last saw Resident #1 in his room before her shift was over at 6:00 a.m LVN B stated they checked resident's wander guards on night shift and Resident #1's was working. LVN B stated they could check the wander guard by walking the resident to the door or they have a machine on the nurse cart to check the wander guards. LVN B stated it was their responsibility as caretaker to make sure the residents were in the facility and safe. LVN B stated the harm could be injury or death. LVN B stated she was in-serviced on missing residents, elopement and not to use the side doors for an exit 04/24/2024. During an interview on 08/07/2024 at 2:55 p.m., the DON stated they were not sure which door Resident # 1 went out. The DON stated Resident #1 was not out of the facility for long. The DON stated Resident #1 could not remember how he got out of the facility. The DON stated the side doors were locked and the staff cannot use them anymore. The DON stated all the staff were responsible for making sure the residents remain in the building. The DON stated it was important the resident stay in the facility to ensure their safety. The DON stated the potential harm to Resident #1 was he was not safe without supervision. The DON stated she had held an in-service on 04/24/2024 on missing residents, elopement and not to use the side doors for an exit. During an interview on 08/07/2024 at 3:04 p.m., the Administrator stated she thinks Resident #1 got out on Hall 300 because of a delay in the door. The Administrator stated Resident # 1 was not out of the facility for long. The Administrator stated Resident # 1 was not any distress when he returned to the facility. The Administrator stated the door was fixed the day of the incident and staff can no longer use the side doors. The Administrator stated it was a team effort to ensure the residents remain in the facility. The Administrator stated it was important to ensure resident remain in the building, so they do not get hurt. The Administrator stated the harm was Resident # 1 could have fallen or hurt himself. During an interview on 08/07/2024 at 3:09 p.m., the Maintenance Supervisor stated he was not aware the door on hall 300 had a delay in locking until Resident # 1's elopement and the door was repaired the same day. The Maintenance Supervisor stated all the staff were responsible for ensuring Resident # 1 remained in the facility. The Maintenance Supervisor stated it was important because it was unsafe for Resident #1 to be outside of the facility unsupervised. The Maintenance Supervisor stated the harm was Resident #1 could have been injured. Record review of a facility's Wandering and Elopement policy revised 09/01/2023, indicated 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. Elopement occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.,,,, Monitoring and managing residents at risk for elopement or unsafe wandering Adequate supervision will be provided to help prevent accidents or elopement The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR, dated 04/24/2024, revealed an investigation was initiated on 04/24/2024 and all required notifications were made which included the responsible party, and physician. Record review of an in-service dated 04/24/2024, topic: Missing Residents / Elopement, description: CODE PINK was the code for a missing resident. Upon suspected elopement, unable to find a resident, staff will call a CODE PINK. The charge nurse will direct staff appropriately: 1-2 staff would go outside and check the perimeter of the facility, the remaining staff will conduct methodic search of every resident room, restroom, every unlocked door in the entire facility. The in-service was signed by 43 employees. Record review of an in-service dated 04/24/2024, topic: Exit Doors, description: staff are not to give door codes to families except to the front door. When giving door code to family, educate them not to share the code with anyone. They must abide by the rule of not saying or displaying the door code just as staff are mandated to keep these codes foe staff only. They must comply to maintain this privilege. Staff are not to say the door codes out loud, in earshot of, or by visual display to/near non-staff persons. Staff are to ensure that upon entering or exiting the building that the door is fully closed and secured. The in-service was signed by 43 employees. Record review of an in-service dated 04/24/2024, topic: Abuse, Neglect, and Exploitation, description: all suspected, alleged, or actual abuse was to be reported immediately to the Abuse Coordinator, who is the Administrator. If for some reason staff are unable to reach the Abuse Coordinator, they are to notify he Director of Nurses. The in-service was signed by 42 employees. Record review of an action plan dated 04/24/2024. Intervention: Elopement Prevention, Action: Educate on Elopement. Intervention: Door Delay, Action: Service contractor needs to be called to check doors. Comments: 4/24/2024 Service Contract Representative came to the facility and checked the doors. The doors had a delay which was fixed immediately. Intervention: Door Checks, Action: Weekly door checks were to be completed. Comments: Maintenance completed more than weekly door checks. Record review of weekly door checks with a start date of 04/24/2024, revealed an exit door on hall 300 had a time delayed issue. Service Contract Representative came to the facility and checked the doors. The doors had a delay which was fixed immediately. No other issue with weekly door checks. 04/25/2024 doors on hall 100, 200, 300 and 400 passed check. 04/26/2024 doors on hall 100, 200, 300 and 400 passed check. 04/29/2024 doors on hall 100, 200, 300 and 400 passed check. 04/30/2024 doors on hall 100, 200, 300 and 400 passed check. 05/01/2024 doors on hall 100, 200, 300 and 400 passed check. 05/02/2024 doors on hall 100, 200, 300 and 400 passed check. 05/06/2024 doors on hall 100, 200, 300 and 400 passed check. 05/07/2024 doors on hall 100, 200, 300 and 400 passed check. 05/08/2024 doors on hall 100, 200, 300 and 400 passed check. 05/09/2024 doors on hall 100, 200, 300 and 400 passed check. 05/10/2024 doors on hall 100, 200, 300 and 400 passed check. 05/13/2024 doors on hall 100, 200, 300 and 400 passed check. 05/14/2024 doors on hall 100, 200, 300 and 400 passed check. 05/17/2024 doors on hall 100, 200, 300 and 400 passed check. 05/20/2024 doors on hall 100, 200, 300 and 400 passed check. 05/21/2024 doors on hall 100, 200, 300 and 400 passed check. 05/22/2024 doors on hall 100, 200, 300 and 400 passed check. 05/23/2024 doors on hall 100, 200, 300 and 400 passed check. 05/24/2024 doors on hall 100, 200, 300 and 400 passed check. 05/28/2024 doors on hall 100, 200, 300 and 400 passed check. 05/29/2024 doors on hall 100, 200, 300 and 400 passed check. 05/30/2024 doors on hall 100, 200, 300 and 400 passed check. 05/31/2024 doors on hall 100, 200, 300 and 400 passed check. 06/01/2024 doors on hall 100, 200, 300 and 400 passed check. 06/08/2024 doors on hall 100, 200, 300 and 400 passed check. 06/15/2024 doors on hall 100, 200, 300 and 400 passed check. 06/22/2024 doors on hall 100, 200, 300 and 400 passed check. 06/29/2024 doors on hall 100, 200, 300 and 400 passed check. 07/06/2024 doors on hall 100, 200, 300 and 400 passed check. 07/13/2024 doors on hall 100, 200, 300 and 400 passed check. 07/20/2024 doors on hall 100, 200, 300 and 400 passed check. 07/27/2024 doors on hall 100, 200, 300 and 400 passed check. 08/03/2024 doors on hall 100, 200, 300 and 400 passed check. Administrator/Designee conducted an elopement drill on 04/26/2024 to ensure that team members understand and carry out an appropriate elopement response. Record review of an QAPI sign in sheet dated 05/08/2024 signed by: Medical Director Administrator DON ADON Activity Director Maintenance Supervisor Social Services MDS Coordinator Medical Records During a phone interview on 08/06/2024 at 9:04 a.m., with the Service Contract Representative stated he came to the facility on [DATE], to work on the doors. He stated he rewired the locks on the front hall door to the right and the back hall door to the left on that day. He stated he came back the next day to rewire the other 2 doors. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 04/24/2024 and ended on 04/24/2024 when all staff had been in-serviced on door alarms, elopement response and abuse and neglect.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for one (Resident #1) of 4 residents reviewed for neglect. The facility failed to administer Resident #1's Tylenol #3 three times a day as ordered by the physician on 05/20/16, 05/21/16, 05/22/16, and 05/23/16. She missed eight doses, resulting in the resident experiencing excruciating back pain. An Immediate Jeopardy (IJ) was identified on 05/27/16. While the IJ was removed 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm, and a scope of pattern because the staff was still being trained and the facility was continuing to monitor the effectiveness of their Plan of Removal (POR). These failures placed the facility's 27 residents who receive pain medication at risk for unnecessary pain, delayed healing, decreased appetite, increased stress, disrupted sleep, anxiety, and depression. Findings included: Resident #1's undated Admission Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was cognitively intact. She required set-up assistance and supervision with ADLs. Resident #1's undated Admission Evaluation reflected, .1. Do you experience pain regularly? (Yes) .What is the intensity of your pain (Use scale below)? .(3) 0.(No hurt), 1.(hurts little bit), 2.(hurts little more), 3.(hurts even more), 4.(hurts whole lot), 5(hurts worst) . Resident #1's Admission Pain Evaluation dated 04/12/16 reflected, she had chronic lower back pain and chronic left knee pain which affected her ability to focus and resulted in decreased physical activities. Resident #1's undated Admission Care Plan reflected, .PAIN, Goal: Resident will be as comfortable as possible .Administer pain medications as ordered . Resident # 1's Care Plan reflected, .Problem: Pain, I am at risk for pain due to a pain disorder .Problem Start Date 4/27/2016 .Approach: Provide Medication as ordered by my MD . A Physician's Telephone Order for Resident #1 dated 05/16/16 signed by the Nurse Practitioner and LVN B reflected, [MEDICATION NAME] ([MEDICATION NAME]) 50mg tab po q 6(hr.) prn dx: pain. A Physician's Telephone Order for Resident #1 dated 05/20/16 and signed by the Nurse Practitioner and LVN C, reflected, D/C [MEDICATION NAME] Start Tylenol #3 q 8 (hrs.) for Pain. Resident #1's Medication Administration Record [REDACTED]. A Nurse's Progress Note for Resident #1 dated 05/21/16 at 2:00 PM and signed by LVN D reflected, Pt. is upset about pain meds. Order is for Tylenol #3, NO (new order) in the chart. The 24 Hour Report dated 05/20/16 reflected, .(Resident #1) .Remarks (Day) .N/O, D/C [MEDICATION NAME] start Tylenol #3 Q 8(hr.) for pain . The 24 Hour Report dated 05/21/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol not in . The 24 Hour Report dated 05/22/16 reflected, .(Resident #1) Remarks (Nights) .Tylenol #3 not here yet . The 24 Hour Report dated 05/23/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol #3 in . Resident #1's Controlled Drug Record dated 05/23/16 reflected, .[MEDICATION NAME]/Cod. #3 tablet QTY 30 (delivered to facility) .Date (5/23/16) .Time(4:30pm) .Amount given (1) .Amount Remaining (29) . An interview on 05/26/16 at 1:10 PM with Resident #1 revealed, her [MEDICATION NAME] (pain medication) was discontinued on 5/20/16 and a new pain medication Tylenol #3 (narcotic pain medication) was ordered at that time but she did not get her first dose of it until three days later on 5/23/16. She was then asked if going three days without her Tylenol #3 caused her any problems. She stated, Yes. I was in excruciating pain in my back. An interview on 05/27/16 at 12:05 PM with CNA G revealed she had worked 05/21/16 with Resident #1. She stated, I was giving her a shower. She was distraught, crying actually because her pain meds hadn't come in yet. An interview on 05/27/16 at 12:00 PM with CNA F revealed she had worked on 05/21/16. She said she recalled working with Resident #1. She stated, I was helping another CNA give her a shower. She was crying and said her pain meds hadn't come in yet. I told the nurse and she just said, Yes they haven't come in. An interview on 05/27/16 at 11:45 AM with LVN E revealed she had worked 05/21/16 and 05/22/16. She said Resident #1 approached her about her pain medication. She said she told Resident #1 the Tylenol #3 was not in yet. She was then asked why she did not call the pharmacy or DON to check on it. She stated, The overnight nurse told me he had called the pharmacy and it required a quantity before they could send it so I just assumed he had called the DON. An interview on 05/26/16 at 12:55 PM with the DON revealed It was her expectation when a new order for a medication was written; the resident should get the new medication at the next scheduled dosing. She was then asked if it was acceptable for a resident to go three days without their pain medication. She stated, No. She was then asked what kind of problems could a resident experience if they did not receive their pain medication as ordered by the physician. She stated, Pain. She was then asked if it would be considered unnecessary pain. She stated, Yes. An interview on 05/26/16 at 3:15 PM with the Administrator revealed, We dropped the ball on Saturday and Sunday. The order was called in on Friday and the pharmacy called back to clarify on Saturday and Sunday. The nurses that took the calls didn't call me or the DON. An interview on 05/27/16 at 1:58 PM with the DON revealed, If they cannot get a medication on the weekend they are supposed to call me. I didn't get any calls last weekend. I don't know why they didn't call me. An interview on 05/27/16 at 11:35 AM with LVN C revealed, she faxed the order on 05/20/16 around 6:30 PM, but failed to notice it did not have a quantity written on it. A facility policy titled Pain Assessment revised December 2003 reflected, .medicate the resident as ordered by the physician . A facility policy titled Administering Oral Medications revised December 2003 reflected, .Administer medications within one (1) hour before or after their scheduled time. A facility policy titled Abuse and Neglect Policy and Procedure revised May 2014 reflected, .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was identified on 05/27/16 at 10:45 AM. The Administrator and the DON were notified of the IJ on 05/27/16 at 10:45 AM. A Plan of Removal was requested at that time. The facility's POR was accepted on 05/28/16 at 9:00 AM. The POR reflected the following: . Pain Evaluation on each resident started 05/27/16, by the ADON, LVN A, and LVN B, and will be completed by end of day 05/27/2016 . .Assessment Description: [DIAGNOSES REDACTED]. Resident ' s verbalization of pain. How the resident describes pain. What increases the resident ' s pain.? Location of Resident ' s pain shown on illustration. Wong-Baker FACES pain Rating Scale (1-10). Identification of present pain. 1 hour after medication is given, 3 hours after pain medication is given, the worst pain gets and the best it gets. PAINAD which identifies pain ques: breathing, negative verbalization, facial expression, body language, and consolability. Changes in ADLs (Activities of Daily Living). Nonverbal/noncognitive signs identified. Relief of pain noted. Conclusion noted. .An immediate audit was completed by the DON and ADON on 05/26/2016 to include all physicians orders in clinical and electronic system and compared to the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for accuracy. Additionally on 05/26/2016 a pain medication audit was completed by the DON and he ADON to ensure that every resident's pain medication was in the facility and available. .LVN C, write up to be completed on 05/30/16 prior to working next shift. .RN K, write up to be completed on 06/03/16 prior to working next shift. .LVN D, do not return notification mailed to agency on 05/27/16. .LVN E, do not return notification mailed to agency on 05/27/16. .The Pharmacy Consultant has stated he would have Pharmacy Consult provide facility full cart audit 6/3/2016, then monthly thereafter. At said time, the Pharmacy Consultant will also audit of all pain medications in the facility and a follow up training to facility staff if necessary. .Pain Assessment In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Medication Ordering In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Telephone Order Transcription In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Proper Notification of Director of Nursing/Administrator if Medication is not received timely in-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. .New Order Protocol not to discontinue current medication until new medication has arrived at the facility for pain, unless otherwise contraindicated. It will be conducted by the DON and ADON and will start on 05/27/16 and be completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service. .The Administrator and the DON will be responsible for implementing the changes and prevent the failure from recurring. .When changes in pain medications are made, the current order will continue until the new medication arrives in the facility. These instructions will be clearly documented on the telephone order and the MAR. .If the medication is not available, the night nurse will contact the pharmacy for a stat delivery or backup pharmacy will be contacted. .Physician will be notified of any concerns regarding timely delivery of pain medication orders. Verifying the Plan of Removal included the following: A review of the Pain evaluations on each Resident conducted by the facility on 05/27/16 reflected no current issues, with all residents experiencing acceptable levels of pain. Resident #1's pain was reported as a 2 on the Wong Baker 0-10 pain scale with a 0 being no pain and a 10 is the worst pain. The location of her pain was documented as lower back. A review of the Pain Medication Audit conducted by the facility staff on 05/26/16 reflected every resident's pain medication was at the facility and available to the residents. A review of the Physicians Orders accurately transcribed on the MAR/TAR Audit conducted by facility staff reflected no discrepancies. A Review of In-Service Training reflected eight nurses had been in-serviced on 05/27/16 on Ordering and Receiving Controlled medication, Ordering Medication Written Documentation (including written examples of correct telephone orders), Administering oral medications, Pain Management (with post-test), Prescription Medication Order Transcription (with post-test), and Coverage of Medication/Pharmacy(with post- test). Two nurses from each of the three shifts including weekend nurses were interviewed: Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do if a new order for pain medication was not available to the resident. They said the proper steps to take included the following; call the pharmacy to check on the status of the order, if a problem exists, notify physician and see if alternative medication could be given and notify the DON/Administrator, and keep the resident informed of the situation. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on the necessary information to be included on a telephone order to be valid when faxing orders to the pharmacy. They said the proper information to include for a telephone order to be valid included the following; Resident's name, Dr.'s name, facility name, date, medication, dose, strength, route, and quantity to dispense. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do should they find an incomplete order. They said the proper steps to take included the following; Call the physician for clarification, write a clarification order, and notify the DON if there are any issues in obtaining the medication. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on missed doses of a scheduled medication. They were asked if a scheduled medication was not available to give a resident due to not arriving from the pharmacy, would they have committed a medication error. They answered, yes. Observations on 05/28/16 beginning at 9:30AM and ending 05/28/16 at 12:20 PM of the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4, revealed they did not have objective signs or symptoms of pain. They had a relaxed demeanor and exhibited no acute distress. Interviews on 05/28/16 beginning at 9:30 AM and ending 05/28/16 at 12:20 PM with the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4,revealed they had no problems obtaining their pain medications. On 05/28/16 at 12:40 PM, the Administrator, DON, and Regional Vice President were notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm and a scope of pattern because the staff was still being trained and the facility was monitoring the effectiveness of the Plan of Removal. An Order Report by Category dated 05/28/16 revealed there were 27 residents who resided at the facility and received medication for the management of their pain.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect of residents for one (Resident #1) of 4 residents reviewed for neglect. The facility failed to administer Resident #1's Tylenol #3 three times a day as ordered by the physician on 05/20/16, 05/21/16, 05/22/16, and 05/23/16. She missed eight doses, resulting in the resident experiencing excruciating back pain. An Immediate Jeopardy (IJ) was identified on 05/27/16. While the IJ was removed 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm, and a scope of pattern because the staff was still being trained and the facility was continuing to monitor the effectiveness of their Plan of Removal (POR). These failures placed the facility's 27 residents who receive pain medication at risk for unnecessary pain, delayed healing, decreased appetite, increased stress, disrupted sleep, anxiety, and depression. Findings included: A facility policy titled Abuse and Neglect Policy and Procedure revised May 2014 reflected, .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. A facility policy titled Pain Assessment revised December 2003 reflected, .medicate the resident as ordered by the physician . A facility policy titled Administering Oral Medications revised December 2003 reflected, .Administer medications within one (1) hour before or after their scheduled time. Resident #1's undated Admission Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was cognitively intact. She required set-up assistance and supervision with ADLs. Resident #1's undated Admission Evaluation reflected, .1. Do you experience pain regularly? (Yes) .What is the intensity of your pain (Use scale below)? .(3) 0.(No hurt), 1.(hurts little bit), 2.(hurts little more), 3.(hurts even more), 4.(hurts whole lot), 5(hurts worst) . Resident #1's Admission Pain Evaluation dated 04/12/16 reflected, she had chronic lower back pain and chronic left knee pain which affected her ability to focus and resulted in decreased physical activities. Resident #1's undated Admission Care Plan reflected, .PAIN, Goal: Resident will be as comfortable as possible .Administer pain medications as ordered . Resident # 1's Care Plan reflected, .Problem: Pain, I am at risk for pain due to a pain disorder .Problem Start Date 4/27/2016 .Approach: Provide Medication as ordered by my MD . A Physician's Telephone Order for Resident #1 dated 05/16/16 signed by the Nurse Practitioner and LVN B reflected, [MEDICATION NAME] ([MEDICATION NAME]) 50mg tab po q 6(hr.) prn dx: pain. A Physician's Telephone Order for Resident #1 dated 05/20/16 and signed by the Nurse Practitioner and LVN C, reflected, D/C [MEDICATION NAME] Start Tylenol #3 q 8 (hrs.) for Pain. Resident #1's Medication Administration Record [REDACTED]. A Nurse's Progress Note for Resident #1 dated 05/21/16 at 2:00 PM and signed by LVN D reflected, Pt. is upset about pain meds. Order is for Tylenol #3, NO (new order) in the chart. The 24 Hour Report dated 05/20/16 reflected, .(Resident #1) .Remarks (Day) .N/O, D/C [MEDICATION NAME] start Tylenol #3 Q 8(hr.) for pain . The 24 Hour Report dated 05/21/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol not in . The 24 Hour Report dated 05/22/16 reflected, .(Resident #1) Remarks (Nights) .Tylenol #3 not here yet . The 24 Hour Report dated 05/23/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol #3 in . Resident #1's Controlled Drug Record dated 05/23/16 reflected, .[MEDICATION NAME]/Cod. #3 tablet QTY 30 (delivered to facility) .Date (5/23/16) .Time(4:30pm) .Amount given (1) .Amount Remaining (29) . An interview on 05/26/16 at 1:10 PM with Resident #1 revealed, her [MEDICATION NAME] (pain medication) was discontinued on 5/20/16 and a new pain medication Tylenol #3 (narcotic pain medication) was ordered at that time but she did not get her first dose of it until three days later on 5/23/16. She was then asked if going three days without her Tylenol #3 caused her any problems. She stated, Yes. I was in excruciating pain in my back. An interview on 05/27/16 at 12:05 PM with CNA G revealed she had worked 05/21/16 with Resident #1. She stated, I was giving her a shower. She was distraught, crying actually because her pain meds hadn't come in yet. An interview on 05/27/16 at 12:00 PM with CNA F revealed she had worked on 05/21/16. She said she recalled working with Resident #1. She stated, I was helping another CNA give her a shower. She was crying and said her pain meds hadn't come in yet. I told the nurse and she just said, Yes they haven't come in. An interview on 05/27/16 at 11:45 AM with LVN E revealed she had worked 05/21/16 and 05/22/16. She said Resident #1 approached her about her pain medication. She said she told Resident #1 the Tylenol #3 was not in yet. She was then asked why she did not call the pharmacy or DON to check on it. She stated, The overnight nurse told me he had called the pharmacy and it required a quantity before they could send it so I just assumed he had called the DON. An interview on 05/26/16 at 12:55 PM with the DON revealed It was her expectation when a new order for a medication was written; the resident should get the new medication at the next scheduled dosing. She was then asked if it was acceptable for a resident to go three days without their pain medication. She stated, No. She was then asked what kind of problems could a resident experience if they did not receive their pain medication as ordered by the physician. She stated, Pain. She was then asked if it would be considered unnecessary pain. She stated, Yes. An interview on 05/26/16 at 3:15 PM with the Administrator revealed, We dropped the ball on Saturday and Sunday. The order was called in on Friday and the pharmacy called back to clarify on Saturday and Sunday. The nurses that took the calls didn't call me or the DON. An interview on 05/27/16 at 1:58 PM with the DON revealed, If they cannot get a medication on the weekend they are supposed to call me. I didn't get any calls last weekend. I don't know why they didn't call me. An interview on 05/27/16 at 11:35 AM with LVN C revealed, she faxed the order on 05/20/16 around 6:30 PM, but failed to notice it did not have a quantity written on it. An IJ was identified on 05/27/16 at 10:45 AM. The Administrator and the DON were notified of the IJ on 05/27/16 at 10:45 AM. A Plan of Removal was requested at that time. The facility's POR was accepted on 05/28/16 at 9:00 AM. The POR reflected the following: . Pain Evaluation on each resident started 05/27/16, by the ADON, LVN A, and LVN B, and will be completed by end of day 05/27/2016 . .Assessment Description: [DIAGNOSES REDACTED]. Resident ' s verbalization of pain. How the resident describes pain. What increases the resident ' s pain.? Location of Resident's pain shown on illustration. Wong-Baker FACES pain Rating Scale (1-10). Identification of present pain. 1 hour after medication is given, 3 hours after pain medication is given, the worst pain gets and the best it gets. PAINAD which identifies pain ques: breathing, negative verbalization, facial expression, body language, and consolability. Changes in ADLs (Activities of Daily Living). Nonverbal/noncognitive signs identified. Relief of pain noted. Conclusion noted . .An immediate audit was completed by the DON and ADON on 05/26/2016 to include all physicians orders in clinical and electronic system and compared to the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for accuracy. Additionally on 05/26/2016 a pain medication audit was completed by the DON and he ADON to ensure that every resident ' s pain medication was in the facility and available. .LVN C, write up to be completed on 05/30/16 prior to working next shift. .RN K, write up to be completed on 06/03/16 prior to working next shift. .LVN D, do not return notification mailed to agency on 05/27/16. .LVN E, do not return notification mailed to agency on 05/27/16. .The Pharmacy Consultant has stated he would have Pharmacy Consult provide facility full cart audit 6/3/2016, then monthly thereafter. At said time, the Pharmacy Consultant will also audit of all pain medications in the facility and a follow up training to facility staff if necessary. .Pain Assessment In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Medication Ordering In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Telephone Order Transcription In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Proper Notification of Director of Nursing/Administrator if Medication is not received timely in-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. .New Order Protocol not to discontinue current medication until new medication has arrived at the facility for pain, unless otherwise contraindicated. It will be conducted by the DON and ADON and will start on 05/27/16 and be completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service. .The Administrator and the DON will be responsible for implementing the changes and prevent the failure from recurring. .When changes in pain medications are made, the current order will continue until the new medication arrives in the facility. These instructions will be clearly documented on the telephone order and the MAR. .If the medication is not available, the night nurse will contact the pharmacy for a stat delivery or backup pharmacy will be contacted. .Physician will be notified of any concerns regarding timely delivery of pain medication orders. Verifying the Plan of Removal included the following: A review of the Pain evaluations on each Resident conducted by the facility on 05/27/16 reflected no current issues, with all residents experiencing acceptable levels of pain. Resident #1's pain was reported as a 2 on the Wong Baker 0-10 pain scale with a 0 being no pain and a 10 is the worst pain. The location of her pain was documented as lower back. A review of the Pain Medication Audit conducted by the facility staff on 05/26/16 reflected every resident's pain medication was at the facility and available to the residents. A review of the Physicians Orders accurately transcribed on the MAR/TAR Audit conducted by facility staff reflected no discrepancies. A Review of In-Service Training reflected eight nurses had been in-serviced on 05/27/16 on Ordering and Receiving Controlled medication, Ordering Medication Written Documentation (including written examples of correct telephone orders), Administering oral medications, Pain Management (with post-test), Prescription Medication Order Transcription (with post-test), and Coverage of Medication/Pharmacy(with post- test). Two nurses from each of the three shifts including weekend nurses were interviewed: Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do if a new order for pain medication was not available to the resident. They said the proper steps to take included the following; call the pharmacy to check on the status of the order, if a problem exists, notify physician and see if alternative medication could be given and notify the DON/Administrator, and keep the resident informed of the situation. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on the necessary information to be included on a telephone order to be valid when faxing orders to the pharmacy. They said the proper information to include for a telephone order to be valid included the following; Resident ' s name, Dr.'s name, facility name, date, medication, dose, strength, route, and quantity to dispense. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do should they find an incomplete order. They said the proper steps to take included the following; Call the physician for clarification, write a clarification order, and notify the DON if there are any issues in obtaining the medication. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on missed doses of a scheduled medication. They were asked if a scheduled medication was not available to give a resident due to not arriving from the pharmacy, would they have committed a medication error. They answered, yes. Observations on 05/28/16 beginning at 9:30AM and ending 05/28/16 at 12:20 PM of the following residents who received narcotic pain medication for the management of their pain; Residents #1, #2, #3, and #4 revealed they did not have objective signs or symptoms of pain. They had a relaxed demeanor and exhibited no acute distress. Interviews on 05/28/16 beginning at 9:30 AM and ending 05/28/16 at 12:20 PM with the following residents who received narcotic pain medication for the management of their pain; Residents #1, #2, #3, and #4 revealed they had no problems obtaining their pain medications. On 05/28/16 at 12:40 PM, the Administrator, DON, and Regional Vice President were notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm and a scope of pattern because the staff was still being trained and the facility was monitoring the effectiveness of the Plan of Removal. An Order Report by Category dated 05/28/16 revealed there were 27 residents who resided at the facility and received medication for the management of their pain.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of 4 residents reviewed for pain management. The facility failed to administer Resident #1's Tylenol #3 three times a day as ordered by the physician on 05/20/16, 05/21/16, 05/22/16, and 05/23/16. She missed eight doses, resulting in the resident experiencing excruciating back pain. An Immediate Jeopardy (IJ) was identified on 05/27/16. While the IJ was removed 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm, and a scope of pattern because the staff was still being trained and the facility was continuing to monitor the effectiveness of their Plan of Removal (POR). These failures placed the facility's 27 residents who receive pain medication at risk for unnecessary pain, delayed healing, decreased appetite, increased stress, disrupted sleep, anxiety, and depression. Findings included: Resident #1's undated Admission Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was cognitively intact. She required set-up assistance and supervision with ADLs. Resident #1's undated Admission Evaluation reflected, .1. Do you experience pain regularly? (Yes) .What is the intensity of your pain (Use scale below)? .(3) 0.(No hurt), 1.(hurts little bit), 2.(hurts little more), 3.(hurts even more), 4.(hurts whole lot), 5(hurts worst) . Resident #1's Admission Pain Evaluation dated 04/12/16 reflected, she had chronic lower back pain and chronic left knee pain which affected her ability to focus and resulted in decreased physical activities. Resident #1's undated Admission Care Plan reflected, .PAIN, Goal: Resident will be as comfortable as possible .Administer pain medications as ordered . Resident # 1's Care Plan reflected, .Problem: Pain, I am at risk for pain due to a pain disorder .Problem Start Date 4/27/2016 .Approach: Provide Medication as ordered by my MD . A Physician's Telephone Order for Resident #1 dated 05/16/16 signed by the Nurse Practitioner and LVN B reflected, [MEDICATION NAME] ([MEDICATION NAME]) 50mg tab po q 6(hr.) prn dx: pain. A Physician's Telephone Order for Resident #1 dated 05/20/16 and signed by the Nurse Practitioner and LVN C, reflected, D/C [MEDICATION NAME] Start Tylenol #3 q 8 (hrs.) for Pain. Resident #1's Medication Administration Record [REDACTED]. A Nurse's Progress Note for Resident #1 dated 05/21/16 at 2:00 PM and signed by LVN D reflected, Pt. is upset about pain meds. Order is for Tylenol #3, NO (new order) in the chart. The 24 Hour Report dated 05/20/16 reflected, .(Resident #1) .Remarks (Day) .N/O, D/C [MEDICATION NAME] start Tylenol #3 Q 8(hr.) for pain . The 24 Hour Report dated 05/21/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol not in . The 24 Hour Report dated 05/22/16 reflected, .(Resident #1) Remarks (Nights) .Tylenol #3 not here yet . The 24 Hour Report dated 05/23/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol #3 in . Resident #1's Controlled Drug Record dated 05/23/16 reflected, .[MEDICATION NAME]/Cod. #3 tablet QTY 30 (delivered to facility) .Date (5/23/16) .Time(4:30pm) .Amount given (1) .Amount Remaining (29) . An interview on 05/26/16 at 1:10 PM with Resident #1 revealed, her [MEDICATION NAME] (pain medication) was discontinued on 5/20/16 and a new pain medication Tylenol #3 (narcotic pain medication) was ordered at that time but she did not get her first dose of it until three days later on 5/23/16. She was then asked if going three days without her Tylenol #3 caused her any problems. She stated, Yes. I was in excruciating pain in my back. An interview on 05/27/16 at 12:05 PM with CNA G revealed she had worked 05/21/16 with Resident #1. She stated, I was giving her a shower. She was distraught, crying actually because her pain meds hadn't come in yet. An interview on 05/27/16 at 12:00 PM with CNA F revealed she had worked on 05/21/16. She said she recalled working with Resident #1. She stated, I was helping another CNA give her a shower. She was crying and said her pain meds hadn't come in yet. I told the nurse and she just said, Yes they haven't come in. An interview on 05/27/16 at 11:45 AM with LVN E revealed she had worked 05/21/16 and 05/22/16. She said Resident #1 approached her about her pain medication. She said she told Resident #1 the Tylenol #3 was not in yet. She was then asked why she did not call the pharmacy or DON to check on it. She stated, The overnight nurse told me he had called the pharmacy and it required a quantity before they could send it so I just assumed he had called the DON. An interview on 05/26/16 at 12:55 PM with the DON revealed It was her expectation when a new order for a medication was written; the resident should get the new medication at the next scheduled dosing. She was then asked if it was acceptable for a resident to go three days without their pain medication. She stated, No. She was then asked what kind of problems could a resident experience if they did not receive their pain medication as ordered by the physician. She stated, Pain. She was then asked if it would be considered unnecessary pain. She stated, Yes. An interview on 05/26/16 at 3:15 PM with the Administrator revealed, We dropped the ball on Saturday and Sunday. The order was called in on Friday and the pharmacy called back to clarify on Saturday and Sunday. The nurses that took the calls didn't call me or the DON. An interview on 05/27/16 at 1:58 PM with the DON revealed, If they cannot get a medication on the weekend they are supposed to call me. I didn't get any calls last weekend. I don't know why they didn't call me. An interview on 05/27/16 at 11:35 AM with LVN C revealed, she faxed the order on 05/20/16 around 6:30 PM, but failed to notice it did not have a quantity written on it. A facility policy titled Pain Assessment revised December 2003 reflected, .medicate the resident as ordered by the physician . A facility policy titled Administering Oral Medications revised December 2003 reflected, .Administer medications within one (1) hour before or after their scheduled time. An IJ was identified on 05/27/16 at 10:45 AM. The Administrator and the DON were notified of the IJ on 05/27/16 at 10:45 AM. A Plan of Removal was requested at that time. The facility's POR was accepted on 05/28/16 at 9:00 AM. The POR reflected the following: . Pain Evaluation on each resident started 05/27/16, by the ADON, LVN A, and LVN B, and will be completed by end of day 05/27/2016 . .Assessment Description: [DIAGNOSES REDACTED]. Resident ' s verbalization of pain. How the resident describes pain. What increases the resident ' s pain.? Location of Resident ' s pain shown on illustration. Wong-Baker FACES pain Rating Scale (1-10). Identification of present pain. 1 hour after medication is given, 3 hours after pain medication is given, the worst pain gets and the best it gets. PAINAD which identifies pain ques: breathing, negative verbalization, facial expression, body language, and consolability. Changes in ADLs (Activities of Daily Living). Nonverbal/noncognitive signs identified. Relief of pain noted. Conclusion noted. .An immediate audit was completed by the DON and ADON on 05/26/2016 to include all physicians orders in clinical and electronic system and compared to the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for accuracy. Additionally on 05/26/2016 a pain medication audit was completed by the DON and he ADON to ensure that every resident ' s pain medication was in the facility and available. .LVN C, write up to be completed on 05/30/16 prior to working next shift. .RN K, write up to be completed on 06/03/16 prior to working next shift. .LVN D, do not return notification mailed to agency on 05/27/16. .LVN E, do not return notification mailed to agency on 05/27/16. .The Pharmacy Consultant has stated he would have Pharmacy Consult provide facility full cart audit 6/3/2016, then monthly thereafter. At said time, the Pharmacy Consultant will also audit of all pain medications in the facility and a follow up training to facility staff if necessary. .Pain Assessment In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Medication Ordering In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Telephone Order Transcription In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Proper Notification of Director of Nursing/Administrator if Medication is not received timely in-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. .New Order Protocol not to discontinue current medication until new medication has arrived at the facility for pain, unless otherwise contraindicated. It will be conducted by the DON and ADON and will start on 05/27/16 and be completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service. .The Administrator and the DON will be responsible for implementing the changes and prevent the failure from recurring. .When changes in pain medications are made, the current order will continue until the new medication arrives in the facility. These instructions will be clearly documented on the telephone order and the MAR. .If the medication is not available, the night nurse will contact the pharmacy for a stat delivery or backup pharmacy will be contacted. .Physician will be notified of any concerns regarding timely delivery of pain medication orders. Verifying the Plan of Removal included the following: A review of the Pain evaluations on each Resident conducted by the facility on 05/27/16 reflected no current issues, with all residents experiencing acceptable levels of pain. Resident #1's pain was reported as a 2 on the Wong Baker 0-10 pain scale with a 0 being no pain and a 10 is the worst pain. The location of her pain was documented as lower back. A review of the Pain Medication Audit conducted by the facility staff on 05/26/16 reflected every resident's pain medication was at the facility and available to the residents. A review of the Physicians Orders accurately transcribed on the MAR/TAR Audit conducted by facility staff reflected no discrepancies. A Review of In-Service Training reflected eight nurses had been in-serviced on 05/27/16 on Ordering and Receiving Controlled medication, Ordering Medication Written Documentation (including written examples of correct telephone orders), Administering oral medications, Pain Management (with post-test), Prescription Medication Order Transcription (with post-test), and Coverage of Medication/Pharmacy(with post-test). Two nurses from each of the three shifts including weekend nurses were interviewed: Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do if a new order for pain medication was not available to the resident. They said the proper steps to take included the following; call the pharmacy to check on the status of the order, if a problem exists, notify physician and see if alternative medication could be given and notify the DON/Administrator, and keep the resident informed of the situation. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on the necessary information to be included on a telephone order to be valid when faxing orders to the pharmacy. They said the proper information to include for a telephone order to be valid included the following; Resident's name, Dr.'s name, facility name, date, medication, dose, strength, route, and quantity to dispense. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do should they find an incomplete order. They said the proper steps to take included the following; Call the physician for clarification, write a clarification order, and notify the DON if there are any issues in obtaining the medication. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on missed doses of a scheduled medication. They were asked if a scheduled medication was not available to give a resident due to not arriving from the pharmacy, would they have committed a medication error. They answered, yes. Observations on 05/28/16 beginning at 9:30AM and ending 05/28/16 at 12:20 PM of the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4, revealed they did not have objective signs or symptoms of pain. They had a relaxed demeanor and exhibited no acute distress. Interviews on 05/28/16 beginning at 9:30 AM and ending 05/28/16 at 12:20 PM with the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4, revealed they had no problems obtaining their pain medications. On 05/28/16 at 12:40 PM, the Administrator, DON, and Regional Vice President were notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm and a scope of pattern because the staff was still being trained and the facility was monitoring the effectiveness of the Plan of Removal. An Order Report by Category dated 05/28/16 revealed there were 27 residents who resided at the facility and received medication for the management of their pain.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate aquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 4 residents reviewed for pharmacy services. The facility failed to aquire Tylenol #3 for Resident #1 in a timely manner. The physician ordered Tylenol #3 to be given three times day starting 05/20/16. The medication did not arrive at the facility until 05/23/16 resulting in the resident missing eight doses of the medication and causing her to experience excruciating pain. An Immediate Jeopardy (IJ) was identified on 05/27/16. While the IJ was removed 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm, and a scope of pattern because the staff was still being trained and the facility was continuing to monitor the effectiveness of their Plan of Removal (POR). These failures placed the facility's 27 residents who receive pain medication at risk for unnecessary pain, delayed healing, decreased appetite, increased stress, disrupted sleep, anxiety, and depression. Findings included: Resident #1's undated Admission Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Resident #1's MDS assessment dated [DATE] reflected the resident was cognitively intact. She required set-up assistance and supervision with ADLs. Resident #1's undated Admission Evaluation reflected, .1. Do you experience pain regularly? (Yes) .What is the intensity of your pain (Use scale below)? .(3) 0.(No hurt), 1.(hurts little bit), 2.(hurts little more), 3.(hurts even more), 4.(hurts whole lot), 5(hurts worst) . Resident #1's Admission Pain Evaluation dated 04/12/16 reflected, she had chronic lower back pain and chronic left knee pain which affected her ability to focus and resulted in decreased physical activities. Resident #1's undated Admission Care Plan reflected, .PAIN, Goal: Resident will be as comfortable as possible .Administer pain medications as ordered . Resident # 1's Care Plan reflected, .Problem: Pain, I am at risk for pain due to a pain disorder .Problem Start Date 4/27/2016 .Approach: Provide Medication as ordered by my MD . A Physician's Telephone Order for Resident #1 dated 05/16/16 signed by the Nurse Practitioner and LVN B reflected, Tramadol (Ultram) 50mg tab po q 6(hr.) prn dx: pain. A Physician's Telephone Order for Resident #1 dated 05/20/16 and signed by the Nurse Practitioner and LVN C, reflected, D/C Ultram Start Tylenol #3 q 8 (hrs.) for Pain. Resident #1's Medication Administration Record [REDACTED]. A Nurse's Progress Note for Resident #1 dated 05/21/16 at 2:00 PM and signed by LVN D reflected, Pt. is upset about pain meds. Order is for Tylenol #3, NO (new order) in the chart. The 24 Hour Report dated 05/20/16 reflected, .(Resident #1) .Remarks (Day) .N/O, D/C Ultram start Tylenol #3 Q 8(hr.) for pain . The 24 Hour Report dated 05/21/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol not in . The 24 Hour Report dated 05/22/16 reflected, .(Resident #1) Remarks (Nights) .Tylenol #3 not here yet . The 24 Hour Report dated 05/23/16 reflected, .(Resident #1) .Remarks (Evening) .Tylenol #3 in . Resident #1's Controlled Drug Record dated 05/23/16 reflected, .Acetaminophen/Cod. #3 tablet QTY 30 (delivered to facility) .Date (5/23/16) .Time(4:30pm) .Amount given (1) .Amount Remaining (29) . An interview on 05/26/16 at 1:10 PM with Resident #1 revealed, her Ultram (pain medication) was discontinued on 5/20/16 and a new pain medication Tylenol #3 (narcotic pain medication) was ordered at that time but she did not get her first dose of it until three days later on 5/23/16. She was then asked if going three days without her Tylenol #3 caused her any problems. She stated, Yes. I was in excruciating pain in my back. An interview on 05/27/16 at 12:05 PM with CNA G revealed she had worked 05/21/16 with Resident #1. She stated, I was giving her a shower. She was distraught, crying actually because her pain meds hadn't come in yet. An interview on 05/27/16 at 12:00 PM with CNA F revealed she had worked on 05/21/16. She said she recalled working with Resident #1. She stated, I was helping another CNA give her a shower. She was crying and said her pain meds hadn't come in yet. I told the nurse and she just said, Yes they haven't come in. An interview on 05/27/16 at 11:45 AM with LVN E revealed she had worked 05/21/16 and 05/22/16. She said Resident #1 approached her about her pain medication. She said she told Resident #1 the Tylenol #3 was not in yet. She was then asked why she did not call the pharmacy or DON to check on it. She stated, The overnight nurse told me he had called the pharmacy and it required a quantity before they could send it so I just assumed he had called the DON. An interview on 05/26/16 at 12:55 PM with the DON revealed It was her expectation when a new order for a medication was written; the resident should get the new medication at the next scheduled dosing. She was then asked if it was acceptable for a resident to go three days without their pain medication. She stated, No. She was then asked what kind of problems could a resident experience if they did not receive their pain medication as ordered by the physician. She stated, Pain. She was then asked if it would be considered unnecessary pain. She stated, Yes. An interview on 05/26/16 at 3:15 PM with the Administrator revealed, We dropped the ball on Saturday and Sunday. The order was called in on Friday and the pharmacy called back to clarify on Saturday and Sunday. The nurses that took the calls didn't call me or the DON. An interview on 05/27/16 at 1:58 PM with the DON revealed, If they cannot get a medication on the weekend they are supposed to call me. I didn't get any calls last weekend. I don't know why they didn't call me. An interview on 05/27/16 at 11:35 AM with LVN C revealed, she faxed the order on 05/20/16 around 6:30 PM, but failed to notice it did not have a quantity written on it. A facility policy titled Pain Assessment revised December 2003 reflected, .medicate the resident as ordered by the physician . A facility policy titled Administering Oral Medications revised December 2003 reflected, .Administer medications within one (1) hour before or after their scheduled time. An IJ was identified on 05/27/16 at 10:45 AM. The Administrator and the DON were notified of the IJ on 05/27/16 at 10:45 AM. A Plan of Removal was requested at that time. The facility's POR was accepted on 05/28/16 at 9:00 AM. The POR reflected the following: . Pain Evaluation on each resident started 05/27/16, by the ADON, LVN A, and LVN B, and will be completed by end of day 05/27/2016 . .Assessment Description: [DIAGNOSES REDACTED]. Resident ' s verbalization of pain. How the resident describes pain. What increases the resident ' s pain.? Location of Resident ' s pain shown on illustration. Wong-Baker FACES pain Rating Scale (1-10). Identification of present pain. 1 hour after medication is given, 3 hours after pain medication is given, the worst pain gets and the best it gets. PAINAD which identifies pain ques: breathing, negative verbalization, facial expression, body language, and consolability. Changes in ADLs (Activities of Daily Living). Nonverbal/noncognitive signs identified. Relief of pain noted. Conclusion noted. .An immediate audit was completed by the DON and ADON on 05/26/2016 to include all physicians orders in clinical and electronic system and compared to the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for accuracy. Additionally on 05/26/2016 a pain medication audit was completed by the DON and he ADON to ensure that every resident ' s pain medication was in the facility and available . .LVN C, write up to be completed on 05/30/16 prior to working next shift. .RN K, write up to be completed on 06/03/16 prior to working next shift. .LVN D, do not return notification mailed to agency on 05/27/16. .LVN E, do not return notification mailed to agency on 05/27/16. .The Pharmacy Consultant has stated he would have Pharmacy Consult provide facility full cart audit 6/3/2016, then monthly thereafter. At said time, the Pharmacy Consultant will also audit of all pain medications in the facility and a follow up training to facility staff if necessary. .Pain Assessment In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Medication Ordering In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Telephone Order Transcription In-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service followed with a post test. .Proper Notification of Director of Nursing/Administrator if Medication is not received timely in-service, conducted by the DON and ADON will start on 05/27/16 and completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. .New Order Protocol not to discontinue current medication until new medication has arrived at the facility for pain, unless otherwise contraindicated. It will be conducted by the DON and ADON and will start on 05/27/16 and be completed 05/27/16. All Nursing staff will complete prior to working their next scheduled shift. It will be a verbal and written in-service. .The Administrator and the DON will be responsible for implementing the changes and prevent the failure from recurring. .When changes in pain medications are made, the current order will continue until the new medication arrives in the facility. These instructions will be clearly documented on the telephone order and the MAR. .If the medication is not available, the night nurse will contact the pharmacy for a stat delivery or backup pharmacy will be contacted. .Physician will be notified of any concerns regarding timely delivery of pain medication orders. Verifying the Plan of Removal included the following: A review of the Pain evaluations on each Resident conducted by the facility on 05/27/16 reflected no current issues, with all residents experiencing acceptable levels of pain. Resident #1's pain was reported as a 2 on the Wong Baker 0-10 pain scale with a 0 being no pain and a 10 is the worst pain. The location of her pain was documented as lower back. A review of the Pain Medication Audit conducted by the facility staff on 05/26/16 reflected every resident's pain medication was at the facility and available to the residents. A review of the Physicians Orders accurately transcribed on the MAR/TAR Audit conducted by facility staff reflected no discrepancies. A Review of In-Service Training reflected eight nurses had been in-serviced on 05/27/16 on Ordering and Receiving Controlled medication, Ordering Medication Written Documentation (including written examples of correct telephone orders), Administering oral medications, Pain Management (with post-test), Prescription Medication Order Transcription (with post-test), and Coverage of Medication/Pharmacy(with post-test). Two nurses from each of the three shifts including weekend nurses were interviewed: Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do if a new order for pain medication was not available to the resident. They said the proper steps to take included the following; call the pharmacy to check on the status of the order, if a problem exists, notify physician and see if alternative medication could be given and notify the DON/Administrator, and keep the resident informed of the situation. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on the necessary information to be included on a telephone order to be valid when faxing orders to the pharmacy. They said the proper information to include for a telephone order to be valid included the following; Resident's name, Dr.'s name, facility name, date, medication, dose, strength, route, and quantity to dispense. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on what to do should they find an incomplete order. They said the proper steps to take included the following; Call the physician for clarification, write a clarification order, and notify the DON if there are any issues in obtaining the medication. Interviews on 05/28/16 with the following LVNs; LVN A, LVN B, LVN C, LVN H, LVN I, and LVN J, revealed they had been in-serviced on missed doses of a scheduled medication. They were asked if a scheduled medication was not available to give a resident due to not arriving from the pharmacy, would they have committed a medication error. They answered, yes. Observations on 05/28/16 beginning at 9:30AM and ending 05/28/16 at 12:20 PM of the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4, revealed they did not have objective signs or symptoms of pain. They had a relaxed demeanor and exhibited no acute distress. Interviews on 05/28/16 beginning at 9:30 AM and ending 05/28/16 at 12:20 PM with the following residents who received narcotic pain medication for the management of their pain, Residents #1, #2, #3, and #4, revealed they had no problems obtaining their pain medications. On 05/28/16 at 12:40 PM, the Administrator, DON, and Regional Vice President were notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on 05/28/16, the facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm and a scope of pattern because the staff was still being trained and the facility was monitoring the effectiveness of the Plan of Removal. An Order Report by Category dated 05/28/16 revealed there were 27 residents who resided at the facility and received medication for the management of their pain.

Based on interview and record review, the facility failed to implement policies and procedures prohibiting neglect for one (Resident #1) of five residents reviewed for injuries of unknown origin. Resident #1 sustained a displaced comminuted fracture of her left clavicle, which was sticking up and had purple bruising to the area. The resident said she fell and staff helped her up but she could not identify the staff, and there were no staff reports of a fall. The facility failed to talk with the resident to determine what happened. These failures could affect the facility's 38 residents by placing them at risk for neglect, abuse, and pain. Findings included: Resident #1's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility initially on 03/28/12. She discharged from the facility on 08/15/14 at 11:00 a.m. The Face Sheet reflected her [DIAGNOSES REDACTED]. Resident #1's most current quarterly MDS assessment, dated 05/02/14, reflected she required one person's limited assistance during transfers. The MDS assessment also reflected she required one staff providing extensive assistance while toileting. Interview with LVN I on 09/09/14 at 4:20 p.m. revealed Resident #1's quarterly MDS assessment was due in August, and the resident discharged from the facility before the MDS assessment could be completed. Resident #1's Monthly Summary Assessment, dated 07/21/14, reflected the resident had short term and long term memory problems, and she was moderately impaired in decision making. Resident #1's Care Plan, dated 08/07/14, following a fall on 08/06/14, the resident was changed from a one-person assist to a two-person assist during transfers. The resident was a two person assist while toileting prior to the fall and remained at two person assist following her fall. The Care Plan also reflected the resident had an unsteady gait and cognitive impairment. According to the Care Plan, Resident #1 had too much furniture in her room, and staff spoke with her concerning the crowded conditions. The resident refused to move any furniture from her room. Nurse's Note, dated 08/14/14 at 9:00 p.m. reflected the family reported Resident #1 was saying she had increased pain in her left shoulder. The resident stated she fell the other day, but she could not remember who got her up. The Note reflected her left shoulder had purple discoloration, an area was raised and tender to touch. The family member requested an x-ray. The nurse called the nurse practitioner and x-rays were ordered. The x-ray technician was present at 12:05 a.m. Nurse's Note, dated 08/15/14, the x-ray results were received by the facility at 4:00 a.m., confirming Resident #1 had a complete comminuted (the bone is broken or splintered into pieces) fracture at the distal clavical with upward displacement proximal segment. There was also surrounding soft tissue contusion/[MEDICAL CONDITION]. Results of the x-rays were faxed to the nurse practioner at 4:00 a.m. New orders were received at 7:00 a.m. for a sling on the left shoulder. Review of the x-ray report, dated 08/14/14, revealed the left shoulder was fractured at the distal clavicle with upward displacement of the proximal segment. The report also had documented surrounding soft tissue had contusion/[MEDICAL CONDITION]. The facility's Provider Investigation Report, reflected the incident date was "08/15/14." The report also reflected there were no witnesses to the "fall" on 08/06/14. The family member discovered the injuries at approximately 8:00 p.m. on 08/14/14. There were no injuries noted to the resident following her fall on 08/06/14. According to the provider investigation report reflected x-rays were ordered on [DATE] which confirmed a fractured clavicle. The report also reflected Resident #1 had complained of pain in her neck on 08/11/14 and was given a Tylenol 325 and her neck was massaged by LVN H. Interview with the Administrator on 09/10/14 at approximately 10:45 a.m. revealed following the investigation, he believed something else happened to Resident #1 causing her fractured clavicle and bruising, other than the fall on 08/06/14. The Administrator said he did not have time to speak with Resident #1 before she discharged from the facility. The Administrator confirmed LVN A did not notify him when the injury was discovered, but he admitted LVN A should have called him when the injury to the clavicle was reported by the resident's family member. Interview via telephone with Resident #1 on 08/27/14 at 9:55 a.m. revealed she fell and someone helped her up, but she did not know who it was. The resident said she was unsure of the day in which she fell . Resident #1 said she experienced pain in her shoulder following the fall in the facility, and nurses gave her Tylenol. Resident #1 revealed she felt better now she had moved because she thought they gave her stronger pain medication. Resident #1 was unsure of the date in which she fell . Incident Reports for last 90 days reflected an Incident Report was not completed on 08/14/14 following the discovery of Resident #1's injury. Interview with Resident #1's Family Member on 08/27/14 at 12:15 p.m. revealed the family member visited Resident #1 at approximately 8:00 p.m. on 08/14/14. The family member said Resident #1 complained of pain in her shoulder, and reported she had fallen. The family member explained Resident #1 had a clavicle that was "sticking up" and the area was bruised very badly. The family member described the bruises as appearing "not as old as the fall." Interview with Resident #1's family member on 09/18/14 at 12:05 p.m. revealed the resident was wearing her sleeping gown when the family member noted the injury to the resident. Interview with CNA H on 08/27/14 at 3:20 p.m. revealed she was working the evening the family member discovered the injury on Resident #1. CNA H confirmed she had not seen the injury until that time, and she did not know of any incident which might have caused the injury. CNA H said she could see the bruising on Resident #1's shoulder. Interview with CNA C on 08/09/14 at 11:25 a.m. reflected she did not observe any bruising or injury on Resident #1, and the resident never complained about pain. CNA C confirmed Resident #1 was a one-person assist with transfers. Computer-generated time sheets reflected CNA C worked with Resident #1 on 08/10/14 through 08/13/14. Interview with CNA D on 09/09/14 at 11:50 a.m. revealed she worked with Resident #1, and she did not see any bruising on the resident. CNA D said the DON asked her if she had worked with the resident, and the DON said staff needed to start helping Resident #1 with transfers. CNA D confirmed that was all the DON asked. CNA D said Resident #1 could stand and one person assisted. CNA D added Resident #1 could walk to her wheelchair using her walker. Interview with CNA G on 09/09/14 at 12:50 p.m. reflected she had not seen any bruises on Resident #1. CNA G confirmed she was asked during the investigation if she had seen bruises or if Resident #1 was complaining about pain. The DON also asked her if she pulled Resident #1's arm at any time. The computer generated-time sheets reflected CNA G had worked with Resident #1 on 08/12/14 through 08/14/14. Interview with LVN A on 08/27/14 at 2:20 p.m. reflected on 08/06/14, Resident #1 returned to her room following dinner where later she was found on the floor. LVN A explained she assessed the resident following the fall, which included bending her elbows, lifting her arms, and bending her knees. LVN A stated she removed the resident's shirt and pants to assess any areas which might have been injured during the fall. The LVN revealed Resident #1 said she did not hit her head, but the resident was placed on 72 hour neurological checks because it was an unwitnessed fall. LVN A stated CNA B found Resident #1 on the floor following the resident's fall. Resident #1 told LVN A she slipped off the bedside commode. Interview with CNA B on 09/09/14 at approximately 4:40 p.m. revealed she did not find Resident #1 on the floor on 08/06/14. The CNA explained she did not know why they put her name down as the one who found the resident, but she did not find the resident. Interview with the PTA on 09/09/14 at approximately 3:10 p.m. revealed he had worked with Resident #1 three times in the week following her fall on 08/06/14, and Resident #1 never complained about pain when he was with her. Interview with the DON on 09/10/14 at approximately 10:00 a.m. revealed she did not interview Resident #1 during the investigation. The DON explained she was not notified of the resident's injuries until 8:00 a.m. on 08/15/14, and the resident discharged at 8:45 a.m. the same morning. She stated Resident #1 was already scheduled to discharge from the facility on 08/15/14. The DON confirmed the interviews presented with the provider investigation report, dated 08/15/14, were the only interviews conducted during the investigation. The DON also confirmed she asked questions, and the DON wrote the responses of the staff members as they spoke. The DON confirmed the responses written on the witness statements were from the seven staff included in the Provider Investigation Report. The DON said there were no other questions answered. The question listed on the interview sheet was "Do you know anything about the incident with (Resident #1) on or about _________? The questions were asked about Resident #1 and the responses follow with the dates which complete the question. The following questions were also asked: "Do you have knowledge of the incident?" "Do you have any knowledge of the injury?" "Do you have knowledge about any test values or physician's orders [REDACTED].?" "Do you know anyone else that might know something about this incident?" Review of the witness statements regarding the incident "on or about 08/06/14" (sic) revealed the following: CNA C's response reflected "she has no knowledge of the fall, but states" The statement was not completed. CNA D's response reflected "did not have knowledge of fall." LVN A's response reflected CNA B "came to advise this nurse that" Resident #1 "was on the floor. Assessment completed revealed no injury, distress at the time of the incident, no complains or needs. Resident slipped off seat of bedside commode per resident statement." CNA E's response reflected "Did not work on this hall during this incident." Review of witness statements regarding the incident "on or about 08/08/14 (sic)" revealed the following: MA F's response reflected CNA B "came to tell" LVN A, Resident #1 "was on floor. When nurse and I arrived, resident was on floor on her bottom with legs straight out in front of her. Resident stated she was not hurt when asked." CNA B's response reflected "Does not remember this incident." Review of witness statements regarding the incident "on or about (there was no date)" and the staff member responding to the questions were as follows: CNA G's response reflected "she has no knowledge of any incident or injury." The facility's current policy on Reporting Abuse to Facility Management, dated 05/20/14, reflected it was the responsibility of the employees of the facility, facility consultants, attending physicians, family members, visitors, volunteers to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the Administrator or his designee. The CMS 672 Resident Census and Conditions, dated 08/27/14 and signed by LVN I, reflected 38 residents resided in the facility.

Based on interview and record review, the facility failed to implement its written policies and procedures prohibiting neglect for one (Resident #1) of five residents reviewed for injuries of unknown origin. Resident #1 sustained a displaced comminuted fracture of her left clavicle, which was sticking up and had purple bruising to the area. The resident said she fell and staff helped her up but she could not identify the staff, and there were no staff reports of a fall. The facility failed to talk with the resident to determine what happened. LVN A failed to immediately notify the Administrator when Resident #1 had a comminuted fracture of her left clavicle that was sticking up and purple bruising to the area. These failures could affect the facility's 38 residents by placing them at risk for neglect, abuse, and pain. Findings included: The facility's current policy on Reporting Abuse to Facility Management, dated 05/20/14, reflected it was the responsibility of the employees of the facility, facility consultants, attending physicians, family members, visitors, volunteers to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property to the Administrator or his designee. Resident #1's undated Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility initially on 03/28/12. She discharged from the facility on 08/15/14 at 11:00 a.m. The Face Sheet reflected her [DIAGNOSES REDACTED]. Resident #1's most current quarterly MDS assessment, dated 05/02/14, reflected she required one person's limited assistance during transfers. The MDS assessment also reflected she required one staff providing extensive assistance while toileting. Interview with LVN I on 09/09/14 at 4:20 p.m. revealed Resident #1's quarterly MDS assessment was due in August, and the resident discharged from the facility before the MDS assessment could be completed. Resident #1's Monthly Summary Assessment, dated 07/21/14, reflected the resident had short term and long term memory problems, and she was moderately impaired in decision making. Resident #1's Care Plan, dated 08/07/14, following a fall on 08/06/14, the resident was changed from a one-person assist to a two-person assist during transfers. The resident was a two person assist while toileting prior to the fall and remained two-person assist following her fall. The Care Plan also reflected the resident had an unsteady gait and cognitive impairment. According to the Care Plan, Resident #1 had too much furniture in her room, and staff spoke with her concerning the crowded conditions. The resident refused to move any furniture from her room. Nurse's Note, dated 08/14/14 at 9:00 p.m. reflected the family reported Resident #1 was saying she had increased pain in her left shoulder. The resident stated she fell the other day, but she could not remember who got her up. The Note reflected her left shoulder had purple discoloration, an area was raised and tender to touch. The family member requested an x-ray. The nurse called the nurse practitioner and x-rays were ordered. The x-ray technician was present at 12:05 a.m. Nurses's Note, dated 08/15/14 reflected the x-ray results were received by the facility at 4:00 a.m., confirming Resident #1 had a complete comminuted (the bone is broken or splintered into pieces) fracture at the distal clavical with upward displacement proximal segment. There was also surrounding soft tissue contusion/[MEDICAL CONDITION]. Results of the x-rays were faxed to the nurse practioner at 4:00 a.m. New orders were received at 7:00 a.m. for a sling on the left shoulder. Review of the x-ray report, dated 08/14/14, reflected the left shoulder had a fracture at the distal clavicle with upward displacement of the proximal segment. The report also had documented surrounding soft tissue had contusion/[MEDICAL CONDITION]. The facility's Provider Investigation Report, reflected the incident date was "08/15/14." The report also reflected there were no witnesses to the "fall" on 08/06/14. The family member discovered the injuries at approximately 8:00 p.m. on 08/14/14. There were no injuries noted to the resident following her fall on 08/06/14. According to the provider investigation report, x-rays were ordered on [DATE] which revealed a fractured clavicle. The report also reflected Resident #1 had complained of pain in her neck on 08/11/14 and was given a Tylenol 325 and her neck was massaged by LVN H. Interview with the Administrator on 09/10/14 at approximately 10:45 a.m. revealed following the investigation, he believed something else happened to Resident #1 causing her fractured clavicle and bruising, other than the fall on 08/06/14. The Administrator said he did not have time to speak with Resident #1 before she discharged from the facility. The Administrator confirmed LVN A did not notify him when the injury was discovered, but he admitted LVN A should have called him when the injury to the clavicle was reported by the resident's family member. Interview via telephone with Resident #1 on 08/27/14 at 9:55 a.m. revealed she fell and someone helped her up, but she did not know who it was. The resident said she was unsure of the day on which she fell . Resident #1 said she experienced pain in her shoulder following the fall in the facility, and nurses gave her Tylenol. Resident #1 revealed she felt better now she had moved because she thought they gave her stronger pain medication. Resident #1 was unsure of the date of the fall. Incident Reports for last 90 days reflected an Incident Report was not completed on 08/14/14 following the discovery of Resident #1's injury. Interview with Resident #1's Family Member on 08/27/14 at 12:15 p.m. revealed the family member visited Resident #1 at approximately 8:00 p.m. on 08/14/14. The family member said Resident #1 complained of pain in her shoulder, and reported she had fallen. The family member explained Resident #1 had a clavicle that was "sticking up" and the area was bruised very badly. The family member described the bruises as appearing "not as old as the fall." Interview with Resident #1's Family Member on 09/18/14 at 12:05 p.m. revealed the resident was wearing her sleeping gown when the family member noted the injury to the resident. Interview with CNA H on 08/27/14 at 3:20 p.m. reflected she was working the evening the family member discovered the injury on Resident #1. CNA H confirmed she had not seen the injury until that time, and she did not know of any incident which might have caused the injury. CNA H said she could see the bruising on Resident #1's shoulder. Interview with CNA C on 08/09/14 at 11:25 a.m. reflected she did not observe any bruising or injury on Resident #1, and the resident never complained about pain. CNA C confirmed Resident #1 was a one-person assist with transfers. Computer-generated time sheets reflected CNA C worked with Resident #1 on 08/10/14 through 08/13/14. Interview with CNA D on 09/09/14 at 11:50 a.m. revealed she worked with Resident #1, and she did not see any bruising on the resident. CNA D said the DON asked her if she had worked with the resident, and the DON said staff needed to start helping Resident #1 with transfers. CNA D confirmed that was all the DON asked. CNA D said Resident #1 could stand and one person assisted. CNA D added Resident #1 could walk to her wheelchair using her walker. Interview with CNA G on 09/09/14 at 12:50 p.m. reflected she had not seen any bruises on Resident #1. CNA G confirmed she was asked during the investigation if she had seen bruises or Resident #1 was complaining about pain. The DON also asked her if she pulled Resident #1's arm at any time. The computer generated time sheets reflected CNA G had worked with Resident #1 on 08/12/14 through 08/14/14. Interview with LVN A on 08/27/14 at 2:20 p.m. revealed on 08/06/14, Resident #1 returned to her room following dinner where later she was found on the floor. LVN A explained she assessed the resident following the fall, which included bending her elbows, lifting her arms, and bending her knees. LVN A stated she removed the resident's shirt and pants to assess any areas which might have been injured during the fall. The LVN revealed Resident #1 said she did not hit her head, but the resident was placed on 72 hour neurological checks because it was an unwitnessed fall. LVN A stated CNA B found Resident #1 on the floor following the resident's fall. Resident #1 told LVN A she slipped off the bedside commode. Interview with CNA B on 09/09/14 at approximately 4:40 p.m. revealed she did not find Resident #1 on the floor on 08/06/14. The CNA explained she did not know why they put her name down as the one who found the resident, but she did not find the resident. Interview with the PTA on 09/09/14 at approximately 3:10 p.m. reflected he had worked with Resident #1 three times in the week following her fall on 08/06/14, and Resident #1 never complained about pain when he was with her. Interview with the DON on 09/10/14 at approximately 10:00 a.m. revealed she did not interview Resident #1 during the investigation.. The DON explained she was not notified of the resident's injuries until 8:00 a.m. on 08/15/14, and the resident discharged at 8:45 a.m. the same morning. She stated Resident #1 was already scheduled to discharge from the facility on 08/15/14. The DON confirmed the interviews presented with the provider investigation report, dated 08/15/14, were the only interviews conducted during the investigation. The DON also confirmed she asked questions, and the DON wrote the responses of the staff members as they spoke. The DON confirmed the responses written on the witness statements were from the seven staff included in the Provider Investigation Report. The DON said there were no other questions answered. The question listed on the interview sheet was "Do you know anything about the incident with (Resident #1) on or about _________? The questions were asked about Resident #1 and the responses follow with the dates which complete the question. The following questions were also asked: "Do you have knowledge of the incident?" "Do you have any knowledge of the injury?" "Do you have knowledge about any test values or physician's orders [REDACTED].?" "Do you know anyone else that might know something about this incident?" Review of the witness statements regarding the incident "on or about 08/06/14" (sic) revealed the following: CNA C's response reflected "she has no knowledge of the fall, but states" The statement was not completed. CNA D's response reflected "did not have knowledge of fall." LVN A's response reflected CNA B "came to advise this nurse that" Resident #1" was on the floor. Assessment completed revealed no injury, distress at the time of the incident, no complains or needs. Resident slipped off seat of bedside commode per resident statement." CNA E's response reflected "Did not work on this hall during this incident." Review of witness statements regarding the incident "on or about 08/08/14 (sic)" revealed the following: MA F's response reflected CNA B "came to tell" LVN A, Resident #1 "was on floor. When nurse and I arrived, resident was on floor on her bottom with legs straight out in front of her. Resident stated she was not hurt when asked." CNA B's response reflected "Does not remember this incident." Review of witness statements regarding the incident "on or about (there was no date)" and the staff member responding to the questions were as followed: CNA G's response reflected "she has no knowledge of any incident or injury." The CMS 672 Resident Census and Conditions, dated 08/27/14 and signed by LVN I, reflected 38 residents resided in the facility.

Based on interview and record review, the facility failed to implement the written policies and procedures that prohibit abuse/neglect or mistreatment for one (Resident #1) of eight residents reviewed for neglect. While repositioning Resident #1,who was totally dependent on staff for all ADLs, CNA H lost control of her resulting in the resident hitting her head on the oxygen concentrator at her bedside causing a bleeding, one-inch gash in her forehead. CNA H returned the resident to bed and left the room. CNA H did not report the incident to anyone and denied knowing anything about the incident. When Resident #3's injury was discovered by CNA J and she reported it to LVN G, the LVN failed to appropriately assess, provide care or notify the physician or family, resulting in further delay of treatment. These failures resulted in a delay in treatment for Resident #1, which allowed for the loss of blood and the potential of further injury without care. These failures could affect the six residents including Resident #1, who were bedfast all or most of the time and placed them at risk for the potential of a delay in treatment when needed, which could result in the exacerbation of current health problems and the potential for hospitalization . Findings included: 1. According to the Medical Record of Admission printed 05/31/13, Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to MDS assessment dated [DATE], she was bed to geri-chair bound, had been receiving hospice services for two years and was totally dependent on staff for all ADLs. Resident #1 was incontinent of bladder and bowel. 2. According to the facility's Provider Investigation Report dated 05/31/13 and timed at 6:40 AM, CNA J discovered Resident #1 with bruising and a laceration on her forehead and with bruising and a skin tear on her right index finger. CNA J called for help from LVN G. At that time, the laceration on the resident's forehead was not bleeding. LVN G went and obtained supplies to "clean and measure" the wound. When LVN G began to clean Resident #1's forehead, the wound started to bleed significantly. LVN G applied a pressure dressing and left the room to call the DON. (LVN G did not notify the physician or family and did not return to the resident to provide care or further assess her.) A Hospice aide arrived and immediately called the Hospice RN, who arrived at the facility at 7:47 AM. The Hospice RN applied direct pressure to the wound and called for help. The Administrator arrived in Resident #1's room shortly before 8:00 AM. At that time, LVN G returned to Resident #1's room and was instructed to call 911 and the resident's family. When EMS arrived, they reportedly stated, "This woman has been assaulted" and called the police. The police arrived to investigate the incident. Resident #1 was transported to the local ER. Resident #1 was treated and returned to the facility around 11:00 AM on 05/31/13. 3. A written statement dated 05/31/13 from CNA N, who worked the 10:00 PM to 6:00 AM shift reflected the CNA last saw Resident #1 at 4:45 AM (on 05/31/13) when she provided incontinent care. CNA N had documented Resident #1 did not have "anything on her (blood)" and the resident was still wearing the same gown the CNA had put on the resident on the 6:00 PM to 10:00 PM shift. 4. CNA J's written statement dated 05/31/13 reflected she found Resident #1 at approximately 6:40 AM (on 05/31/13). CNA J documented the top sheet was over the resident's eyes but not her forehead. The statement reflected Resident #1 was wide awake and lying on her right side. CNA J documented the resident had "Dry blood on/down both sides of her forehead" with some seepage (of blood) noted. The statement further reflected Resident #1 had two skin tears on her right hand. Attempts to contact CNA J were unsuccessful. 5. According to a written statement dated 05/31/13 and verified by the Hospice Aide during an interview by phone on 06/06/13 at 3:15 PM, when she reported the injury and bleeding to LVN G, the LVN said it was "old," and she knew about it. The Hospice Aide stated LVN G did not return to the room to assess Resident #1's bleeding. 6. Hospice RN was interviewed by phone on 06/06/13 at 4:50 PM. Hospice RN verified the Hospice Aide called to report Resident #1's injury and that it was bleeding. Hospice RN stated she came immediately to the facility and applied pressure to the wound. Hospice RN stated she called for LVN G, who did not come to Resident #1's room. Hospice RN stated the Administrator arrived at 8:00 AM, and at that time, LVN G came to Resident #1's room and was instructed by the Administrator to call 911 and the family. 7. In an interview with Administrator on 06/06/13 at 2:00 PM, he stated the investigation had determined Resident #1 was last seen by CNA N at 5:00 AM on 05/31/13 and so the incident must have occurred between 5:00 AM and 6:40 AM. The Administrator stated due to not knowing what had happened or how the injury occurred, all facility staff on the night shift (10:00 PM - 6:00 AM) and day shift (6:00 AM - 2:00 PM) were suspended pending investigation. Corporate staff began interviewing facility staff. As staff were cleared of being involved in the incident, they were allowed to return to work or to go home. From interviews and talking with police, the Administrator stated it was determined an accident occurred during the provision of care. The Administrator stated it was felt the incident occurred during the 6:00 AM - 2:00 PM shift, but none of the staff admitted to causing the injury and they remained suspended. During the same interview, the Administrator additionally told the surveyor , Resident #1's family members were questioning staff and residents about the incident on 06/02/13 at approximately 2:00 PM and were interrupting the operation of the facility. When the family members were requested to stop the questioning, the family members escalated the situation and the police became involved. The family called EMS to transport Resident #1 back to the hospital. At that time, the police reported to the Administrator they would be conducting polygraph tests on CNAs H and J in regard to Resident #1's injury. CNAs H and J remained suspended at that time since they could not be cleared of the incident and to protect the residents. The Administrator stated CNA J finally admitted she dropped Resident #1 about two months ago. CNA J said she reported it to LVN M, but LVN M denied any knowledge of the incident. CNA J changed the information several times but when she finally identified a date when the incident occurred, LVN M was not on duty. The Administrator stated CNA J was terminated. Continuing with the same interview, the Administrator told the surveyor he was notified by the local Police Department on 06/04/13, CNA H had confessed to dropping Resident #1 resulting in her injury, and they arrested the CNA for assault. The Administrator stated CNA H and LVN G were terminated. 8. On 06/10/13 at 4:10 PM, a sergeant from the local Police Department was interviewed by phone. He acknowledged CNA H had confessed to being involved in Resident #1's injury. The sergeant informed the surveyor CNA H told them his back went out, he dropped Resident #1's upper body and she hit her head on the oxygen concentrator causing the laceration to her forehead. The sergeant stated CNA H told them he returned the resident to bed and did not report the event to anyone despite the facility's protocol. 9. The facility's current Abuse and Neglect Policy and Procedure dated 11/11/11 defined Neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." It further reflected, "Our facility implements an effective system for the prevention of abuse and neglect... Allegations are immediately reported to appropriate agencies... Residents, families and staff will be provided information on Grievance and Complaint Procedures, on how and to whom they may report concerns, incidents and grievances without the fear of retribution...." 10. Review of the CMS 672, Resident Census and Conditions of Residents, dated 06/25/13, revealed six residents were bedfast all or most of the time.

Based on interview and record review, the facility failed to implement the written policies and procedures that prohibit abuse/neglect or mistreatment for one (Resident #1) of eight residents reviewed for neglect. While repositioning Resident #1,who was totally dependent on staff for all ADLs, CNA H lost control of her resulting in the resident hitting her head on the oxygen concentrator at her bedside causing a bleeding, one-inch gash in her forehead. CNA H returned the resident to bed and left the room. CNA H did not report the incident to anyone and denied knowing anything about the incident. When Resident #3's injury was discovered by CNA J and she reported it to LVN G, the LVN failed to appropriately assess, provide care or notify the physician or family, resulting in further delay of treatment. These failures resulted in a delay in treatment for Resident #1, which allowed for the loss of blood and the potential of further injury without care. These failures could affect the six residents including Resident #1, who were bedfast all or most of the time and placed them at risk for the potential of a delay in treatment when needed, which could result in the exacerbation of current health problems and the potential for hospitalization . Findings included: 1. According to the Medical Record of Admission printed 05/31/13, Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to MDS assessment dated [DATE], she was bed to geri-chair bound, had been receiving hospice services for two years and was totally dependent on staff for all ADLs. Resident #1 was incontinent of bladder and bowel. 2. According to the facility's Provider Investigation Report dated 05/31/13 and timed at 6:40 AM, CNA J discovered Resident #1 with bruising and a laceration on her forehead and with bruising and a skin tear on her right index finger. CNA J called for help from LVN G. At that time, the laceration on the resident's forehead was not bleeding. LVN G went and obtained supplies to "clean and measure" the wound. When LVN G began to clean Resident #1's forehead, the wound started to bleed significantly. LVN G applied a pressure dressing and left the room to call the DON. (LVN G did not notify the physician or family and did not return to the resident to provide care or further assess her.) A Hospice aide arrived and immediately called the Hospice RN, who arrived at the facility at 7:47 AM. The Hospice RN applied direct pressure to the wound and called for help. The Administrator arrived in Resident #1's room shortly before 8:00 AM. At that time, LVN G returned to Resident #1's room and was instructed to call 911 and the resident's family. When EMS arrived, they reportedly stated, "This woman has been assaulted" and called the police. The police arrived to investigate the incident. Resident #1 was transported to the local ER. Resident #1 was treated and returned to the facility around 11:00 AM on 05/31/13. 3. A written statement dated 05/31/13 from CNA N, who worked the 10:00 PM to 6:00 AM shift reflected the CNA last saw Resident #1 at 4:45 AM (on 05/31/13) when she provided incontinent care. CNA N had documented Resident #1 did not have "anything on her (blood)" and the resident was still wearing the same gown the CNA had put on the resident on the 6:00 PM to 10:00 PM shift. 4. CNA J's written statement dated 05/31/13 reflected she found Resident #1 at approximately 6:40 AM (on 05/31/13). CNA J documented the top sheet was over the resident's eyes but not her forehead. The statement reflected Resident #1 was wide awake and lying on her right side. CNA J documented the resident had "Dry blood on/down both sides of her forehead" with some seepage (of blood) noted. The statement further reflected Resident #1 had two skin tears on her right hand. Attempts to contact CNA J were unsuccessful. 5. According to a written statement dated 05/31/13 and verified by the Hospice Aide during an interview by phone on 06/06/13 at 3:15 PM, when she reported the injury and bleeding to LVN G, the LVN said it was "old," and she knew about it. The Hospice Aide stated LVN G did not return to the room to assess Resident #1's bleeding. 6. Hospice RN was interviewed by phone on 06/06/13 at 4:50 PM. Hospice RN verified the Hospice Aide called to report Resident #1's injury and that it was bleeding. Hospice RN stated she came immediately to the facility and applied pressure to the wound. Hospice RN stated she called for LVN G, who did not come to Resident #1's room. Hospice RN stated the Administrator arrived at 8:00 AM, and at that time, LVN G came to Resident #1's room and was instructed by the Administrator to call 911 and the family. 7. In an interview with Administrator on 06/06/13 at 2:00 PM, he stated the investigation had determined Resident #1 was last seen by CNA N at 5:00 AM on 05/31/13 and so the incident must have occurred between 5:00 AM and 6:40 AM. The Administrator stated due to not knowing what had happened or how the injury occurred, all facility staff on the night shift (10:00 PM - 6:00 AM) and day shift (6:00 AM - 2:00 PM) were suspended pending investigation. Corporate staff began interviewing facility staff. As staff were cleared of being involved in the incident, they were allowed to return to work or to go home. From interviews and talking with police, the Administrator stated it was determined an accident occurred during the provision of care. The Administrator stated it was felt the incident occurred during the 6:00 AM - 2:00 PM shift, but none of the staff admitted to causing the injury and they remained suspended. During the same interview, the Administrator additionally told the surveyor , Resident #1's family members were questioning staff and residents about the incident on 06/02/13 at approximately 2:00 PM and were interrupting the operation of the facility. When the family members were requested to stop the questioning, the family members escalated the situation and the police became involved. The family called EMS to transport Resident #1 back to the hospital. At that time, the police reported to the Administrator they would be conducting polygraph tests on CNAs H and J in regard to Resident #1's injury. CNAs H and J remained suspended at that time since they could not be cleared of the incident and to protect the residents. The Administrator stated CNA J finally admitted she dropped Resident #1 about two months ago. CNA J said she reported it to LVN M, but LVN M denied any knowledge of the incident. CNA J changed the information several times but when she finally identified a date when the incident occurred, LVN M was not on duty. The Administrator stated CNA J was terminated. Continuing with the same interview, the Administrator told the surveyor he was notified by the local Police Department on 06/04/13, CNA H had confessed to dropping Resident #1 resulting in her injury, and they arrested the CNA for assault. The Administrator stated CNA H and LVN G were terminated. 8. On 06/10/13 at 4:10 PM, a sergeant from the local Police Department was interviewed by phone. He acknowledged CNA H had confessed to being involved in Resident #1's injury. The sergeant informed the surveyor CNA H told them his back went out, he dropped Resident #1's upper body and she hit her head on the oxygen concentrator causing the laceration to her forehead. The sergeant stated CNA H told them he returned the resident to bed and did not report the event to anyone despite the facility's protocol. 9. The facility's current Abuse and Neglect Policy and Procedure dated 11/11/11 defined Neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." It further reflected, "Our facility implements an effective system for the prevention of abuse and neglect... Allegations are immediately reported to appropriate agencies... Residents, families and staff will be provided information on Grievance and Complaint Procedures, on how and to whom they may report concerns, incidents and grievances without the fear of retribution...." 10. Review of the CMS 672, Resident Census and Conditions of Residents, dated 06/25/13, revealed six residents were bedfast all or most of the time.

Based on observation, interview, and record review, it was determined the facility failed to ensure each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #4) of five residents reviewed for pain management, and for two (Residents #2 and #3) of three residents reviewed for Foley catheter care. 1) Resident #4 was admitted to the facility from the hospital on [DATE] at 3:00 p.m. having had back surgery. The facility failed to: a) ensure the resident's medication orders were immediately verified and sent to the pharmacy to be filled; b) ensure Resident #4's complaints of pain were assessed and documented; c) ensure Resident #4 was provided with an alternate pain management technique; d) ensure the physician was notified of the resident's unresolved pain; e) ensure Resident #4 was not administered medication brought by a family member without a physician's orders [REDACTED]. f) ensure LVN E did not offer her own personal pain medication for the resident's use; and g) ensure Resident #4 did not have to wait over five hours for pain medication. These failures affected Resident #4 and could affect the 11 residents in the facility, who were on a pain management program, and placed them at risk for unmanaged, unrelieved pain resulting in the potential for self-isolation and a decreased quality of life. 2) Residents #2 and #3 had Foley catheters with large amounts of sediment in the drainage tubing. The facility failed to: a) fully assess and document the abnormalities in the residents' urine. b) ensure there were available supplies to change the residents' catheters. c) ensure an order for [REDACTED]. These failures could affect the three residents in the facility with a catheter, including Residents #2 and #3, and placed them at risk for a potential delay in treatment, discomfort, pain and could cause embarrassment, social embarrassment, a loss of self-esteem, and [MEDICAL CONDITION]. Findings included: 1) The MDS assessment, dated as complete on 03/12/2012, reflected Resident #4 was a [AGE] year-old female, admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident received prn (as needed) pain medications and had vocally expressed complaints of pain within the last five days. The MDS assessment also reflected Resident #4 complained or showed evidence of pain or possible pain within the last one to two days. The Care Area Assessment (CAA) Summary section of the MDS assessment reflected the resident's pain should be addressed in the care plan. Resident #4's admission paperwork, dated 03/09/2012, reflected she had the following additional Diagnoses: [REDACTED]. An interview with Resident #4's family member on 04/03/2012 at 9:48 a.m. revealed the resident was admitted to the facility at 3:00 pm on 03/09/2012 and began calling family members crying and reporting she was in pain. The family member stated the resident said the facility was not giving her pain medication. Resident #4's family member stated he/she went back to the facility at 8:00 pm on 03/09/2012 to find out what was going on with the resident. The family member stated when he/she got to the facility, Resident #4 was sitting in the lobby with no facility staff with her. Resident #4's family member stated the resident was not supposed to be walking unassisted after her surgery. He/She stated he/she asked the LVN on duty (later identified as LVN E) about the resident's pain medication, and LVN E told her the medication had not arrived from the pharmacy. In the same interview, the family member stated LVN E then called the pharmacy to find out what time the medication would be delivered to the facility, and LVN E was told it would be around 10:00 p.m. The family member then asked LVN E what she was going to do for Resident #4's pain. He/She stated LVN E said the facility would have to wait until the pain medication arrived, or she (LVN E) could go out to her car and get some of her (LVN E's) [MEDICATION NAME] (narcotic) medication. Resident #4's family member stated he/she asked LVN E if the facility had any pain medication on hand, and LVN E said the facility did not, because the medications had all been destroyed. The family member then asked if Resident #4 could take her pain medication from home. He/She stated LVN E replied the family could bring the pain medication to the facility and give it to the resident. Resident #4's family member told the surveyor the resident's pain medication was brought from home and given to the resident at 8:30 p.m. The family member stated after he/she gave the pain medication to Resident #4, LVN E came in with a [MEDICATION NAME]. He/She stated LVN E said it was from another resident, who had been discharged . The family member stated Resident #4's medication arrived from the pharmacy at approximately 9:30 p.m. Resident #4's family member then told the surveyor the resident called the family member's spouse Saturday morning (03/10/2012) around 7:00 a.m. and asked him/her to come get her and take her home. The family member stated Resident #4 signed herself out of the facility against medical advice and another family member took the resident to the ER, because she was in so much pain. The family member told the surveyor the resident received [MEDICATION NAME] and [MEDICATION NAME] in the ER in order to get her pain under control. The hospital MAR, dated 03/09/2012, reflected Resident #4 received [MEDICATION NAME] intravenously every three hours as needed for pain at 2:30 a.m., 5:25 a.m. and 8:27 a.m. The hospital Patient Transfer Form, dated 03/09/2012, reflected Resident #4 last received [MEDICATION NAME] one mg intravenously at 11:40 a.m. on 03/09/2012, and [MEDICATION NAME] 10 mg/325 mg one tablet by mouth was given at 1:40 p.m. The facility's contract pharmacy was contacted on 04/03/2012 at 12:55 p.m. During the interview, Pharmacy Personnel A stated the pharmacy received Resident #4's order at 5:56 p.m. on 03/09/2012. She stated the medications were delivered to the facility and signed for at 9:20 p.m. on the same date. Pharmacy Personnel A stated the facility did not have a contract to have an emergency medication box for narcotics. Pharmacy Personnel A stated the pharmacy had a four-hour turn-around time when medications were ordered STAT (immediately). In an interview with LVN E on 04/03/2012 at 2:00 p.m., the LVN confirmed she had admitted Resident #4 to the facility. She stated the family and the resident were upset, because the pain medication had not arrived at the facility. LVN E stated she explained to them she had ordered the medication and was waiting for the medication to be delivered. LVN E stated the family was very demanding. When LVN E was asked what type of pain Resident #4 was experiencing, LVN E stated the resident was having lower back pain at probably an "8" on a pain scale from 1 to 10 with "10" being the worst pain. The surveyor then asked LVN E about the family member bringing medication from home and LVN E administering [MEDICATION NAME] to the resident. LVN E confirmed both incidents happened that night. When the surveyor asked LVN E why she did not document the resident's complaint of pain or the events that occurred that night, LVN E stated she did not know why, and there was no excuse for it. LVN E then stated, "I wish I would have documented all that happened that night, because it is coming back to bite me in the butt." Resident #4's admission orders [REDACTED]. The orders reflected there was no order for Resident #4 to take pain medication from home. The Admission Assessment, dated 03/09/2012, reflected LVN E documented Resident #4's right leg pain, but did not get the resident to rate the pain on a pain scale. The assessment did not mention the resident's lower back pain. In an interview with LVN E on 04/03/2012 at 2:30 p.m., she stated Resident #4's pain level was between "6 to 8." LVN E stated the family brought pain medication to the facility; however, the pain medication was not what was ordered. She stated Resident #4 was to receive [MEDICATION NAME] 5 mg/325 mg, two tabs, instead of [MEDICATION NAME] 10 mg/325 mg one tab by mouth every four hours as needed for pain. A Nursing Note, dated 03/10/2012 at 2:50 a.m., reflected Resident #4 was alert and oriented, and able to make her needs known. The note reflected Resident #4 was given [MEDICATION NAME] 10 mg/325 mg one tab by mouth at 12:30 a.m. for complaints of back pain, and then received [MEDICATION NAME] 5 mg by mouth at 2:00 a.m. The note reflected the resident complained of back pain at 4:35 a.m. and was given [MEDICATION NAME] 10 mg/325 mg one tab by mouth. A Progress Note, dated 03/10/2012 at 9:00 a.m., reflected Resident #4's family member was at the nurses' station wanting the resident to be discharged from the facility. The note reflected the family member was not satisfied with the care the resident had received. The note reflected Resident #4 and her family member were informed the resident would have to sign a document, which reflected the resident was leaving against medical advice. The note reflected both Resident #4 and her family member stated their understanding. A form entitled Statement of Patient Leaving Against Medical Advice, dated 03/10/2012, reflected it was signed by Resident #4's family member. 2) The facility's current policy and procedure for Admissions/Readmissions, dated 11/11/2011, reflected the following: "...5. Notify the attending physician of the resident's arrival and verify the orders with the physician. 6. Fax your request for medications to the pharmacy. You may use the transfer order if legible, or fax the white copy of your admission orders [REDACTED] ...10. Complete the Admission Assessment...." The facility's current policy and procedure entitled, "Medications Brought To Nursing Care Center By Resident Or Family Member," dated 2007, reflected the following: "Policy Medications brought into the nursing care center by a resident or family member are used only upon written order by the resident's prescriber, after the contents are verified by the nurse, and if the packaging meets the state, federal and pharmacy's guidelines. Other unauthorized medications are not accepted by the nursing care center." The facility's current policy and procedure for Pain Assessment and Management, dated 11/11/2011, reflected the following: "Residents residing in long term care facilities are likely to have multiple [DIAGNOSES REDACTED]. Optimizing pain assessment and management can alleviate many of these conditions and can improve quality of life. - Residents will be assessed for pain on Admission...Residents with pain will be assessed and monitored daily. - Assessment for pain will be done anytime a resident complains of pain or indicates non-verbally that they are experiencing pain. - ...Institute nonpharmacologic measures to promote physical comfort such as positioning, turning, applications of heat or cold (per physician order.) Administer [MEDICATION NAME] as ordered, on time and titrate the medication dosage / frequency within prescribed guidelines. - Provide measures for distraction - relaxation, diversional activities, music therapy, etc. - ...Pain Management will be documented on the back of the Pain Assessment Form." The facility's current policy and procedure entitled Pain Management Guideline, dated 11/11/2011, reflected the following: "Assess pain with the resident and encourage them to verbalize what pain, how much pain, and when they experience pain...Assess the psychological implication of pain." 3) The MDS assessment, dated as complete on 10/26/2011, reflected Resident #2, an [AGE] year-old female, was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment also reflected the resident had an indwelling Foley catheter. The Record of Admission, dated 02/17/2012, reflected Resident #2, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with the following additional Diagnoses: [REDACTED]. Resident #2's Comprehensive Plan of Care, dated 10/21/2011 through 01/17/2012, reflected the resident required a Foley catheter due to the inability to void and staff would provide Foley catheter care every shift. The plan also reflected nursing staff would monitor for signs of foul smelling urine and report to the physician as needed. On 04/03/2012 at 11:46 a.m., the surveyor was in Resident #2's room and observed a large amount of sediment in the Foley catheter drainage tubing. On 04/04/2012 at 9:55 a.m., Resident #2 was observed to have a Foley catheter. There was urine in the drainage tubing with a large amount of sediment. At that time, Resident #2 told the surveyor she was due for a catheter change, but it could be changed whenever it was needed. Resident #2 stated she asked LVN F, who told her it could be changed. Resident #2 stated she hoped it was changed before Thursday, because her family member was taking her out. Resident #2 stated she wanted the catheter changed because of the odor. Resident #2 stated she had asked staff for the catheter to be changed, but she had not received a definite answer on when it would be changed. An interview on 04/04/2012 at 10:32 a.m. with LVN F revealed the CNAs were supposed to empty the urinary drainage bags and tell the nurse if there were problems. LVN F stated she saw each one of her patients who had Foley catheters on a daily basis. She stated Resident #2 needed her catheter changed, but LVN F stated she did not have the supplies. LVN F stated she could change the catheter bag, but did not want to just change the bag and not the catheter. LVN F stated she had contacted Hospice, and they were bringing the supplies. LVN F told the surveyor there had been staffing turnover, and there was no one at the facility to order supplies, so corporate ordered supplies and reordering the catheters was missed. LVN F said she had noticed on 04/03/2012 Resident #2's catheter needed to be changed, because there was sediment in the tubing. LVN F stated Resident #2 had sediment at times, but she did not know the cause. LVN F stated Resident #2's physician only wanted a urinalysis run when the resident was running a temperature or if the resident was not feeling good. LVN F stated she did not check the catheters on a daily basis. CNA D was interviewed on 04/04/2012 at 11:46 a.m. She stated she emptied Resident #2's urinary catheter bag on 04/03/2012 after lunch. (Lunch was served at 12:00 noon). She stated Resident #2's urine looked normal then. She stated the urine was light yellow, and there was no sediment or cloudiness. CNA D stated Resident #2's urine had a strong smell, but it always had a strong smell. She added there was nothing unusual about the odor. On 04/04/2012 at 1:47 p.m., the surveyor went to Resident #2's room. Resident #2 told the surveyor her catheter had been changed. The privacy bag containing the urinary drainage bag was noted to be on the floor. An interview on 04/04/2012 at 2:02 p.m. with CNA I revealed she took care of Resident #2 on 04/03/2012. She stated she emptied the resident's urinary drainage bag and cleaned the Foley catheter during incontinent care. CNA I stated she would notify the nurse if the catheter was leaking, if there was an odor, and if there were particles in the urine. CNA I stated Resident #2's urine had an odor to it, and there were particles in the tubing, but she did not see any blood. CNA I stated Resident #2 usually had particles in her urine. Review of the Nurses Notes for Resident #2 revealed in January 2012, Resident #2 was treated for [REDACTED]. There was no documentation of vital signs being taken. Review of Resident #2's Evaluation of Indwelling Catheter Use, dated 02/23/2012, revealed the resident had a terminal illness and was diagnosed with [REDACTED]. Review of Resident #2's Consolidated Physicians Orders for March and April 2012 revealed: "Foley Catheter 18 F with 30 cc bulb to be changed Q 3 weeks and PRN...Foley Catheter care to be done Q shift." Review of the Physician's Telephone Orders for Resident #2 revealed on 02/23/2012, there was an order to discontinue use of the Foley catheter. Another order dated 02/23/2012 reflected not to remove the Foley catheter until the physician was consulted. On 03/26/2012, there was an order to change the Foley catheter every 30 days and to start changing the catheter and/or catheter bag as needed. 4) The MDS assessment, dated as complete on 12/24/2011, reflected Resident #3 was a [AGE] year-old male, who was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident was always incontinent of urine and frequently incontinent of bowel. The undated Record of Admission reflected Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. On 04/04/2012 at 10:51 a.m., observation revealed Resident #3 was sitting up in his recliner. Resident #3 had a catheter and the catheter bag was not covered. The catheter drainage tubing was observed to have a large amount of sediment. An interview on 04/04/2012 at 1:16 p.m. with CNA G revealed she took care of Resident #3 on 04/03/2012 and 04/04/2012. She stated when she took care of a resident's catheter, she had to empty it each shift and she had to clean around it. CNA G stated Resident #3's urine was clear on both days, not cloudy. On 04/03/12, CNA G stated the urine had an odor to it, but stated it did not smell like an infection but it was a strong smell. CNA G stated the resident's urine was "pretty concentrated here lately." When asked what type of things she would report to the nurse, CNA G stated, "Sediment, cloudiness, chunks in the tubing, blood, leaking, and really yellow or [MEDICATION NAME] colored (urine)." She stated Resident #3 had bleeding a while back, because of having to do an in-and-out catheter. CNA G stated she saw Resident #3's catheter earlier in the day and stated she had placed the urinary drainage bag in a privacy bag around lunch. She stated she did not pay attention to the color or anything about the urine at that time. On 04/04/2012 at 1:45 p.m., Resident #3 gave the surveyor permission to photograph his catheter tubing, drainage tubing and urinary drainage bag. The photographs included a picture of the urinary drainage bag and tubing with sediment in the tubing. There were close-ups taken of the bag and the tubing. The privacy bag holding the urinary drainage bag was on the floor and was not secured around the urinary drainage bag. On 04/04/2012 at 1:53 p.m., the surveyor requested the Interim DON to look at Resident #3's catheter. The Interim DON stated, "Oh my God, it is pretty cloudy." When asked what was in the drainage tubing, he replied, "Sediment." The Interim DON stated the urinary catheters needed to be assessed, vital signs needed to be taken, the physician needed to be notified of "heavy" sediment and fluids needed to be pushed unless they were contraindicated. The Interim DON then talked with the nurse, returned to the surveyor and stated Hospice had been in the building. The Interim DON stated the physician had instructed the nurses to only get a urinalysis when the resident was feverish. An interview on 04/04/2012 at 1:55 p.m. with LVN H revealed she did not assess the residents' catheters. She stated she thought Resident #3's urine was clear. LVN H stated she saw the catheters "in passing." She stated Resident #3 was noted to have "odorless" urine. She stated she did not document this information, but she had spoken with the Hospice nurse on 04/04/2012 when she arrived. LVN H stated she believed a urinalysis had been taken. An interview on 04/04/2012 at 2:10 p.m. with CNA J revealed when she was taking care of residents with catheters, she cleaned them, made sure they were not leaking and not uncomfortable for the resident. CNA J stated she cleaned the areas, and cleaned and emptied the urinary drainage bags. She stated she took care of Resident #3 on 04/03/2012. She said Resident #3's urine was always a little bit cloudy, and it had always been that way since she started working with him. CNA J described Resident #3 as having a real strong urine smell, but nothing out of the ordinary. Review of Resident #3's Consolidated Physician Orders, dated 03/01/2012 through 04/30/2012, revealed the following: "Foley Catheter care Q shift...Foley Catheter to be changes (sic) Q Month and PRN (16th of every month)...." Review of the Comprehensive Intake-Output Record for Resident #3, dated 03/11/2012, revealed there was urine output of 300 cc once and no additional data was documented. Review of Progress Notes for Resident #3, dated 03/21/2012, revealed his Foley catheter had been changed. There was no documentation of vital signs being taken. Resident #3's Physician's Telephone Order, dated 03/26/2012, reflected an order to discontinue the changing of the Foley catheter on a monthly basis and to start changing the Foley catheter and bag as needed. Resident #3 was treated for [REDACTED]. 5) The facility's current Catheter Care, Urinary Policy, dated December 2003, reflected the following: "The purpose of this procedure is to prevent infection of the resident's urinary tract. ...1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to your supervisor. ...3. Check the urine for unusual appearance (i.e., color, blood, etc.). ...7. Maintain an accurate record of the resident's daily output, per facility policy and procedure. ...14. Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]. Report findings to the supervisor immediately... Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor...." 6) The CMS Form 672, Resident Census and Conditions of Residents, dated 04/03/2012, reflected 11 residents in the facility were on a pain management program, and three residents in the facility had indwelling or external catheters.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents and the potential for accidents for five (Residents #2, #3, #4, #5 and # 6) of 13 residents reviewed/observed for falls and wandering. These failures could affect all 51 residents in the facility, including Residents #2, #3, #4, #5, and # 6, by placing them at risk for abuse/neglect. These failures had the potential to result in falls and injury to the residents. 1) Resident #2 had an unwitnessed fall in his room. The resident, who required the assistance of two people to transfer and was severely cognitively impaired, was left unattended on the bedside commode. He fell when trying to transfer himself without assistance, sustained a contusion on his forehead and bruising as well as pain to his left shoulder and was sent to the hospital for evaluation. This failure resulted in Resident #2 injurying himself, necessitating a trip to the hospital for evaluation and treatment. 2) Resident #3 sustained an unwitnessed fall resulting in left knee pain. Not all staff were aware of the resident's need for two people to assist with transfers. The facility's corporate nurse reported the resident only needed stand-by assistance. 3) Resident #4 was a two-person transfer assist, which was not on the care plan and was identified as requiring a personal alarm. The two CNAs providing care for him were unaware of the need for a personal alarm. 4) Resident #6 sustained two falls with no interventions implemented other than to instruct the resident to use the call light. The DON thought the resident had a personal alarm due to his history of falls. 5) Resident #5 was found wandering on the facility's back parking lot unsupervised. Even though the family had informed the facility the resident was an elopement risk, it was not until the resident left the facility a wanderguard was implemented. These failures could affect the 29 residents, who required assistance with transfers and the 17 residents with behavior symptoms, plus Residents # 2, #3, #4, #5 and #6, by placing them at risk for falls and injury without providing a safe environment, supervision and assistance devices to prevent the potential for falls and/or wandering, which could result in pain, discomfort, injury and/or the need for hospitalization . Findings included: 1) The MDS assessment, dated 01/27/2012, reflected Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment also reflected Resident #2's BIMS score was four, which indicated the resident was severely cognitively impaired. The assessment reflected Resident #2 was totally dependent and required a two-person assist with transfers, was unable to ambulate and balance during transitions, was not steady and only able to stabilize with human assistance. The assessment also reflected Resident #2 had limited ROM in both arms and legs. On 02/23/2012 at 10:45 AM Resident #2 was observed on a stretcher being taken from the facility. At that time, the Corporate Nurse stated the resident had an unwitnessed fall in his room. The resident was left unattended on the bedside commode and fell when trying to transfer himself without assistance. The Corporate Nurse stated Resident #2 had sustained a contusion on his forehead and had bruising as well as pain to his left shoulder, 911 had been called and he was being sent to the hospital for further evaluation. The Incident/Accident Report dated 02/23/2012 for Resident #2 reflected the date of the incident/accident was 02/23/2012. The Report reflected, "Called to Room by Housekeeping Resident laying on (left) side, blood noted on floor, assessed. Ltr (letter) size indention to front of forehead. Resident, alert & O x 3. Stated I fell off the toilet & I'm bleeding." The Clinical Assessment of Occurrence reflected, "Res. was trnsferred to B.S.C. for bowel evacuation. His call light was in place & CNA stepped outside of the door to afford him PVCY which is the normal routine for this res. Res. fell while attempting to self-transfer off BSC to chair. Hit his forehead, (left) shoulder & (left) cheek on fooring & sustained contusion & bruising as well as c/o (left) shoulder pain. Assess for bed/chair alarm (sic) Use until Rehab assesses res." Resident #2's Physician order [REDACTED]. The order date was 11/25/2011. On 02/24/2012 at 2:15 PM, the surveyor and the DON made observation rounds of the residents, which were identified by the facility with orders for a personal alarm. At that time, Resident #2 was observed in his recliner at his bedside. The DON said the resident had returned from the hospital. No personal alarm was observed in use. On 02/24/2012 at approximately 2:28 PM, the DON was observed to ask Resident # 2, "What did you do with your alarm? I thought you had an alarm?" During an interview with the facility's Corporate Nurse on 02/27/2012 at approximately 11:00 AM, she was asked if Resident #2 had a history of [REDACTED]. The Nurse Treatment sheet for February 2012 reflected nursing staff had been initialing Resident #2's bed alarm on a daily basis for all three shifts and chair alarm were in place on a daily basis for the day and evening shifts as scheduled. The bed and chair alarm had effective dates of 11/25/2011. During an interview on 02/27/2012 at approximately 2:00 PM with LVN C, she stated she could not say for certain Resident #2 had a personal alarm, but she confirmed she had been initialing the Nurse Treatment sheet Resident #2 did have a personal alarm. The Comprehensive Plan of Care, dated 07/06/2010 through 02/15/2012, reflected Resident #2 had problems, which affected his ability to walk, had a history of [REDACTED]." The plan reflected the following approach: "I may need 1 to 2 staff to assist me with transfers at times." The undated CNA Care Plan reflected Resident #2 was dependent on staff for transfers requiring two-person assistance. The plan also reflected Resident #2 was a high fall risk. The Incident/Accident Report, dated 02/08/2012, reflected Resident #2 had to be lowered to the floor three times during a two-person transfer resulting in a skin tear to his right arm. 2) The MDS assessment, dated 01/18/2012, reflected Resident #3 was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated the resident was cognitively intact. The MDS assessment reflected the resident required extensive assistance with two-person physical assistance with transfers and extensive assistance with ambulation with the physical assistance of two people. The MDS assessment further reflected the resident was unable to maintain balance stabilization during transitions and walking was not steady, and only able to stabilize with human assistance. The MDS assessment also reflected the resident had limitation in ROM to both legs. The Incident/Accident Report, dated 02/07/2012, reflected Resident #3 had an unwitnessed fall in her room. The Report reflected the resident was backing up to sit in her wheelchair, and her knee got tired and gave way, making her lose her balance and slip to the floor. The Report reflected the resident's gait and mobility as independent on repositioning, but required one person assistance for transfer and ambulation. The undated CNA Care Plan revealed Resident #3 was a high risk for falls, partial weight bearing and required extensive assistance with transfers by two people. The CNA Monthly ADL Tracker for February 2012 reflected Resident #3 was totally dependent. The ADL Tracker was initialed by the CNAs whenever the resident was transferred by one person. The Comprehensive Plan of Care, dated 01/17/2012, reflected Resident #3 had problems, which affected her ability to walk, and she had a history of [REDACTED]. The plan reflected the goal as the following: "I will be safe and not have a fall or accident over the next 90 days." The plan reflected the approach as the following: "I may need 1 to 2 staff to assist me with transfers at times." The plan was not updated after the fall on 02/07/2012. In an interview with LVN K on 02/23/2012 at approximately 4:00 PM, she stated Resident #3 should be a two-person assist with transfers. In an interview with LVN C on 02/24/2012 at approximately 2:45 PM, she stated she could not transfer Resident #3 by herself. She stated the resident required two people to assist with transfers. During an interview with the facility's Corporate Nurse on 02/27/2012 at approximately 11:05 AM, she stated she asked Resident #3 how she transferred, and the resident told her she just needed someone to stand by her. The facility's Corporate Nurse stated the MDS Coordinator was putting in a change of assessment on Resident #3 to indicate the resident required stand-by assistance. In an interview with LVN B on 02/27/2012 at approximately 11:30 AM, she stated the Corporate Nurse told her Resident #3 only needed stand-by assistance. LVN B stated on her assessment of Resident #3, the resident continued to require two-person assistance to transfer. 3) The MDS assessment dated [DATE] reflected Resident #4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident #4 had a BIMS score of 2, which indicated he was severely impaired cognitively. The MDS assessment further reflected the resident needed the extensive assistance of one person with transfers, was unable to ambulate, was unsteady with walking, and only able to stabilize with human assistance. The MDS assessment also reflected Resident #4 had functional limitations with ROM impairment in both legs. An Incident/Accident Report dated 02/03/2012, reflected Resident #4 was found on the floor in the doorway of his bathroom, sitting upright on his bottom. The Report reflected the resident did not hit his head, no injury was noted. staff assisted the resident back into his wheelchair and transferred him back to bed. The Report reflected Resident #4 was attempting to transfer himself from the toilet to the wheelchair. The only interventions given were to educate the resident on using the call light and letting staff assist him with transfers. An observation on 02/24/2012 at 11:03 AM revealed CNAs E and H transferring Resident #4 from his wheelchair to his bed using a gait belt. Resident #4 was unable to assist with the transfer, but was able to bear weight. Immediately following the observation, CNAs E and H were interviewed. They stated Resident #4 was not able to transfer without the assistance of two people. They said the resident did not have a personal alarm on his wheelchair, because the resident was not able to independently get out of his wheelchair. Resident #4's undated CNA Care Plan reflected the resident required extensive assistance with one person to transfer. The plan reflected the resident was to have a personal body alarm and wander guard, and was a "High Risk for Falls." Resident #4's CNA Monthly ADL Tracker for February 2012 reflected the resident was totally dependent and required one person assistance with transfers. The Comprehensive Plan of Care dated from 05/04/2010 through 01/18/2012, reflected Resident #4 had problems, which affected his ability to walk, and had a history of [REDACTED]. The plan reflected Resident #4 had three falls on 07/11/2011, 07/26/2011 and 09/22/2011. The plan reflected the following approach: "I may need 1 or 2 staff to assist me with transfers at times." No new interventions added to the care plan after his fall on 02/03/2012. On 02/24/2012 at 2:05 PM, the DON was requested for a list of facility residents with bed chair alarms. Resident #4 was on the list. On 02/24/2012 at approximately 2:24 PM, Resident #4 was observed with a personal alarm in place. Review of Resident #4's consolidated physician orders [REDACTED]. A Physician's Telephone Order dated 02/26/2012 at 2:45 PM, reflected the following for Resident #4: "Place bed alarm for safety for clarification." 4) The MDS assessment dated [DATE] reflected Resident #6 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident # 6's BIMS score was 12, which indicated the resident was moderately impaired cognitively. The MDS assessment reflected the resident transferred independently and needed the extensive assistance of one person, the resident's walking was not steady and he was only able to stabilize with assistance, and he had functional limitations with ROM in both legs. The assessment reflected the resident had one fall since the previous assessment with no injury noted. Review of Resident #6's Incident/Accident Reports revealed he sustained two falls, one on 01/30/2012 and another on 02/02/2012. Both falls were as a result of Resident #6 sliding out of his recliner. He was found on the floor both times. The Report dated 01/30/2012 reflected Resident #6 was on the ground and scooted himself to the door after sliding out of his chair, and was found at the door to his room when staff got there. No intervention was noted on the Incident/Accident Report. The Report dated 02/02/2012 reflected interventions were to educate Resident #6 on the use of the call light when getting out of chair. The Comprehensive Plan of Care dated from 12/06/2010 through 02/08/2012 reflected Resident #6 had a potential to fall due to arthritis and weakness in his legs. The plan reflected a notation the resident fell on [DATE], 01/30/2012 and 02/02/2012 with no new interventions noted. Resident #6's Nursing to Therapy Communication and Screen Form, dated 02/01/2012, (following a fall) reflected the following under Therapy Recommendations: "No documentation noted about decline in pt's functional status. No changes consistently noted about pt's function. Pt does not require physical therapy services at this time. Pt stated that function is the same currently as prior level of function. Pt stated that (he) has not needed increased assistance for mobility and transfers and does not exhibit decreased strength from previous state." Review of the Resident #6's quarterly review on the Nursing to Therapy Communication and Screen form dated 02/08/2012 revealed under Therapist Recommendations: "No documentation noted about decline and resident's functional status. Nothing noted in the chart on change in function. Resident does not require physical therapy at this time. If any changes noted due to function, documentation is needed." An observation on 02/24/2012 at 2:15 PM, while accompanied by the DON, revealed Resident #6 did not have a chair or personal alarm. At that time, the DON stated she thought Resident #6 had an alarm because of his history of sliding out of his recliner. 5) The MDS assessment dated [DATE] reflected Resident #5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected Resident #5's BIMS score was five, which indicated severe impairment cognitively. The MDS assessment also reflected Resident #5 had disorganized thinking and delusions, and had a history of [REDACTED]. The MDS assessment reflected Resident #5 required limited assistance of one person with a transfer and was able to ambulate independently. A Nurses Note dated 01/23/2012 reflected Resident #5 went out the back door of the facility while other residents were outside smoking. The note reflected Resident #5 indicated she was going home and was looking for her mother. LVN C brought the resident back inside the facility and showed Resident #5 her room. LVN C placed a wanderguard on Resident #5 and documented notifying the family of the wanderguard placement. There was no incident report made on this elopement. An interview with LVN C on 02/27/2012 at approximately 3:30 PM revealed Resident #5 went out the back door, past the laundry, onto the parking lot. LVN C stated someone came in and told her Resident #5 was outside wandering. She stated the resident said she was going home. LVN C stated she did not fill out an incident report. She stated she placed a wanderguard on Resident #5 after the incident. An interview with Resident #5's POA on 02/27/2012 at 3:45 PM revealed he was not aware Resident #5 had wandered outside of the building unsupervised. In an interview with Resident #5's family member on 02/27/2012 at approximately 3:50 PM, he/she stated it seemed like the facility told him/her something about Resident #5 having tried to get out of the facility, but did not. The family member stated the family told the facility at the time of admission Resident #5 had a history of [REDACTED]. Resident #5's family member also stated he/she hated to say yes or no about being informed of Resident #5 leaving the facility, but he/she did not recall being informed. Resident #5's family member confirmed the resident did not have a wanderguard for a couple of days after admission. Interview with the Administrator and DON on 02/27/2012 at approximately 4:30 PM revealed they were not aware of the incident in which Resident #5 left the faciity on [DATE]. Resident #5's initial assessment dated [DATE] reflected the resident was at high risk for wandering and exhibited behavioral symptoms of wandering. Resident #5's Elopement Risk assessment dated [DATE] reflected the assessment was inaccurate in regard to identification of her diagnoses, and not identifying the resident's history of eloping. None of the interventions listed on the Elopement Risk Assessment were identified as being needed and the Summary/Conclusions/Recommendations were not followed. Resident #5's Comprehensive Plan of Care dated 01/24/2012 reflected the resident had multiple problems, which affected her ability to think clearly. The plan reflected Resident #5 was an elopement risk and should wear a wanderguard to alert staff whenever she attempted to leave the building without supervision or assistance. 6) The facility's current Abuse Prevention Program Policies and Procedures, dated 11/11/2011, reflected the following: "...Abuse Prevention, Policies and Procedures...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. Neglect is also defined as the failure to protect the resident from abuse, neglect, or exploitation. Neglect is considered repeated conduct or a single incident of carelessness, which produces or could reasonably be expected to result in serious physical or psychological injury, including a substantial risk of death." An Inservice Record, dated 02/24/2012, reflected the following: "...guideline for Health Care Plans...introduce a new approach (symbol for with) each incident. Update comprehensive health care plans (symbol for with) acute health care plan interventions...Until March 31st 2012, the MDS Coordinator is responsible for acute health care plans (symbol for with) each event. After March 31st, the DON/ADON is responsible for acute HCPs (Health Care Plans)." An Inservice Record dated 02/26/2012 reflected the following subjects were reviewed with staff: Accident/Incident system, Witnessed/unwitnessed falls, Fall Prevention Orientation: A safer environment, QAAC monthly to review Falls, and Standards of Care weekly to review Falls. The record also reflected the facility initiated a "Falling Star Program," and staff were instructed on new interventions to be initiated following a fall. and the facility's Accident/Incident Reporting System. 7) The facility's CMS form 672, Resident Census and Conditions of Residents, dated 02/23/2012 reflected 29 residents in the facility required assistance with transfers and 17 residents were identified with behaviors.

Based on observation, interview and record review, the facility failed to implement it's written policies and procedures, which prohibit neglect for for four (Residents #2, #4, #5 and # 6) of 13 residents reviewed for abuse/neglect. 1) Resident #2 had an unwitnessed fall in his room. The resident, who required the assistance of two people to transfer and was severely cognitively impaired, was left unattended on the bedside commode. He fell when trying to transfer himself without assistance, sustained a contusion on his forehead and bruising as well as pain to his left shoulder and was sent to the hospital for evaluation. This failure resulted in Resident #2 injurying himself, necessitating a trip to the hospital for evaluation and treatment. 2) Resident #4 was a two-person transfer assist, which was not on the care plan and was identified as requiring a personal alarm. The two CNAs providing care for him were unaware of the need for a personal alarm. 3) Resident #6 sustained two falls with no interventions implemented other than to instruct the resident to use the call light. The DON thought the resident had a personal alarm due to his history of falls. These failures could affect the 29 residents, who required assistance with transfers, plus Residents #2, #4 and #6, by placing them at risk for falls without implementing interventions to prevent the potential for falls, which could result in pain, discomfort, injury and/or the need for hospitalization . 4) Resident #5 was found wandering on the facility's back parking lot unsupervised. Even though the family had informed the facility the resident was an elopement risk, it was not until the resident left the facility a wanderguard was implemented. This failure could affect the 17 residents with behavior symptoms, plus Resident #5, and placed them at risk for not receiving the supervision and care needed resulting in the potential for eloping, falling, pain, discomfort, injury and/or the need for hospitalization . Findings included: The facility's current Abuse Prevention Program Policies and Procedures, dated 11/11/2011, reflected the following: "...Abuse Prevention, Policies and Procedures...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. Neglect is also defined as the failure to protect the resident from abuse, neglect, or exploitation. Neglect is considered repeated conduct or a single incident of carelessness, which produces or could reasonably be expected to result in serious physical or psychological injury, including a substantial risk of death." 1) The MDS assessment, dated 01/27/2012, reflected Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment also reflected Resident #2's BIMS score was four, which indicated the resident was severely cognitively impaired. The assessment reflected Resident #2 was totally dependent and required a two-person assist with transfers, was unable to ambulate and balance during transitions, was not steady and only able to stabilize with human assistance. The assessment also reflected Resident #2 had limited ROM in both arms and legs. On 02/23/2012 at 10:45 AM Resident #2 was observed on a stretcher being taken from the facility. At that time, the Corporate Nurse stated the resident had an unwitnessed fall in his room. The resident was left unattended on the bedside commode and fell when trying to transfer himself without assistance. The Corporate Nurse stated Resident #2 had sustained a contusion on his forehead and had bruising as well as pain to his left shoulder, 911 had been called and he was being sent to the hospital for further evaluation. The Incident/Accident Report dated 02/23/2012 for Resident #2 reflected the date of the incident/accident was 02/23/2012. The Report reflected, "Called to Room by Housekeeping Resident laying on (left) side, blood noted on floor, assessed. Ltr (letter) size indention to front of forehead. Resident, alert & O x 3. Stated I fell off the toilet & I'm bleeding." The Clinical Assessment of Occurrence reflected, "Res. was trnsferred to B.S.C. for bowel evacuation. His call light was in place & CNA stepped outside of the door to afford him PVCY which is the normal routine for this res. Res. fell while attempting to self-transfer off BSC to chair. Hit his forehead, (left) shoulder & (left) cheek on fooring & sustained contusion & bruising as well as c/o (left) shoulder pain. Assess for bed/chair alarm (sic) Use until Rehab assesses res." Resident #2's Physician order [REDACTED]. The order date was 11/25/2011. On 02/24/2012 at 2:15 PM, the surveyor and the DON made observation rounds of the residents, which were identified by the facility with orders for a personal alarm. At that time, Resident #2 was observed in his recliner at his bedside. The DON said the resident had returned from the hospital. No personal alarm was observed in use. On 02/24/2012 at approximately 2:28 PM, the DON was observed to ask Resident # 2, "What did you do with your alarm? I thought you had an alarm?" During an interview with the facility's Corporate Nurse on 02/27/2012 at approximately 11:00 AM, she was asked if Resident #2 had a history of [REDACTED]. The Nurse Treatment sheet for February 2012 reflected nursing staff had been initialing Resident #2's bed alarm on a daily basis for all three shifts and chair alarm were in place on a daily basis for the day and evening shifts as scheduled. The bed and chair alarm had effective dates of 11/25/2011. During an interview on 02/27/2012 at approximately 2:00 PM with LVN C, she stated she could not say for certain Resident #2 had a personal alarm, but she confirmed she had been initialing the Nurse Treatment sheet Resident #2 did have a personal alarm. The Comprehensive Plan of Care, dated 07/06/2010 through 02/15/2012, reflected Resident #2 had problems, which affected his ability to walk, had a history of [REDACTED]." The plan reflected the following approach: "I may need 1 to 2 staff to assist me with transfers at times." The undated CNA Care Plan reflected Resident #2 was dependent on staff for transfers requiring two-person assistance. The plan also reflected Resident #2 was a high fall risk. The Incident/Accident Report, dated 02/08/2012, reflected Resident #2 had to be lowered to the floor three times during a two-person transfer resulting in a skin tear to his right arm. 2) The MDS assessment dated [DATE] reflected Resident #4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident #4 had a BIMS score of 2, which indicated he was severely impaired cognitively. The MDS assessment further reflected the resident needed the extensive assistance of one person with transfers, was unable to ambulate, was unsteady with walking, and only able to stabilize with human assistance. The MDS assessment also reflected Resident #4 had functional limitations with ROM impairment in both legs. An Incident/Accident Report dated 02/03/2012, reflected Resident #4 was found on the floor in the doorway of his bathroom, sitting upright on his bottom. The Report reflected the resident did not hit his head, no injury was noted. staff assisted the resident back into his wheelchair and transferred him back to bed. The Report reflected Resident #4 was attempting to transfer himself from the toilet to the wheelchair. The only interventions given were to educate the resident on using the call light and letting staff assist him with transfers. An observation on 02/24/2012 at 11:03 AM revealed CNAs E and H transferring Resident #4 from his wheelchair to his bed using a gait belt. Resident #4 was unable to assist with the transfer, but was able to bear weight. Immediately following the observation, CNAs E and H were interviewed. They stated Resident #4 was not able to transfer without the assistance of two people. They said the resident did not have a personal alarm on his wheelchair, because the resident was not able to independently get out of his wheelchair. Resident #4's undated CNA Care Plan reflected the resident required extensive assistance with one person to transfer. The plan reflected the resident was to have a personal body alarm and wander guard, and was a "High Risk for Falls." Resident #4's CNA Monthly ADL Tracker for February 2012 reflected the resident was totally dependent and required one person assistance with transfers. The Comprehensive Plan of Care dated from 05/04/2010 through 01/18/2012, reflected Resident #4 had problems, which affected his ability to walk, and had a history of [REDACTED]. The plan reflected Resident #4 had three falls on 07/11/2011, 07/26/2011 and 09/22/2011. The plan reflected the following approach: "I may need 1 or 2 staff to assist me with transfers at times." No new interventions added to the care plan after his fall on 02/03/2012. On 02/24/2012 at 2:05 PM, the DON was requested for a list of facility residents with bed chair alarms. Resident #4 was on the list. On 02/24/2012 at approximately 2:24 PM, Resident #4 was observed with a personal alarm in place. Review of Resident #4's consolidated physician orders [REDACTED]. A Physician's Telephone Order dated 02/26/2012 at 2:45 PM, reflected the following for Resident #4: "Place bed alarm for safety for clarification." 3) The MDS assessment dated [DATE] reflected Resident #6 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident # 6's BIMS score was 12, which indicated the resident was moderately impaired cognitively. The MDS assessment reflected the resident transferred independently and needed the extensive assistance of one person, the resident's walking was not steady and he was only able to stabilize with assistance, and he had functional limitations with ROM in both legs. The assessment reflected the resident had one fall since the previous assessment with no injury noted. Review of Resident #6's Incident/Accident Reports revealed he sustained two falls, one on 01/30/2012 and another on 02/02/2012. Both falls were as a result of Resident #6 sliding out of his recliner. He was found on the floor both times. The Report dated 01/30/2012 reflected Resident #6 was on the ground and scooted himself to the door after sliding out of his chair, and was found at the door to his room when staff got there. No intervention was noted on the Incident/Accident Report. The Report dated 02/02/2012 reflected interventions were to educate Resident #6 on the use of the call light when getting out of chair. The Comprehensive Plan of Care dated from 12/06/2010 through 02/08/2012 reflected Resident #6 had a potential to fall due to arthritis and weakness in his legs. The plan reflected a notation the resident fell on [DATE], 01/30/2012 and 02/02/2012 with no new interventions noted. Resident #6's Nursing to Therapy Communication and Screen Form, dated 02/01/2012, (following a fall) reflected the following under Therapy Recommendations: "No documentation noted about decline in pt's functional status. No changes consistently noted about pt's function. Pt does not require physical therapy services at this time. Pt stated that function is the same currently as prior level of function. Pt stated that (he) has not needed increased assistance for mobility and transfers and does not exhibit decreased strength from previous state." Review of the Resident #6's quarterly review on the Nursing to Therapy Communication and Screen form dated 02/08/2012 revealed under Therapist Recommendations: "No documentation noted about decline and resident's functional status. Nothing noted in the chart on change in function. Resident does not require physical therapy at this time. If any changes noted due to function, documentation is needed." An observation on 02/24/2012 at 2:15 PM, while accompanied by the DON, revealed Resident #6 did not have a chair or personal alarm. At that time, the DON stated she thought Resident #6 had an alarm because of his history of sliding out of his recliner. 4) The MDS assessment dated [DATE] reflected Resident #5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected Resident #5's BIMS score was five, which indicated severe impairment cognitively. The MDS assessment also reflected Resident #5 had disorganized thinking and [MEDICAL CONDITION], and had a history of [REDACTED]. The MDS assessment reflected Resident #5 required limited assistance of one person with a transfer and was able to ambulate independently. A Nurses Note dated 01/23/2012 reflected Resident #5 went out the back door of the facility while other residents were outside smoking. The note reflected Resident #5 indicated she was going home and was looking for her mother. LVN C brought the resident back inside the facility and showed Resident #5 her room. LVN C placed a wanderguard on Resident #5 and documented notifying the family of the wanderguard placement. There was no incident report made on this elopement. An interview with LVN C on 02/27/2012 at approximately 3:30 PM revealed Resident #5 went out the back door, past the laundry, onto the parking lot. LVN C stated someone came in and told her Resident #5 was outside wandering. She stated the resident said she was going home. LVN C stated she did not fill out an incident report. She stated she placed a wanderguard on Resident #5 after the incident. An interview with Resident #5's POA on 02/27/2012 at 3:45 PM revealed he was not aware Resident #5 had wandered outside of the building unsupervised. In an interview with Resident #5's family member on 02/27/2012 at approximately 3:50 PM, he/she stated it seemed like the facility told him/her something about Resident #5 having tried to get out of the facility, but did not. The family member stated the family told the facility at the time of admission Resident #5 had a history of [REDACTED]. Resident #5's family member also stated he/she hated to say yes or no about being informed of Resident #5 leaving the facility, but he/she did not recall being informed. Resident #5's family member confirmed the resident did not have a wanderguard for a couple of days after admission. Interview with the Administrator and DON on 02/27/2012 at approximately 4:30 PM revealed they were not aware of the incident in which Resident #5 left the faciity on [DATE]. Resident #5's initial assessment dated [DATE] reflected the resident was at high risk for wandering and exhibited behavioral symptoms of wandering. Resident #5's Elopement Risk assessment dated [DATE] reflected the assessment was inaccurate in regard to identification of her diagnoses, and not identifying the resident's history of eloping. None of the interventions listed on the Elopement Risk Assessment were identified as being needed and the Summary/Conclusions/Recommendations were not followed. Resident #5's Comprehensive Plan of Care dated 01/24/2012 reflected the resident had multiple problems, which affected her ability to think clearly. The plan reflected Resident #5 was an elopement risk and should wear a wanderguard to alert staff whenever she attempted to leave the building without supervision or assistance. 5) An Inservice Record, dated 02/24/2012, reflected the following: "...guideline for Health Care Plans...introduce a new approach (symbol for with) each incident. Update comprehensive health care plans (symbol for with) acute health care plan interventions...Until March 31st 2012, the MDS Coordinator is responsible for acute health care plans (symbol for with) each event. After March 31st, the DON/ADON is responsible for acute HCPs (Health Care Plans)." An Inservice Record dated 02/26/2012 reflected the following subjects were reviewed with staff: Accident/Incident system, Witnessed/unwitnessed falls, Fall Prevention Orientation: A safer environment, QAAC monthly to review Falls, and Standards of Care weekly to review Falls. The record also reflected the facility initiated a "Falling Star Program," and staff were instructed on new interventions to be initiated following a fall. and the facility's Accident/Incident Reporting System. 6) The facility's CMS form 672, Resident Census and Conditions of Residents, dated 02/23/2012 reflected 29 residents in the facility required assistance with transfers and 17 residents were identified with behavioral symptoms. The facility's Resident Worklist dated 02/23/2012 reflected eight residents had personal, bed, or chair alarms, and six residents had a low bed or specialty bed.

Based on observation, interview and record review, it was determined the facility failed to develop and/or implement its policies and procedures, which prohibit neglect for four (Residents #2, #4, #5 and # 6) of 13 residents reviewed for abuse/neglect. 1) Resident #2 had an unwitnessed fall in his room. The resident, who required the assistance of two people to transfer and was severely cognitively impaired, was left unattended on the bedside commode. He fell when trying to transfer himself without assistance, sustained a contusion on his forehead and bruising as well as pain to his left shoulder and was sent to the hospital for evaluation. This failure resulted in Resident #2 injurying himself, necessitating a trip to the hospital for evaluation and treatment. 2) Resident #4 was a two-person transfer assist, which was not on the care plan and was identified as requiring a personal alarm. The two CNAs providing care for him were unaware of the need for a personal alarm. 3) Resident #6 sustained two falls with no interventions implemented other than to instruct the resident to use the call light. The DON thought the resident had a personal alarm due to his history of falls. These failures could affect the 29 residents, who required assistance with transfers, plus Residents #2, #4 and #6, by placing them at risk for falls without implementing interventions to prevent the potential for falls, which could result in pain, discomfort, injury and/or the need for hospitalization . 4) Resident #5 was found wandering on the facility's back parking lot unsupervised. Even though the family had informed the facility the resident was an elopement risk, it was not until the resident left the facility a wanderguard was implemented. This failure could affect the 17 residents with behavior symptoms, plus Resident #5, and placed them at risk for not receiving the supervision and care needed resulting in the potential for eloping, falling, pain, discomfort, injury and/or the need for hospitalization . Findings included: 1) The MDS assessment, dated 01/27/2012, reflected Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment also reflected Resident #2's BIMS score was four, which indicated the resident was severely cognitively impaired. The assessment reflected Resident #2 was totally dependent and required a two-person assist with transfers, was unable to ambulate and balance during transitions, was not steady and only able to stabilize with human assistance. The assessment also reflected Resident #2 had limited ROM in both arms and legs. On 02/23/2012 at 10:45 AM Resident #2 was observed on a stretcher being taken from the facility. At that time, the Corporate Nurse stated the resident had an unwitnessed fall in his room. The resident was left unattended on the bedside commode and fell when trying to transfer himself without assistance. The Corporate Nurse stated Resident #2 had sustained a contusion on his forehead and had bruising as well as pain to his left shoulder, 911 had been called and he was being sent to the hospital for further evaluation. The Incident/Accident Report dated 02/23/2012 for Resident #2 reflected the date of the incident/accident was 02/23/2012. The Report reflected, "Called to Room by Housekeeping Resident laying on (left) side, blood noted on floor, assessed. Ltr (letter) size indention to front of forehead. Resident, alert & O x 3. Stated I fell off the toilet & I'm bleeding." The Clinical Assessment of Occurrence reflected, "Res. was trnsferred to B.S.C. for bowel evacuation. His call light was in place & CNA stepped outside of the door to afford him PVCY which is the normal routine for this res. Res. fell while attempting to self-transfer off BSC to chair. Hit his forehead, (left) shoulder & (left) cheek on fooring & sustained contusion & bruising as well as c/o (left) shoulder pain. Assess for bed/chair alarm (sic) Use until Rehab assesses res." Resident #2's Physician order [REDACTED]. The order date was 11/25/2011. On 02/24/2012 at 2:15 PM, the surveyor and the DON made observation rounds of the residents, which were identified by the facility with orders for a personal alarm. At that time, Resident #2 was observed in his recliner at his bedside. The DON said the resident had returned from the hospital. No personal alarm was observed in use. On 02/24/2012 at approximately 2:28 PM, the DON was observed to ask Resident # 2, "What did you do with your alarm? I thought you had an alarm?" During an interview with the facility's Corporate Nurse on 02/27/2012 at approximately 11:00 AM, she was asked if Resident #2 had a history of [REDACTED]. The Nurse Treatment sheet for February 2012 reflected nursing staff had been initialing Resident #2's bed alarm on a daily basis for all three shifts and chair alarm were in place on a daily basis for the day and evening shifts as scheduled. The bed and chair alarm had effective dates of 11/25/2011. During an interview on 02/27/2012 at approximately 2:00 PM with LVN C, she stated she could not say for certain Resident #2 had a personal alarm, but she confirmed she had been initialing the Nurse Treatment sheet Resident #2 did have a personal alarm. The Comprehensive Plan of Care, dated 07/06/2010 through 02/15/2012, reflected Resident #2 had problems, which affected his ability to walk, had a history of [REDACTED]." The plan reflected the following approach: "I may need 1 to 2 staff to assist me with transfers at times." The undated CNA Care Plan reflected Resident #2 was dependent on staff for transfers requiring two-person assistance. The plan also reflected Resident #2 was a high fall risk. The Incident/Accident Report, dated 02/08/2012, reflected Resident #2 had to be lowered to the floor three times during a two-person transfer resulting in a skin tear to his right arm. 2) The MDS assessment dated [DATE] reflected Resident #4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident #4 had a BIMS score of 2, which indicated he was severely impaired cognitively. The MDS assessment further reflected the resident needed the extensive assistance of one person with transfers, was unable to ambulate, was unsteady with walking, and only able to stabilize with human assistance. The MDS assessment also reflected Resident #4 had functional limitations with ROM impairment in both legs. An Incident/Accident Report dated 02/03/2012, reflected Resident #4 was found on the floor in the doorway of his bathroom, sitting upright on his bottom. The Report reflected the resident did not hit his head, no injury was noted. staff assisted the resident back into his wheelchair and transferred him back to bed. The Report reflected Resident #4 was attempting to transfer himself from the toilet to the wheelchair. The only interventions given were to educate the resident on using the call light and letting staff assist him with transfers. An observation on 02/24/2012 at 11:03 AM revealed CNAs E and H transferring Resident #4 from his wheelchair to his bed using a gait belt. Resident #4 was unable to assist with the transfer, but was able to bear weight. Immediately following the observation, CNAs E and H were interviewed. They stated Resident #4 was not able to transfer without the assistance of two people. They said the resident did not have a personal alarm on his wheelchair, because the resident was not able to independently get out of his wheelchair. Resident #4's undated CNA Care Plan reflected the resident required extensive assistance with one person to transfer. The plan reflected the resident was to have a personal body alarm and wander guard, and was a "High Risk for Falls." Resident #4's CNA Monthly ADL Tracker for February 2012 reflected the resident was totally dependent and required one person assistance with transfers. The Comprehensive Plan of Care dated from 05/04/2010 through 01/18/2012, reflected Resident #4 had problems, which affected his ability to walk, and had a history of [REDACTED]. The plan reflected Resident #4 had three falls on 07/11/2011, 07/26/2011 and 09/22/2011. The plan reflected the following approach: "I may need 1 or 2 staff to assist me with transfers at times." No new interventions added to the care plan after his fall on 02/03/2012. On 02/24/2012 at 2:05 PM, the DON was requested for a list of facility residents with bed chair alarms. Resident #4 was on the list. On 02/24/2012 at approximately 2:24 PM, Resident #4 was observed with a personal alarm in place. Review of Resident #4's consolidated physician orders [REDACTED]. A Physician's Telephone Order dated 02/26/2012 at 2:45 PM, reflected the following for Resident #4: "Place bed alarm for safety for clarification." 3) The MDS assessment dated [DATE] reflected Resident #6 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment reflected Resident # 6's BIMS score was 12, which indicated the resident was moderately impaired cognitively. The MDS assessment reflected the resident transferred independently and needed the extensive assistance of one person, the resident's walking was not steady and he was only able to stabilize with assistance, and he had functional limitations with ROM in both legs. The assessment reflected the resident had one fall since the previous assessment with no injury noted. Review of Resident #6's Incident/Accident Reports revealed he sustained two falls, one on 01/30/2012 and another on 02/02/2012. Both falls were as a result of Resident #6 sliding out of his recliner. He was found on the floor both times. The Report dated 01/30/2012 reflected Resident #6 was on the ground and scooted himself to the door after sliding out of his chair, and was found at the door to his room when staff got there. No intervention was noted on the Incident/Accident Report. The Report dated 02/02/2012 reflected interventions were to educate Resident #6 on the use of the call light when getting out of chair. The Comprehensive Plan of Care dated from 12/06/2010 through 02/08/2012 reflected Resident #6 had a potential to fall due to arthritis and weakness in his legs. The plan reflected a notation the resident fell on [DATE], 01/30/2012 and 02/02/2012 with no new interventions noted. Resident #6's Nursing to Therapy Communication and Screen Form, dated 02/01/2012, (following a fall) reflected the following under Therapy Recommendations: "No documentation noted about decline in pt's functional status. No changes consistently noted about pt's function. Pt does not require physical therapy services at this time. Pt stated that function is the same currently as prior level of function. Pt stated that (he) has not needed increased assistance for mobility and transfers and does not exhibit decreased strength from previous state." Review of the Resident #6's quarterly review on the Nursing to Therapy Communication and Screen form dated 02/08/2012 revealed under Therapist Recommendations: "No documentation noted about decline and resident's functional status. Nothing noted in the chart on change in function. Resident does not require physical therapy at this time. If any changes noted due to function, documentation is needed." An observation on 02/24/2012 at 2:15 PM, while accompanied by the DON, revealed Resident #6 did not have a chair or personal alarm. At that time, the DON stated she thought Resident #6 had an alarm because of his history of sliding out of his recliner. 4) The MDS assessment dated [DATE] reflected Resident #5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected Resident #5's BIMS score was five, which indicated severe impairment cognitively. The MDS assessment also reflected Resident #5 had disorganized thinking and [MEDICAL CONDITION], and had a history of [REDACTED]. The MDS assessment reflected Resident #5 required limited assistance of one person with a transfer and was able to ambulate independently. A Nurses Note dated 01/23/2012 reflected Resident #5 went out the back door of the facility while other residents were outside smoking. The note reflected Resident #5 indicated she was going home and was looking for her mother. LVN C brought the resident back inside the facility and showed Resident #5 her room. LVN C placed a wanderguard on Resident #5 and documented notifying the family of the wanderguard placement. There was no incident report made on this elopement. An interview with LVN C on 02/27/2012 at approximately 3:30 PM revealed Resident #5 went out the back door, past the laundry, onto the parking lot. LVN C stated someone came in and told her Resident #5 was outside wandering. She stated the resident said she was going home. LVN C stated she did not fill out an incident report. She stated she placed a wanderguard on Resident #5 after the incident. An interview with Resident #5's POA on 02/27/2012 at 3:45 PM revealed he was not aware Resident #5 had wandered outside of the building unsupervised. In an interview with Resident #5's family member on 02/27/2012 at approximately 3:50 PM, he/she stated it seemed like the facility told him/her something about Resident #5 having tried to get out of the facility, but did not. The family member stated the family told the facility at the time of admission Resident #5 had a history of [REDACTED]. Resident #5's family member also stated he/she hated to say yes or no about being informed of Resident #5 leaving the facility, but he/she did not recall being informed. Resident #5's family member confirmed the resident did not have a wanderguard for a couple of days after admission. Interview with the Administrator and DON on 02/27/2012 at approximately 4:30 PM revealed they were not aware of the incident in which Resident #5 left the faciity on [DATE]. Resident #5's initial assessment dated [DATE] reflected the resident was at high risk for wandering and exhibited behavioral symptoms of wandering. Resident #5's Elopement Risk assessment dated [DATE] reflected the assessment was inaccurate in regard to identification of her diagnoses, and not identifying the resident's history of eloping. None of the interventions listed on the Elopement Risk Assessment were identified as being needed and the Summary/Conclusions/Recommendations were not followed. Resident #5's Comprehensive Plan of Care dated 01/24/2012 reflected the resident had multiple problems, which affected her ability to think clearly. The plan reflected Resident #5 was an elopement risk and should wear a wanderguard to alert staff whenever she attempted to leave the building without supervision or assistance. 5) The facility's current Abuse Prevention Program Policies and Procedures, dated 11/11/2011, reflected the following: "...Abuse Prevention, Policies and Procedures...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition. Neglect is also defined as the failure to protect the resident from abuse, neglect, or exploitation. Neglect is considered repeated conduct or a single incident of carelessness, which produces or could reasonably be expected to result in serious physical or psychological injury, including a substantial risk of death." An Inservice Record, dated 02/24/2012, reflected the following: "...guideline for Health Care Plans...introduce a new approach (symbol for with) each incident. Update comprehensive health care plans (symbol for with) acute health care plan interventions...Until March 31st 2012, the MDS Coordinator is responsible for acute health care plans (symbol for with) each event. After March 31st, the DON/ADON is responsible for acute HCPs (Health Care Plans)." An Inservice Record dated 02/26/2012 reflected the following subjects were reviewed with staff: Accident/Incident system, Witnessed/unwitnessed falls, Fall Prevention Orientation: A safer environment, QAAC monthly to review Falls, and Standards of Care weekly to review Falls. The record also reflected the facility initiated a "Falling Star Program," and staff were instructed on new interventions to be initiated following a fall. and the facility's Accident/Incident Reporting System. 6) The facility's CMS form 672, Resident Census and Conditions of Residents, dated 02/23/2012 reflected 29 residents in the facility required assistance with transfers and 17 residents were identified with behaviors. The facility's Resident Worklist dated 02/23/2012 reflected eight residents had personal, bed, or chair alarms, and six residents had a low bed or specialty bed.

Based on observation, record review, and interviews, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for six (Residents # 1, #2, #3, #4, #5 and #6) of 13 residents reviewed. 1) Resident #2 had an unwitnessed fall in his room. The resident, who required the assistance of two people to transfer and was severely cognitively impaired, was left unattended on the bedside commode. He fell when trying to transfer himself without assistance, sustained a contusion on his forehead and bruising as well as pain to his left shoulder and was sent to the hospital for evaluation. This failure resulted in Resident #2 injurying himself, necessitating a trip to the hospital for evaluation and treatment. 2) Resident #3 sustained an unwitnessed fall resulting in left knee pain. Not all staff were aware of the resident's need for two people to assist with transfers. The facility's corporate nurse reported the resident only needed stand-by assistance. 3) Resident #1 sustained six falls within the past three months and hit her head twice. The facility did not implement safety precautions to prevent the potential for the resident falling sustaining potential harm and/or injury. 4) Resident #4 was a two-person transfer assist, which was not on the care plan and was identified as requiring a personal alarm. The two CNAs providing care for him were unaware of the need for a personal alarm. 5) Resident #6 sustained two falls with no interventions implemented other than to instruct the resident to use the call light. The DON thought the resident had a personal alarm due to his history of falls. These failures could affect the 29 residents, who required assistance with transfers, plus Residents #1, #2, #3, #4 and #6, by placing them at risk for falls without implementing interventions to prevent the potential for falls, which could result in pain, discomfort, injury and/or the need for hospitalization . 6) Resident #5 was found wandering on the facility's back parking lot unsupervised. Even though the family had informed the facility the resident was an elopement risk, it was not until the resident left the facility a wanderguard was implemented. This failure could affect the 17 residents with behavior symptoms, plus Resident #5, and placed them at risk for not receiving the supervision and care needed resulting in the potential for eloping, falling, pain, discomfort, injury and/or the need for hospitalization . These failures could affect all 51 residents in the facility, including Residents #1, #2, #3, #4, #5 and #6, and placed them at risk for not receiving the supervision and assistance needed resulting in the potential for falls, which could result in pain, discomfort, injury and/or the need for hospitalization . Findings included: 1) The MDS assessment, dated 01/27/12, reflected Resident #2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment also reflected Resident #2's BIMS score was four. The assessment reflected Resident #2's functional status, which indicated the resident was totally dependent and a two-person assist with transfers. The assessment reflected Resident #2 was unable to ambulate and balance during transitions, was not steady and only able to stabilize with human assistance. The assessment also reflected Resident #2 had limited ROM in both his upper and lower extremities. An observation on 02/23/12 at 10:45 AM revealed Resident #2 had an unwitnessed fall in his room. The resident was left unattended on the bedside commode and fell when trying to transfer himself without assistance. Resident # 2 was sent to the hospital for further evaluation. Resident #2 had sustained a contusion on his forehead and bruising as well as pain to his left shoulder. The Incident/Accident Report dated 02/23/2012 for Resident #2 reflected the date of the incident/accident was 02/23/2012. The Report reflected, "Called to Room by Housekeeping Resident laying on (left) side, blood noted on floor, assessed. Ltr (letter) size indention to front of forehead. Resident, alert & O x 3. Stated I fell off the toilet & I'm bleeding." The Clinical Assessment of Occurrence reflected, "Res. was trnsferred to B.S.C. for bowel evacuation. His call light was in place & CNA stepped outside of the door to afford him PVCY which is the normal routine for this res. Res. fell while attempting to self-transfer off BSC to chair. Hit his forehead, (left) shoulder & (left) cheek on fooring & sustained contusion & bruising as well as c/o (left) shoulder pain. Assess for bed/chair alarm (sic) Use until Rehab assesses res." Resident #2's Physician order [REDACTED]. The order date was 11/25/2011. On 02/24/2012 at 2:15 PM, the surveyor and the DON made observation rounds of the residents, which were identified by the facility with orders for a personal alarm. At that time, Resident #2 was observed in his recliner at his bedside. The DON said the resident had returned from the hospital. No personal alarm was observed in use. On 02/24/2012 at approximately 2:28 PM, the DON was observed to ask Resident # 2, "What did you do with your alarm? I thought you had an alarm?" During an interview with the facility's Corporate Nurse on 02/27/12 at approximately 11:00 AM, she was asked if Resident #2 had a history of [REDACTED]. During an interview on 02/27/12 at approximately 2:00 PM with LVN C, she stated she could not say for certain that Resident #2 had a personal alarm; although, she had initialed off that he did. The Nurse Treatment MAR, effective date 01/31/12, reflected nursing staff had been initialing that Resident #2's bed alarm and chair alarm were intact. The Comprehensive Plan of Care, dated 07/06/10 through 02/15/12, reflected Resident #2 had problems that affected his ability to walk, and had a history of [REDACTED]." The plan reflected the following approach: "I may need 1 to 2 staff to assist me with transfers at times." The undated CNA Care Plan revealed Resident #2 was dependent for transfers requiring two-person assistance. The plan also revealed, under the comments section, Resident #2 was a high fall risk. The Incident/Accident Report, dated 02/08/12, reflected Resident #2 had to be lowered to the floor three times during a one-person transfer resulting in a skin tear to his right arm. 2) The MDS assessment, dated 01/18/12, reflected Resident #3 was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Further evaluation of Resident #3's MDS revealed a BIMS score of 14. The assessment revealed the resident's functional status as requiring extensive assistance with two-person physical assistance with transfers. The assessment revealed the resident required extensive assistance with ambulation with physical assistance of two people. The assessment revealed the resident needed balance during transitions and walking was not steady, only able to stabilize with human assistance. The assessment also revealed the resident had limitations in ROM to her bilateral lower extremities. The Incident/Accident Report, dated 02/07/12, reflected Resident #3 had an unwitnessed fall in her room. The report reflected the resident was backing up to sit in her wheelchair, and her knee got tired and gave way, making her loose her balance and slip to the floor. The report reflected the resident's gait and mobility as independent on repositioning, but required one person assistance for transfer and ambulation. The undated CNA Care Plan revealed Resident #3 was a high risk for falls, partial weight bearing and required extensive assistance with transfers by two people. The CNA Monthly ADL Tracker form for February 2012 revealed Resident #3 was totally dependent. The form was initialed by the CNAs whenever the resident was transferred by one person. The Comprehensive Plan of Care, dated 01/17/12, reflected Resident #3 had problems that affected her ability to walk, and had a history of [REDACTED]. The plan reflected the goal as the following: "I will be safe and not have a fall or accident over the next 90 days." The plan reflected the approach as the following: "I may need 1 to 2 staff to assist me with transfers at times." The plan was not updated after the fall on 02/07/12. In an interview with LVN K on 02/23/12 at approximately 4:00 PM, she stated Resident #3 should be a two-person assist with transfers. In an interview with LVN C on 02/24/12 at approximately 2:45 PM, she stated she could not transfer Resident #3 by herself. She stated the resident required two people to assist with transfers. Interview with the facility's Corporate Nurse on 02/27/12 at approximately 11:05 AM, she stated she asked Resident #3 how she transferred and the resident told her she just needed someone to stand by her. She stated the MDS Coordinator was putting in a change of assessment on Resident #3 to indicate the resident required stand-by assistance. In an interview with LVN B on 02/27/12 at approximately 11:30 AM, she stated the Corporate Nurse told her that Resident #3 only needed stand-by assistance. LVN B stated on her assessment of Resident #3, the resident continued to require two person assistance to transfer. 3) The MDS assessment, dated 02/08/12, reflected Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #1 had a BIMS score of nine and her functional status indicated she required transfers with limited physical assistance of one person. The assessment reflected Resident #1 require limited assistance with one person for ambulation and balance during transitions. The assessment reflected the resident's walking was not steady, only able to stabilize with human assistance. The assessment reflected Resident #1 had ROM impairment on one side of the lower extremities and a history of falls. Review of the Incident/Accident Reports for Resident #1, dated 12/03/11 through 02/02/12, reflected the resident sustained [REDACTED]. The Incident/Accident Report, dated 02/02/12, reflected Resident #1 was heard yelling out and discovered lying on her right side against her roommate's bed. The report reflected Resident #1 stated, "she fell back on to roommates bed, landed on table...and broke table 1/2 (in half)." The report reflected Resident #1 complained of right knee pain and right rib pain. The report reflected the only interventions listed as instructing Resident #1 to use call light for assistance. Resident #1's Fall Risk Assessment, dated 02/02/12, reflected a score of 11, which represented high risk" for falls. The physician's orders [REDACTED]. Resident #1's Physician's Telephone Order, dated 02/24/12, reflected the following: "May use Bed pad alarm." Review of Resident #1's previous telephone orders revealed the following: 12/01/11 - "X-Ray in AM Rt (right) Hip and Lt (left) Hip Dx (diagnosis): fall c/o leg Pain" 01/11/12 - "X-ray (symbol for right) arm STAT (emergency) r/o (related to) Fx (fracture)" 01/28/12 - "Transfer to (hospital) D/T (due to) fall out of bed and hit back of head" 02/02/12 - "Send to (hospital) for eval (evaluation) & (and) tx (treatment)" (Related to fall) The Comprehensive Plan of Care, dated 07/07/11 through 02/01/12, reflected Resident #1 had problems that affected her ability to walk, and had a history of [REDACTED]. The plan reflected the following approaches: "I may need 1 to 2 staff to assist me with transfers at times." The plan was not updated with new interventions after the resident fell on [DATE]. The Nursing to Therapy Communication and Screen Form, dated 02/01/12, reflected the following under Therapist Recommendations: "No documentation noted in chart as to decline in pt.'s (patient's) functional level. Pt. does not require physical therapy services at this time." (However, Resident # 1 had numerous falls - 3 falls prior to this quarterly screening.) Resident #1's CNA Monthly ADL Tracker form for February 2012 reflected CNAs were documenting that Resident required limited transfer assistance with one person. The form also reflected CNAs documented that Resident #1 was not transferred with one person assistance. There was no CNA Care Plan found in the CNA ADL book for Resident #1. During interviews on 02/24/12, CNA's J, H, E and F stated they were to review the CNA Care Plan, which was in the ADL book, for information on how to transfer a resident and the amount of assistance required for each resident. 4) The MDS assessment, dated 01/27/12, reflected Resident #4 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected Resident #4 had a BIMS score was 2 and his functional status indicated he needed extensive assistance of one person with transfers. The assessment reflected Resident # 4 was unable to ambulate, was unsteady with walking, and only able to stabilize with human assistance. The assessment also reflected Resident #4 had functional limitations with ROM impairment in both lower extremities. An Incident/Accident Report, dated 02/03/12, reflected Resident #4 was found on the floor in the doorway of his bathroom, sitting upright on his bottom. The report reflected the resident did not hit his head and no injury was noted. The report reflected staff assisted the resident back into his wheelchair and transferred him back in bed. The report reflected Resident #4 was attempting to transfer himself from the toilet to the wheelchair and the only interventions given were to educate the resident on using the call light and letting staff assist him with transfers. An observation on 02/24/12 at 11:03 AM revealed CNAs E and H transferring Resident #4 from his wheelchair to his bed using a gait belt. Resident #4 was unable to assist with the transfer, but was able to bear weight. Immediately following the observation, CNAs E and H were interviewed and stated Resident #4 was not able to transfer without the assistance of two people. They stated the resident did not have a personal alarm on his wheelchair, because the resident was not able to independently get out of his wheelchair. Resident #4's undated CNA Care Plan revealed the resident required extensive assistance with one person. The plan revealed the resident was to have a personal body alarm and wander guard, and was a "High Risk for Falls." Resident #4's CNA Monthly ADL Tracker form for February 2012 revealed the resident was totally dependent and required one person assistance with transfers. The Comprehensive Plan of Care, dated 05/04/10 through 01/18/12, reflected Resident #4 had problems that affected his ability to walk, and had a history of [REDACTED]. The plan reflected three falls were identified on the following dates: 07/11/11, 07/26/11 and 09/22/11. The plan reflected the following approach: "I may need 1 or 2 staff to assist me with transfers at times." No new interventions added to the care plan. Resident #4's Nursing to Therapy communication form, dated 02/27/11, reflected the following: "No functional changes noted; No PT indicated." A Physician's Telephone Order, dated 02/26/12, reflected the following for Resident #4: "Place bed alarm for safety for clarification." 5) The MDS assessment, dated 11/14/11, reflected Resident #6 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected Resident # 6's BIMS score was 12. The assessment reflected the resident transferred independently and needed extensive assistance of one person. The assessment also reflected the resident's walking was not steady and he was only able to stabilize with human assistance, and he had functional limitations with ROM in the bilateral lower extremities. The assessment reflected the resident had one fall since the previous assessment with no injury noted. Review of Resident #6's Incident/Accident Reports reflected he sustained two falls, one on 01/30/12 and another on 02/02/12. Both falls were as a result of Resident #6 sliding out of his recliner. He was found on the floor both times. The report, dated 01/30/12, reflected Resident #6 was on the ground and had to scoot to the door after sliding out of his chair, and was at the door of his room when staff got there. No intervention was noted on the incident report. The report, dated 02/02/12, reflected interventions listed to educate Resident #6 on use of call light when getting out of chair. The Comprehensive Plan of Care, dated 12/06/10 through 02/08/12, reflected Resident #6 had potential to fall due to arthritis and weakness in his legs. The plan reflected a notation the resident fell on [DATE], 01/30/12 and 02/02/12, with no new interventions noted. Resident #6's Nursing to Therapy Communication and Screen Form, dated 02/01/12, (following a fall) reflected the following under Therapy Recommendations: "No documentation noted about decline in pt's functional status. No changes consistently noted about pt's function. Pt does not require physical therapy services at this time. Pt stated that function is the same currently as prior level of function. Pt stated that (he) has not needed increased assistance for mobility and transfers and does not exhibit decreased strength from previous state." Review of Nursing to Therapy Communication and Screen from date 02/08/12 quarterly review revealed under Therapist Recommendations: No documentation noted about decline and resident ' s functional status. Nothing noted in the chart on change in function. Resident does not require physical therapy at this time. If any changes noted due to function, documentation is needed. An observation on 02/24/12 at 2:15 PM, while accompanied by the DON, revealed Resident #6 did not have a chair or personal alarm. At this time, the DON stated she thought Resident #6 had an alarm, because of his history sliding out of his recliner. 6) The MDS assessment, dated 01/26/12, reflected Resident #5 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The assessment reflected the resident's BIMS score was five. The assessment also reflected Resident #5 had disorganized thinking and [MEDICAL CONDITION], and had a history of [REDACTED]. The assessment reflected Resident #5's required limited assistance with transfer of one person and was able to ambulate independently. A Nurses Note, dated 01/23/12, reflected Resident #5 went out the back door of the facility while other residents were outside smoking. The note reflected Resident #5 indicated she was going home and was looking for her mother. LVN C brought the resident back inside the facility and showed Resident #5 her room. LVN C placed a wanderguard on Resident #5 and documented notifying the family of the wanderguard placement. There was not incident report made on this elopement. An interview with LVN C on 02/27/12 at approximately 3:30 PM revealed Resident #5 went out the back door, past the laundry, onto the parking lot. LVN C stated someone came in and told her that Resident #5 was outside wandering. She stated the resident said she was going home. LVN C stated she did not fill out an incident report. She stated she placed a wanderguard on Resident #5 after the incident. An interview with Resident #5's POA on 02/27/12 at 3:45 PM revealed he was not aware Resident #5's wandered outside of the building unsupervised. In an interview with Resident #5's daughter on 02/27/12 at approximately 3:50 PM, she stated it seemed like the facility told her something about her mom tried to get out of the facility, but did not. The daughter stated the family told the facility at the time of admission that Resident #5 had a history of [REDACTED]. Resident #5's daughter also stated she hated to say yes or no about being informed of Resident #5 leaving the facility, but she did not recall being informed. Resident #5's daughter confirmed her mother did not have a wanderguard for a couple of days after admission. Interview with Administrator and DON on 02/27/12 stated that they were not aware of the occurrence of Resident # 5 ' s leaving the facility on 01/23/12. Resident #5's Initial assessment, dated 01/21/12, reflected the resident was at high risk for wandering and exhibited behavioral symptoms of wandering. Resident #5's Elopement Risk Assessment, dated 01/21/12, reflected the assessment was inaccurate and incomplete, but it identified the resident required increased supervision. No monitoring device had been implemented. Resident #5's Comprehensive Plan of Care, dated 01/24/12, reflected the resident had multiple problems that affected her ability to think clearly. The plan reflected Resident #5 was an elopement risk and should wear a wanderguard to alert staff whenever she attempted to leave the building without supervision or assistance. 7) Review of the facility's posted staffing pattern for 02/23/12 revealed the following: Days = 1 RN, total hours 8 hours; 2 LVNs, total 14 hours; and 4 CNAs, total 28 hours Evenings = no RN; 2 LVNs, total 14 hours; and 4 CNAs, total 28 hours Nights = no RN; 2 LVNs, total 14 hours; and 4 CNAs, total 28 hours An observation on 02/23/12 at approximately 11:00 AM revealed call lights on the facility's back hall were not able to be heard on the front hall. An interview with the Administrator on 02/23/12 at approximately 2:30 PM revealed the number of CNAs for the Day shift had been decreased by one staff since January 2012. The Administrator stated the change had been made by corporate budget cuts and a decline in the census. An interview with the DON on 02/23/12 at approximately 3:45 PM revealed LVN and CNA hours had been cut to seven hours per shift and mandating staff take an hour for lunch. The DON stated the change had been implemented since October 2011. She stated the facility started enforcing the reduction on 01/01/12. Review of the facility's daily schedule and payroll timesheets, dated 02/01/12 through 02/22/12, revealed the following: Short CNA staff : 02/04/12 - Day shift short 1 staff 7.0 hours 02/05/12 - Evening short 1 staff 7.0 hours 02/06/12 - Evening short 3.5 hours 02/07/12 - Evening short 1 staff 7.0 hours 02.09/12 - Night shift short 3.0 hours 02/10/12 - Night shift short 4.0 hours 8) Review of a Resident Worklist, dated 01/03/12, revealed a list of residents that required assistance with feeding. The list revealed 13 residents required assistance with feeding. An interview with LVN A on 02/24/12 at approximately 11:00 AM revealed during mealtime all available CNAs, except one, were assisting in the dining room. LVN A stated this left only one LVN and one CNA to care for all the residents on the halls. 9) The DON provided an undated list of residents who required Nursing treatments. The list reflected 29 residents required wound, skin care, and/or respiratory treatments, and 18 residents required blood sugar monitoring. 10) The DON provided a undated list of residents who smoked. The list reflected seven residents. Review of an undated document entitled "Scheduled Smoke Times For Supervised Smoking," revealed Nursing staff were scheduled to supervise smokers four out of seven scheduled times. Those times were 9:00 AM to 9:15 AM, 4:30 PM to 4:45 PM, 9:00 PM to 9:15 PM, and 10:45 PM to 11:00 PM. 11) An interview with the DON on 02/24/12 at approximately 3:50 PM revealed she was frustrated with the decrease in staffing, which impacted the ability for nurses and CNAs to complete necessary care and ensure the safety of the residents. An interview on 02/27/12 with an unidentified CNA staff revealed "they work off the clock" to provide the care the residents need. The CNA also stated nurses had to assist with CNA care, which prevented them from completing their own job duties. An interview with the Administrator on 02/27/12 at 10:38 AM revealed the reduction in staff hours had started prior to her being hired September 2011. She stated the CNAs were frustrated with their decrease in hours, but felt it was more of a financial burden. She stated she was unaware of any concerns related to staff not getting the work done. During an interview with LVN B on 02/27/12 at approximately 10:50 AM, she stated she did not feel the nurses were able to get the nurses notes done. She stated the nurses wrote blanket statements, because they didn't have enough time. She stated the ADL sheets were not done completely and they just "copycat" them, and did not even look at the names. She stated the facility would normally write staff up for those behaviors, but they did not have enough time to do it. LVN B also stated she was working as a charge nurse on the front hall, where there was only one nurse and one CNA. She stated the CNA had to take lunch for one hour and "it was horrendous." She stated she did not know how the nurses were able to complete all their job duties on a daily basis. LVN B stated she, the DON, and LVN A had brought the decreasing in staffing as a major issue that had not been addressed. During an interview with LVN L on 02/27/12 at approximately 2:00 PM, she stated she sometimes was unable to take a lunch break due to assisting CNAs and providing supervision in care. During an interview with LVN C on 02/27/12 at approximately 2:10 PM, she was questioned regarding her initials on Resident #2's Treatment MAR related to the use of the personal alarm. LVN C stated some days she was assuming it was on and would initial the MAR. She stated she did not look to ensure the alarm was being used every day. She stated, "I have a lot to do on the 6-2 shift. It is very hectic. Sometimes I want to cry." Review of the facility's Budget PPD staffing ladder for February 2012 revealed the amount of staffing hours were allocated per discipline. The ladder revealed for a census of 51 residents, the total amount of CNA hours for a 24-hours period was 79.56 hours. However, the facility's posted staffing schedule for a 24-hour period of time on 02/23/12 totaled 77 hours. 12) The Resident Census and Conditions of Residents form, dated 02/23/12, reflected the following: 35 dependent residents who needed assistance with bathing, 19 dependent residents who needed assistance dressing, 14 dependent residents who needed assistance transferring, 28 dependent resident who needed assistance with toilet use, six dependent residents needed assistance eating, 13 residents required one or two staff for bathing, 23 residents required assistance from one or two staff for dressing, 16 residents required one or two staff assistance with transferring, eight residents required one or two staff assistance for toilet use, and eight residents required one or two staff assistance for eating. The form reflected a total census of 51 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #1) of two residents with pressure ulcers received necessary treatment and services to promote healing and prevent the development of new pressure ulcers. Resident #1 was admitted with one pressure ulcer on her coccyx measuring 0.5 cm. Assessments were incomplete and/or inaccurate. The resident was not positioned for relief of pressure and pressure-relieving devices wre not utilized. Resident #1 was not provided pain medication prior to a dressing change. These failures resulted in Resident #1's pressure ulcer, present on admission, deteriorating to a Stage IV pressure ulcer within approximately 15 days of admission to the facility. Resident #1 also developed three new pressure ulcers: a Stage III pressure ulcer to the left thigh; an unstageable pressure ulcer to the left thigh; and a Stage III pressure ulcer to the right outer ankle. The resident also experienced unnecessary pain during a dressing change. These failures had the potential to create confusion as to whether the pressure ulcers were healing or deteriorating, thus affecting treatment interventions, and creating undue pain and discomfort for the resident and could affect all five residents in the facility with pressures ulcers. Finding included: 1) The MDS assessment, dated 09/13/11, reflected Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The assessment reflected Resident #1 was totally dependent on staff for bed mobility with two person physical assistance. She was assessed to have bilateral lower extremity range of motion functional impairment. Resident #1 was not on a scheduled pain management regimen or receiving any PRN pain medications. The assessment reflected the resident was at risk for developing pressure ulcers and had one Stage I pressure ulcer and one Stage II pressure ulcer, which were present on admission to the facility. Granulation tissue was identified as the most severe tissue type associated with any pressure ulcer. During the initial tour on 10/29/11 at 9:15 AM, while accompanied by the Weekend Supervisor/RN A, Resident #1 was observed in her room in bed. At this time, RN A stated Resident #1 required total assistance with her ADLs. She stated the resident had a stroke and was now aphasic. She stated the resident had a large wound on her hip related to a heating pad burn at her home prior to her admission to the facility. She also stated she thought Resident #1 had three different pressure ulcers, but she was not certain. An observation of Resident #1 at that time revealed she was on an air-loss mattress. The resident had a urinary catheter in place draining clear yellow urine. The resident had severe bilateral upper extremity contractures, and she had wool fabric in both of her contracted hands. Resident #1 did not respond when spoken to. At the time of the observation, the resident's lower body was covered so the surveyor was unable to observe the resident's lower extremities. The Admission Assessment, dated 09/08/11, reflected Resident #1 had a 0.5 cm open area to the coccyx with no redness or drainage. The Nurse's Note, dated 09/08/11, reflected Resident #1 had contractures of both arms and right leg. The note did not identify any other skin impairments at that time. The Comprehensive Care Plan, dated 09/08/11, reflected Resident #1 was at risk for pressure areas. The care plan goal indicated the resident was not to develop any pressure areas or skin breakdown over the next 90 days. The care plan approaches indicated the facility was to provide medications as ordered, give medications the way the doctor ordered it, and reposition the resident during the day. The Comprehensive Care Plan, dated 09/23/11, reflected a new Stage IV Decubitus ulcer to Resident #1's buttocks. The care plan did not identify any new approaches be implemented since the Comprehensive Care Plan dated 09/08/11. A Physician's Progress Notes, dated 09/23/11, reflected Resident #1 had a right leg contracture that pulled the right leg over the left leg. The note also reflected the resident had a Stage IV Decubitus Ulcer with buttocks excoriation and the following documentation: "pillows between contractures." On 10/29/11 at 12:50 PM, Resident #1 was observed lying in bed. The resident's right leg was contracted, bent at the knee, so the resident's right outer ankle rested on top of the resident's left thigh. Resident #1 had pressure ulcers on her right outer ankle and her left thigh. The resident did not have any pressure-relieving device between her legs or ankle. There were no off-loading measures or pressure-relieving measures in place at the time of the observation to prevent the resident's bony prominences on her legs from touching. At this time, LVN B stated she put a pillowcase between the ulcers to catch the excess drainage. During the observation, LVN B was providing dressing changes to Resident #1's right outer ankle and left thigh pressure ulcers. During the procedure, Resident #1 had a facial grimace and she yelled,"Ouch!" When asked if the resident had been given any pain medication before performing the dressing changes, LVN B stated, "I told her nurse to give her some." After completion of the dressing changes, LVN B did not put any pressure relieving device between Resident #1's legs to relieve the pressure. During an observation of Resident #1's dressing changes on 10/29/11 at 3:20 PM, the surveyor made the following observations: Coccyx Pressure Ulcer - Stage IV measuring approximately 1.0 cm x 2.0 cm x 2.0 cm surrounded with approximately 15.0 cm x 10.0 cm of reddened area. Left Lower Thigh Pressure Ulcer - Unstageable pressure ulcer measuring approximately 5.0 cm x 7.0 cm, with approximately 3.0 cm x 5.0 cm of eschar and 2.0 cm x 2.0 cm of slough. Left Upper Thigh Pressure Ulcer - Stage III measuring approximately 4.0 cm x 5.0 cm x 1.0 cm. Right Outer Ankle Pressure Ulcer - Stage III measuring approximately 10.0 cm x 6.0 cm x 0.5 cm. Review of Resident #1's Weekly Skin Assessments revealed the following: A. Coccyx Pressure Ulcer 09/08/11 - Stage II pressure ulcer measuring 0.5 cm x 0.5 cm surrounding 4.0 cm x 6.0 cm area reddened, with no depth documented. 09/14/11 - Stage II pressure ulcer measuring 0.5 cm x 0.5 cm surrounding 4.0 cm by 6.0 cm area reddened, with no depth documented. 09/19/11 - Stage II pressure ulcer measuring 12.0 cm x 7.0 cm with no depth documented. 10/08/11 - Right buttock (sacrum) Stage IV pressure ulcer measuring 4.0 cm x 3.0 cm x 2.0 cm depth. (Note the pressure ulcer was increased to a Stage IV after the physician's assessment on 09/23/11.) 10/15/11 - Right buttock (sacrum) Stage IV pressure ulcer measuring 4.0 cm x 4.0 cm x 3.0 cm depth. B. Right Outer Ankle 09/16/11 - Stage II pressure ulcer measuring 8.0 cm x 2.0 cm with no depth documented. The assessment reflected the following: "Pillow to offload." 09/19/11 - Right outer foot, 5.0 cm x 1.5 cm with no stage or depth documented. The assessment reflected the following: "Turn every two hours pillows." 10/08/11 - Stage III left ankle wound 5.0 cm x 2.0 cm with no depth documented. The assessment reflected the following: "Turn and reposition every two hours offload." 10/15/11 - Stage III left ankle wound, 5.0 cm x 3.0 cm with no depth documented. The assessment reflected the following: "Turn and reposition every two hours offload." C. Left Upper Leg Thigh 10/08/11 - Stage II pressure ulcer, 2.0 cm x 3.0 cm with no depth. The assessment reflected the following: "Wound status deteriorated. Offload." 10/15/11 - Stage II, 2.0 cm x 3.0 cm with no depth documented. The assessment reflected the following: "Wound status deteriorated" and the assessor's signature was missing. D. Left Lower Leg Thigh 10/08/11 - Stage II pressure ulcer, 2.0 cm x 2.0 cm with no depth. The assessment area entitled Stage/Type was blank and the assessor's signature was missing. The Braden Scale For Predicting Pressure Sore Risk, dated 10/08/11, reflected Resident #1 had a score a 10 out of a total score of 12, which represented High Risk for the development of pressure ulcers. There were no follow-up assessments. The October 2011 MAR reflected Resident #1 had not been given anything for pain since 10/11/11 when it was documented that she received Tylenol 500 mg. The DON was interviewed on 10/29/2011 at 3:46 PM regarding Resident #1's pressure ulcers. She was provided with the skin assessment sheets for Resident #1. After reviewing the assessments, the DON (referring to the development of the pressure ulcers on the resident's thighs and ankle) stated, "You're right. In-house." She stated she was unaware the pressure ulcers developed at the facility. She stated she terminated one of her charge nurses, because she failed to complete accurate documentation. She stated the night nurse did not know how to document on pressure ulcers, so she had the day nurse, LVN B, do the documentation and assessment. The surveyor informed the DON that while LVN B was providing a dressing change to Resident #1's right outer ankle and left thigh pressure ulcers, the resident had a facial grimace and yelled, "Ouch!" and when asked if the resident had been given any pain medication before performing the dressing change, LVN B stated, "I told her nurse to give her some." The surveyor also informed the DON the resident's October 2011 MAR reflected the resident had not been given anything for pain since 10/11/11. The DON stated the resident should have received something for pain, because she had orders for pain medications. When asked what type of preventative measures the facility had implemented for Resident #1, she stated the ADON made a built-up foam pad, which was to use used for off-loading as well as pillows. She stated she would have to find out what happened to the built-up foam pad. She acknowledged there should have been some type of pressure-relieving device used with Resident #1 and she stated she would make sure the resident had one. The undated pressure ulcer measurements, provided by the DON on 10/31/11, reflected the following: Coccyx - Stage IV measuring 1.0 cm x 2.0 cm x 1.9 cm with 0.5 cm tunneling at five o'clock, surrounding tissue 14.0 cm by 10.0 cm reddened. Left thigh - eschar area measuring 2.5 cm x 4.5 cm x 0.3 cm, slough area 4.5 cm x 5.5 cm, granulation area 5.0 cm x 7.0 cm Stage IV. Left thigh - slough area measuring 1.0 cm x 3.0 cm x 0.5 cm and granulation area 3.5 cm x 4.5 cm Stage III. Right ankle - Stage III measuring 9.5 cm x 6.0 cm x 0.2 cm. In a telephone interview on 11/07/11 at 3:30 PM, the DON revealed errors were made on the skin assessments. She stated Resident #1 did not have a right buttock (sacrum) Stage IV pressure ulcer as previously assessed and documented (See Care Plan dated 09/23/11 and skin assessments dated 10/08/11 and 10/15/11). She stated the Stage IV pressure ulcer was on the resident's coccyx. The DON also clarified that Resident #1 had a Stage III right outer ankle pressure ulcer. In a telephone interview on 11/08/11 at approximately 2:00 PM, the DON stated, "Nurses assigned to (Resident #1) provide the wound care." The facility's current "Skin System" policy, dated 08/23/10, reflected the following: "1. Senior Living Properties has selected the Braden Scale for the assessment tool to predict Pressure Sore Risk...It is necessary to assess the resident and interview Direct Care Staff to ensure accuracy...High Risk: Total Score 10-12... 2. A Braden Scale should be completed the day of Resident admission/readmission to the facility weekly for four weeks, upon discovery of new pressure area and quarterly thereafter. 3. A Braden scale should also be completed upon each significant change in a Resident's condition and discovery of any pressure ulcer, regardless of Stage including Suspected Deep Tissue Injury as well as Unstageable ulcers... 4. The Health Care Plan should be updated with treatment changes as well as with changes in the Pressure Ulcer presentation. Each site requires a separate individualized (sic) care plan. ...7. The facility DON is responsible for assignment of weekly skin assessments... 9. In the event that a resident does exhibit a skin interruption of any type: Each site has a separate form for documentation purposes. The intent of the separate form per site is to quickly and correctly track the healing progression or decline of each specific identified area... 10. The facility DON should visualize areas related to pressure weekly and be able to report observations...The DON is also visually validating the accuracy of the description of the pressure ulcer documented on the weekly skin assessment form. 13. If a Resident has a pressure ulcer, daily documentation on the Daily Pressure Ulcer Documentation Form will occur until the Pressure Ulcer is resolved. We review treatment success/failure at least every 14 days and notify the physician of assessment... 18. A limited pain assessment...should be generated prior to each dressing change and documented on the Medication Administration Record. The Nurse or CMA (Medication Aide) will administer pain medication(s), per physician orders, in advance of the dressing change. Licensed Nurse is responsible for assessment to determine effectiveness of medication. ...21. A Pressure Ulcer Surveillance Report should be completed weekly by the Director of Nursing or designee...." 2) The Resident Census and Conditions of Residents form, dated 10/29/11, reflected a census of 53 residents in the facility, including five residents identified with Stage II pressure ulcers or higher.

Based on observation, interview and record review, it was determined the facility failed to ensure a psychological evaluation ordered approximately six months ago, was not completed until surveyor intervention. Resident #8's physician was not notified that the evaluation was not done. These failures affected Resident #8 with continued weight gain and depression. This failure has the potential to affect 33 residents who had [DIAGNOSES REDACTED]. A psychological evaluation ordered approximately six months ago, was not completed until surveyor intervention. Resident #8's physician was not notified that the evaluation was not done. These failures affected Resident #8 with continued weight gain and depression. This failure has the potential to affect 33 residents who had [DIAGNOSES REDACTED]. Findings included: 1. According to a summary of admissions and discharges provided by the Business Office Manager on 04/05/11, Resident #8 was first admitted to the facility on [DATE] and discharged to Houston with family on 04/05/10. Resident #8, a [AGE] year-old female, was readmitted to the facility on [DATE] according to the Record of admitted d 10/14/10. The Diet Roster, dated 04/05/11, reflected the Resident's current diet as Regular, Low Concentrated Sweets, No Added Salt, large portions at Breakfast. 2. Resident #8 was first observed during the initial tour on 04/05/11 at 11:15 AM by the surveyor, while accompanied by LVN A. LVN A stated Resident #8 was depressed and was seeing a psychiatrist. LVN A stated Resident #8 had Insulin Dependent Diabetes Mellitus, had a [MEDICAL CONDITION], and ambulated independently with a dropped right foot. LVN A stated Resident #8 ate when she was depressed, had an increased appetite and ate a lot. 3. The facility's weight reports reflected Resident #8's height was 63 inches (5 ft 3 inches). Resident #8's weight records were as follows: Month Weight in lbs (Resident was readmitted in July 2010) Aug. 2010 254.5 Sept. 2010 258.1 Oct. 2010 268.1 Nov. 2010 267.7 Dec. 2010 273.4 Jan. 2011 274.9 Feb. 2011 275.6 Mar. 2011 291.6 4. A review of Resident #8's Physician's Telephone Orders dated 10/15/10, revealed revealed, "Psychology evaluation and treat as indicated by ____ (Psychologist N)." Review of a "Referral For Mental Health Services," dated 10/15/10 revealed Resident #8 was being referred for "Crying and/or persistent feelings of sadness/depression." Review of the clinical record did not reveal any evidence of a psychological evaluation. LVN A was interviewed on 04/06/11 at 11:08 AM. LVN A stated Resident #8 was gaining weight due to depression. The surveyor asked if the physician had been notified about the resident's weight gain. LVN A stated the Nurse Practitioner had seen the resident several times, and the doctor came on Tuesdays. The surveyor asked if LVN A was aware of any discussions with the physician or Nurse Practitioner regarding any interventions, which might be necessary to implement for the resident, LVN A stated the only thing she knew about was the consult for a breast reduction, and the surgery did not take place. LVN A was interviewed on 04/06/11 at 1:00 PM regarding the referral for a psychological evaluation. LVN A stated Psychologist N only saw residents who were covered by Medicare. Resident #8 was covered by an HMO. LVN stated, "I should have let ____ (Resident #8's physician) know," and possibly she would have been referred to someone else. Resident #8 was not seen by the psychologist. 5. Review of Resident #8's care plans dated 01/11/11 revealed the problem/need, "I am morbidly obese." The interventions which nursing was responsible for included the following: "...My physician will be contacted for interventions as necessary. ...I will be educated on the possible risks associated with being non-adherent with my nutritional plan of care...." The surveyor asked if LVN A knew whether Resident #8 had been educated on the possible risks associated with being non-adherent (non-compliant) with her diet. LVN A stated the nurses would carry out the care plan, and the care plan was accessible to the nurses. The surveyor asked how the facility would know if this had been done and what kind of accountability there was for carrying out the care plan. LVN A stated the nurses' notes or the doctor's reports would reflect if the education had been done. LVN A looked through the nurses' notes, doctor's notes and nurse practitioner's notes and found nothing to reflect the resident had been educated as care planned. LVN A stated the issue had not been addressed. LVN A stated this would be caught at the next care plan meeting or the Standards of Care meeting. She stated the next care plan meeting would be the following week. She stated the Standards of Care meetings were weekly. The surveyor commented they had been meeting weekly since 01/11/11, and this issue with Resident #8 had not been caught. The DON was interviewed on 04/07/11 at 1:32 PM. The DON stated she had been employed at the facility, since January 2011. Resident #8's care plan was reviewed with the DON. The surveyor asked if weight gain warranted an intervention. The DON stated it would if it met the protocol of a 5% weight gain in three months. She stated she would contact the physician if there was a weight gain of more than 5% in three months. The DON stated if the resident's education was assigned to nursing, the charge nurses should carry out the plan. Resident #8's weights were reviewed with the DON. Resident #8 weighed 273.4 in December 2010. In March 2011, her weight was 291.9. This represented a weight gain of 6.7% in three months. The March 2011 weight also reflected a weight gain of 13.1 % over six months. The surveyor asked if anyone had contacted the physician about Resident #8's weight gain. The DON stated she would have called, but she did not remember contacting him. She was able to produce a Resident Weight Record, which reflected the physician had been notified on 02/24/11 of Resident #8's weight gain. A review of a physician notification from dated 02/22/11 reflected the physician was notified of Resident #8's 30-pound weight increase in a seven month period of time, and the dietitian had also been notified. LVN I, the 6:00 AM to 2:00 PM charge nurse for Resident #8's hall, was interviewed on 04/07/11 at 1:49 PM. LVN I stated she had not done any education with Resident #8 regarding following her diet. LVN M, the 2:00 - 10:00 PM charge nurse for Resident #8's hall, was interviewed on 04/07/11 at 2:43 PM. She stated she had not educated Resident # 8 about her diet lately. She stated she was not sure if she did a long time ago, but she had definitely not done anything in 2011. 6. Resident #8 was interviewed several times over the course of the survey. During an interview on 04/05/11 at 2:33 PM, Resident #8 stated she had gone to Houston with her daughter, but their apartment burned down in July 2010. Her daughter went back to Louisiana, and the resident came back to the facility. She stated she wanted to go to Louisiana as soon as she could. During an interview on 04/06/10 at 1:38 PM, Resident #8 stated she was diabetic. She stated none of the staff had spoken to her about her diet or foods diabetics might limit. Resident #8 stated one year ago, she weighed under 240 lbs. Resident #8 stated she would be interested in learning how to keep from gaining weight and how to lose weight. During a subsequent interview on 04/07/11 at 11:00 AM, Resident #8 stated she did get depressed, but not that often. She stated she was depressed at this time and wanted to leave the nursing facility and go home. 7. The Nurse Practitioner (NP) was interviewed by phone on 04/08/11 at approximately 2:00 PM. She stated Resident #8 had gained weight and was depressed. She stated they were working on getting Resident #8's diabetes stabilized. The NP stated Resident #8 had gained 70 lbs since November 2009. She stated, "She must be more depressed than we thought." The Nurse Practitioner stated she was not aware the referral for a psychological evaluation in October 2010 had not resulted in an evaluation. She stated Resident #8 appeared depressed. She stated the last two to three months Resident #8 had been telling her (the NP) her daughter was going to pick her up, but she did not. The NP stated of course Resident #8 was disappointed. She stated the resident was leaving her clothes on the floor, had moved to another hall and was not walking like she had been. She stated the resident was somewhat depressed. She stated it was a good idea to get a psychological evaluation. She stated the changes in medication to stabilize Resident #8's diabetes might be responsible for some of the weight gain, but only 10 to 15 lbs. She stated the dietitian definitely needed to speak with Resident #8. 8. The Consultant Dietitian was interviewed by phone on 04/07/11 at 1:52 PM. The surveyor asked if she had ever counseled residents about their diets or if that was the nursing staff's responsibility. She stated she rarely counseled residents. She stated she had done it in the past, if a doctor had written an order for [REDACTED]. The surveyor commented Resident #8 had gained 70 lbs since November 2009. The Consultant Dietitian stated she mainly looked at the one-month, three-month, and six-month variances for weight gain; she did not necessarily look at weights for the whole time a resident was in the facility. The surveyor pointed out incremental weight gains may not trigger the one-month, three-month or six-month variances, but they still could add up to a large weight gain over a period of time. 9. Psychologist N was interviewed on 04/08/11 at 3:30 PM. She stated Resident #8 was depressed. She stated the resident did not want to take any medication. A review of the Psychologist's Treatment plan, dated 04/08/11 revealed Resident #8 agreed to psychotherapy for her depression. 10. The CMS-672 (Resident Census and Conditions of Residents) dated 04/06/2011 and signed by LVN A reflected 33 residents who had [DIAGNOSES REDACTED].