Every finding on record at Bay Crest Care Center

Based on interview and record review, the facility failed to ensure one Certified Nurse Assistant (CNA) 1 demonstrated the competencies necessary to provide safe and appropriate care to one of three sampled residents (Resident) 2 exhibited by:CNA 1's employee file did not contain documentation of completion of the facility's abuse prevention training and post-test upon hire.CNA 1 did not receive individualized, one-on-one in-service education regarding abuse prevention and appropriate resident handling prior to returning to resident care. These deficient practices placed the Resident's at risk for receiving care from CNA 1 who had not received documented abuse-prevention education and individualized education addressing appropriate resident handlingFindings: During an concurrent observation and interview on 8/25/2026 at 9:14 am with Resident 2 in his room, the resident was lying in bed. Resident 2 was alert and oriented and his speech was noted to be slurred. Resident 2's left upper extremity (arm) was observed to be flaccid (weak). Resident 2 stated that on 8/14/2026 during the night shift, two CNAs were in his room providing care and changing him. Resident 2 stated that he did not know their names. Resident 2 stated the alleged perpetrator was on one side of him and another CNA was on the opposite side. Resident 2 stated while he was being turned, CNA 1 pulled him towards his right side, and caused his forehead to strike the side bed rail (metal bars attached to the side of a bed to help people get in and out safely or to prevent them from falling out). Resident 2 stated, When she turned me, my forehead hit the bed rail. Resident 2 stated he experienced pain to his forehead following the incident and was given Tylenol (helps to reduce pain), which provided some relief. Resident 2 stated he reported the incident to the social worker and subsequently was sent to the GACH. Resident 2 denied anything similar had occurred previously with CNA 1 or with any other staff member. Resident 2 stated he did not currently feel safe in the facility because he was concerned a similar incident could happen again.During an interview on 8/25/2026 at 11:50 am with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assisting the resident's assigned CNA with care and repositioning at approximately 9:00 p.m. CNA 1 stated she was positioned on the resident's left side, while the assigned CNA was positioned on the resident's right side. The CNA 1 stated the resident was holding onto the bed rail and that both CNAs turned the resident toward his right side.CNA 1 stated during the repositioning, the resident did not come into contact with the bed rail. CNA 1 stated she did not observe any injury, bruising, swelling, or change in the resident's condition following the repositioning. CNA 1 stated she was off work and was not made aware of the allegation until approximately two days after the incident. CNA 1 stated the Director of Staff Development (DSD) informed her of the allegation and that she would be suspended pending further investigation. CNA 1 stated she returned to work after two days of suspension. CNA 1 stated that she had received abuse prevention training approximately one week prior to the incident. CNA 1 stated that she did not receive any additional abuse in-service training upon returning to work following the allegation.During an interview on 8/25/2026 at 12:11 pm with License Vocational Nurse (LVN) 1, LVN 1 stated that she was made aware of the incident involving Resident 2 on August 14, 2026, by the RN Supervisor (RNS). The LVN 1 stated that she was informed that Resident 2 had come into contact with the bed rail while being handled by CNA 1 during the provision of care, and that the CNA 1 was reportedly rushing while providing care. The LVN 1 stated that she completed an assessment of Resident 2 and completed a change-of-condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) assessment. The LVN 1 stated that Resident 2 complained of a headache rated 5/10 on the pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). The LVN 1 stated that Tylenol 325 milligrams ([mg]unit of measurement) was administered for the resident's complaint. The LVN 1 stated that she did not observe redness, swelling, bruising, tenderness, or other visible injury. The LVN 1 stated that neurological checks (is a fast medical test that evaluates how well a person's brain, spinal cord, and nerves are working) were initiated and completed. The LVN 1 stated that the physician was notified and ordered that Resident 2 be sent to the emergency department due to the resident's complaint of a headache. The LVN 1 stated that an incident report was completed. The LVN 1 stated that CNA 1 was removed from Resident 1's assignment pending completion of the investigation. The LVN 1 stated that she had not received abuse prevention training. The LVN 1 identified physical abuse, verbal abuse, and financial abuse. The LVN 1 stated that physical abuse could include hitting, pushing, or handling a resident roughly; verbal abuse could include yelling at, threatening, or using inappropriate language toward a resident; and financial abuse could include taking or misusing a resident's money or belongings. The LVN 1 stated that abuse prevention training is important because staff need to know how to recognize, prevent, and report suspected abuse and how to protect residents from harm. The LVN 1 stated that failure to recognize or report abuse could result in a resident being harmed, feeling unsafe, or experiencing emotional distress, and could allow inappropriate treatment to continue without being reported.During an interview on 8/25/2026 at 1:15 pm with the Director of Nursing (DON), the DON stated that she first became aware of the allegation involving Resident 2 on August 14, 2026, when she was notified by the Social Services Director. The DON stated that Resident 2 reported that during the provision of care, CNA 1 was rushing while turning him and accidentally pushed his head into the side bed rail. The DON stated that an investigation was initiated immediately and that CNA 1 was suspended pending further investigation. The DON stated that Resident 2 was assessed following the allegation and complained of pain. The resident was subsequently transferred to the GACH for further evaluation. The DON stated that both CNAs involved in providing care to Resident 2 were interviewed. The DON stated that an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) meeting was conducted regarding the incident. The DON stated that CNA 1 should have received one-on-one in-service education regarding abuse prevention and appropriate resident handling following the allegation. The DON stated that failure to provide 1:1 education regarding abuse prevention and appropriate resident handling may result in staff not fully understanding appropriate methods for providing care, recognizing inappropriate resident handling, or preventing recurrence of similar incidents and may place residents at risk for injury, emotional distress, or feeling unsafe during the provision of care.During a concurrent interview and record review on 8/25/2026 at 2:04 pm with the Infection Preventionist (IP)/Director of Staff Development (DSD), CNA 1's employee file was reviewed, the employee file indicated, no documentation of abuse prevention post-test upon hire. The IP/DSD validated that CNA 1 had not received individualized, one-on-one abuse prevention training prior to returning to work following the allegation. The IP/DSD acknowledged that CNA 1 should have received individualized abuse prevention education prior to returning to resident care. The IP/DSD stated that failure to provide one-on-one abuse prevention education may result in staff not recognizing or appropriately responding to inappropriate resident handling and may place residents at risk for injury, emotional distress, or recurrence of similar incidents. During a of the Certified Nursing Assistant Job Description dated 2024, indicated, Staff Development Functions: Attend and participate in facility in-service training programs as instructed including resident rights, prevention of abuse and neglect, dementia care, behavioral management and competencies for Certified Nursing Assistants (CNAs).

Based on interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1, received and completed required training related to abuse prevention, recognition of abuse, neglect and exploitation, and the facility's procedures for reporting allegations of abuse. The deficient practice had the potential to place residents at risk for abuse, neglect, exploitation, or failure to recognize and appropriately report suspected abuse.Findings:During an interview on 8/25/2026 at 11:50 am with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assisting the resident's assigned CNA with care and repositioning at approximately 9:00 p.m. CNA 1 stated she was positioned on the resident's left side, while the assigned CNA was positioned on the resident's right side. CNA 1 stated the resident was holding onto the bed rail and both CNAs turned the resident toward his right side. CNA 1 stated she did not observe any injury, bruising, swelling, or change in the resident's condition following the repositioning. CNA 1 stated she was off work and was not made aware of the allegation until approximately two days after the incident. CNA 1 stated the Director of Staff Development (DSD) informed her of the allegation and she would be suspended pending further investigation. CNA 1 stated she returned to work after two days of suspension. CNA 1 stated she had received abuse prevention training approximately one week prior to the incident. CNA 1 stated that she did not receive any additional abuse in-service training upon returning to work following the allegation.During an interview on 8/25/2026 at 12:11 pm with License Vocational Nurse (LVN) 1, LVN 1 stated she was made aware of the incident involving Resident 2 on August 14, 2026, by the Registered Nurse Supervisor (RNS). LVN 1 stated she was informed Resident 2 had come into contact with the bed rail while being handled by CNA 1 during the provision of care, and that CNA 1 was reportedly rushing while providing care. LVN 1 stated CNA 1 was removed from Resident 1's assignment pending completion of the investigation. LVN 1 stated physical abuse could include hitting, pushing, or handling a resident roughly; verbal abuse could include yelling at, threatening, or using inappropriate language toward a resident; and financial abuse could include taking or misusing a resident's money or belongings. LVN 1 stated abuse prevention training is important because staff need to know how to recognize, prevent, and report suspected abuse and how to protect residents from harm. LVN 1 stated failure to recognize or report abuse could result in a resident being harmed, feeling unsafe, or experiencing emotional distress, and could allow inappropriate treatment to continue without being reported.During an interview on 8/25/2026 at 1:15 pm with the Director of Nursing (DON), the DON stated she first became aware of the allegation involving Resident 2 on August 14, 2026, when she was notified by the Social Services Director. The DON stated Resident 2 reported during the provision of care, CNA 1 was rushing while turning him and accidentally pushed his head into the side bed rail. The DON stated an investigation was initiated immediately and CNA 1 was suspended pending further investigation. The DON stated CNA 1 should have received one-on-one in-service education regarding abuse prevention and appropriate resident handling following the allegation. The DON stated failure to provide 1:1education regarding abuse prevention and appropriate resident handling may result in staff not fully understanding appropriate methods for providing care, recognizing inappropriate resident handling, or preventing recurrence of similar incidents and may place residents at risk for injury, emotional distress, or feeling unsafe during the provision of care.During a concurrent interview and record review on 8/25/2026 at 2:04 pm with the Infection Preventionist (IP)/Director of Staff Development (DSD), CNA 1's employee file was reviewed, the employee file indicated, no documentation of abuse prevention post-test upon hire. The IP/DSD validated CNA 1 had not received individualized, one-on-one abuse prevention training prior to returning to work following the allegation. The IP/DSD acknowledged CNA 1 should have received individualized abuse prevention education prior to returning to resident care. The IP/DSD stated failure to provide one-on-one abuse prevention education may result in staff not recognizing or appropriately responding to inappropriate resident handling and may place residents at risk for injury, emotional distress, or recurrence of similar incidents.During a review of the Staff Development Coordinator Job Description dated 2010, indicated, The primary purpose of this position is to plan, organize, develop and direct all in-service education programs throughout the facility in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the Administrator to assure that the highest degree of quality resident care can be maintained at all times.

Based on interview and record review the facility failed to ensure one resident of three sampled residents (Resident) 2 was free from inappropriate and unnecessary physical contact during the provision of care by Certified Nurse Assistant (CNA) 1.This deficient practice resulted in Resident 2 complaint of a headache following the incident and subsequently sent to a General Acute Care Hospital (GACH) for further evaluation. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including quadriplegia (the inability to move) in all four limbs (both arms and both legs), and cerebral infarction (damage to tissues in the brain). During a review of Resident 2's Minimum Data Set (MDS a resident assessment tool) dated 7/24/2026, the MDS indicated Resident 2 was dependent (helper does all of the effort) of care for oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 2's History and Physical (H&P) dated 6/1/2026, the H&P indicated, the resident did not have the capacity to understand and make decisions.During an concurrent observation and interview on 8/25/2026 at 9:14 am with Resident 2 in his room, the resident was lying in bed. Resident 2 was alert and oriented and his speech was noted to be slurred. Resident 2's left upper extremity (arm) was observed to be flaccid (weak). Resident 2 stated on 8/14/2026 during the night shift, two CNAs were in his room providing care and changing him. Resident 2 stated he did not know their names. Resident 2 stated the alleged perpetrator was on one side of him and another CNA was on the opposite side. Resident 2 stated that while he was being turned, CNA 1 pulled him towards his right side, and caused his forehead to strike the side bed rail (metal bars attached to the side of a bed to help people get in and out safely or to prevent them from falling out). Resident 2 stated, When she turned me, my forehead hit the bed rail. Resident 2 stated he experienced pain to his forehead following the incident and was given Tylenol (helps reduce pain), which provided some relief. Resident 2 stated he reported the incident to the social worker and subsequently was sent to the GACH. Resident 2 denied anything similar had occurred previously with CNA 1 or with any other staff member. Resident 2 stated he did not currently feel safe in the facility because he was concerned that a similar incident could happen again.During an interview on 8/25/2026 at 11:50 am with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assisting the resident's assigned CNA with care and repositioning at approximately 9:00 p.m. CNA 1 stated she was positioned on the resident's left side, while the assigned CNA was positioned on the resident's right side. CNA 1 stated the resident was holding onto the bed rail and that both CNAs turned the resident toward his right side. CNA 1 stated that during the repositioning, the resident did not come into contact with the bed rail. The CNA 1 stated that she did not observe any injury, bruising, swelling, or change in the resident's condition following the repositioning. CNA 1 stated that she was off work and was not made aware of the allegation until approximately two days after the incident. CNA 1 that the Director of Staff Development (DSD) informed her of the allegation and that she would be suspended pending further investigation. The CNA 1 stated that she returned to work after two days of suspension. The CNA 1 stated that she had received abuse prevention training approximately one week prior to the incident. The CNA 1 stated that she did not receive any additional abuse in-service training upon returning to work following the allegation.During an interview on 8/25/2026 at 12:11 pm with License Vocational Nurse (LVN) 1, LVN 1 stated she was made aware of the incident involving Resident 2 on August 14, 2026, by the RN Supervisor (RNS). LVN 1 stated she was informed Resident 2 had come into contact with the bed rail while being handled by CNA 1 during the provision of care, and CNA 1 was reportedly rushing while providing care. LVN 1 stated she completed an assessment of Resident 2 and completed a change-of-condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) assessment. LVN 1 stated Resident 2 complained of a headache and rated 5/10 on the pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible). LVN 1 stated Tylenol 325 mg (unit of measurement) was administered for the resident's complaint of pain. LVN 1 stated she did not observe redness, swelling, bruising, tenderness, or other visible injury. LVN 1 stated neurological checks (is a fast medical test that evaluates how well a person's brain, spinal cord, and nerves are working) were initiated and completed. LVN 1 stated the physician was notified and ordered Resident 2 be sent to the emergency department due to the resident's complaint of a headache. LVN 1 stated an incident report was completed. The LVN 1 stated that CNA 1 was removed from Resident 1's assignment pending completion of the investigation. LVN 1 stated she had not received abuse prevention training. LVN 1 identified physical abuse, verbal abuse, and financial abuse. LVN 1 stated physical abuse could include hitting, pushing, or handling a resident roughly; verbal abuse could include yelling at, threatening, or using inappropriate language toward a resident; and financial abuse could include taking or misusing a resident's money or belongings. LVN 1 stated abuse prevention training is important because staff need to know how to recognize, prevent, and report suspected abuse and how to protect residents from harm. LVN 1 stated failure to recognize or report abuse could result in a resident being harmed, feeling unsafe, or experiencing emotional distress, and could allow inappropriate treatment to continue without being reported.During an interview on 8/25/2026 at 1:15 pm with the Director of Nursing (DON), the DON stated she first became aware of the allegation involving Resident 2 on August 14, 2026, when she was notified by the Social Services Director. The DON stated Resident 2 reported during the provision of care, CNA 1 was rushing while turning him and accidentally pushed his head into the side bed rail. The DON stated an investigation was initiated immediately and CNA 1 was suspended pending further investigation. The DON stated Resident 2 was assessed following the allegation and complained of pain. The resident was subsequently transferred to the GACH for further evaluation. The DON stated both CNAs involved in providing care to Resident 2 were interviewed. The DON stated an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) meeting was conducted regarding the incident. The DON stated CNA 1 should have received one-on-one in-service education regarding abuse prevention and appropriate resident handling following the allegation. The DON stated failure to provide 1:1 education regarding abuse prevention and appropriate resident handling may result in staff not fully understanding appropriate methods for providing care, recognizing inappropriate resident handling, or preventing recurrence of similar incidents and may place residents at risk for injury, emotional distress, or feeling unsafe during the provision of care.During a review of the facility's policy and procedure titled Resident Rights, dated 2001, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity.

Based on interview and record review, the facility failed to ensure a resident (Resident 2) who had a diagnosis of type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and received glipizide (a medication used to lower blood sugar levels) daily for his DM, was administered according to physician's orders for one of three sampled residents (Resident 2). These failures resulted in the resident receiving glipizide on eight separate occasions when Resident 2's capillary blood glucose ([CBG] blood sugar level) was less than 120. These failures placed the Resident 2 at risk for hypoglycemia (low blood sugar level).Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 was admitted with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a slight paralysis or weakness on one side of the body). During a review of Resident 2's History and Physical (H&P) dated 10/10/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 2's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 2 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, maximal assistance (helper does more than half the effort) from staff for dressing and shower/bathing and was dependent (helper does all the effort) on staff for toileting. During a review of Resident 2's Care Plan dated 10/12/2025, the Care Plan Resident 2 had a diagnosis of DM. Under this Care Plan a goal for Resident 2 was to be free of all signs and symptoms of hypoglycemia. The Care Plan's interventions included for facility staff to administer hypoglycemic medications as ordered. During a review of Resident 2's Order Summary Report (Physician's Orders) dated 3/18/2026, the report indicated an order was placed for Resident 2 to receive glipizide oral tablet 2.5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) once a day for DM and hold if capillary blood glucose ([CBG] blood sugar) is less than 120, ordered on 3/4/2026. During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2026 to 3/31/2026, the MAR indicated Resident 2's had the following CBG levels:1. On 3/8/2026, Resident 2 had a CBG level of 98.2. On 3/10/2026, Resident 2 had a CBG level of 102.3. On 3/11/2026, Resident 2 had a CBG level of 100.4. On 3/13/2026, Resident 2 had a CBG level of 119.5. On 3/14/2026, Resident 2 had a CBG level of 117.6. On 3/15/2026, Resident 2 had a CBG level of 96.7. On 3/16/2026, Resident 2 had a CBG level of 101.8. On 3/17/2026, Resident 2 had a CBG level of 100.During a continued review of Resident 2's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated Resident 2 received glipizide oral tablet 2.5 mg at 9 a.m. on 3/8/2026, 3/10/2026, 3/11/2026, 3/13/2026, 3/14/2026, 3/15/2026, 3/16/2026, and on 3/17/2026 despite having CBG levels less than 120. During a concurrent interview and record review on 3/18/2026 at 11:19 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 2's MAR dated 3/2026 was reviewed. LVN 3 acknowledged he had administered glipizide to Resident 2 outside of the parameters on multiple occasions. LVN 3 stated he was unaware Resident 2's glipizide order had parameters to hold the medication for a CBG less than 120. LVN 3 stated he was not familiar with glipizide having parameters, and he did not see the complete order when he administered the medication to Resident 2. LVN 3 stated he was off duty when the glipizide was ordered and stated if he had been on duty when the medication was received, he would have called the doctor to confirm the order since glipizide does not usually have parameters. LVN 3 stated he should not have assumed the medication order did not have parameters and followed the doctor's order. LVN 3 stated Resident 2 could have become hypoglycemic from giving the glipizide outside of the parameters.During a concurrent interview and record review on 3/18/2026 at 1:04 p.m., with Registered Nurse (RN) 1, Resident 2's Order Summary Report, MAR, Nursing Progress Notes, and Change of Condition (COC) reports dated 3/2026 was reviewed. RN 1 confirmed glipizide was administered on multiple occasions when the CBG was less than 120. RN 1 stated nurses must check parameters before administering medications and follow physician orders. RN 1 further confirmed there was no documentation in the nursing progress notes or COC which reported the glipizide errors.During a telephone interview on 3/18/2026 at 4:17 p.m., with RN 2, RN 2 stated he took the telephone order for Resident 2's glipizide on 3/4/2025. RN 2 stated he repeated the order back to the physician to confirm the parameters, which included holding the medication for CBG less than 120.During a review of facility's P&P titled Medication Errors, dated 6/28/2022, the P&P indicated a medication error means the administration of medications to the wrong resident, at the wrong time, at the wrong dose, via the wrong route, or which is not currently prescribed.

Based on interview and record review, the facility failed to notify the physician and Responsible Party (RP) for one of three sampled residents (Resident 2) when Resident 2 received medications that should have been held. This deficient practice resulted in Resident 2's physician and RP being unaware that Resident 2 received medications that should have been held. This deficient practice resulted in the inability of Resident 2's physician to give timely instructions for Resident 2's care and the inability for Resident 2's RP to participate and make decisions in Resident 2's immediate care needs. This deficient practice had the potential for the RP to remain uninformed about changes in Resident 2's health status. Findings:During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 was admitted with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a slight paralysis or weakness on one side of the body). During a review of Resident 2's History and Physical (H&P) dated 10/10/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 2's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 2 required set-up and clean up assistance (helper sets up or cleans up; resident completes the activity) from staff for eating, maximal assistance (helper does more than half the effort) from staff for dressing and shower/bathing and was dependent (helper does all the effort) on staff for toileting.During a review of Resident 2's Order Summary Report (Physician's Orders) dated 3/18/2026, the report indicated an order was placed for Resident 2 to receive glipizide oral tablet 2.5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount) once a day for DM and hold if capillary blood glucose ([CBG] blood sugar) is less than 120, ordered on 3/4/2026.During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2026 to 3/31/2026, the MAR indicated Resident 2's had the following CBG levels:1. On 3/8/2026, Resident 2 had a CBG level of 98.2. On 3/10/2026, Resident 2 had a CBG level of 102.3. On 3/11/2026, Resident 2 had a CBG level of 100.4. On 3/13/2026, Resident 2 had a CBG level of 119.5. On 3/14/2026, Resident 2 had a CBG level of 117.6. On 3/15/2026, Resident 2 had a CBG level of 96.7. On 3/16/2026, Resident 2 had a CBG level of 101.8. On 3/17/2026, Resident 2 had a CBG level of 100.During a continued review of Resident 2's MAR dated 3/1/2026 to 3/31/2026, the MAR indicated Resident 2 received glipizide oral tablet 2.5 mg at 9 a.m. on 3/8/2026, 3/10/2026, 3/11/2026, 3/13/2026, 3/14/2026, 3/15/2026, 3/16/2026, and on 3/17/2026 despite having CBG levels less than 120. During a concurrent interview and record review on 3/18/2026 at 11:19 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 2's MAR dated 3/2026 was reviewed. LVN 3 stated he had administered glipizide when CBG was less than 120, contrary to physician orders. LVN 3 stated he did not notice that there were parameters for administering glipizide. LVN 3 stated he did not notify the physician of the medication administration errors. LVN 3 stated if he had identified the errors, he would have completed a change of condition (COC), notified the physician, Registered Nurse (RN) supervisor, Director of Nursing (DON), and the resident's family, and rechecked the Resident 2's blood glucose level. During a concurrent interview and record review on 3/18/2026 at 1:04 p.m., with Registered Nurse (RN) 1, Resident 2's Order Summary Report, MAR, Nursing Progress Notes, and COC reports dated 3/2026 was reviewed. RN 1 confirmed glipizide was administered on multiple occasions when the CBG was less than 120. RN 1 stated licensed nurses must check parameters before administering medications and follow physician orders. RN 1 further confirmed there was no documentation in the nursing progress notes or COC which reported the glipizide errors, notification to the physician or the resident's family.During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, dated 8/25/2021, the P&P indicated the facility must immediately inform the resident, consult with the resident's physician, and notify the resident representative in the event of an accident involving the resident, a significant change in the resident's condition, or a need to alter treatment significantly.During a review of the facility's policy and procedure (P&P) titled, Medication Errors, dated 6/28/2022, the P&P indicated all errors related to the administration of medications must be reported immediately to the Director of Nursing, the attending physician, and the Administrator. Upon discovery of an error, the Director of Nursing would notify the attending physician, resident, and responsible party, and a medication error report would be completed for all medication errors.

Based on observation and interview and record review, the facility failed to store food items safely for all residents by not ensuring that a carton of thickened water, chocolate pudding powder, frozen donut holes, and frozen pork chops were labeled with open dates.This failure had the potential to expose residents to food borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).Findings:During an observation on 3/10/2026 at 8:20 a.m. in the kitchen, multiple open food items were found without open dates, including a carton of thickened water, chocolate pudding powder, frozen donut holes, and frozen pork chops.During an interview on 3/13/2026 at 11:48 a.m. with the Dietary Aide (DA), the DA stated all food items must be labeled with an open date once opened to ensure they were served fresh. The DA stated residents could get sick if food was not served fresh.During an interview on 3/13/2026 at 11:56 a.m. with the Dietary Supervisor (DS), the DS stated he was aware multiple open food items did not have open dates and acknowledged they should be labeled to ensure freshness and resident satisfaction. The DS added that there was a possibility of stomach issues when food was not fresh.During an interview on 3/13/2026 at 1:47 p.m. with the Administrator (ADM), the ADM stated when food was opened it must be dated to ensure freshness and food should be visually appealing. The ADM added there was a risk for residents to develop an upset stomach if food was not served fresh.During a review of the facility's policy and procedure (P&P) titled Food Storage dated 2/2023, the P&P indicated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on interview and record review, the facility failed to ensure resident was free from significant medication errors for one of six sampled residents (Resident 2) by failing to:1.Administer Quetiapine Fumarate (Seroquel), an antipsychotic medication prescribed to treat mental health conditions) , as ordered by the physician from 3/5/2026 through 3/12/2026.2.Notify the physician when the Seroquel order contained no dosage on 2/24/2026 and when the medication was not administered for eight consecutive days.These failures had the potential to result in increased agitation and behavioral disturbances due to the omission (failure to administer an ordered dose of medication) of a prescribed medication.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 2 with diagnoses including Alzheimer's disease( a disease characterized by a progressive decline in mental abilities), gastrostomy ( a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia( difficulty in swallowing), unspecified dementia( a progressive state of decline in mental abilities), and depression (serious mental health condition characterized by persistent sadness and a loss of interest in activities that affects daily functioning),During a review of facility's pharmacy delivery receipt dated 2/4/2026 timed at 12:29 a.m., the pharmacy delivery receipt indicated Resident 2's Quetiapine Fumarate 25 milligrams (mgs- unit of measurement) with a quantity of 30 tablets were received by the facility.During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 2/6/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to a chair.During a review of Resident 2's Order Summary Report dated 2/24/2026, the Order Summary Report indicated a physician telephone order of Quetiapine Fumarate (Seroquel) one tablet via gastrostomy tube tube (GT- a feeding tube inserted directly into the stomach through the abdomen used for long term nutrition, and administration of medication) at bedtime for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by pulling out of GT. The Order Summary Report indicated no dose was ordered and documented for Seroquel.During a review of Resident 2's Medication Administration Record dated March 2026, the MAR indicated Quetiapine Fumarate one tablet via GT at bedtime for psychosis manifested by pulling out of GT. The MAR indicated Resident 2 did not receive Quetiapine Fumarate on 3/5/2026, 3/6/2026, 3/7/2026, 3/8/2026,3/9/2026, 3/10/2026, 3/11/2026, and 3/12/2026.During a review of Resident 2's electronic medication administration (EMAR) Progress Notes dated 3/5/2026 to 3/12/2026, the EMAR Progress Notes indicated the following:1.On 3/5/2026, the EMAR Progress Notes indicated that Quetiapine Fumarate give one tablet via GTube is on order and waiting for pharmacy.2.On 3/6/2026, the EMAR Progress Notes indicated that Quetiapine Fumarate was on order and pending pharmacy delivery.3.On 3/7/2026, the EMAR Progress Notes indicated Quetiapine Fumarate was on order and awaiting pharmacy delivery.4.On 3/8/2026, the EMAR Progress Notes Quetiapine Fumarate was on order.5.On 3/9/2026, the EMAR Progress Notes indicated Quetiapine Fumarate was on order.6.On 3/10/2026, the EMAR Progress Notes indicated Quetiapine Fumarate was still on order.7.On 3/11/2026, the EMAR Progress Notes indicated Quetiapine Fumarate on order and calling pharmacy tonight.8.On 3/12/2026, the EMAR Progress Notes indicated Quetiapine Fumarate was on order and awaiting pharmacy delivery.During a concurrent observation and interview on 3/13/2026 at 10:55 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there was no Seroquel available for Resident 2 in the medication cart. LVN 1 stated the licensed nurses should have clarified the Seroquel order with the physician and contacted the pharmacy to follow up. LVN 1 stated he had never seen a pharmacy deliver medication without a physician ordered dose.During a concurrent interview and record review on 3/13/2026 at 11:02 a.m., with Registered Nurse Supervisor (RNS) 1 , reviewed Resident 2's Medication Administration Record for March 2026 and the Order Summary Report. RNS 1 stated Resident 2 had an order for Seroquel, one tablet at bedtime, for psychosis manifested by pulling out the gastrostomy tube (GT). RNS 1 stated a physician's order must include a medication dosage, and it was the responsibility of the licensed nurses to clarify and notify the physician regarding the missing Seroquel dose when the order was entered on 2/24/2026. RNS 1 stated she entered the telephone order for Quetiapine Fumarate on 2/24/2026 and did not include the dosage. RNS 1 stated the licensed nurses should have clarified the Seroquel order with the physician, entered the correct dose, and sent the complete order to the pharmacy. RNS 1 stated Resident 2's targeted behavior for Seroquel therapy was not being treated, and the behavior could worsen if the resident missed eight days of Seroquel. RNS 1 stated the licensed nurses should have notified the physician and initiated a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) report, as the omission of Seroquel represented a clinically important deviation from the resident's behavioral and cognitive baseline.During an interview on 3/13/2026 at 2:53 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses should have addressed the issue by contacting the physician and obtaining an order to resolve the problem. The DON stated she did not believe staff had contacted the pharmacy to determine why Seroquel had not been delivered to the facility. The DON stated the facility should have followed up by calling the pharmacy, notifying the physician and the responsible party, and completing a COC. The DON stated Resident 2 may experience increased agitation as a result of not receiving Seroquel for eight days.During a review of facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated 2/2016, the P&P indicated to administer medications in a safe and effective manner.During a review of facility's P&P titled, The Physician Orders, dated 3/22/2022, the P&P indicated the facility will ensure all physician orders are complete and accurate. The P&P indicated medication orders will include name of medication, dosage, frequency, duration of order, route and the condition for which the medication is ordered.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) received ongoing activities in accordance with their comprehensive assessment, preferences, and interests, and supported their physical, mental, and psychosocial well-being.This failure had the potential to result in decreased physical activity and diminished sense of self-worth for Resident 41.Findings:During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility on [DATE] ith diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 41's History and Physical (H&P), dated 1/8/2025, the H&P indicated Resident 41 had the capacity to understand and make decisions.During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool), dated 1/9/2026, the MDS indicated Resident 41 needed substantial to maximal nursing assistance with transferring, toileting, showering and dressing.During a review of Resident 41 Care Plan, dated 1/16/2025, the Care Plan indicated Resident 41 liked to exercise. The Care Plan indicated it is important for Resident 41 to engage in his favorite activities. and exercise.During a review of Resident 41's Recreation Comprehensive Assessment, dated 1/16/2025, the Recreation Comprehensive Assessment indicated the things Resident 41 likes to do currently and in the past was reading and exercise.During an interview on 3/11/2026 at 1:13 p.m., with Resident 41, Resident 41 stated he used to be active and likes to walk.During a concurrent interview and record review on 3/13/2026 at 10:00 a.m., with Activities Director (AD), Resident 41 Participation Record, dated January 2026, February 2026 and March 2026 was reviewed, the participation records indicated no documentation that Resident 41 was offered exercise, physical activity and walking. AD stated if the activities Resident 41 likes were not offered it could lead to depression.During an interview on 3/13/2026 at 3:29 p.m., with the Director of Nursing (DON), the DON stated the AD needs to be offering Resident 41 activities he likes and that motivate him to decrease depression and for good comradery (mutual trust, and friendship) with other residents.During a review of the facility's policy and procedure (P&P), titled Resident Self Determination and Participation the P&P indicated, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: daily routine, such as sleeping and waking, eating, exercise and bathing schedules; personal care needs, such as bathing methods, grooming styles and dress; health care scheduling, such as times of day for therapies and certain treatments; providers of healthcare services; activities, hobbies and interests;. Residents are provided assistance as needed to engage in their preferred activities on a routine basis. For example: if the resident enjoys reading, the facility will provide access to books (in large print if needed); if the resident enjoys regular exercise, he or she will be assisted attending exercise classes or given access to open areas for walks.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7), who was dependent on staff for Activities of Daily Living (ADLs), received appropriate personal care. The facility failed to:1.Ensure Resident 7's long fingernails were trimmed and free of dirt and black grime underneath.This failure placed Resident 7 at risk for discomfort and increased the risk of infection from cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary conditions) due to inadequate nail hygiene.Findings:During a review of Resident 7's admission Record, the admission record indicated Resident 7 was admitted on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7 with diagnosis including schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety (emotion characterized by feelings of tension, worried thoughts) and dementia (loss of memory, language, problem-solving and other thinking abilities).During a review of Resident 7's History & Physical (H&P) dated 6/25/2025, the H&P indicated Resident 7 did not have the ability to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS-resident assessment tool) dated 2/13/2026, the MDS indicated Resident 7's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 7 needed partial/moderate assistance (helper does less than half the work) with activities of daily living (ADL's) like toileting, bathing and dressing).During a concurrent observation and interview on 3/13/2026 at 8:36 a.m. in Resident 7's room, Resident 7 was observed eating breakfast. Resident 7's fingernails were long with visible dirt and black grime underneath. Resident 7 stated he would like to have his fingernails cleaned and trimmed.During a concurrent observation and interview on 3/13/2026 at 8:45 a.m. with Certified Nursing Assistant (CNA) 4 at Resident 7's bedside, CNA 4 stated Resident 7's fingernails were dirty and long and needed to be cleaned and trimmed. CNA 4 stated there was a possibility of bacteria accumulating under Resident 7's fingernails, which could make him sick, and added that Resident 7 could also scratch and hurt himself.During an interview on 3/13/2026 at 2:56 p.m. with the Director of Nursing (DON), the DON stated residents' fingernails need to be kept clean and trimmed to prevent the possibility of ingesting bacteria and developing stomach issues.During a review of the facility's policy and procedure (P&P) titled Nail Care dated 10/2022, the P&P indicated To provide residents safe, hygienic, and thorough nail care assistance. Direct care staff will consult with a Registered nurse for any special directions as they may apply to a diabetic residentPROCEDURE:1. Gather needed equipment2. Explain procedure and provide privacy to resident3. Wash hands4. Soak resident's hands or feet in warm soapy water for 2-3 minutes.5. Clean nails and under nails.6. Thoroughly dry hands/feet.7. File nails straight across, if needed, to a length to allow white to show under the entire nail, leaving no rough edges.8. Apply lotion to skin. (Do not apply lotion between toes)9. Wash hands10. Clean equipment, as needed11. Notify RN if any new nail, cuticle, or skin issues are observed.12. Document any nail care provided

Based on observation, interview, and record review, the facility failed to provide an alternative means of communication in a language that the resident could understand for one of three sampled residents (Resident 2).This failure had the potential to cause Resident 2 to feel frustrated and isolated, and to limit her ability to communicate her needs to staff, which could lead to delays in receiving appropriate care and services.Findings:During an observation on 3/10/2026 at 12:00 p.m., Resident 2 was seated in a Geri chair (a specialized padded recliner on wheels designed for individuals with limited mobility) in the lobby, smiling and speaking in a foreign language.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 2 with diagnoses including Alzheimer's disease( a disease characterized by a progressive decline in mental abilities), gastrostomy( a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia( difficulty in swallowing), unspecified dementia( a progressive state of decline in mental abilities), and depression (serious mental health condition characterized by persistent sadness and a loss of interest in activities that affects daily functioning),During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 2/6/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to a chair.During a review of Resident 2's Care Plan titled, The resident has impaired communication as evidenced by rarely being able to make herself understood or understand others related to cognitive impairment, dementia, Alzheimer's disease, impaired hearing in the left ear, and use of another language, initiated on 3/13/2023, the Care Plan indicated a goal of meeting Resident 2's daily communication needs. The Care Plan interventions included providing emotional support and encouragement.During an interview on 3/10/2026 at 12:20 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was unable to speak English and communicated in another language. CNA 1 stated she used hand signals and body gestures to communicate with Resident 2 and sometimes relied on the resident's family member to help translate or interpret for Resident 2. CNA 1 stated there were no visual aids or communication boards (a visual tool with symbols or words that helps residents with limited verbal, cognitive, or hearing abilities express their needs) in Resident 2's room to assist with communication, and no staff at the facility spoke Resident 2's language.During an interview on 3/11/2026 at 4:05 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff monitored Resident 2's body language as a way to communicate with her. LVN 3 stated relying on body language alone was not an effective method of communication. LVN 3 stated Resident 2 could experience a decline in her activities of daily living (ADLs-such as bathing, dressing, and toileting) if staff were unable to address her concerns or needs due to a lack of proper communication.During an observation on 3/12/2026 at 12:28 p.m. in the lobby, Resident 2 was seated in a Geri chair and was yelling in a foreign language. Licensed Vocational Nurse (LVN) 2 approached, sat beside Resident 2, and used a translator app (a mobile application that can instantly translate text, speech, images, and real time conversations in multiple languages) on his personal phone to help interpret what Resident 2 was saying as she pointed to people and objects in the lobby.During a concurrent observation and interview on 3/12/2026 at 12:32 p.m., with LVN 2, LVN 2 stated there was no communication board in Resident 2's room. LVN 2 stated using a translation app on his personal phone was not an appropriate method for communicating with Resident 2 because it was unclear whether the resident understood what he was communicating to her.During an interview on 3/12/2026 at 4:21 p.m., with Registered Nurse Supervisor (RNS) 1 , RNS 1 stated using hand signals to communicate with Resident 2, who does not speak English, was not an effective method of communication. RNS 1 stated staff may not accurately understand the resident's needs, which could result in her concerns not being addressed properly.During an interview on 3/12/2026 at 12:44 p.m. and subsequent interview on 3/13/2026 at 2:53 p.m. with the Director of Nursing (DON), the DON stated Resident 2 needs a communication board to help communicate with the staff and using a translator app on a personal phone was not a good way to communicate with Resident 2. The DON stated it was important to meet Resident 2 needs for communication to ensure her wants and needs were met.During a review of facility's policy and procedure (P&P) titled, Accommodation of Residents Communication, dated 2/19/2026, the P&P indicated The facility will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. The P&P indicated the facility will help residents with communication challenges through several adaptive services.

Based on interview and record review the facility failed to ensure a safe discharge and transfer for two of two sampled residents (Resident 7 and Resident 11) by falling to:1. Ensure the Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified when Resident 7 was transferred to the General Acute Care Hospital (GACH).2. Ensure Resident 7 and Resident 11 were offered a bed hold before being transferred to the GACH.These failures placed Resident 7 and Resident 11 at risk for an unsafe transfer and violated Resident 7 and Resident 11's rights to informed transfer to GACH. Findings:During a review of Resident 7's admission Record, the admission record indicated Resident 7 was admitted on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7 with diagnosis including schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety (emotion characterized by feelings of tension, worried thoughts) and dementia (loss of memory, language, problem-solving and other thinking abilities).During a review of Resident 7's History & Physical (H&P) dated 6/25/2025, the H&P indicated Resident 7 did not have the ability to understand and make decisions.During a review of Resident 7's Minimum Data Set (MDS-resident assessment tool) dated 2/13/2026, the MDS indicated Resident 7's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 7 needed partial/moderate assistance (helper does less than half the work) with activities of daily living (ADL's) like toileting, bathing and dressing).During a review of Resident 7's Transfer Form dated 10/15/2025, the transfer form indicated Resident 7 was transferred to the GACH on 10/15/2025.During a review of Resident 7's Transfer Form dated 11/11/2025, the transfer form indicated Resident 7 was transferred to the GACH on 11/11/2025.During a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE], with diagnosis including anemia (a condition in which there is lack of enough red blood cells), bone cancer (uncontrolled growth of cells) and hypertension (high blood pressure).During a review of Resident 11's History & Physical (H&P) dated 12/17/2025, the H&P indicated Resident 11 does not have the capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS a resident assessment tool), dated 2/11/2026, the MDS indicated Resident 11 had severe cognitive impairment. The MDS indicated Resident 11 was dependent (helper does all the work) with activities of daily living (ADL's) like toileting, bathing and dressing).During a review of Resident 11's Transfer Form dated 12/11/2025, the transfer form indicated Resident 11 was transferred to the GACH on 12/11/2025.During a concurrent interview and record review on 3/12/2026 at 3:09 p.m. with the Registered Nurse Supervisor (RNS), Resident 7's transfer forms dated 10/15/2025 and 11/11/2025, and Resident 11's transfer form dated 12/11/2025, were reviewed. The RNS stated the Ombudsman was not notified when Resident 7 was transferred to the GACH on 10/15/2025 and should have been. The RNS also stated Resident 7 was not provided information on the duration state bed hold on 10/15/2025 or 11/11/2025, and Resident 11 was not provided information on the duration state bed hold on 12/11/2025, and they should have been. The RNS stated when residents are transferred to the GACH, the Ombudsman should be notified to ensure the discharge and placement meet the residents' needs. The RNS stated a bed hold must be offered upon discharge so residents do not worry and know they will have a bed when they return to the facility.During an interview on 3/13/2026 at 3:16 p.m. with the Director of Nursing (DON), the DON stated the Ombudsman serves as an advocate for residents and should be notified when a resident was discharged to the GACH to ensure the resident was placed at the appropriate level of care. The DON stated when a resident was discharged to the GACH, resident should be provided information on the duration state bed hold so the resident does not worry and knows a bed will be available upon their return.During a review of the facility's policy and procedure (P&P) titled Bed Holds and Returns, dated 10/2022, the P&P indicated Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. All residents/representatives are provided written information regarding the facility and state bed hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: notice 1: well in advance of any transfer ( e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).During a review of the facility's P&P titled Residents Rights (undated) the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.

Based on observation, interview and record review the facility failed to ensure one of 18 sampled residents (Resident 2) was free from the use of a physical restraint (any object or device that an individual cannot remove easily which restricts freedom or movement). The facility failed to:1. Ensure an informed consent was obtained and documented before applying an abdominal binder (wide, elastic belt worn around the stomach reducing movement) as a restraint to prevent Resident 2 from pulling out her gastrostomy tube (GT- a feeding tube inserted directly into the stomach through the abdomen used for long term nutrition, and administration of medication) on 5/28/2025.2. Ensure an ongoing assessment, monitoring and evaluation to ensure the resident's safety and continued need for the use of the abdominal binder.This failure had the potential to place Resident 2 at risk for unnecessary prolonged use of physical restraint leading to impaired blood circulation, skin injuries and unnecessary use of Seroquel (antipsychotic, a type of medication prescribed to treat mental health problem) to prevent Resident 2 from pulling GT.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 2 with diagnoses including Alzheimer's disease( a disease characterized by a progressive decline in mental abilities), gastrostomy ( a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia( difficulty in swallowing), unspecified dementia( a progressive state of decline in mental abilities), and depression (serious mental health condition characterized by persistent sadness and a loss of interest in activities that affects daily functioning),During a review of Resident 2's Physician Order dated 5/28/2025, the Physician Order indicated application of abdominal binder for gastrostomy tube displacement prevention every shift.During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 2/6/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to a chair.During a review of Resident 2's Order Summary Report dated 2/24/2026, the Order Summary Report indicated a physician order of Quetiapine Fumarate (Seroquel) one tablet via GT at bedtime for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by pulling out of GT.During a review of Resident 2's Device Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered on application of a medical device), the Device Informed Consent indicated an abdominal binder will be placed at all times to prevent GT being pulled out. The Device Informed Consent indicated the consent was obtained from Family Member (FM) on 2/17/2026.During a review of Resident 2's Care Plan titled, Resident is at risk for complications of restraint use (abdominal binder), initiated and revised on 10/22/2025, the Care Plan indicated interventions including providing informed consent to resident or health care decision maker and assessing for adverse effects (a harmful or unwanted result caused by a treatment, medicine or external factor) of restraint use such as skin breakdown, decrease functional ability and confusion.During a telephone interview on 3/12/2026 at 5:13 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 2 used an abdominal binder to prevent her from tugging or pulling on the GT. CNA 2 stated she checked the abdominal binder during incontinence care to ensure it was not too tight and that the GT remained in place. CNA 2 stated if the abdominal binder was not properly monitored, Resident 2 could develop redness, irritation, or a pressure injury from the abdominal binder.During a concurrent interview and record review on 3/12/2026 at 4:36 p.m., and during a subsequent interview on 3/13/2026 at 11:02 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 2's electronic chart was reviewed. RNS 1 stated the abdominal binder order for Resident 2 was initiated on 5/28/2025, but informed consent for the abdominal binder was not obtained until 2/17/2026. RNS 1 stated consent had not been obtained at the time the binder was first applied and stated this was missed by the facility. RNS 1 stated the facility should have obtained informed consent from the resident or the family representative before applying the abdominal binder.RNS 1 stated that Certified Nursing Assistants (CNAs) apply the binder and licensed nurses were responsible for ensuring correct placement because improper placement can restrict the resident's abdominal area and cause nausea, discomfort, or pain. RNS 1 stated Resident 2 received Seroquel 25 mg via gastrostomy tube at bedtime for psychosis manifested by pulling at the GT, and the abdominal binder was used to prevent her from pulling out the tube. RNS 1 stated the abdominal binder was removed only during personal care and adult brief changes. RNS 1 stated there was no monitoring system in place for the use of the abdominal binder. RNS 1 stated the facility should have performed ongoing assessment and monitoring to identify potential complications such as skin breakdown or impaired circulation.During an interview on 3/13/2026 at 2:53 p.m., with the Director of Nursing (DON), the DON stated the facility's expectation was to obtain informed consent before applying an abdominal binder for Resident 2. The DON stated that failing to conduct assessment and monitoring of the abdominal binder could result in skin breakdown and bruising, and staff would not be able to determine whether the resident continued to require the binder to prevent pulling on the gastrostomy tube (GT).During a review of facility's policy and procedure (P&P) titled, Use of Restraints, undated, the P&P indicated restraint will only be used after obtaining a consent from the resident and/or representative. The P&P indicated restrained individuals will be reviewed regularly to determine whether they are a candidate for restraint reduction and on-going reevaluation for the need for restraints will be documented by the facility.

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 25) received a morning shower as requested and preferred by the resident. This failure resulted in Resident 25 waiting approximately six hours for a shower and had the potential to cause Resident 25 to experience feelings of uncleanliness.Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), quadriplegia(paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 25's care plan titled Resident 25 requires assistance and is dependent for Activities of Daily Living (ADLs) such as bathing, grooming, and personal hygiene, revised 9/19/2023, the care plan indicated a goal for Resident 25 was for ADL care and needs to be anticipated and met throughout the review period.During a review of Resident 25's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 25 was alert and oriented to name, place and time and had normal speech. The H&P indicated Resident 25 was dependent on nursing staff and required total care with bathing.During a review of Resident 25 Minimum Data Set (MDS-a resident assessment tool) dated 2/26/2026, the MDS indicated Resident 25 had the ability to express ideas and wants. The MDS indicated Resident 25 had the ability to understand others. The MDS indicated Resident 25 needed partial to moderate assistance with showering and toileting. The MDS indicated Resident 25 needed substantial to maximal with oral hygiene, personal hygiene, dressing and transferring.During a review of the Facility's Care Center Assignment Sheet, dated 3/12/2026 the Facility's Care Center Assignment Sheet indicated Resident 25 was assigned to shower on Wednesdays and Saturdays in the morning on the day shift.During an interview on 3/24/2026 at 10:47 a.m. with Resident 25, the resident stated she had been waiting all morning to shower. Resident 25 stated she prefers to shower in the morning as early as possible. The resident stated Certified Nursing Assistant (CNA) 5 informed her at 10:45 a.m. that she could shower.During an interview on 3/13/2026 at 11:53 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 25's scheduled shower days were Wednesdays on the morning shift. CNA 5 stated Resident 25 preferred to shower in the morning. CNA 5 stated she showered Resident 25 at 1:30 p.m. and that she did not follow Resident 25's preferred shower time. CNA 5 stated she was assisting another resident, then took a break, and when she returned, lunch trays had already been delivered. CNA 5 stated she should have asked another nurse for assistance in showering Resident 25 before taking her break. CNA 5 stated if a resident prefers a morning shower, staff were expected to prioritize providing it. CNA 5 stated failing to honor a resident's preferred shower time could lead the resident to feel unheard, angry, depressed, or unclean when required to wait until the afternoon.During an interview on 3/13/2026 at 3:27 p.m. with the Director of Nursing (DON), the DON stated residents have the right to choose their shower preferences and to have those preferences honored.During a review of the facility's policy and procedure titled, Dignity Resident Rights, undated, the P&P indicated, .Resident goals, choices, preferences, values, and beliefs are respected and honored to the extent possible. This begins with the initial admission and continues throughout the resident's facility stay.

Based on observation, interview, and record review, the facility failed to maintain respect and dignity for one of two sampled residents (Resident 2) by standing over the resident while providing assistance during a meal.This failure had the potential to place Resident 2 at risk for choking and to negatively impact the resident's self esteem.Findings:During a dining observation on 3/10/2026 at 12:29 p.m., Certified Nursing Assistant (CNA) 2 was observed standing while feeding Resident 2, who was seated in a Geri chair (a specialized padded recliner on wheels designed for individuals with limited mobility). Resident 2's meal tray ticket indicated a regular diet with pureed texture (standard foods blended, mashed, or strained to a completely smooth, pudding like consistency).During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 2 with diagnoses including Alzheimer's disease( a disease characterized by a progressive decline in mental abilities), gastrostomy( a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia( difficulty in swallowing), unspecified dementia( a progressive state of decline in mental abilities), and depression (serious mental health condition characterized by persistent sadness and a loss of interest in activities that affects daily functioning),During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 2/6/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to a chair.During a review of Resident 2's Order Summary Report dated 6/20/2025, the Order Summary Report indicated an order for enteral feed (tube feeding -a method of delivering nutrients directly into the stomach using a soft tube) order of Jevity 1.2 calorie ( CAL-high-protein, fiber fortified liquid nutrition formula) to administer via pump at 45 milliliters per hour for 12 hours. The Order Summary indicated the enteral feed will be on at 8:00 p.m. and off at 8:00 a.m.During a review of Resident 2's Order Summary Report dated 2/3/2026, the Order Summary Report indicated an order of Regular diet with pureed texture.During a telephone interview on 3/12/2026 at 5:13 p.m., CNA 2 stated she had been standing while assisting Resident 2 with a spoon during lunchtime. CNA 2 stated she was expected to sit while assisting the resident so the resident would not feel intimidated and for safety reasons. CNA 2 stated Resident 2's family member did not want the resident to eat with her hands, which is why staff the staff has to help her with the spoon during mealtime.During an interview on 3/13/2026 at 2:53 p.m., the Director of Nursing (DON), the DON stated staff should sit and be engaged with Resident 2 during meals. The DON stated Resident 2's dignity and safety could be affected when staff stand over her. The DON explained that sitting while assisting Resident 2 supports her dignity and helps prevent choking because staff can better observe whether the resident was chewing and swallowing her food.During a review of facility's policy and procedure (P&P) titled, Dignity, undated, the P&P indicated Each resident should be cared in a manner that will promote and enhance individuality, sense of well-being, and feelings of self-worth and self-esteem.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 67) received a recommended follow up appointment with an ear, nose, and throat (ENT- specialist for diminished hearing) per recommendation of ENT physician on 4/16/2025.This failure caused Resident 67 emotional distress due to frequently needing staff to repeat themselves and placed the resident at risk for miscommunicating her needs.Findings:During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to facility on 1/14/2025, and readmitted on [DATE], with diagnoses including hearing loss, hypertension (high blood pressure) and muscle weakness.During a review of Resident 67's History & Physical (H&P) dated 1/31/2025, the H&P indicated Resident 67 did not have the capacity to understand and make decisions.During a review of Resident 67's Minimum Data Set (MDS-resident assessment tool) dated 1/21/2026, the MDS indicated Resident 67's cognition (ability to think, understand, learn, and remember)was intact. The MDS indicated Resident 67 was dependent (helper does all the work) with activities of daily living (ADL's) like toileting, bathing and dressing).During an interview on 3/10/2026 at 12:28 p.m. with Resident 67, Resident 67 stated she needed staff to repeat themselves because she was hard of hearing. Resident 67 also stated that hearing aids would help her hear better.During an interview on 3/13/2026 at 10:14 a.m. with Certified Nursing Assistant (CNA 5), CNA 5 stated Resident 67 had difficulty hearing and could benefit from hearing aids. CNA 5 stated she would feel lost if she were unable to hear and believed there was a possibility that Resident 67's needs might not be met due to her hearing loss.During a concurrent interview and record review on 3/13/2026 at 1:15 p.m. with the Registered Nurse Supervisor (RNS), Resident 67's ENT Physician Progress Note dated 4/16/2025 was reviewed. The note indicated Resident 5 with diminished hearing and a recommendation for a follow up appointment in six months. The RNS stated Resident 67 should have been seen by the ENT in October 2025. The RNS stated difficulty hearing could make it hard for Resident 67 to express her needs and increase the potential for miscommunication.During an interview on 3/13/2026 at 3:02 p.m. with the Director of Nursing (DON), the DON stated Resident 67 should have had a follow up appointment with the ENT last year. The DON stated Resident 67 was at risk of having her needs unmet due to her hearing loss.During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living dated 3/2018, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Communication (speech, language, and any functional communication systems). Care and services to prevent and/or minimize functional decline.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 25) was provided with additional food after informing Restorative Nursing Assistant (RNA) 1 she was still hungry.This failure had the potential to result in inadequate caloric intake and possible weight loss for Resident 25 who requested and were not offered additional food items of their choice and preference.Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses of severe protein-calorie malnutrition ( a life threatening deficiency of protein and energy), nutritional anemia ( a common disorder caused by a lack of essential nutrients), and hypertension (HTN-high blood pressure).During a review of Resident 25 Minimum Data Set (MDS-a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 25 had the ability to express ideas and wants. The MDS indicated Resident 25 had the ability to understand others. The MDS indicated Resident 25 needed nursing supervision and touching assistance with eating. The MDS indicated Resident 25 needed substantial to maximal assistance with oral hygiene, personal hygiene, dressing and transferring.During a review of Resident 25's History and Physical (H&P), dated 3/3/2026, the H&P indicated Resident 25 was alert and oriented to name, place and time and had normal speech. The H&P indicated Resident 25 was dependent on nursing staff and required total care with bathing.During a review of Resident 25's Order Summary, dated 2/17/2026, the Order Summary indicated Resident 25 had an order for a regular no salt and regular textured diet.During an interview on 3/10/2026 at 12:52 p.m., with Resident 25, Resident 25 stated she wanted more chili on her potatoes and will request more chili from RNA 1.During an observation on 3/10/2026 at 1:06 PM in Resident 25's room, Resident 25 told RNA 1 she was still hungry and wanted more chili. RNA 1 was observed cutting up her baked potatoes in multiple tiny pieces then went to assist two other residents.During an interview on 3/10/2026 at 1:52 p.m., with RNA 1, RNA 1 stated Resident 25 told him she was still hungry. RNA 1 stated when a resident requests another tray or indicates they were still hungry, he should provide additional food for the resident.During an interview on 3/13/2026 at 3:24 p.m., the Director of Nursing (DON), the DON stated she had in serviced RNA 1 on offering residents additional food or appropriate alternatives to ensure they have enough to eat and to help prevent weight loss.During a review of the facility's policy and procedure (P&P) titled, Dignity Resident Rights, undated, the P&P indicated, .When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to.eat, and conduct activities of daily living as they choose .

Based on interview and record review, the facility failed to ensure a coordinated hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) plan of care was integrated with the facility's plan of care and accessible to facility nursing staff for one of six residents reviewed for hospice services (Resident 5).The facility failed to:1. Incorporate Resident 5's active order for morphine (opioid pain medication) and fentanyl ( opioid pain medication) into the facility care plan,2.Document an effective communication process with the hospice provider to ensure 24 hour continuity of care, and maintained conflicting medication orders in Resident 5's health record without a coordinated plan between the hospice provider and the facility.This failure had the potential to put Resident 5 at risk for missed care, duplicate therapy, and adverse events, including respiratory depression and opioid overdoseFindings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including right sided hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) , diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and bi polar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 5's History & Physical (H&P) dated 1/31/2026, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool) dated 1/7/2026, the MDS indicated Resident 5's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 5 was dependent (helper does all the work) with activities of daily living (ADL's like toileting, bathing and dressing). The MDS indicated Resident 5 was taking opioids (pain medication). The MDS indicated Resident 5 was receiving hospice services.During a review of Resident 5's hospice Patient Care Order dated 1/26/2026, the Patient Care Order indicated an order for:1.morphine 20 milligrams/milliliter (mg/ml -units of measure) oral (by mouth) administer one ml every 4 hours as needed (PRN) for severe pain.2.Fentanyl 25 microgram/ hour (mcg/hr unit of measure and time) transdermal (skin) patch, apply one patch transdermal every 72 hours for severe pain, discontinued (d/c) on 2/16/2026.During a review of Resident 5's Order Recap Report , the Order Recap Report indicated Resident 5 was receiving fentanyl 50 mcg/hr transdermal patch apply 1 patch transdermal every 72 hours for severe pain and apply a 25 mcg /hr transdermal patch. Apply one 50 mcg/hr and one 25 mcg /hr for a total dose of 75 mcg/hr. Hold for respirations less than (<) 12. Hospice nurses to apply patches, start date 2/16/2026, (d/c) on 3/9/2026.During a review of Resident 5's Order Recap Report, the Order Recap Report indicated Resident 5 was receiving fentanyl 50 mcg/hr transdermal patch, apply 2 patches transdermal every 72 hours for severe pain for a total dose of 100 mcg/hr, hold for respirations < 12. Hospice nurse to apply patches, start date 3/09/2026.During an interview on 3/12/2026 at 12:15 p.m. with the hospice Registered Nurse (HRN), the HRN stated Resident 5's fentanyl pain medication dose had been increased multiple times in the last month. HRN stated Resident 5's care plans were on the HRN's lap top with no access for facility nurses.During a concurrent interview and record review on 3/13/2026 at 1:02 p.m. with the Registered Nurse Supervisor (RNS), Resident 5's hospice interdisciplinary ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) care plans dated 1/27/2026 through 3/10/2026 and the facility's care plan titled Resident 5 at risk for opioid overdose were reviewed. RNS stated no coordinated plan of care was found for use of fentanyl or morphine. The RNS stated hospice and facility care plans must be integrated to ensure continuity and to avoid missed care. RNS stated she could not find any coordinated plan for Resident 5's use of fentanyl or morphineDuring an interview on 3/13/2026 at 3:11 p.m. with the Director of Nurses (DON), the DON stated no comprehensive plan of care was in place for Resident 5's fentanyl and morphine use. The DON stated hospice nurses and facility nurses should work together to ensure Resident 5's continuity of care, pain being managed, and to reduce negative outcomes.During a review of the facility's policy and procedure (P&P) titled Hospice Program (undated), the P&P indicated Hospice services are available to residents at the end of life coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. The coordinated care will be revised and updated as necessary to reflect the residents current status .

Based on observation, interview, and record review, the facility failed to implement infection control practices for two of 18 sampled residents (Resident 2 and Resident 9). Specifically, the facility failed to:1.Provide hand hygiene (including handwashing with soap and water or use of alcohol based hand sanitizers) for Resident 2 before lunch service, as resident used her bare hands to eat.2.Performed COVID 19 (highly contagious respiratory disease caused by Coronavirus, which is transmitted thru coughing, talking, sneezing and touching contaminated surfaces) testing for staff who cared for Resident 9 after the resident tested positive for COVID 19.These failures had the potential to contribute to the transmission and spread of infection among residents, staff, and visitors in the facility. Findings: 1.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 2 with diagnoses including Alzheimer's disease( a disease characterized by a progressive decline in mental abilities), gastrostomy( a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia( difficulty in swallowing), unspecified dementia( a progressive state of decline in mental abilities), and depression (serious mental health condition characterized by persistent sadness and a loss of interest in activities that affects daily functioning), During a review of Resident 2's Minimum Data Set (MDS- resident assessment tool) dated 2/6/2026, the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was dependent on the staff with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to a chair. During an observation on 3/12/2026 at 12:37 p.m., Certified Nursing Assistant (CNA) 1 brought Resident 2's lunch tray. Resident 2, who was seated in a Geri chair (a specialized padded recliner on wheels designed for individuals with limited mobility), was observed eating her food with her bare hands and fingers. Hand hygiene was not offered or provided to Resident 2 before she began eating. During an interview on 3/12/2026 at 12:46 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated it was important to offer and provide hand hygiene to Resident 2 to remove germs present on the resident's hands. CNA 1 stated that germs on Resident 2's hands could be transferred to her mouth and make her sick, leading to infection. During an interview on 3/13/2026 at 10:53 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated CNA 1 should have provided hand sanitizer to Resident 2 before eating to help prevent illness caused by dirty hands and fingers. During an interview on 3/13/2026 at 2:53 p.m., with the Director of Nursing (DON), the DON stated not providing hand hygiene to Resident 2 could affect her dignity and had the potential to cause infection. 2. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to facility on 9/11/2025 with diagnoses of depression (medical illness causing persistent sadness, hopelessness, and a loss of interest in activities), hypertension (HTN-high blood pressure), chronic kidney disease (a long term condition where the kidneys are damaged and cannot filter blood effectively as they should for a period of at least three months) and cerebral infarction (lack of adequate blood supply to the brain). During a review of Resident 9's History and Physical (H&P), dated 9/12/2025, the H&P indicated Resident 9 did not have the capacity to understand and make decisions but is able to make decisions for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 9's Minimum Data Set, (MDS-a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 9 needs partial to moderate assistance with oral hygiene, toileting, showering, sitting, lying down. The MDS indicated Resident 9 was not up to date for the COVID 19 vaccination. During a review of Resident 9's [NAME] of Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death), dated 3/3/2026, the COC indicated Resident 9 went to the General acute Care (GACH) for evaluation of septic (presence of harmful microorganisms in the blood) arthritis on the right knee. During a concurrent interview and record review on 3/11/2026 at 1:34 p.m., with Infection Preventionist Nurse (IPN), the facility's policy and procedure (P&P) titled Covid-19 Management, dated 1/2025, was reviewed. The P&P indicated When contact tracing is feasible serially test close contacts and exposed staff identified in contact tracing three times on days one, three, and five after the last exposure. The IPN stated Resident 9 had swelling and pain in the right knee and was transferred to the GACH on 3/3/2026. The IPN stated Resident 9 tested positive for Covid-19 on 3/4/2026 in the GACH. The IPN stated Resident 9 returned to the facility on 3/5/2026. The IPN stated Resident 9 could have contracted Covid-19 here at facility from visitors or staff. The IPN stated contact isolation (measures used to prevent the spread of germs transmitted through direct patient contact or indirect contact with their environment), started on 3/6/2026. The IPN stated there was no Covid-19 testing done for staff exposed to Resident 9. The IPN stated she did not identify staff exposed to Covid-19 to prevent an outbreak because the staff did not have any symptoms. During a review of facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 9/18/2023, the P&P indicated The facility considers hand hygiene as the primary means of preventing infection. The P&P indicated residents, family members and visitors are encouraged to practice hand hygiene. During a review of facility's P&P titled, Assisting the Resident with In-Room Meals, the P&P indicated The resident is prepared to receive the meal by washing hands and face, bedpan and urinal was offered and hair was combed.

Based on observation, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) with severe cognitive (ability to think, understand, learn, and remember) impairment and high fall risk was provided with fall prevention measures, including the use of bed rails (a barrier attached to the side of a bed) as ordered by Resident 1's physician on 2/23/2026. The facility failed to:1.Implement fall prevention interventions including use of bedrails immediately following Resident 1's falls on 2/20/2026 and 2/27/20262.Follow a physician's order written on 2/23/2026 to install bed rails and inform Resident 1's physician of the delay in installing the ordered bed rails.3. Revised Resident 1's care plan to include post fall interventions to prevent future falls.4. Follow facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, dated 2018, which indicated the staff and physician will identify pertinent interventions to try to prevent subsequent falls and address the risks of falling.These failures resulted in Resident 1 falling on 2/27/2026 and 3/1/2026. On 3/1/2026 Resident 1 was transferred to a General Acute Care Hospital (GACH). Resident 1 sustained a possible nondisplaced lateral malleolus (bony prominences on either side of the ankle) fracture [broken bone] of uncertain chronicity [medical condition where it is unclear if symptoms will be long-lasting (chronic) or temporary (acute]). Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities),multiple fractures (broken bones) of the ribs and history of fallsDuring a review of Resident 1's History & Physical (H&P) dated 9/28/2026, the H&P indicated that Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Care Plan titled Resident 1 has a history of confusion/decreased safety awareness secondary to dementia, dated 1/13/2026, the Care plan goal indicated Resident 1 will be free of falls and Resident 1 will return to previous level of activity. The Care Plan interventions included to cue resident for safety, and educate resident and resident representative regarding proper ambulation and transfer techniques.During a review of Resident 1's Nursing Documentation Evaluation, dated 2/12/2026, the Nursing Documentation Evaluation indicated, Resident 1's fall risk factor including history of falls in the last six months, disoriented/confused, poor safety judgement, and impaired balance.During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool) dated 2/20/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, bathing, and showering.During a review of Resident 1's Change of Condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive behavioral, or functional status which without immediate intervention, may result in complications or death) dated 2/20/2026, the COC indicated, Resident 1 was found laying on her back at the end of the bed. The COC indicated Resident 1 reports hitting her left ribs and her back. Resident 1 denies hitting her head. Resident 1 reports pain on her upper back with a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) of 4/10, pain medication was administered.During a review of Resident 1's Order Summary Report dated 2/23/2026, the Order Summary Report indicated an order for side rails with fall precautions.During a review of Resident 1's Physical Therapy (PT- licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation dated 2/25/2026, the PT Evaluation indicated Resident 1 needs moderate assistance to ambulate (walk) 10 feet (ft- unit of measurement) with two wheeled walker ( assistive device used to walk).During a review of Resident 1's COC dated 2/27/2026, the COC indicated Resident 1 was found sitting on the floor near her doorway. The COC indicated Resident 1 reported she attempted to get up without assistance.During a review of Resident 1's IDT Care Conference Note dated 2/27/2026, the IDT Care Conference Note indicated Resident 1 had a recent fall resulting in a rib fracture on 2/20/2026, as well as another fall on 2/27/2026. Resident 1 has decreased safety awareness and attempts to ambulate independently. On 2/27/2026, a Certified Nursing Assistant (CNA) placed Resident 1 on a shower chair and briefly left to gather supplies. Upon returning, the CNA found Resident 1 on the floor. The notes indicated interventions including providing cueing for safety and placing bilateral mats at the bedside.During a review of Resident 1's x-ray (imaging test that produce pictures of structures inside the body, particularly bones) of left tibia and fibula (two bones of the lower leg), dated 3/1/2026, the x-ray of left tibia and fibula indicated, possible lateral malleolus nondisplaced fracture, chronicity uncertain.During an observation on 3/6/2026 at 8:30 a.m. in Resident 1's room, bed rails were present on both sides at the head of the bed. No floor mats (cushioned pads designed to help prevent injury in the event of a fall) were observed next to the bed. Resident 1 was not in the room and was reported to have been admitted to a GACH.During an interview on 3/6/2026 at 9:00 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1's care needs. CNA 1 stated Resident 1 was dependent on ADL's and required staff assistance during ambulation and used a wheelchair. CNA 1 stated Resident 1 was considered a fall risk and did not have bed rails installed until after the resident was admitted to the hospital on [DATE]. CNA 1 stated residents identified as fall risks should have interventions in place, which may include a low bed, floor mats, side rails, bed alarms (a pad with sensors that alerts staff if a resident attempts to stand unassisted), and signage at the foot of the bed indicating fall risk status. CNA 1 stated Resident 1 had a history of attempting to get out of bed without assistance and required frequent monitoring. CNA 1 stated staff were expected to conduct rounds every two hours and as needed.During a concurrent interview and record review on 3/6/2026 at 9:15 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Communication Notes dated 3/1/2026 were reviewed. The Communication Notes indicated that Resident 1's Family Member (FM)1 expressed ongoing concerns and repeatedly requested that bed rails be installed on Resident 1's bed. The request had been made to both the Director of Nursing (DON) and the charge nurse. The Communication Notes indicated staff requested that the appropriate paperwork be provided so the bed rails could be installed. LVN 1 stated Resident 1's FM 1 had repeatedly requested bed rails since the resident's initial fall on 2/20/2026. LVN 1 stated she did not know why bed rails were not installed after the first fall on 2/20/2026. LVN 1 stated bed rails could have potentially prevented Resident 1 from rolling out of bed during the fall on 3/1/2026. LVN 1 stated on 3/1/2026 at approximately 6:00 p.m., as she approached Resident 1's room, she saw Resident 1 was falling from the bed to the floor. LVN 1 stated she immediately entered the room and called for assistance. LVN 1 stated Resident 1 was assessed after the fall and did not sustain injuries, and that no new interventions were implemented following the incident. LVN 1 stated Resident 1 did not have floor mats, bed rails, or a bed alarm at the time of the fall on 3/1/2026. LVN 1 stated for residents identified as a fall risk, staff should implement fall prevention interventions based on the residents' assessment and care plan. LVN 1 stated these interventions may include placing the bed in the low position, activating a bed alarm, using bed rails when appropriate, placing floor mats, encouraging the resident to use the call light, and providing assistance with ambulation as needed. LVN 1 stated that she was unable to explain why the bed rails were not installed in a timely manner or why the physician was not notified of the delay. LVN 1 stated Resident 1 did not have bed rails installed after her first fall on 2/20/2026 and ordered on 2/23/2026. LVN 1 stated if appropriate fall prevention interventions were not in place, residents who are at risk for falls and attempt to get out of bed or ambulate without assistance may sustain falls resulting in fractures, bleeding in residents on blood thinners or death.During a concurrent interview and record review on 3/6/2026 at 10:30 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's Order Summary dated 2/23/2026 was reviewed. The Order Summary indicated a physician's order for bed rails with fall precautions. RNS 1 stated the facility's process when a resident requires bed rails was to complete a bed rail assessment, obtain a physician's order, and obtain consent from the resident and/or the resident's representative prior to implementation. RNS 1 stated that once these steps were completed, the bed rails should be installed without delay. RNS 1 stated staff should notify the physician if there was any delay in implementing a physician's order to ensure residents receive timely and appropriate care. RNS 1 stated physician orders reflect the clinician's judgment regarding interventions necessary to maintain the resident's safety and prevent harm. RNS 1 stated delays in implementing ordered interventions may place the resident at risk because the intended safety measure was not in place. RNS 1 stated she was unable to explain why the side rails were not installed on Resident 1's bed until 3/2/2026. RNS 1 stated according to Resident 1's medical record and the facility's documentation, no interventions were implemented immediately following the falls on 2/27/2026 and 3/1/2026. RNS 1 stated bed rails could have prevented the resident from falling from the bed. RNS 1 stated Resident 1 was admitted to GACH on 3/1/2026 at 5:51 p.m. after being found unresponsive in her wheelchair near the nurses' station by the Licensed Vocational Nurse (LVN). RNS 1 stated she had observed the resident in her wheelchair in the hallway shortly before the event and the resident did not appear to be in any distress.During a concurrent interview and record review on 3/6/2026 at 11:15 a.m. with the Director of Nursing (DON), Resident 1's Care Plans were reviewed. The Care Plan indicated that no new interventions were implemented following Resident 1's falls on 2/27/2026 and 3/1/2026. The DON stated no new physician orders or additional fall prevention interventions were implemented after these two falls. The DON stated Resident 1's FM 1 had been requesting bed rails since the initial fall on 2/20/2026.The DON stated Resident 1 was identified as a fall risk due to her history of previous falls and her diagnosis of dementia. The DON stated additional interventions, such as a bed alarm and bed rails, should have been implemented and may have prevented repeat falls. The DON stated bed rails were intended to provide support for mobility, assist with repositioning, and help prevent falls. The DON stated facility policy requires a bed rail assessment prior to installation, followed by obtaining a physician's order and securing consent from the resident and/or resident representative. The DON stated bed rails should be installed without delay, within 24 hours. The DON stated the maintenance department was not contacted to install the bed rails until 3/2/2026, and she did not know why the installation was not completed sooner. The DON stated timely implementation of physician orders and care plan interventions was essential to resident safety. The DON stated failure to promptly implement interventions may increase the resident's risk for repeat falls and related injuries, including head trauma, fractures, or death. The DON stated Resident 1's FM 1 had been requesting bed rails since the resident's initial fall on 2/20/2026.During an interview on 3/6/2026 at 11:45 a.m. with Maintenance Director (MD), MD stated he was first made aware that the bed rails needed to be installed during the facility's stand-up meeting on 3/2/2026, by the DON. MD acknowledged that no prior notification or request had been made regarding the installation of the bed rails before that date. MD stated the bed rails were installed on 3/2/2026. During a review of the facility's policy & procedures (P&P) titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.During a review of the facility's policy & procedures (P&P) titled, Bed Rails, dated 2018, the P&P indicated, Based on the preceding assessment the staff and physician will identify interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based on observation, interviews and record review the facility failed to ensure one of three sampled residents (Resident 1) was assess for the risks of entrapment (event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and the possible risks and benefits of bed rails ( a barrier attached to the side of a bed) were reviewed prior to installation. The facility failed to:1.Obtain a bed rail assessment (a mandatory, documented evaluation conducted by healthcare staff before using bed rails) before bed rails may be used to ensure they are safe, necessary, and functioning as a physical restraint (devices, or materials used to restrict a person's movement, freedom, or access to their body). 2.Obtain informed consent (voluntary agreement to accept treatment and/ or procedures after receiving education regarding risks, benefits, and alternatives offered) for bed rails from the resident and/or Resident's Representative (is a person authorized to act on behalf of a resident in a long-term care facility). 3.Follow Resident 1's physician's order dated 2/23/2026 to install bed rails with fall precautions in a timely manner.These failures placed Resident 1 at risk for repeated falls on 2/27/2026, 3/1/2026 and potential entrapment.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities),multiple fractures (broken bones) of the ribs and history of fallsDuring a review of Resident 1's History & Physical (H&P) dated 9/28/2025 , the H&P indicated that Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Care Plan titled Resident 1 has a history of confusion/decreased safety awareness secondary to dementia, dated 1/13/2026, the Care plan goal indicated Resident 1 will be free of falls and Resident 1 will return to previous level of activity. The Care Plan interventions included to cue resident for safety, and educate resident and resident representative regarding proper ambulation and transfer techniques.During a review of Resident 1's Nursing Documentation Evaluation, dated 2/12/2026, the Nursing Documentation Evaluation indicated, Resident 1's fall risk factor including history of falls in the last six months, disoriented/confused, poor safety judgement, and impaired balance.During a review of Resident 1's Minimum Data Set (MDS a resident assessment tool) dated 2/20/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting, bathing, and showering.During a review of Resident 1's Change of Condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 2/20/2026, the COC indicated, Resident 1 was found laying on her back at the end of the bed. The COC indicated Resident 1 reports hitting her left ribs and her back. Resident 1 denies hitting her head. Resident 1 reports pain on her upper back with a pain scale (pain screening tool using numerical value to assess the level of pain ranging from 0 to 3-mild pain, from 4 to 6- moderate pain, and from 7 to 9-severe pain, and 10- the worse pain possible) of 4/10, pain medication administered.During a review of Resident 1's Order Summary Report dated 2/23/2026, the Order Summary Report indicated an order for side rails with fall precautions.During a review of Resident 1's COC dated 2/27/2026, it was noted that Resident 1 was found sitting on the floor near her doorway. The COC indicated that Resident 1 reported she attempted to get up without assistance.During a review of Resident 1's IDT Care Conference Note dated 2/27/2026, the IDT Care Conference Note indicated Resident 1 had a recent fall resulting in a rib fracture on 2/20/2026, as well as another fall on 2/27/2026. Resident 1 has decreased safety awareness and attempts to ambulate independently. On 2/27/2026, a Certified Nursing Assistant (CNA) placed Resident 1 on a shower chair and briefly left to gather supplies. Upon returning, the CNA found Resident 1 on the floor. The notes indicated interventions including providing cueing for safety and placing bilateral mats at the bedside.During a review of Resident 1's x-ray (imaging test that produce pictures of structures inside the body, particularly bones) of left tibia and fibula (two bones of the lower leg), dated 3/1/2026, the x-ray of left tibia and fibula indicated, possible lateral malleolus nondisplaced fracture, chronicity uncertain.During an observation on 3/6/2026 at 8:30 a.m. in Resident 1's room, bed rails were present on both sides at the head of the bed. No floor mats (cushioned pads designed to help prevent injury in the event of a fall) were observed next to the bed. Resident 1 was not in the room and was reported to have been admitted to General Acute Care Hospital (GACH).During an interview on 3/6/2026 at 9:00 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated that she is familiar with Resident 1's care. CNA 1 stated Resident 1 was considered a fall risk and did not have bed rails installed until after the resident was admitted to the hospital on [DATE].During a concurrent interview and record review on 3/6/2026 at 9:15 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Communication Notes dated 3/1/2026 were reviewed. The Communication Notes indicated that Resident 1's Family Member (FM)1 expressed ongoing concerns and repeatedly requested that bed rails be installed on Resident 1's bed. The request had been made to both the Director of Nursing (DON) and the charge nurse. The Communication Notes indicated staff requested that the appropriate paperwork be provided so the bed rails could be installed. LVN 1 stated Resident 1 FM 1 had repeatedly requested bed rails since the resident's initial fall on 2/20/2026. LVN 1 stated she did not know why bed rails were not installed after the first fall on 2/20/2026. LVN 1 stated bed rails could have potentially prevented Resident 1 from rolling out of bed during the fall on 3/1/2026. LVN 1 stated that the facility's process for residents who may require bed rails includes completing a bed rail assessment to ensure the rails are safe, necessary, and not being used as a physical restraint. LVN 1 stated the assessment was used to evaluate safety risks, determine the resident's physical abilities, and identify potential entrapment hazards. LVN 1 stated once the bed rail assessment was completed, the licensed nurse must obtain a physician's order and secure informed consent from the resident and/or the resident's representative, after providing education on the risks, benefits, and alternatives. LVN 1 stated the bed rails should be installed immediately after consent was obtained and the order was written.LVN 1 stated that if there was any delay in installing the bed rails, the physician must be notified promptly. She was unable to explain why the bed rails were not installed in a timely manner or why the physician was not informed of the delay. LVN 1 stated Resident 1 did not have bed rails installed after her fall on 2/20/2026 or after the physician's order was written on 2/23/2026.During a concurrent interview and record review on 3/6/2026 at 10:30 a.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's Order Summary dated 2/23/2026 was reviewed. The Order Summary indicated a physician's order for bed rails with fall precautions. RNS 1 stated the facility's process when a resident requires bed rails was to complete a bed rail assessment, obtain a physician's order, and obtain consent from the resident and/or the resident's representative prior to implementation. RNS 1 stated that once these steps were completed, the bed rails should be installed without delay. RNS 1 stated staff should notify the physician if there was any delay in implementing a physician's order to ensure residents receive timely and appropriate care. RNS 1 stated physician orders reflect the clinician's judgment regarding interventions necessary to maintain the resident's safety and prevent harm. RNS 1 stated delays in implementing ordered interventions may place the resident at risk because the intended safety measure was not in place. RNS 1 stated she was unable to explain why the side rails were not installed on Resident 1's bed until 3/2/2026.During a interview on 3/6/2026 at 11:15 a.m. with the Director of Nursing (DON), The DON stated Resident 1's FM 1 had been requesting bed rails since the initial fall on 2/20/2026.The DON stated Resident 1 was identified as a fall risk due to her history of previous falls and her diagnosis of dementia. The DON stated additional interventions, such as a bed alarm and bed rails, should have been implemented and may have prevented repeat falls. The DON stated bed rails were intended to provide support for mobility, assist with repositioning, and help prevent falls. The DON stated facility policy requires a bed rail assessment prior to installation, followed by obtaining a physician's order and securing consent from the resident and/or resident representative. The DON stated bed rails should be installed without delay, within 24 hours. The DON stated the maintenance department was not contacted to install the bed rails until 3/2/2026, and she did not know why the installation was not completed sooner.During an interview on 3/6/2026 at 11:45 a.m. with Maintenance Director (MD), MD stated he was first made aware that the bed rails needed to be installed during the facility's stand-up meeting on 3/2/2026, by the DON. MD stated no prior notification or request had been made regarding the installation of the bed rails before 3/2/2026. MD stated the bed rails were installed on 3/2/2026. During a review of the facility's policy & procedures (P&P) titled, Falls-Clinical Protocol, dated 2018, the P&P indicated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.During a review of the facility's P&P titled, Use of Restraints, [undated], the P&P indicated, Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve symptoms.During a review of the facility's P&P titled, Bed Rails, dated 2018, the P&P indicated, Based on the preceding assessment the staff and physician will identify interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based on observation interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who required minimal assistance with ambulation (walking) using a front wheel walker (FWW- assistive walking device), did not exit through the unsupervised, non-alarmed front door without staff knowledge. The facility failed to: 1. Ensure there was a system in place to monitor the facility's front door after 6:30 pm during times when the receptionist was not present to prevent residents from leaving the facility without staff knowledge. 2. Ensure Resident 1 was accurately assessed for the risk of elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) and developed a plan of care with intervention to prevent elopement. Resident 1 was assessed as low risk for elopement due to being unable to ambulate (walk) and unable to self-propel a wheelchair. According to Resident 1's general acute care hospital (GACH) 1 record titled Physical Therapy Notes and an interview with the facility's occupational Therapist (OT- profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Resident 1 required minimal assistance ( a person can perform most of the walking task independently but requires some help which may include minor physical guidance, verbal cues, or setup) with ambulation using a FWW. 3. Ensure there were interventions in place to ensure Resident 1's safety and address possible elopement. 4. Ensure staff responded to the alarm when the emergency exit door, located on Station 3, was alarming on 11/7/2025 for eight minutes to ensure door was secure and no resident had eloped (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision). As a result of these deficient practices, Resident 1 eloped from the facility on 11/4/2025 at approximately 8:00 p.m. On 11/4/2025 Resident 1 was found at a local restaurant located approximately one mile away from the facility. While at the restaurant Resident 1 complained of shortness of breath, 911 ( a phone number used to contact the emergency services) was called and the resident was transported to the GACH. Upon arrival at the GACH on the same day at 11:04 p.m., Resident 1 experienced a cardiac arrest (heart attack) and was pronounced dead on 11/4/2025 at 11:39 pm. These deficient practices placed 13 residents, assessed as being at risk of elopement, at an increased risk of leaving the facility's premises and being exposed to adverse environmental conditions (rain and/or cold), hypothermia (a dangerously low body temperature), injuries from motor vehicle accidents, medical complications, and/or death. On 11/08/2025 at 1:35 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) due to the facility's failure to assess, monitor and supervise Resident 1 to prevent the resident's elopement from the facility on 11/04/2025. On 11/10/2025 the facility submitted an acceptable IJ Removal Plan ([IJRP]) interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/10/2025 at 1:26 p.m., in the presence of the facility's Administrator (ADM).The IJRP included the following immediate actions: 1. On 11/5/25, the Elopement Evaluation for 73 active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). There were 13 residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1 -involves a sitter or companion to prevent harm) monitoring, sitter (a person who provides non-medical supervision to a resident), hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice. 2. On 11/5/25, the care plan for the 13 residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions of the 13 residents included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Two residents currently placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) after 30 days from 11/9/25 for continuation or discontinuation. Three residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT after 30 days from 11/9/25 for continuation/discontinuation. 3. On 11/5/25, the IDT initiated a care plan meeting for the 13 residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse on 11/9/2025. 4. On 11/5/2025, the Maintenance Director checked six facility egress doors (door that provides safe and accessible exit route) and tested all six audible door alarms for functionality. There were no negative findings identified in all six exit doors. On 11/8/25, the Maintenance Director checked facility egress door and tested all seven audible door alarms for functionality. There were no negative findings identified in all seven exit doors. Seven egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS (mechanism to communicate maintenance services needed), Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions. 5. On 11/5/2025, the DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all six exit doors are attended and checked for resident safety. On 11/5/2025, the DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all six exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. On 11/8/25, Staff training provided by the DSD/Designee on monitoring all seven exit doors and ensuring all seven exit doors are secured and alarm in place. Staff training with emphasis on ensuring all seven exit doors are secured and an alarm in place:a. From 7am to 8pm daily, the front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the seven exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the seven exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of all seven doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift. 6. On 11/5/2025, the DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan. 7. The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle (daily stand-up meeting ) and Point Click Care Communication ( messaging tool that enables healthcare professionals to exchange resident information in real time) Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily (Monday to Friday) Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends (Saturday and Sunday). If pink wristbands are not in place, Department Managers (Monday to Friday) will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1. 8. On 11/5/2025, the Medical Director was informed by DON regarding the incident. No new orders were given. 9. On 11/6/25, the Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station (Stations 1, 2 ,3) and the reception area. 10. On 11/6/2025, the DSD/Designee placed pink wristbands to 13 residents as an elopement identifier. 11. On 11/6/2025, The Maintenance Director initiated daily checks on all 6 exit doors to ensure they were properly latched and alarms functioning. 12. Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of seven exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of seven exit doors as assigned hourly. 13. On 11/8/25, the facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area. 14. On 11/8/25, the receptionist hours were increased from 7 a.m. to 8 p.m., daily, including weekends, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place 15. On 11/8/25, The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated on 11/5/25 regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. 16. The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed. Actions to prevent occurrence or recurrence: 1. On 11/9/2025, the facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed. 2. On 11/6/2025, the facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily. 3. DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation. 4. All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained. Findings: During a review of GACH 1's Physical Therapy (PT (licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) assessment dated [DATE], the PT assessment indicated Resident 1 was alert, able to ambulate 10 feet (ft-unit of measure) with a FWW. The PT Assessment indicated Resident 1's gait (walking) was slow, and Resident 1 complained of fatigue (lack of energy). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted from GACH 1 to the facility on [DATE] with the diagnosis including acute myocardial infraction (MI-heart attack), presence of coronary angioplasty implant and graft (minimally invasive procedure used to open narrowed or blocked coronary [arteries which surround and supply the heart] arteries), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) chronic obstructive pulmonary disease (COPD-lung disease) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's Joint Mobility Screening (a series of tests to assess a person's joint health and flexibility) dated 11/04/2025 , the Joint Mobility Screening indicated Resident 1 had full range of motion (FROM- performing an exercise without limitations) to bilateral (both) upper extremities (BUE-right and left arm) and bilateral lower extremities (BLE - right and left leg). During a review of Resident 1's Occupational Therapy Evaluation (OT-profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities), dated 11/04/2025, the OT evaluation indicated Resident 1 had excellent rehab potential as evidenced by the ability to follow multi-step directions, active participation in skilled treatment and a high prior level of function. During a review of Resident1's Transfer Reposition assessment dated [DATE], the Transfer Reposition Assessment indicated Resident 1 was able to bear weight (stand) on both legs and that Resident 1 was able to consistently perform a stand and pivot transfer (move from one place to the other) with limited assistance. During a review of Resident 1's admission assessment dated [DATE], the admission Assessment indicated Resident 1 was alert to person, had clear speech, was able to follow simple commands, and make his needs known, he was able to understand others. The admission Assessment indicated Resident 1 was confused with poor safety judgement. The admission Assessment indicated Resident 1 did not use any assistive devices for ambulation (walking). During a review of Resident1's Elopement Risk Assessment, dated 11/04/2025, the Elopement Risk Assessment indicated Resident 1 could not walk or self-propel wheelchair independently. During a review of Resident 1's Change of Condition Evaluation ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 11/04/2025, the COC indicated Resident 1 was last seen at 7:20 p.m. on 11/04/2025 in his room. The COC also indicated that at 8:30 p.m. was when staff first noticed that Resident 1 had eloped from the facility. During a review of Resident1's GACH's emergency room (ER) Record dated 11/4/2025, the GACH ER record indicated Resident 1 was found at local restaurant located approximately one mile away from the facility. Resident 1 complained of shortness of breath while in the restaurant. 911 was called and Resident 1 was transported to a GACH. The GACH emergency room Record indicated Resident 1 arrived at GACH at 11:04 p.m., experienced a cardiac arrest and was pronounced dead on 11/4/2025 at 11:39 pm. During an observation on 11/07/2025 at 6:55 a.m. at the facility entrance, the front door was observed propped open with a box of gloves, and the lobby area was unsupervised, with no staff present to monitor the entrance. During a concurrent observation and interview on 11/07/2025 at 7:02 a.m. at the facility's front entrance, Certified Nursing Assistant (CNA) 1 stated the front door should remain closed, as it locks from the outside and was equipped with a doorbell. CNA 1 stated that Station 1 staff were responsible for opening the door for staff entering the facility. CNA 1 stated a box of gloves had been used to prop the door open so that staff would not have to repeatedly open it for incoming facility staff. CNA 2 further stated that leaving the door open without supervision posed a risk, as residents could potentially exit the facility unsupervised, and unauthorized individuals could enter, creating significant safety concern. During an observation on 11/07/2025 at 7:10 a.m., the emergency exit door located in Station Three was observed alarming. The alarm continued to sound until 7:18 a.m., when Certified Nursing Assistant (CNA) 2 arrived and turned off the alarm and secured the door. During an observation on 11/07/2025 at 7:17 a.m. at Nursing Station 3, CNA 2, CNA 3, and Licensed Vocational Nurse (LVN) 1 were observed sitting at the nursing station and conversing with one another, while the emergency exit door alarm on Station Three continued to sound. During an interview on 11/07/2025 at 7:20 a.m., with CNA 2, CNA 2 stated he did not have the key to turn off the emergency door alarm and only Licensed Vocational Nurses (LVNs) were authorized to do so. CNA 2 stated CNAs were not permitted to touch the alarms. CNA 2 stated a resident could have pushed the door open and exited the facility, as the door locks from the outside and alarms when opened from the inside. During an interview on 11/07/2025 at at 7:25 a.m., with CNA 3, CNA 3 stated LVNs were responsible for silencing the emergency exit door alarms because they have the keys. CNA 3 stated she could not locate the LVN to inform her about the alarm sounding. CNA 3 stated she should have checked the door herself to determine the cause of the alarm, as a resident could have exited or an unauthorized person could have entered the facility. CNA 3 stated leaving the door unsecured could pose a serious safety risk. During an interview on 11/07/2025 at 7:32 a.m., with LVN 1, LVN 1 stated he heard the alarm but was busy with preparing staff's schedule and assumed that a CNA would respond to the door. LVN 1 stated she forgot she had the key to silence the alarm. LVN 1 stated she should have checked the door immediately to ensure that no residents had left the facility. During an interview on 11/7/2025, at 8:00 a.m., with the Receptionist the Receptionist stated the front door of the facility was typically open around 7:45 a.m. and closed around 6:30 p.m. The Receptionist stated the door locks from the outside, but can be opened freely from the inside, allowing individuals to exit without restriction. The Receptionist stated there was no alarm system on the front door, however, a doorbell was present. The Receptionist stated that she was aware staff had been propping the front door open with box of gloves in the mornings prior to her arrival. The Receptionist stated she had repeatedly instructed staff to keep the door closed, due to concern for safety. The Receptionist stated the Administrator was aware of this practice, and she believed it was not safe. The Receptionist stated on 11/4/2025, at approximately 10:00 a.m., she observed Resident 1 in the lobby, pacing back and forth using an FWW. The Receptionist stated Resident 1 appeared unsteady and had difficulty walking. The Receptionist stated Resident 1 was an elopement risk and should have reported her observation, but she became distracted by a phone call and did not do so. During an interview on 11/07/2025 at 8:50 a.m. with the Maintenance Supervisor (MS), the MS stated the facility has a total of six exit doors. MS stated six exit doors were locked from the outside and always alarmed from the inside. MS stated if any of these doors were opened from the inside, an alarm would sound. MS stated the front door does not have an alarm system installed. During a phone interview on 11/07/2025 at 11:32 a.m. with CNA 4, CNA 4 stated she was responsible for Resident 1 on the night Resident 1 went missing. CNA 4 stated the last time she saw Resident 1 was around 7:30 p.m., at which time Resident 1 was in his bed. CNA 4 stated she believed Resident 1 exited through the front door. CNA 4 stated the front door locks from the outside but can easily be opened from the inside, as there was no alarm system in place. CNA 4 stated because staff were often busy, it was difficult to monitor the front door consistently. During a concurrent interview and record review on 11/7/2025 at 12:03 p.m. with the Physical Therapy Director (PTD), Resident1's Joint Mobility Screening dated 11/04/2025 was reviewed. The PTD stated she had completed the assessment and stated Resident 1 demonstrated full range of motion in both upper and lower extremities. PTD stated Resident 1 was able to walk to the bathroom using a FWW with minimal assistance but required frequent safety cues due to being impulsive while walking. During a concurrent interview and record review on 11/7/2025 at 1:59 p.m. with RNS 1, Resident 1's Elopement Risk assessment dated [DATE] and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 1 stated she had completed the Elopement Risk Assessment for Resident 1. RNS 1 stated that prior to completing the assessment, she interviewed Resident 1 and reviewed Resident 1's GACH 1's record. RNS 1 stated she observed Resident 1 was unresponsive, only answering questions selectively. RNS 1 stated she observed Resident 1's arms were moving erratically, and when asked if he could walk, Resident 1 did not provide a clear yes or no response. RNS 1 stated based on her observations, Resident 1 was non-ambulatory (not walking) and unable to self-propel in a wheelchair. RNS 1 stated that in her assessment, he looked like he could not walk. RNS 1 stated she did not review the PT's notes from GACH 1's, which indicated that Resident 1 was able to ambulate with a FWW with minimal assistance. RNS 1 stated that had she known Resident 1 was ambulatory (able to walk), she would have assessed Resident 1 as high risk for elopement and implemented appropriate interventions to alert staff. RNS 1 stated Resident 1's elopement was avoidable and that staff should have been more attentive to his condition and risk level. During a concurrent interview and record review on 11/8/2025 at 8:22 a.m. with RNS 2 Resident 1's Elopement Risk assessment dated [DATE] and GACH 1's PT notes dated 10/31/2025 were reviewed. RNS 2 stated that RNS 1 inaccurately assessed Resident 1 on 11/4/2025 as not being at risk for elopement. RNS 2 stated based on the available information, Resident 1 should have been assessed as high risk for elopement. RNS 2 stated when a resident was identified as high risk for elopement, the facility was expected to implement specific interventions, including placement of an elopement bracelet on the resident, room assignment near the nurses' station, facility-wide staff notification regarding the resident's elopement risk and frequent visual checks, typically every 15 minutes. RNS 2 stated the facility failed Resident 1 by not identifying and addressing his elopement risk appropriately. RNS 2 stated concern about the front door security, stating that when the lobby was closed, the facility relies on Station 1 staff to monitor the front door, even though there was no alarm system to alert staff if someone exits. RNS 2 stated any resident can simply push the door open, and that staff are often too busy providing care to continuously monitor the front entrance. During an interview on 11 /09/2025 at 12:27 p.m., with ADM, the ADM stated that she believed Resident 1 eloped through the front door. The ADM stated the front door was not equipped with an alarm system, and the facility relies on staff at Station 1 to monitor the door. The ADM stated Resident 1's elopement was avoidable, if staff had been more vigilant in monitoring the front door, and if the elopement risk assessment had been completed accurately, appropriate interventions could have been implemented to better monitor Resident 1. The ADM stated, I'm sure the outcome would have been different. During a review of the Facility's Policy and Procedure (P&P) titled Wandering and Elopement (undated), the P&P indicated The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the residents. if resident is identified as risk for elopement the resident care plan will have strategies and interventions to maintain the resident's safety.

Based on observation, interview and record review, the facility failed to ensure a resident, who had diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body) and generalized muscle weakness, did not sustain a second-degree burn (a burn injury that damages the outer layers of the skin [epidermis] and/or part of the underlying layer of the skin [dermis] but does not penetrate deeper into the subcutaneous tissue (the deepest layer of the skin beneath the epidermis and dermis) to his left thigh while using an egg cooker in his room for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 did not have in his possession and use an unauthorized appliance (egg cooker) in his room. 2. Ensure when the Director of Nursing (DON) and Administrator (ADM), who were aware that Resident 1 had an egg cooker in his room, examined the egg cooker for safety and provided an approval for the use of the appliance in writing, per the facility's Policy and Procedure (P/P) titled Electrical Appliances. 3. Ensure after Resident 1 reported the burn to his left leg from using the egg cooker, the facility then assessed the egg cooker for safety, provided instruction/direction to Resident 1 for its use, removed the egg cooker from Resident 1's room and/or provided written authorization approving its use. 4. Ensure the facility followed their P/P, titled Electrical Appliances that indicated only authorized electrical appliances would be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,) within their living area, unless approved, in writing, by the Administrator, or his/her designee. This deficient practice resulted in Resident 1 sustaining a second-degree burn to his left anterior (front or top of) thigh and had the potential for continued injuries if left in the resident's room/possession. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia and generalized muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/5/2025, the MDS indicated Resident 1 was cognitively (mental action or process of acquiring knowledge and understanding ability) intact and required partial/moderate assistance (helper does less than half the effort ) with activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Change of Condition (COC) form, dated 10/7/2025, the COC form indicated Resident 1 reported, I burned myself when I was cooking eggs. The COC form indicated Resident 1 had a 5.0 centimeter ([cm] a unit of measurement) in length by 5.0 cm in width by 0.1 cm in thickness, partial thickness loss from a burn (a wound that affects the epidermis and/or the dermis but does not penetrate deeper into the subcutaneous tissue). During a review of Resident 1's Order Summary Report (Physician's Order) dated 10/7/2025, the Physician's Order indicated to apply Silver Sulfadiazine cream 1% (an antibiotic medicated cream used to prevent and treat infection in severe burn wounds) to Resident 1's left anterior thigh, topically (surface of the skin) daily during the day shift, for 30 days, for a second degree burn for 30 days. During an interview on 10/17/2025, at 9:23 a.m., Resident 1 stated on 10/4/2025 he was cooking eggs in his room using an egg cooker (the resident would not disclose where he obtained the egg cooker or eggs). Resident 1 stated when the eggs were done cooking, he took four of them out of the egg cooker, placed them in a large bowl that he sat on his lap. Resident 1 stated, he went to the bathroom with the eggs in the bowl and did not feel the heat immediately. Resident 1 stated when he was in the bathroom, his left thigh was red, and he knew it was burned. Resident 1 stated he waited a couple of days after burning himself, until he thought the burn needed to be treated, to tell staff about the burn on his leg. During an interview on 10/17/2025 at 12:06 p.m., Licensed Vocational Nurse (LVN) 1 stated that on 10/7/2025 at 11:30 a.m., Resident 1 told her he burned his left leg while cooking eggs. LVN 1 stated she told the ADM on 10/7/2025 about Resident 1 getting burned when he used the egg cooker. LVN 1 stated she knew Resident 1 had an egg cooker in his room, because when she went there daily to treat his other wounds, she would see the egg cooker on the floor. LVN 1 stated residents were not allowed to have heating/cooking devices in their room because it could be dangerous, causing a fire and/or burns to the resident(s) but she did not tell anyone prior to his report of a burn that he had the egg cooker. During an interview on 10/17/2025 at 12:26 p.m., the DON stated he knew Resident 1 had an egg cooker in his room at one time, but he thought the egg cooker was finally gone. The DON stated he never checked Resident 1's room to verify if the egg cooker was gone. The DON stated if he knew the egg cooker was still in Resident 1's room, he would have checked the egg cooker to make sure it was functioning properly, educated Resident 1 on using the device safely and created a care plan. During an interview on 10/17/2025 at 12:41 p.m., the ADM stated, she believes Resident 1 came to the facility with an egg cooker, when she found out about it, she told him he could not have it in his room (date unknown). The ADM stated she did not check Resident 1's room to verify if the egg cooker was gone because of the resident's behavior of yelling, cursing, calling staff names and accusing staff of stealing his personal items, and because the Resident initially hid the egg cooker in a box that was in his room. The ADM stated because the resident's egg cooker looked old and dirty, she purchased an egg cooker and eggs and kept them in the facility's kitchen for Resident 1's use, whenever he wanted eggs. The ADM stated she was notified by LVN 1 (10/7/2025) that Resident 1 had burned himself. The ADM stated she could not remember if LVN 1 told her the burn was from an egg cooker. The ADM stated she did not go to Resident 1's room after the burn was reported to her to check on Resident 1. The ADM stated residents were told they were not allowed to have heating devices in their room because of safety issues. The ADM stated she never gave approval for Resident 1 to have a cooking appliance in his room because it was not safe. During a review of the facility's undated P&P titled, Electrical Appliances the P&P indicated only authorized electrical appliances will be permitted in residents living area. Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.,) within their living area, unless approved, in writing, by the Administrator, or his/her designee. Should electrical appliances be permitted, each must be in good working order, free of frayed cords and UL ([Underwriters Laboratories] a product that has been tested and certified by an independent safety science company, to meet specific safety, performance, or quality standards) approved .

Based on interview, and record review, the facility failed to ensure, when a resident was found unresponsive and pulseless (no detectable heart beat), the nursing staff immediately initiated basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) by performing cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), checked Resident 1's pulse when on [DATE] at approximately 4:50 a.m. Resident 1 was found unresponsive and not breathing, called for help, activated Code Blue (a specific code used to signal a patient who is having a life-threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops beating] or respiratory arrest [when a person stops breathing]), initiated CPR and stayed with Resident 1 per the facility's policy and procedure (P&P) titled, Emergency Procedure-Cardiopulmonary Resuscitation, and the American Heart Association (AHA) Guidelines. 2. Ensure Licensed Vocational Nurse (LVN) 1 immediately initiated CPR when she found Resident 1 was unresponsive, without a pulse and not breathing, instead of leaving the resident's room to get her personal blood pressure (BP) machine (a device that measures a person's BP) from the medication cart, which lost critical time needed to increase Resident 1's chance of survival. 3. Ensure LVN 1 placed Resident 1 in a flat position on his back prior to beginning chest compressions (the act of applying pressure to someone's chest to help blood flow), according to the American Red Cross guidelines that indicate to place the person on their back on a firm, flat surface. 4. Ensure staff called 911 as soon as Resident 1 was found unresponsive and pulseless on [DATE] at 4:50 a.m., per the facility's P&P titled, Emergency Procedure-Cardiopulmonary Resuscitation and the American Red Cross guidelines that indicated if the person does not respond and is not breathing or only gasping to call 911. 5. Ensure CNA 1 and LVN 1 followed the facility's P&P titled, Emergency Cardiopulmonary Resuscitation, which indicated to initiate CPR if sudden cardiac arrest is likely. These failures resulted in: 1. A delay in providing CPR to Resident 1 who was found unresponsive and not breathing on [DATE] at approximately 4:50 a.m. 2. A delay in calling 911 when CNA 1 and LVN 1 found Resident 1 on [DATE] at 4:50 a.m., unresponsive with no chest rising and was not breathing. Resident 1 was pronounced dead on [DATE] at 5:05 a.m. These failures place 66 residents, who were Full Code (a medical term indicating a patient's consent to receive all possible life-saving measures in the event of a cardiac or respiratory arrest) at risk of not receiving basic life saving measures timely, including CPR, leading to possible death. On [DATE] at 12:35 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Director of Nursing (DON), Registered Nurse Supervisor (RNS) and the Administrator (over the phone) due to the facility's failure to provide timely basic life support (BLS), to Resident 1, including immediate initiation of CPR. An IJ Removal Plan ([IJRP], an intervention to immediately correct the deficient practices) was requested. On [DATE] at 10:18 a.m., the DON submitted an acceptable IJRP. After onsite verification of IJRP implementation through observation, interview, and record reviews, the IJ was removed on [DATE] at 1:57 p.m., in the presence of the ADM, the DON and the Director of Staff Development (DSD). The IJRP included the following: 1. On [DATE], the DON conducted an audit of residents with Full Code status. There were 66 residents with full code status. 2. On [DATE], the DON conducted an audit for the past 30 days of expired residents (a resident who has died). Based on the audit, three residents (including Resident 1) expired, 2 out of 3 residents were Full Code and 1 resident was Do Not Resuscitate ([DNR] resident will not receive CPR or other life-saving measures if their heart or breathing stops). Two residents (1 Full Code and 1 DNR) were not affected by the alleged deficient practice. 3. On [DATE], the DON/Designee provided a 1:1 in-service (training or coaching session for a single employee) to CNA 1 on the P&P titled Emergency Procedure-Cardiopulmonary Resuscitation, with emphasis on not leaving resident unattended when unresponsive and to check resident's carotid (under the angle of the jaw) pulse. CNA 1 will activate Code Blue by yelling/screaming for help and place resident in a supine (flat) position, and initiate CPR immediately. The second responder will call 911. 4. On [DATE], the DON/Designee provided a 1:1 in-service to LVN 1 on the P&P titled Emergency Procedure-Cardiopulmonary Resuscitation, with emphasis on not leaving a resident unattended when unresponsive and to check the resident's carotid pulse. LVN 1 will activate Code Blue by yelling/screaming for help and will place the resident in a supine position, and initiate CPR immediately. The second responder will call 911. 5. On [DATE], the DON/Designee provided a 1:1 in-service to LVN 2 on the P&P titled Emergency Procedure-Cardiopulmonary Resuscitation, with emphasis on not leaving a resident unattended when found unresponsive and to check the resident's carotid pulse. LVN 1 will activate Code Blue by yelling/screaming for help and will place resident in a supine position, and initiate CPR immediately. The second responder will call 911. 6. On [DATE], [DATE], and [DATE], the DON/Designee provided in-service to nursing staff on the P&P titled Emergency Procedure-Cardiopulmonary Resuscitation, with emphasis on not leaving a resident unattended when found unresponsive and to check the resident's carotid pulse. Responder 1 will activate Code Blue by yelling/screaming for help and place the resident in a supine position, and initiate CPR immediately. The second responder will call 911. There are 65 total active nursing staff, four Registered Nurses, 18 LVNs and 43 CNAs. Four RNs, 17 LVNs (1 LVN on leave of absence, and 34 CNAs (one on vacation, six on leave of absence, were in-serviced. LVNs and CNAs who are on Leave of Absence (LOA), and vacation, will be in-serviced prior to their next scheduled shift. 7. On [DATE], [DATE], and [DATE], a licensed clinical Basic Life Support (BLS) instructor provided training to the licensed nurses and CNAs on CPR/BLS. There are 65 total active nursing staff. 8. The DSD/Designee will track the licensed nurses and CNAs that have not been in-service due to leave of absence/vacation and will report to the DON/designee when the staff is scheduled to return. The three CNAs who did not attend the in-service will be taken off schedule until trained by the DSD/Designee. 9. Newly hired licensed nurses, CNAs and registry nurses will receive in-service with skills competency from the DSD/Designee on the P&P titled Emergency Procedure-Cardiopulmonary Resuscitation, as part of the orientation process with emphasis on not leaving resident unattended when found unresponsive and to check the resident's carotid pulse. Responder 1 will activate Code Blue by yelling/screaming for help and place resident in a supine position, and initiate CPR immediately. The second responder will call 911. 10. The DON/Designee will utilize the active roster list for licensed nurses and CNAs to check if they have been in-serviced. 11. The DON placed a blue dot on the name of the resident by the door to recognize the DNR status of a resident. Daily and upon room change or discharge, the RN Supervisor will be responsible for ensuring the identifier is updated and accurate. The DON/Designee will conduct a bi-weekly check of the DNR identifier for accuracy until substantial compliance is achieved. 12. On [DATE], the DON initiated an in-service to licensed staff and CNAs on Policy and Procedure on Emergency Procedure-Cardiopulmonary Resuscitation with emphasis not leaving resident unattended when found unresponsive, check the resident's carotid pulse, activate Code Blue, call 911, place the resident in a supine position, and initiate CPR immediately, a post test was given. 13. On [DATE], the DON/Designee initiated competency skills on CPR process using the CPR Skills competency form. 14. On [DATE], the facility implemented a Quality Assurance Performance Improvement ([QAPI] a systematic, data-driven frame-work in long-term care that combines Quality Assurance [QA] which focuses on maintaining acceptable cafe standards with Performance Improvement [PI] which emphasizes continuous improvement of processes and outcomes) on CPR process. 15. The DON/Designee will validate the competency of LVNs and CNAs with the facility's P&P on Emergency Procedure-Cardiopulmonary Resuscitation, through a post-test to five random licensed nurses and CNAs weekly for three months or until substantial compliance is achieved. Findings will be reported at the monthly QAPI committee meeting. 16. On [DATE], the DON/Designee will conduct a Code Blue drill with licensed nursing staff. The Code Blue drills will continue to be held twice monthly for three months or until substantial compliance is achieved. When compliance is achieved, the DON/Designee will conduct a Code Blue drill annually or as needed. Findings will be reviewed at the monthly QAPI Committee meeting. 17. The DON/Designee will review residents with a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) that resulted in a Code Blue from Monday through Friday. The DON/Designee will review the e-interact (electronic health record) and interview the staff that were present during the Code Blue to determine if it aligns with the facility's CPR process. On weekends, a licensed nurse/Designee will review any COC that resulted in a Code Blue to ensure proper CPR process was followed. 18. The DSD/Designee will audit the licensed nurses and CNAs CPR certification quarterly. 19. Newly hired licensed nurses and CNAs will receive an in-service on the P&P on Emergency Procedure-Cardiopulmonary Resuscitation, as part of the orientation process. 20. Newly hired licensed nurses and CNA will receive the skills competency in CPR as part of their orientation process. 21. On [DATE], the DSD/Designee revised the orientation checklist to include the in-service and skills competency on the P&P on the Emergency-Cardiopulmonary Resuscitation. 22. The DON/Designee will report on the findings of the COC that resulted in a Code Blue to the QAPI committee for further recommendations monthly for three months or until substantial compliance is achieved.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cervical spine fracture (broken neck), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury [the conduit {tube} between the brain and the rest of the body]), and chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and he had the ability to understand and be understood by others. The MDS indicated Resident 1 was fully dependent on staff (requiring two or more-person assistance to complete the activity) for activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was a Full Code status. During a review of Resident 1's Physician Orders for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life) dated [DATE], the POLST indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. During a review of Resident 1's Nurses Progress Notes dated [DATE] and timed at 5:10 a.m., the Nurses Progress Notes indicated CNA 1 notified LVN 1 that Resident 1 was unresponsive on [DATE] at 4:50 a.m., LVN 1 went to assess Resident 1 and found him with absent vital signs ([v/s] measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate). The Nurses Progress Notes indicated LVN 1 initiated chest compressions and sent CNA 1 to get LVN 2, Code Blue was initiated. The Nurses Progress Notes indicated LVN 2 took over the Code Blue with assistance from CNA (CNA) 2, 911 was called at 4:57 a.m. (seven minutes after CNA1 and LVN 1 found Resident 1 was found unresponsive), Paramedics (a highly trained healthcare professional who provides advanced emergency medical care) arrived at 5:05 a.m., assessed Resident 1, who had absent v/s and was not breathing. During a review of Emergency Medical Service Report ([EMS] a detailed document completed by emergency medical personnel that serves as a record of a patient's pre-hospital assessment and the care they received), dated [DATE] and timed at 5:05, the EMS Report indicated Paramedics were called on [DATE] at 4:57 a.m. (seven minutes after Resident 1 was found unresponsive and without a pulse) and arrived on [DATE] at 5:05 a.m., where they found Resident 1 deceased . The EMS Report indicated the facility staff reported Resident 1 was last seen alive on [DATE] at 12 a.m. During a telephone interview on [DATE] at 2:20 p.m., and a subsequent interview at 5:20 p.m., CNA 1 stated on [DATE] around 4:45 a.m., during her rounds, she walked into Resident 1's room and did not see Resident 1's chest rising (not breathing). CNA 1 stated she did not check Resident 1's pulse when she found Resident 1 not breathing. CNA 1 stated she did not initiate CPR immediately and left Resident 1 unattended to get LVN 1, who was at Nursing Station 2. CNA 1 stated she did not initiate CPR immediately because she wanted a witness and it was her first time experiencing an unresponsive resident. During an interview on [DATE] at 3 p.m., LVN 2 stated on [DATE] she was informed by CNA 1 that LVN 1 needed help. LVN 2 stated when she entered Resident 1's room, she saw LVN 1 on top of Resident 1's bed on her knee but she did not see LVN 1 performing chest compressions on Resident 1. LVN 2 stated Resident 1 did not have a pulse, so she initiated chest compressions and directed LVN 1 to get the crash cart (a set of trays/drawers/shelves on wheels used in hospital or skilled nursing facility for transportation and dispensing of emergency medication/equipment at site). LVN 2 stated when a resident (in general) is found without a pulse, CPR must be initiated immediately while another staff member calls 911 to increase the chance of survival and prevent brain damage. During an interview on [DATE] at 7:08 a.m., LVN 1 stated on [DATE], around 4:45 a.m., CNA 1 reported that Resident 1 was not responding to verbal stimuli (words or phrases designed to trigger a reaction) or tactile stimuli (physical touch). LVN 1 stated when CNA 1 and LVN 1 entered Resident 1's room, Resident 1 was in bed in an upright position with the head of the bed at an approximate 30 degree angle. LVN 1 stated she was not able to arouse Resident 1 and did not find a pulse. LVN 1 stated she then went out of Resident 1's room, down the hallway, to get her personal BP machine, she returned to Resident 1's room and checked Resident 1's BP twice. LVN 1 stated both BP readings indicated ERROR. LVN 1 stated she did not instruct CNA 1 to initiate CPR on Resident 1 while she (LVN 1) left CNA 1 alone in Resident 1's room to get a BP machine. LVN 1 stated after she could not obtain Resident 1's pulse and BP, she initiated CPR and instructed CNA 2 to call LVN 2 for help. LVN 1 stated CNA 2 came back with LVN 2, and CNA 2 continued chest compressions. LVN 1 stated she then ran to Station 3, but did not call 911, grabbed the POLST binder to check Resident 1's code status, ran to Station 2 and called 911. LVN 1 stated paramedics arrived at 5:05 a.m., assessed Resident 1 and stated Resident 1 was deceased . LVN 1 stated she did not lower the head of the bed while performing chest compressions on Resident 1 because she stated it was an emergency, it was four in the morning, and she did the best that she could. LVN 1 stated she should have placed Resident 1 in a flat position by lowering the head of bed while performing CPR to effectively perform chest compressions. During an interview on [DATE] at 3:43 p.m., the DON stated when a resident is found unresponsive, staff should immediately check for a pulse, if the resident does not have a pulse, then immediately start chest compressions, call for help, and immediately call 911. The DON stated, if chest compressions and/or CPR was not initiated immediately after the heart stops beating, the chances of the resident's survival decrease significantly, and the risk of permanent brain damage or death increases drastically. The DON stated the resident's bed must be flat prior to initiating CPR so the person who performs chest compressions provides the appropriate compressions necessary to pump blood from the heart to the rest of the body. During a concurrent telephone interview and record review on [DATE] at 8:36 a.m., with a paramedic ([PM] a highly trained healthcare professional who provides advanced emergency medical care) who was on the scene when Resident 1 was confirmed deceased , Resident 1's Emergency Medical Service Report ([EMS] a detailed document completed by emergency medical personnel that serves as a record of a patient's pre-hospital assessment and the care they received) dated [DATE] and timed at 5:05 was reviewed. The EMS report indicated paramedics were called on [DATE] at 4:57 a.m. (seven minutes after Resident 1 was found unresponsive and without a pulse). The EMS report indicated the following: Resident 1 was found unresponsive, he appeared to be deceased upon arrival, bilateral eyes were non-reactive (the black center of the eyes [pupils] were fixed which indicates brain death), there was severe rigor (stiffening of the joints and muscles of a body), lividity (a purplish-red skin discoloration that occurs after death due to the pooling of blood in the lower parts of the body, caused by gravity when circulation stops and is a visible sign of death) was present, he was pale and cold, there were no breath sounds, his BP was unobtainable, and he had no pulse. The PM stated when they arrived, the facility staff were attempting CPR by pressing on Resident 1's sternum (breastbone) but not providing effective chest compressions, appearing to just go through the motions. The PM stated upon their assessment, Resident 1 looked deceased with obvious signs of death, he had no obvious chest rise, his eyes were open, his pupils were fixed, his skin was pale and cold, and he had rigor to his jaw and torso (the main part of the body that contains the chest, abdomen, pelvis, and back). The PM stated the facility staff reported Resident 1 was last seen alive by facility staff on [DATE] at 12 a.m. The PM stated rigor, and lividity were signs that Resident 1 had been deceased for several hours. During a review of an online article titled, American Heart Association 2020 CPR and Emergency Cardiovascular Care Committee Guidelines, the article indicated, the adult basic life support algorithm (a process or set rules to be followed) for healthcare providers included verifying for scene safety, check for responsiveness, shout for nearby help, look for no breathing or only gasping and check pulse simultaneously (at the same time). The guidelines further indicated if there was no breathing, or only gasping, with no pulse, to immediately begin CPR and perform cycles of thirty chest compressions and two breaths.https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines During a review of an online article titled, How to Perform CPR - Adult CPR Steps the article indicated, to check the scene for safety, check the person for responsiveness/breathing, if the person does not respond and is not breathing or only gasping, call 911, get equipment, or tell someone to do so, kneel beside the person, and place them on their back on a firm, flat surface. The guidelines indicated to be begin chest compressions 30 at a time, give two breaths and to continue the cycle of 30 chest compression and two breaths.www.redcross.org During a review of the facility's P&P titled, Emergency Procedure-Cardiopulmonary Resuscitation, revised [DATE], the P&P indicated the facility will implement guidelines regarding CPR. The P&P indicated if an individual is found unresponsive briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR and instruct a staff member to activate the emergency response (code) and call 911. The P&P indicated all rescuers, trained or not, should provide chest compression to victims of cardiac arrest.

Based on interview and record review, the facility failed to ensure a resident, who had severe generalized body pain, and had pain medication (Oxycodone Hydrochloride [a narcotic (a drug that works in the brain to dull the sense of pain) to relieve moderate to severe pain] 10 milligrams ([mg] a unit of measurement) available for administration to control their pain, was provided pain medication, for one of six sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Oxycodone Hydrochloride 10 mg for Resident 1's moderate to severe pain before the medication's quantity was depleted. 2. Ensure licensed nurses contacted Resident 1's physician to obtain authorization to access the facility's emergency kit ([E-Kit] a kit which contains a small quantity of medications which can be dispensed when pharmacy service is not available) containing Oxycodone HCL tablets to administer to Resident 1 to relieve Resident 1's severe pain. 3. Ensure Resident 1 received Oxycodone HCL for severe pain, per Resident 1's care plan and as ordered by Resident 1's physician. 4. Ensure the licensed nurses followed the facility's Policy and Procedure (P/P) titled, Medication Shortages/Unavailable Medications, to immediately initiate action to obtain Oxycodone HCL from the facility's Emergency Medication Supply (E-Kit), when the medication supply was depleted, in order to administer it to Resident 1 when Resident 1 complained of severe pain. 5. Ensure licensed nurses followed the facility's P/P titled, Pain Management, to maintain the residents' highest possible level of comfort. These deficient practices resulted in Resident 1 experiencing unrelieved severe pain and increased anxiety (persistent and excessive worry which interferes with daily activities) for seven days. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis including lung cancer (diseases in which abnormal cells divide without control and can invade nearby tissues), a Stage 3 pressure injury (a localized injury to the skin and/or underlying tissue usually over a bony area) to the sacro-coccyx (tailbone), cervical (relating to the neck) disc degeneration (when one or more of the cushioning discs in the cervical spine start to break down due to wear and tear), anxiety disorder, low back pain and generalized body pain. A review of Resident 1's History and Physical (H/P), dated 12/8/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 1/15/2024, indicated Resident 1 was able to make independent decisions which were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced moderate pain over the last five days. A review of Resident 1's Care Plan, dated 10/7/2022, indicated Resident 1 exhibited or was at risk for alterations in comfort related to chronic pain due to low back pain, cervical disk degeneration, and arthritis (swelling of one or more joints). Under this care plan the goal for Resident 1 was to achieve an acceptable level of pain control and not to exhibit non-verbal signs of pain for the next 90 days (until the next care plan evaluation). The care plan interventions included to medicate Resident 1 as ordered for pain, monitor for non-verbal signs/symptoms of pain, and monitor Resident 1 for changes in mood or mental status. A review of Resident 1's Physician's Orders indicated the following: 1. The physician's order dated 1/10/2024 for Acetaminophen (Tylenol) 325 mg, two tablets every four hours as needed for mild pain rated from one to four on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). 2. The physician's order dated 1/10/2024 for Oxycodone HCL 10 mg, one tablet every eight hours as needed for moderate to severe pain rated from five to 10. 3. The physician's order dated 1/10/2024 for Lorazepam (a medication used to treat anxiety) 0.5 mg, one tablet every eight hours as needed for anxiety. A review of Resident 1's Medication Administration Record (MAR) for 1/2024, indicated Resident 1 received Oxycodone 10 mg on the following days and times: 1. On 1/11/2024 at 9:53 a.m., for a pain level rated 7 out of 10. 2. On 1/12/2024 at 9:49 a.m., and 4:45 p.m., for a pain level of 7 out of 10. 3. On 1/14/2024 at 5 a.m., and 1:14 p.m., for a pain level of 7 out of 10. 4. On 1/16/2024 at 5 a.m., for a pain level of 6 out of 10. 5. On 1/16/2024 at 9:30 a.m., for a pain level of 8 out of 10. A review of Resident 1's MAR indicated the last dose of Oxycodone was documented as given to Resident 1 on 1/16/2024 at 9:30 a.m. for a pain level of 8 out of 10. A review of Resident 1's Controlled Medication Count Sheet, dated 1/16/2024 and timed at 9 p.m., (this was not documented on Resident 1's MAR) indicated Resident 1 received one tablet of Oxycodone HCL 10 mg. The Controlled Medication Count sheet indicated there were no more Oxycodone HCL 10 mg tablets available. A review of the Pharmacy Notes dated 1/17/2024 indicated, a refill for Resident 1's Oxycodone HCL 10 mg was requested at the time when there was no more Oxycodone available. The Pharmacy Notes indicated the Continuance Form (Refill Order) was faxed from the pharmacy to Resident 1's Physician's at 1:09 p.m., on 1/17/2024. (16 hours after the last dose of Oxycodone was administered to Resident 1 on 1/16/2024 at 9 p.m.). A review of the Facility's Controlled Substance Inventory Count - Emergency Kit form dated 1/18/2024, indicated there were 10 tablets of Oxycodone 5 mg available in the E-Kit. A review of a text message dated 1/18/2024 and timed at 10:37 a.m., (13.5 hours after the pharmacy's initial fax request to refill Resident 1's Oxycodone), from the facility's phone, between LVN 1 and Resident 1's physician indicated a request to have Resident 1's Oxycodone refilled. The text message indicated Resident 1's physician stated, I will take care of it when I get to the office. A review of the Pharmacy Notes dated 1/18/2024, indicated the pharmacy received a Refill Order pending the physician's approval. The Pharmacy Note indicated Resident 1's physician was expected to arrive at his office at approximately 1 p.m. on 1/18/2024 and the office staff would remind the physician to sign the Refill Order for Oxycodone HCL. A review of Resident 1's MAR, dated 1/19/2024 and timed at 8:50 a.m., indicated Tylenol 650 mg was administered to Resident 1 for a pain level of five (moderate pain). However, Resident 1's physician ordered Tylenol for a mild pain level rated one to four). A review of a text message dated 1/19/2024 and timed at 5:23 p.m., (52 + hours after the pharmacy's initial fax request to refill Resident 1's Oxycodone), from the facility's phone, between LVN 2 and Resident 1's physician, indicated the licensed nurse requested a refill for Resident 1's Oxycodone HCL because the pharmacy had not received the prescription refill. The text message indicated there was no response from Resident 1's physician. A review of a text message dated 1/19/2024 and timed at 6:06 p.m., between Resident 1 and Resident 1's Friend indicated Resident 1 wrote I cannot eat, sleep and all I do is cry. This is patient cruelty, withholding medications. I have to request Tylenol 650 mg for pain because there are no other medications available to help with my pain. A review of a text messages dated 1/20/2024 and timed at 8:06 p.m., between Resident 1 and Resident 1's Friend indicated Resident 1 wrote, I am in constant pain and am having difficulty breathing because of the pain. I had to request my anxiety pill because of the pain. The medication nurse told me yesterday they have an Oxycodone HCL in the emergency package, but the insurance will not pay for it. A review of the Pharmacy Notes dated 1/20/2024 indicated the Refill Order was re-faxed to Resident 1's physician at 10:14 p.m., (73 hours after the pharmacy's initial fax request to refill Resident 1's Oxycodone). A review of Resident 1's MAR, dated 1/21/2024 and timed at 10:13 a.m., indicated Resident was administered Tylenol 650 mg for a pain level of five (moderate pain). A review of the Pharmacy Notes dated 1/21/2024 and timed at 1:05 p.m., indicated Resident 1's Refill Order for Oxycodone m HCL was re-faxed to Resident 1's physician. A review of a text message dated 1/21/2024 and timed at 1:06 p.m., (97 hours after the pharmacy's initial fax request to refill Resident 1's Oxycodone), from facility's phone, between LVN 2 and Resident 1's physician, indicated Resident 1's refill for Oxycodone HCL had not been received and Resident 1 was requesting Oxycodone HCL. The text message response from Resident 1's physician indicated have the pharmacy call me. A review of a text message dated 1/22/2024 and timed at 6:42 a.m., between Resident 1 and Resident 1's Friend indicated Resident 1 wrote, now the diarrhea and nausea started because of the withdrawals from the Oxycodone. A review of a text message dated 1/22/2024 and timed at 10:16 a.m., between Resident 1 and Resident 1's Friend indicated Resident 1's Friend wrote, I have talked to the Registered Nurse (RN 1) and you are supposed to receive an emergency dose of Oxycodone HCL as soon as it arrives from the pharmacy. The doctor finally did that order today. A review of Resident 1's MAR dated 1/22/2024 indicated, there was no documentation to indicate Oxycodone HCL was obtained from the facility's E-Kit to administered to Resident 1. A review of the Pharmacy Notes dated 1/23/2024, indicated a Refill order was re-faxed to Resident 1's physician at 9:16 a.m., (140 hours after the pharmacy's initial fax request to refill Resident 1's Oxycodone). A review of a text message dated 1/23/2024 and timed at 9:19 a.m., from the facility's phone, between RN 1 and Resident 1's physician indicated the licensed nurse wrote that the pharmacy needed an authorization for Resident 1's Oxycodone HCL refill. The text message indicated Resident 1's physician responded, Ok. A review of Resident 1's Pharmacy Delivery Receipt dated 1/23/2024, indicated 90 tablets of Oxycodone HCL 10 mg were delivered to the facility at 6:15 p.m., seven days after Resident 1 requested Oxycodone for pain and after Resident 1's last dose of Oxycodone HCL was administered to Resident 1 on 1/16/2023. During a telephone interview on 2/6/2024 at 11:10 a.m., Resident 1's Friend stated on 1/18/2024 Resident 1 told her that she (Resident 1) had not received any Oxycodone HCL for pain since 1/16/2024. Resident 1's Friend stated Resident 1 told her that she (Resident 1) requested Oxycodone HCL for pain on several occasions, but the nurses told her (Resident 1) they sent the refill request to the pharmacy, but Resident 1's physician had not signed the authorization form. Resident 1's Friend stated Resident 1 told her there was no refill for the pain medication from 1/19/2024 through 1/23/2024. During an interview on 2/6/2024, at 5:10 p.m., LVN 1 stated, on 1/17/2024, there was no more Oxycodone HCL available to administer to Resident 1, so she (LVN 1) called the facility's pharmacy to obtain a refill. LVN 1 stated, when medications are close to running out and are down to approximately two tablets, an order should be placed to refill the medication. LVN 1 stated she did not know she should call Resident 1's physician to request a refill for Resident 1's Oxycodone HCL During an interview on 2/7/2024 at 1:38 p.m., LVN 2 stated on several occasions (dates unknown) Resident 1 asked for Tylenol 650 mg because Oxycodone was not available. During an interview on 2/7/2024 at 2:57 p.m., LVN 1 stated on 1/18/2024 at 2:23 p.m., Resident 1 requested Oxycodone HCL for pain. LVN 1 stated she informed Resident 1, Oxycodone was still pending the physician's authorization and was not available. LVN 1 stated Resident 1 had increased anxiety related to pain and because Oxycodone was not available. LVN 1 stated she administered Lorazepam 0.5 mg to Resident 1. LVN 1 stated she should have contacted the Director of Nursing (DON) or the Administrator (ADM) when she could not get in contact with Resident 1's physician. During an interview on 2/8/2024 at 2:06 p.m., the facility's Pharmacist Consultant (PC) stated, if a resident, who regularly receives Oxycodone HCL for pain, suddenly stops, there is a potential for withdrawal, increased pain, and increased anxiety which had the potential to lead to unnecessary hospitalization s. During an interview on 2/9/2024 at 9:59 a.m., RN 1 stated medication should be reordered at least five days before the medication runs out. RN 1 stated licensed nurses should have reordered Resident 1's Oxycodone before it was completely out of stock. RN 1 stated when nurses were made aware that Oxycodone was not available and when Resident 1 experienced pain and requested the pain medication, LVN 1 should have contacted Resident 1's physician to obtain access to the Oxycodone from the facility's E-Kit so there was no delay in relieving Resident 1's pain. RN 1 stated she could not remember if she notified the DON or the ADM when Resident 1's physician did not respond to the request to refill Oxycodone HCL. During an interview on 2/9/2024 at 10:45 a.m., Resident 1's physician stated it was unfortunate that Resident 1 had to wait seven days without pain medication and that should not have happened. Resident 1's physician stated there must have been issues with receiving and sending faxes to the pharmacy. During an interview on 2/9/2024 at 12:23 p.m., the DON stated if the physician does not respond the licensed nurses should contact her and/or the ADM if assistance is needed to obtain medication or other emergency services. The DON stated there was a potential for Resident 1 to have increased pain, psychological changes, and potential withdrawals when Resident 1 did not receive pain medication. Resident 1 was transferred from the facility to a General Acute Care Hospital (GACH) on 2/1/2024 and was not available for interview. A review of the facility's P/P, titled, Medication Shortages/Unavailable Medications, revised 1/1/2013, indicated upon discovery that the facility has an inadequate supply of a medication to administer to a resident, the facility staff should immediately initiate action to obtain the medication from the pharmacy. If the medication shortage is discovered at the time of the medication administration, the licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply (E-Kit). The P/P indicated if the facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, the facility nurse should notify the nursing supervisor and contact the facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage. A review of the facility's policy and procedure (P/P) dated 8/25/2021 and titled, Pain Management the P/P indicated the purpose of pain management was to maintain the residents' highest possible level of comfort thereby providing the residents a system to evaluate their pain and manage their pain consistently with the professional standards of practice in accordance with their personalized comprehensive care plan, their goals, and preferences.

Based on observation, interview, and record review, the facility failed to prevent the resident from having an unplanned severe (severe weight loss is the weight loss greater than 5 % in one month and greater than 7.5 % in three months) weight loss of 22 pounds ([lbs.] 5.9 percent [%] in one month and 19.6 % in three months) for one of 18 sampled residents (Resident 57). The facility failed to: 1. Ensure the Registered Dietitian (RD) followed the facility's P&P titled Weight Management to assess Resident 57's nutritional needs while the resident was on isolation due to Covid-19, document the assessment, and make recommendations in the resident's medical record. 2. Ensure staff provided Resident 57 with one can of Ensure (nutritional supplement that provides concentrated calories and protein to help patients gain or maintain healthy weight) three times a day with medication pass per RD's recommendation and physician's order. 3. Ensure staff consistently monitored Resident 57's consumed meal percentages and documented daily per facility policy, including time when Resident 57 was on isolation (used to reduce transmission of microorganisms in healthcare and residential settings by placing a resident in a separate room) for Covid-19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever, cough, and is capable of progressing to severe symptoms and in some cases death) from 12/9/2023-12/18/2023. 4. Ensure Resident 57 was provided with one on one ([1:1] health care support worker whose role it is to provide one to one nursing or observation care to an individual patient for a period) supervision during mealtimes as care planned. 5. Ensure staff followed Resident 57's Care Plan titled Nutritional Risk and implemented interventions including 1:1 feeding supervision by facility staff for all meals and weight the resident weekly. 6. Ensure the facility held Interdisciplinary Team ([IDT] group of healthcare professionals working together to plan the care needed for each resident) meeting to address Resident 57's progressive unplanned weight loss and make recommendations to prevent further weight loss. 7. Ensure the licensed nurses assessed, planed, implemented, and evaluated Resident 57's care plan titled, Nutritional Risk, to monitor Resident 57's weight weekly, food intake, and to provide oversight of the CNAs to record accurate meal intake. 8. Ensure the facility held IDT to evaluate Resident 57's progressive weight loss per facility's policy and procedure P&P titled Weight Management and to have Resident 57's weekly weights. These failures resulted in Resident 57's severe weight loss of 22 pounds from 10/14/2023 to 1/5/2024 what was equivalent to 19.6 % of weight loss in three months. Findings: On 1/9/2024 at 1 p.m., Resident 57 was observed in bed being fed lunch by a Family Member (FM). Resident 57 was observed consuming around 65% of his lunch. On 1/10/2024 at 9:35 a.m., Resident 57 was observed in bed being fed breakfast by a Family Member (FM). Resident 57 was observed eating oatmeal and half of the banana (at the time of the observation). Resident 57 was eating very slow. During a review of Resident 57's Admission Record (Face Sheet), the Face Sheet indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including anorexia (an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight), anemia (low red blood cells) and severe protein-calorie malnutrition (when you are not consuming enough protein and calories). During a review of Resident 57's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 10/17/2023, the MDS indicated Resident 57 had severe impairment in cognitive (ability to learn, remember, understand, and make decisions) skills for daily decision making and memory impairment. The MDS indicated Resident 57 was dependent on staff for eating. The MDS indicated Resident 57 admitting weight was 113 pounds (lbs.) and was at risk for malnutrition. During a review of Resident 57's Care Plan titled Nutritional Risk initiated on 10/17/2023, the Care Plan indicated the goal for the resident was to have gradual weight gain towards the admission weight and Ideal Body Weight ([IBW] weight for height at the lowest risk of mortality) weight range of 100-120 lbs. The CP interventions included to have 1:1 feeding supervision by facility staff for all meals, weekly weights, and to alert Registered Dietician (RD) and physician of any resident's significant weight loss. The Care Plan indicated it was revised on 1/11/2024. During a review of Resident 57's Physician's Order dated 10/13/2023, the Physician's Order indicated to administer Megestrol Acetate Suspension ([Megace] an appetite stimulant) 20 milligram per milliliter ([mg/ml]-unit of measurement) by mouth one time a day for appetite stimulant. The Megace was discontinued per Physician's Order dated 12/8/2023. During a concurrent interview and record review with the Registered Nurse Supervisor (RNS) on 1/12/2024 at 2:04 p.m., Resident 57's Physician's Order dated 11/6/2023 was reviewed. The Physician's Order indicated to give Resident 57 one can of Ensure three times a day. The RNS stated Resident 57 had an order for Ensure on 11/6/2023 as a dietary recommendation but Resident 57 did not receive it because it was not available in the facility from 11/6/ 2023 to 1/11/2023. During a review of Resident 57's Change of Condition (COC) dated 12/8/2023, the COC indicated Resident 57 was tested positive for Covid-19 on 12/8/2023 and was placed on isolation precautions. During a review of Resident 57's Registered Dietician (RD) initial Nutritional assessment dated [DATE], the Nutritional assessment indicated Resident 57 weight on 10/14/2023 was 113 lbs., and the resident's body mass index ([BMI] measure of body fat based on height and weight that applies to adult men and women) was 18.8. BMI equal or less than 18.5 -Underweight, range between 18.5 to 24.9 -Normal weight, and range between 25 to 29.9- Overweight. Resident 57's Nutritional Assessment indicated the resident was on regular liberalized (no restrictions on the foods you eat) dysphagia (difficulty in swallowing) puree diet (a pudding-like texture that is smooth, blended, or pureed). The Nutritional Assessment indicated Resident 57's nutritional goals were to avoid weight loss. During a review of Resident 57's RD's Progress Notes dated 10/26/2023, The RD notes indicated Resident 57's weight was 101.4 lbs., on 10/23/2023, which was 10.3 % less in one-week (from 10/14/2023), the resident was on regular diet with dysphagia puree texture with fortified (e.g., adding protein, fat, and/or carbohydrate to foods such as hot cereal to increase the nutritional quality of the food, usually high in calories) cereal at breakfast. The RD's Progress Notes indicated the recommendation were for Resident 57 to have a House shake (a nutritional drink which provides extra calories and protein) three times a day for 30 days, Ensure one carton three times a day with medication pass for 30 days, and 1:1 feeding assistance with meals. The RD Progress Notes indicated the goal for Resident 57 was to avoid the weight loss and to have food intake greater than or equal to 75%. During a review of Resident 57's Physician's Orders for November 2023, indicated the Physician's Order dated 11/14/2023, for Resident 57 to have a House shake three times a day between meals for 30 days. During a review of Resident 57's RD's Progress Notes dated 11/13/2023, the RD's notes indicated Resident 57 weight was 96. lbs., with BMI 16. 0, the resident was on a regular diet with dysphagia puree texture, with fortified cereal at breakfast, and four ounces ([oz]-unit of measurement) of house shakes three times a day between meals and Ensure one carton three times a day with medication pass. The RD's Progress Note indicated Resident 57 had severe unintentional/unplanned weight loss in one month. The RD's Progress Notes indicated the goal for Resident 57 was to avoid severe weight loss and to have food and nutrition supplement intake greater or equal to 75 %. During a review of Resident 57's RD's Progress Notes dated 11/24/2023, the RD's notes indicated Resident 57 weight was 97.2 lbs., with BMI 16.1, on a regular diet with dysphagia puree texture, and with fortified cereal at breakfast. The RD's Progress Note indicated Resident 57 was currently underweight for his BMI. During a review of Resident 57's weight summary dated 10/14/2023 to 1/5/2024, the weight summary indicated the following resident's weights: 1. On 10/14/2023-113 pounds 2. On 10/23/2023-101.4 pounds 3. On 11/3/2023-96.4 pounds 4. On 11/12/2023-93.2 pounds 5. On 11/21/2023-97.2 pounds 6. On 12/4/2023-96.6 pounds 7. On 1/5/2023-90.9 pounds (6.2% weight loss since 12/4/2023). During a review of Resident 57's Medication Administration Record (MAR) dated 11/1/2023 to 11/30/2023, the MAR indicated on 11/14/2023 to weigh Resident 57 every day for 28 days (four weeks) as care planned. The MAR also indicated Resident's was consuming from 0% to 100% of House shake from 11/15/2023 to 11/30/2023 and from 12/1/2023 to 12/31/2023. During a review of Resident 57's medical record, the medical record indicated there were no documentation the resident's weights was taken daily for 28 days (four weeks) starting 11/14/2023. During an interview on 1/9/2024 at 1 p.m. with Resident 57's family member (FM), the FM stated she was at the facility during all three meals (breakfast, lunch, and dinner) to ensure Resident 57 ate his meal. FM stated she was in the facility from 7:30 a.m. to 7 p.m. every day to ensure she was there for all meals before she goes home. FM stated Resident 57 has lost weight since he had Covid-19 from 12/8/2023 to12/18/2023. FM stated she could not come into the facility to feed Resident 57 three times a day for breakfast, lunch, and dinner because Resident 57 was on isolation. During a concurrent interview and Resident 57's medical record review on 1/10/2024 at 3:46 p.m. with RD, the RD stated Resident 57 lost 5.7 lbs. from 12/4/2023 to 1/5/2024 and it was a severe weight loss. The RD stated the last time she assessed Resident 57 for weight loss was on 11/24/2023. During a review of Resident 57's RD progress notes dated 11/25/2023 to 1/8/2024, the RD's progress notes indicated there was no documented RD's assessment or recommendation to prevent the resident's weight loss. The RD stated she did not assess Resident 57 from 12/8/2023 to 12/18/2023 for weight loss because Resident 57 was on isolation for Covid-19. The RD stated she does not go into isolation rooms. The RD stated she relied on a Certified Nurse Assistants (CNAs) to give updates on Resident 57 weight while Resident 57 was in isolation. The RD stated it was her responsibility to assess Resident 57, especially that he had a severe weight loss. RD stated when Resident 57 came off isolation on 12/18/2023, she did not assess his nutritional status and weight loss. The RD stated the next time she assessed Resident 57 nutritional status was on 1/9/2024. The RD stated she failed to assess Resident 57's weight loss and did not make recommendations to prevent the resident's further weight loss for three and a half weeks. The RD stated Resident 57 had to be assessed weekly and three and half weeks was too long for her (RD) not to assess Resident 57's nutritional status due to a weight loss and to not make recommendations to prevent further weight loss. The RD stated any resident, who has a weight loss, should have an IDT meeting to address the resident's weight loss and have a weekly weight. The RD reviewed Resident 57 medical record and stated there were no IDT meeting done for Resident 57 until 1/11/2024. The RD stated Resident 57 was ordered one can of Ensure daily but could not confirmed if it was given to Resident 57 from 11/6/2023 to 1/9/2024. During an interview on 1/11/2024 at 2:35 p.m. CNA 1 stated Resident 57 was a feeder (needs to be fed during mealtime), but the resident's wife always fed the resident for all three meals (breakfast, lunch, dinner). CNA 1 stated the facility staff did not feed Resident 57 because the resident's wife was always at the facility to feed Resident 57 except when Resident 57 was tested positive for Covid-19 and was on isolation. CNA 1 stated staff did not offer to feed Resident 57; staff would only bring the resident's meal tray to the room. During an interview on 1/12/2024 at 9:22 a.m. the Restorative Nurse Assistant (RNA 1) stated if a resident is losing weight, the resident has to be weighed weekly. RNA 1 stated it was the responsibility of the CNAs to feed Resident 57 because Resident 57 was on 1:1 feeding supervision. RNA 1 confirmed Resident 57's weekly weights were not done from 12/5/2023 to 1/4/2024. During a concurrent interview and record review on 1/12/2024 at 10:21 a.m. with RD, the RD stated Resident 57 should have been weighed weekly since December 2023, because of his weight loss. The RD stated staff did not weigh Resident 57 every week from 12/4/2023 to 1/5/2024. The RD stated there were no weights recorded from 12/5/2023 to 1/4/2024 in Resident 57's medical record. The RD stated Resident 57 had a physician's orders for 1:1 supervision for feeding at mealtimes and it was the responsibility of the facility staff to feed him and not Resident 57's FM. The RD stated, Resident 57 FM fed the resident for breakfast, lunch, and dinner. The RD stated any resident losing over 5.0 % of their weight should be on the Weight Variance Committee (a group of medical professionals determining how much weight a resident has lost and making recommendations to prevent further weight loss) to be monitored for continued weight loss. The RD stated Resident 57 was not on the Weight Variance Committee even though he lost 19. 6% of body weight by 1/5/ 2024, and it was a severe weight loss in three months. The RD stated the required caloric intake (the amount of energy consumed from food and beverage) for Resident 57 was between 1239 to 1446 calories a day. The RD stated Resident 57's caloric intake should have been 1610 calories daily based on the meal percentage that was documented by CNAs on Meal Percentage Report. The RD stated she did not verified Resident 57's meal percentage and the caloric intake of 1610 calories per day. The RD stated Resident 57's caloric intake could have been inaccurate (not correct). The RD stated, during record review of meal percentage documentation, there were a lot of meal percentages that were not documented by CNAs, and it was the licensed nurses responsibility to ensure Resident 57's percentage of the consumed meal was documented. During a review of Resident 57's Meal Percentage Report (account of all food, beverages and dietary supplements consumed by a resident over one or more days), the Meal Percentages Report indicated the following: 1. On 12/9/23- no breakfast meal percentage documented. 2. On 12/9/23-no lunch meal percentage documented. 3. On 12/9/23-no dinner meal percentage documented. 4. On 12/10/23-no breakfast, lunch, or dinner meal percentage documented. 5. On 12/11/23-no breakfast, lunch or dinner meal percentage documented. 6. On 12/12/23-no breakfast, lunch or dinner meal percentage documented. 7. On 12/13/23 lunch-75% eaten. 8. On 12/14/23 -no breakfast meal percentage documented. 9. On 12/14/23-no lunch meal percentage documented. 10. On 12/14/23-no dinner meal percentage documented. 11. On 12/15/23-no breakfast meal percentage documented. 12. On 12/15/23-no lunch meal percentage documented. 12/15/23-50% eaten. 13. On 12/16/23-no breakfast meal percentage documented. 14. On 12/16/23-no lunch meal percentage documented. 15. On 12/16/23-no dinner meal percentage documented. 16. On 12/17/23-no breakfast meal percentage documented. 17. On 12/17/23-no lunch meal percentage documented. 18. On 12/17/23-no dinner meal percentage documented. 19. On 12/18/23-no breakfast meal percentage documented. 20. On 12/18/23-no lunch meal percentage documented. 12/18/23-25% eaten. During a concurrent interview and record review on 1/12/2024 at 2:04 p.m. Resident 57's Weight Summary and Meal Percentage report was reviewed. The Registered Nurse Supervisor (RNS) stated she was aware Resident 57 had been losing weight since October 2023. The RNS stated when a resident is losing weight, the RD makes recommendations to prevent further weight loss and the resident weighed weekly. The RNS stated Resident 57 had no daily weights taken/documented after 12/24/2023 and it was 96.6 pounds (on 12/4/2023). The RNS stated Resident 57 was on 1:1 staff supervision for feeding so the staff had to monitor how much Resident 57 ate and document his consumed meal percentages. The RNS stated Resident 57 was on isolation for Covid-19 from 12/8/2023 to 12/18/2023 but could not confirmed if the facility staff documented how much Resident 57 ate during that time (12/8/2023-12/18/2023). The RNS stated it was the responsibility of the licensed nurses to make sure the meal percentages were documented and were accurate. The RNS stated Resident 57 had an order for Ensure on 11/6/2023 as a dietary supplement but Resident 57 did not receive it because it was not available in the facility from 11/6/2023 to 1/11/2023. The RNS stated if a resident was losing weight the facility should have had an IDT meeting and COC to see why the resident had a weight loss and what measures to take to prevent further weight loss. The RNS reviewed Resident 57's Medical Record (MR) dated from 11/24/2023 to 1/10/2024 and stated the MR did not indicate any initiation of COC for weight loss for Resident 57. The RNS stated there was no COC for weight loss done for Resident 57's from 11/24/2023 to 1/10/2024. The RNS stated if the meal percentage was not documented she could not validate if Resident 57 ate, and it could have contributed to his weight loss. The RNS stated Resident 57's continuing weight loss placed him at risk for physical and mental decline. The RNS stated when consumed meal percentages were not documented it is not known whether the resident ate a meal or what meal percentage was consumed, and if the caloric intakes met the resident required needs. The RNS reviewed the Meal Percentage Record and confirmed the following meal intake percentages were not recorded in the medical record for Resident 57: 1. On 12/9/23 breakfast meal not recorded. 2. On 12/9/23 lunch meal not recorded. 3. On12/10/23 breakfast not recorded. 4. On 12/10/23 dinner not recorded. 5. On12/11/23 breakfast not recorded. 6. On 12/11/23 lunch not recorded. 7. On 12/12/23 breakfast not recorded. 8. On 12/15/23 lunch not recorded. 9. On 12/16/23 breakfast not recorded. 10. On 12/16/23 lunch not recorded. During a review of the facility policy and procedure (P&P) titled Quality of Life-Dignity dated February 2020, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being. During a review of the job description (JD) titled Registered Nurse dated May 2022, the JD indicated the RN is responsible to consult and coordinate with the IDT team to assess, plan, implement, and evaluate individualized resident care plans. The JD indicated the RN is responsible to monitor for resident acute changes of condition. The JD indicated the RN is responsible to monitor resident weight and intake of food and notify the physician of significant weight loss or changes in consumption of food. The JD indicated the RN provides oversight for the CNAs as directed. During a review of the facility P&P titled Weight Management dated 8/25/2021, the P&P indicated weights will be obtained weekly for four weeks after admission and if a resident condition warrants assessment and reassessment. The P&P indicated in the event of a significant or unplanned weight loss (5% in 30 days or 7.5% in 90 days), the facility will notify the physician and family member, and notify the RD. The P&P indicated the RD will assess the resident, document the assessment, make recommendations in the resident's medical record. The P&P indicated the facility will have an IDT to collaborate and determine the need for initiation or discontinue of weights other than weekly or ordered by the physician and request lab work if necessary. During a review of JD titled Registered Dietician revised October 2020, the JD indicated the RD will assess the nutritional needs of the residents and determine if the dietary care plan is being followed; discuss problem areas with the Director of Nurses (DON). The JD indicated the RD will review the dietary requirements of each resident and assist the physician in planning for the resident's prescribed diet plan.

Based on observation, interview and record review, the facility failed to identify and eliminate accident hazards during transport of residents' meal trays via a meal delivery cart (a large, metal, storage device used to deliver residents' meal trays in bulk), to prevent and avoid a collision with one of three sampled residents (Resident 1), when a Dietary Aide (DA 1) transported a meal delivery cart down the facility's hallway and collided into Resident 1. This deficient practice resulted in DA 1 hitting Resident 1 with a metal meal delivery cart causing Resident 1 to fall, hitting her back on the floor and her head against the wall. DA 1 was turning the corner of the facility's hallway while pushing the meal delivery cart and ran into Resident 1, due to his obstructed view of the facility's hallway and residents who were in the hallway, by a meal delivery cart that was taller than DA 1. As a result, Resident 1 was transferred to a General Acute Care Hospital (GACH) on 6/6/2023, where she was treated for acute compression fractures (a type of break in a bone caused by pressure and in which the bone collapses) of the third, sixth, and tenth thoracic (middle section of the back) vertebrae (back bone) and an acute compression fracture of the fifth lumbar (lower back) vertebrae, requiring a lumbar kyphoplasty (procedure in which special cement is put into the back bones to treat painful compression fractures) on 6/8/2023 and a thoracic (the area between the neck and the abdomen) kyphoplasty on 6/9/2023. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including traumatic rupture (tears or bursts open) of the symphysis pubis (pelvic joint), right and left side lumbago (lower back pain) with sciatica (pain, weakness, numbness or tingling in the leg), and a malignant neoplasm (cancerous tumor) of overlapping sites of the rectum (area where a person holds stool before excreting it from the body), anus (opening where the stool comes out) and anal canal (part which connects the rectum to the anus). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 4/10/2023, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required a one-person physical assist from staff for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1's balance was not steady, and she had lower extremity (leg) impairment on one side and used a wheelchair for mobility. During a review of Resident 1's Change of Condition Evaluation Form (COCEF) dated 6/6/2023, and timed at 6 p.m., the COCEF indicated Resident 1 fell to the floor and her head was resting against the wall. The COCEF indicated 911 (a phone number used to contact emergency services) was called and Resident 1 was transferred to a GACH. During a review of the GACH's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the GACH on 6/6/2023 due to a fall sustaining blunt head trauma and low back pain. During a review of GACH's Radiology Computerized Tomography scan ([CT] a series of picture taken from different angles around the body using computer processing to create sliced images of the bones, blood vessels and soft tissues inside of the body) dated 6/6/2023, the CT scan indicated Resident 1 had a wedge compression deformity (when the body of the vertebrae becomes fragmented as in a fracture crush) of the sixth and eighth thoracic vertebral body and a compression deformity of the fifth lumbar vertebral body. During a review of the GACH's Interventional Radiology Report ([IRR] a range of minimally invasive alternatives to open surgery techniques which rely on the use of radiological image guidance [X-ray or CT] to precisely target therapy which are minimally invasive alternatives to open surgery), dated 6/8/2023 and 6/9/2023, the IRR indicated Resident 1 had a lumbar kyphoplasty of the fifth lumbar vertebrae, and the third, sixth and tenth thoracic vertebrae due to acute compression fractures and persistent debilitating (serious impairment of strength or ability to function) pain. During an observation on 6/9/2023 at 10:10 a.m., of the facility's hallway, there were no safety mirrors (used reduce blind spots and allow people to see oncoming objects or people at hallway intersections where visibility is obstructed) observed. During an interview on 6/9/2023 at 11:03 a.m., with the facility's Case Manager (CM), the CM stated she was walking down the facility's hallway (6/6/2023) in front of the Administrator's (ADM) office, when she heard a metal crash sound. The CM stated she turned to her right and saw Resident 1 lying on the floor with her head against the wall. The CM stated she saw a meal tray cart facing Resident 1 and DA 1 holding onto the meal delivery cart. During an observation on 6/9/2023 at 12:58 p.m., a meal cart was observed in the facility's hallway. The meal cart was approximately 6 feet tall by 3 feet long and 2 feet wide. DA 1 was observed to be approximately 5' 6 tall. During an interview on 6/12/2023 at 4:13 p.m., with DA 1, DA 1 stated he was facing the meal delivery cart while pushing it down the right side of the facility's hallway, the meal delivery cart was flush (having direct contact; being right next to) against the wall and the left side of the cart was facing the hallway. DA 1 stated he looked to the left of the meal delivery cart to make sure there was nothing in the way of the cart before turning right but he was not able to see down the hallway to the right or in front of him because the meal delivery cart was taller than he was, and the meal delivery cart obstructed his view. DA 1 stated, as he turned the corner, he heard a metal sound and when he looked around the left side of the meal delivery cart, he saw Resident 1 lying on the floor directly in front of the cart. During an interview on 6/15/2023 at 8:54 a.m., with Resident 1, Resident 1 stated she was using a FWW ([Front Wheeled Walker] a device that assist in walking that has two wheels fixed in place) to walk from Station 3 back to her room when she was hit with a meal delivery cart. Resident 1 stated the impact caused her to lose her balance and she fell hitting her back on the floor and the right side of her head on the wall. During an interview on 6/15/2023 at 4:25 p.m., the Administrator in Training (AIT) stated the facility does not have a policy on safe maneuvering and handling of meal delivery carts.

Based on interview and record review, the facility failed to ensure a resident, who was receiving medications that act as a central nervous system ([CNS] a complex of nerve tissues that controls the activities of the body) depressant (a type of medication which slows down brain activity and causes the muscles to relax), including Quetiapine (Seroquel), an antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]), Gabapentin [(Neurontin) an anti-convulsant medication used to prevent or treat seizures pain caused by nerve damage] and Cymbalta [(Duloxetine) an anti-depressant used to treat tingling pain associated with nerve damage] in combination with Oxycodone (an opioid [medication used to treat moderate to severe pain], was prescribed and used as indicated for pain and was monitored for opioid adverse side effects including opioid toxicity and overdose for one of eight sampled residents who were receiving opioids (Resident 1). By failing to: 1. Ensure the nursing staff followed Resident 1's Care Plan that indicated Resident 1 was at risk for alteration in comfort and implemented interventions as care planned by completing the Resident 1's pain assessment, determining the need for pain medication adjustment, and monitoring for pain medication side effects. 2. Ensure the nursing staff acted upon Pharmacists' Consultation Report by notifying Resident 1's physician about the pharmacist's recommendation to reduce the Oxycodone frequency administration from every six hours to every eight hours. These deficient practices resulted in Resident 1 experiencing an opioid overdose on three separate occasions, 9/5/2022, 9/9/2022 and 9/24/2022, leading to Resident 1's transfer to a General Acute Care Hospital (GACH) and the administration of Narcan (a medication used to treat a narcotic overdose by temporarily reversing the effects of opioid medicines and drugs) on 9/5/2022, 9/9/2022 and 9/18/2022. These deficient practices placed other residents, who were receiving opioids for pain management, at risk for overdose and possible death. On 4/29/2023 at 4 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure Resident 1 was not administered CNS depressant medication in combination with opioids leading to Resident 1's medication overdose on three occasions, failure to ensure Resident 1 was assessed and monitored for opioids adverse side effect, and failure to act upon the consulting pharmacist's recommendations to decrease the frequency of Oxycodone administration. On 5/4/2023 at 12:23 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 5/4/2023 at 1:40 p.m., in the presence of the ADM, Senior [NAME] President of Clinical Operations, Senior [NAME] President of Operations, Regional Clinical Resource, Regional [NAME] President of Operations (RVPO 1), Regional [NAME] President of Operations (RVPO 2), and the Pharm D (Doctor of Pharmacy) Consultant Pharmacist. The IJRP included the following: 1. The Director of Nursing initiated a series of in-services to licensed nurses on 4/29/2023 - 5/01/2203 on but not limited to: a. Residents are free from unnecessary pain medications, i.e., antipsychotic medications and other CNS depressant medications. b. Refrain from use of unnecessary medication in combination of the following: All unnecessary medication will be reviewed by the Pharmacist and recommendations will be forwarded to and reviewed by Director of Nursing and/or designee and given to the Physician for review. d. Person centered care plans developed specific to black box warnings, Opioid use, and possible overdose risks to include Opioids and/or combination of opioids with CNS depressant medications. e. During the monthly drug regimen the Pharmacist consultant will review and identify residents with the potential for adverse reaction/side effects on the use of all medications including residents receiving opioids and/or combinations of opioids and CNS depressant medications as it relates to the need for opioids medication use, dose, and frequency. f. Proper use of Narcan (Naloxone), located in facility Omni-cycle, will be administered per MD order for potential opioid overdose. 2. The facility will obtain orders from the Physician to have Narcan readily available in the facility in the event of Opioid overdose. The Licensed Nurses will administer Narcan and follow Emergency Naloxone Administration Nasal and Injection policy for any identification of potential overdose, such as constricted pupil, unresponsive, stupor or sedation, respiratory depression, decreased oxygen saturation, slow heart rate, hypotension, and fingernails and lips are blue or purple. 3. The Director of Nursing will review pharmacy recommendations and the License Nurses and/or Registered Nurse Supervisor will notify the Physician in a timely manner within 72 hours or sooner as needed and recommendations will be acted on immediately. 4. The facility will conduct an Interdisciplinary Team (IDT) meeting and care planning for residents receiving Opioids and residents receiving opioids and other CNS depressant medications. The MDS coordinator will review admission and re-admissions within 72 hours to identify residents baseline care plans specific to risk and care needs on all unnecessary medications and/or combination with other CNS depressant medications. 5. On 4/29/2023 - 4/30/2023 the medical records staff and/or designee initiated an audit of newly admitted residents within the last 30 days consistent with the physician orders surrounding Opioids to include residents receiving opioids and/or combination of opioids with CNS depressant medications and identified 12 residents receiving Opioids and combination of opioids with CNS depressant medications. All Identified residents were reviewed for care plans, black box warning, order accuracy and monitoring to include pain scale parameter monitoring for PRN medications. 6. On 4/30/2023 - 5/1/2023 the pharmacist conducted a drug regimen audit on all residents to identify irregularities, need for Opioid medication, accuracy and correct medication dose and frequency and to have an accurate indication for use. Findings were provided to the Director of Nursing and/or designee for appropriate review and follow up on 5/2/2023 and it was all followed-up, completed and validated by the Director of Nursing and Regional Director of Clinical Operations on 5/2/2023. 7. On 4/29/2023 the Director of Nursing and or Designee acted on the monthly Drug Regimen Review during the last 30 days and followed up on recommendations in collaboration with appropriate primary physicians. The Director of Nursing audited and completed 35 resident reviews. All medications were reviewed. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), chronic obstructive pulmonary disease ([COPD] a group of diseases which cause airflow blockage and breathing-related problems), congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should), schizophrenia (a disorder which affects a person's ability to think, feel, and behave clearly), idiopathic neuropathy (a nerve problem which causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), and chronic respiratory failure with hypoxia (a serious condition which makes it difficult to breathe on your own). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 8/22/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living, required extensive two plus persons physical assist for bed mobility and dressing and required a one-person physical assist to eat, for toilet use, personal hygiene, and bathing. According to the MDS, Resident 1 received opioids and antipsychotic medication. During a review of Resident 1's MDS, dated [DATE], the MDS indicated for Resident 1's, cognitive skills for daily decision making were moderately impaired. During a review of Resident 1's History and Physical (H/P), dated 9/8/2022, the H/P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 8/2022 to 9/2022, the OSR indicated an order for Resident 1 to receive the following medications: 1. On 8/17/2022 an order for Quetiapine Fumarate (Seroquel) 100 milligrams ([mg] a unit of measurement) twice a day for schizophrenia. 2. On 8/17/2022 an order for Gabapentin 800 mg three times a day for neuropathy (a result of damage to the nerves located outside the brain and spinal cord). 3. On 8/23/2022 an order for Oxycodone 5 mg every six hours for pain. The order did not indicate the severity of pain and location of pain. 4. On 9/8/2022 an order for Oxycodone 5 mg every four hours for pain. The order did not indicate the severity of pain and the location of pain. 5. On 9/18/2022 an order for Gabapentin 300 mg three times a day for nerve pain. 6. On 9/18/2022 an order for Duloxetine Hydrochloride (Cymbalta) 30 mg at bedtime for neuropathy. During a review of Resident 1's Care Plan (CP) dated 8/17/2022, the CP indicated Resident 1 exhibited or was at risk for alteration in comfort. The CP's goal for Resident 1 was to achieve an acceptable level of pain control and not to experience pain for the next 90 days. The CPs interventions indicated to utilize a pain scale (a way to measure pain using a numbers from 0-10, with 0 being no pain and 10 the most severe pain), medicate Resident 1 as ordered for pain, monitor for the effectiveness and side effects of pain medication, report to the physician as indicated, the side effects, monitor frequency of episodes of breakthrough pain to determine the need for pain medication adjustment, complete a pain assessment per protocol (the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity) and to monitor for changes in Resident 1's mood or mental status. During a review of Resident 1's Progress Notes (PN), dated 9/4/2022 and timed at 11:31 p.m., the PN indicated Resident 1 was unresponsive to stimuli (an individual whose level of consciousness is such that they are not responsive to irritants, sights, smells, sounds, or temperature changes). During a review of Resident 1's Prehospital Care Report ([PCP]) used by emergency medical responders to record patient data when arriving to the scene), dated 9/4/2022, the PCP indicated Emergency Medical Response ([EMS]) a system that provides emergency medical care) were called to the skilled nursing facility (SNF). The PCP indicated Resident 1's level of consciousness was a 3 based on the Glasgow Coma Scale ([GCS] clinical scale used to reliably measure a person's level of consciousness which is scored between 3 and 15, with 3 being the worst and 15 the best). The PCP indicated Resident 1 was hypotensive (low blood pressure) with pinpoint pupils (black part of the eye which remains very small even in bright light). The PCP indicated EMS administered Narcan 2.0 mg intravenously ([IV], in the vein) and Resident 1 was subsequently transferred to a GACH. During a review of Resident 1's GACH Transfer Orders (TO) to Skilled Nursing Facility, dated 9/7/2022, the TO indicated Resident 1 was hospitalized from 9/5/2022 to 9/7/2022 with diagnosis including altered mental status and adverse effect of drugs (unintended, harmful events attributed to the use of medicines). The TO discharge medication indicated Oxycodone HCL 5 mg every six hours as needed (PRN) for pain. During a review of Resident 1's Nursing Documentation Evaluation (NDE) dated 9/7/2022 and timed at 9:37 p.m., the NDE indicated Resident 1 was readmitted to the SNF on 9/7/2022. During a review of Resident 1's PCP, dated 9/9/2022, the PCP indicated EMS were called to the SNF and found Resident 1 had an altered level of consciousness ([ALOC] the patient is not as awake, alert, or able to understand or react to the surrounding environment), her GCS was 3, she was hypotensive with pinpoint pupils. The PCP indicated EMS administered Narcan 2.0 mg intranasally ([IN], in the nose), which was ineffective and an additional 2.0 mg IV was given. Resident 1 was subsequently transferred to GACH. During a review of Resident 1's GACH TO, dated 9/18/2022, the TO indicated Resident 1 was hospitalized from 9/9/2022 to 9/18/2022 with diagnosis including altered mental status ([AMS] a change in mental function). The TO discharge instructions by the physician indicated, It appears opioid pain medications may be causing confusion, please make sure to limit unnecessary medications. The TO discharge medications indicated Oxycodone HCL 5 mg every four hours as PRN for pain. During a review of Resident 1's NDE dated 9/18/2022 and timed at 10:12 p.m., the NDE indicated Resident 1 was readmitted to the SNF on 9/18/2022. Resident 1 was receiving the following medications: Quetiapine 100 mg twice a day, Gabapentin 300 mg three times a day, Cymbalta 30 mg at bedtime, and Oxycodone 5 mg every 4 hours. During a review of Resident 1's PN dated 9/24/2022 and timed at 1:40 p.m., the PN indicated Resident 1 was very lethargic, slow to respond, had shallow breathing and the staff were unable to acquire a blood pressure ([BP], the pressure of circulating blood against the walls of the blood vessels) reading. The PN indicated 911 was called and 911 arrived at the SNF at 1:50 p.m. During a review of Resident 1's PCP dated 9/24/2022, the PCP indicated EMS were called to the SNF and found Resident with an ALOC, pinpoint pupils, and decreased respiratory rate (12 breaths per minute [normal rate 18-20 breaths per minute]). The PCP indicated EMS administered Narcan 2.0 mg IV to Resident 1 and the resident was subsequently transferred to GACH. The PCP indicated Resident 1 did not return to the facility. During a review of Resident 1's Medication Administration Record (MAR) dated 8/1/2022 to 8/31/2022, the MAR indicated Resident 1 was administered Oxycodone 5.0 mg every six hours RTC (Round the Clock) without indications of pain on 8/23/2022 at 12 p.m. and 6 p.m., on 8/24/2022 at 12 p.m., on 8/26/2022 at 12 a.m., 6 a.m., and 6 p.m., on 8/28/2022 at 6 p.m., on 8/29/2022 at 12 p.m., on 8/30/2022 at 12 p.m., and on 8/31/2022 at 6 a.m. and 6 p.m. During a review of Resident 1's MAR dated 9/1/2022 to 9/30/2022, the MAR indicated Resident 1 received Oxycodone 5.0 mg every four hours, Quetiapine Fumarate 100 mg twice per day, Gabapentin 300 mg three times per day, Duloxetine Hydrochloride 30 mg at bedtime despite the recommendation by the facility's pharmacist consultant on 9/19/2022 (see below). The MAR indicated no documentation regarding a Black Box warning. The MAR indicated Resident 1 was administered Oxycodone 5 mg every six hours RTC despite Resident 1 having zero pain on 9/2/2022 at 12 a.m., 12 p.m., and 6 p.m., 9/3/2022 at 6 a.m., and 9/4/2022 at 12 a.m., and 6 a.m. During a review of Resident 1's Pharmacist Consultation's Report (PCR) dated 9/8/2022, the PCR recommendation indicated, Does Resident 1 need to continue routine Oxycodone every six hours, or could the medication time be reduced to every eight hours? During a review of Resident 1's PCR dated 9/19/2022, the PCR indicated Resident 1 had a prescription for an opioid, Oxycodone 5.0 mg every four hours routinely RTC, in combination with CNS depressant medication including Gabapentin, Duloxetine and Quetiapine, which may increase the adverse effects of the opioid. This combination may increase the risk of opioid toxicity and overdose. The PCP indicated the FDA issued a Boxed Warning stating health care professionals should limit prescribing opioid pain medicines with other CNS depressants (e.g., benzodiazepines, gabapentinoids, sedatives, muscle relaxants, antipsychotics) only to those for whom alternative treatment options are inadequate. If prescribed together, the minimum dose and duration of each drug needed to maintain the desired clinical effect should be used. Please consider avoiding or minimizing concomitant (occurring or existing at the same time as something else) use, perhaps changing the Oxycodone to as needed (PRN) or reducing the frequency if the medication is still needed routinely. During a review of Resident 1's clinical record dated 8/2022 to 9/2022, there was no licensed nurses' documentation indicating Resident 1 was monitored for possible side effects and adverse reaction of the Oxycodone including respiratory depression, respiratory failure, medication overdose, toxicity, and possible death due to a concurrent use of multiple CNS depressant medications and opioid. During an interview and concurrent record review on 3/22/2023, at 9:18 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 1s MAR dated 9/2022 was reviewed. LVN 3 stated a Resident 1's pain level should have been assessed before administration of pain medication and if Resident 1 was not in pain, the pain medication should not have been administered. The MAR indicated Oxycodone 5.0 mg one tablet by mouth was administered to the Resident 1 when the resident's pain level was assessed as zero (no pain). LVN 3 stated Oxycodone is an opioid (narcotic) pain medicine and residents receiving Oxycodone should be monitored for the side effect when using it because it can cause respiratory depression which can lead to respiratory failure and death. During a telephone interview on 3/23/2023, at 1:15 p.m. with LVN 5, LVN 5 stated Resident 1 received narcotic pain medicine and the resident's vital signs ([v/s] clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) should have been monitored and the resident also should have been monitored for lethargy (a state of sleepiness or deep unresponsiveness and inactivity). LVN 5 stated if Resident 1 were overmedicated with opioid medication it could cause over sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs), and the resident's heart rate and respiratory rate could be lowered, and the resident could have decreased level of consciousness which could lead` to death. During a telephone interview on 4/28/2023 at 11:54 a.m., with Medical Doctor 1 (MD 1), MD 1 stated, Resident 1 had issues with her neck and was on narcotic pain medication. MD 1 stated he was aware Resident 1 had a suspected overdose from use of a narcotic and was aware Resident 1 received Narcan for an overdose, but stated he was not aware Resident 1 had an overdose on three occasions. MD 1 stated if the licensed nurses would have made him aware of the pharmacist's recommendations to change Resident 1's medications he would have acted upon the pharmacist's recommendations appropriately. During an interview on 4/28/2023 at 1:54 p.m., with MD 2, MD 2 stated Resident 1 was a difficult patient and not easy to take care of. MD 2 stated he saw Resident 1 one to two times in the facility and stated he documented about Resident 1's uncontrolled pain on his progress notes. MD 2 stated he was the one who ordered the Oxycodone 5.0 mg every four hours because Resident 1 kept complaining of pain. During a telephone interview on 4/27/2023 at 4:27 p.m., with the facility's Pharmacy Consultant 1 (PC 1), PC 1 stated, when a resident is admitted or readmitted to the facility, he reviews the resident's medications for any potential interactions, then he emails his recommendations to the DON. PC 1 stated on 9/8/2022, following Resident 1's admission he reviewed Resident 1's medications and made a recommendation to clarify the order for Oxycodone 5 mg every six hours or change it to every eight hours. PC 1 stated on 9/18/2022 he reviewed Resident 1's medications and noticed Resident 1 was on a combination of medications which included Oxycodone, Gabapentin, Duloxetine and Quetiapine. PC 1 stated these medications concurrent administration could lead to respiratory depression, sedation and overdose due to the potential medication interaction. PC 1 stated he made a recommendation to Resident 1's physician to consider avoiding or minimizing concomitant use, perhaps changing the Oxycodone to as needed or reducing the frequency if the medication still required routine administration. PC 1 stated he did not notify Resident 1's physician regarding his recommendations nor did he follow up because it was the nurse's responsibility to notify the physician of his recommendations. PC 1 stated nursing staff were expected to monitor Resident 1 for the potential side effects of these medications to see if the resident could tolerate these medications without adverse side effects. During an interview on 4/27/2023 at 3:03 p.m., with the DON, and a subsequent interview with the DON on the same day at 5:03 p.m., the DON stated, the licensed nurses, including myself, did not question the Oxycodone order dated 9/8/2022 being increased to every four hours RTC because Resident 1 would constantly complain of pain. The DON stated staffing was an issue during that time and she did not know if the nurses knew how to accurately document the pain scale. The DON stated the purpose of the pharmacist consultant report (PCR) was to prevent residents from receiving unnecessary medication, to notify licensed nursing staff and the physician of needed changes in medication regimen and medication contraindications. The DON stated she did not see Resident 1's toxicity and overdose as an issue at the time and stated she did not follow-up with the pharmacists' consultant recommendations because she thought the RN Supervisor at the time took care of it. During a review of Resident 1's Physician's Order Detail (POD) dated 9/8/2022, the POD indicated an Alert and Black Box warning for Oxycodone 5.0 mg included the following: 1. Serious, life-threatening, or fatal respiratory depression may occur with use of Oxycodone. 2. Monitor for respiratory depression, especially during initiation of Oxycodone or following a dose increase. 3. Concomitant use of opioids with benzodiazepines or other CNS depressants, may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of Oxycodone and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. During a review of an online article titled Gabapentin, Opioids, and the Risk of Opioid-Related Death: A Population-Based Nested Case-Control Study - PMC, National Institute of Health https://www.nih.gov/ indicated clinicians should take caution when combining opioids and CNS depressants, patients should be closely monitored, and doses may need to be adjusted to avoid potential drug overdose. The article also indicated prescribing opioids and CNS depressants was associated with a considerable increased risk of opioid related death. During a review of facility's P/P titled Pain Management, dated 8/25/2021, the P/P indicated residents receiving interventions for pain will be monitored for the effectiveness and side effects (e.g., constipation, sedation) in providing pain relief. Pain management should be consistent with professional standards of practice, comprehensive person-centered care plan and the Resident's goals and preferences is provided to Residents who require services. During a review of the facility's P/P titled Psychotropic Medication Use, revised 7/2022, the P/P indicated residents receiving psychotropic medications are monitored for adverse consequences, including altered metal status and excessive sedation. During a review of the facility's P/P dated 4/2022 and titled, Medication Reference Sources and Texts, the P/P indicated medications with boxed warnings which may indicate a need to closely evaluate and monitor the potential benefits and risks of the medications. During a review of the facility's P/P titled, Reconciliation of Medications on Admission, revised 5/2017, the P/P indicated the purpose is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse, including disparaging (opinion of little worth) and derogatory (critical or disrespectful attitude) words and disrespect for one of three sampled residents (Resident 24) by Licensed Vocational Nurse (LVN) 34. The facility failed to: 1. Ensure LVN 34 did not use profanity and disparaging words about and towards Resident 24 after Resident 24 continue to complain for over four months (8/2022-12/2022) of verbal abuse and mistreatment. 2. Ensure LVN 34 did not use profanity to describe Resident 24 during morning huddles (a brief meeting of nursing staff, regarding residents' care) date and time unknown, while in the facility's hallway, in the earshot of other residents and staff. 3. Ensure LVN 34 adheres to the facility's policy and procedures regarding abuse and resident's rights to prohibit abuse and treat each resident with respect and dignity. 4. Report Resident 24 alleged verbal abuse from LVN 34 after multiple grievance filed by Resident 24. 5. Investigate Resident 24's alleged verbal abuse from LVN 34 for the last 4 months (August 2022- December 2022). 6. The facility failed to prevent further abuse and mistreatment from LVN 34 to Resident 24 by allowing LVN 34 to continue to work with Resident 24 after the resident reported LVN 34. These deficient practices resulted in Resident 24 being verbally and psychologically abused by LVN 34 for over four months while feeling depressed (a mood disorder that causes a persistent feeling of sadness and loss of interest), stressed, humiliated, apprehensive (anxious or fearful that something bad or unpleasant will happen) and singled out for mistreatment by staff. These failures had the potential to affect other residents in the facility under LVN 34's care. On 12/30/22 at 4:57 p.m., in the presence of the Registered Nurse Supervisor (RNS) and Charge Nurse (CN), an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified, and declared due to the facility's failure to ensure LVN 34 did not use profanity and disparaging words about and towards Resident 24 after Resident 24 continued to complain for months of verbal abuse, failure to ensure LVN 34 did not use profanity to describe Resident 24 during morning huddles while in the facility's hallway in the earshot of others, failure to ensure LVN 34 adheres to the facility's policy and procedures to prohibit abuse. The facility failed to report Resident 24's alleged verbal abuse from LVN 34 after multiple grievances were filed by Resident 24. The facility failed to investigate Resident 24's alleged verbal abuse from LVN 34 for the last 4 months. The facility failed to prevent further abuse and mistreatment from LVN 34 to Resident 24. On 1/2/23 at 6:57 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1. LVN 34 has not worked at the facility since 12/23/22 and was suspended pending investigation on 12/31/2022. 2. Resident 24 will be seen by the psychologist on 1/3/23. Facility initiated monitoring for the Resident 24 for 72 hours. 3. Abuse allegation report was submitted to CDPH, Ombudsman and Police on 12/31/2022. 4. DON/Designee initiated resident interviews to rule out any other allegations of abuse. There were 13 residents interviewed on 1/1/23, and these residents reported that there were no instances of abuse to report. 5. Grievance logs for the last 60 days were reviewed and there were no grievances that were not acted upon regarding abuse. 6. 1 on 1 in-service provided to Administrator and Director of Nursing (DON) regarding abuse prevention policy by the regional nurse consultant on 1/1/23. 7. Administrator initiated education for all staff regarding abuse prevention policy on 12/31/2022. These in-services will be completed by 1/3/23. Interdisciplinary Team will initiate person-centered interviews of residents daily. 8. Results of person-centered interviews will be communicated during the daily morning meeting and any identification of abuse will be immediately communicated to Administrator/designee. 9. Administrator/designee will investigate all staff/resident reports of abuse allegations. 10. Quarterly education regarding abuse prevention policy to be provided to participants of all staff. This education was initiated on 12/31/22 and will be ongoing for a 12-month period. Administrator will ensure adherence to the abuse prevention policy. 11. DON/Designee to conduct observation for potential abuse including use of profanity during daily huddle rounds. Observations will be conducted five times per week on a weekly basis for four weeks, or until substantial compliance is achieved. 12. Grievances will be reviewed during daily stand-up meeting by the Administrator and social services designee (SSD). Grievances received will be immediately investigated. Grievances will be reviewed weekly to verify completion. 13. Abuse allegations/investigations will be reviewed during monthly QAA meeting for trends and necessary follow ups. Grievance log will be reviewed during monthly QAA meetings to discuss trends and recommendations with Quality Assurance team. On 1/3/23 at 10:22 am, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the facility's IJ Removal Plan by observations, interviews, and record reviews. The Administrator was informed. Findings: During a review of Resident 24's Admission Record (AR), the AR indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included pedestrian with car accident with multiple fractures (broken bones) of the pelvis (large bony structure near the base of the spine), left tibia (a bone in the lower leg) and right patella (a small bone located in front of the knee joint, sacrum (a large triangular bone at the base of the spine), right ulna (a long bone in the forearm), heart failure, and a colostomy (a surgically created opening in the abdomen in which a piece of the colon is brought outside the abdominal wall to create a stoma [opening on the abdomen] through which digested food passes into an external pouching system). During a review of LVN 34's job description, dated and signed by LVN 34 on 9/21/2022, the job description indicated LVN 34's job entailed to ensure that all consumers/resident rights were protected. During an interview on 11/10/2022 at 4:50 p.m. with Resident 24, Resident 24 stated LVN 34 disrespects and talks negatively about her during the facility's shift report (Huddle). Resident 24 stated LVN 34 told staff she (Resident 24) was homeless and LVN 34 would ask her if her accident was a suicide attempt. Resident 24 stated she heard LVN 34 in the hallway outside of her room telling another staff she (Resident 24) was crazy. Resident 24 stated the comments made by LVN 34 made her feel, ignored, mistreated/abused, singled out by staff, terrible, and depressed. Resident 24 stated she is tense and apprehensive with staff. Resident 24 stated, It is hard to keep my spirits up. Resident 24 stated as of 12/27/2022, she feels depressed, stressed, humiliated, apprehensive regarding her abuse treatment from LVN 34. During a review of Resident 24's untitled care plan, dated 11/14/2022, the care plan indicated Resident 24 verbalized concerns of being verbally abuse by the nursing staff as the charge nurse (LVN 34) spoke with an aggressive tone of voice toward the resident. During a review of Resident 24's Minimum Data Set (MDS), a comprehensive assessment and care-screening tool, dated 11/16/2022, the MDS indicated Resident 24 had the ability to express ideas and wants and has clear comprehension (capability of understanding something). The MDS indicated Resident 24 needed limited assistance with toileting, personal hygiene, transferring and required supervision with bed mobility. During an interview on 12/14/2022 at 2:52 p.m. with LVN 23 (who works with LVN 34), LVN 23 stated LVN 34 would say disrespectful things about Resident 24 during the nursing staff's morning huddles (date and time unknown) and in the hallways in the earshot of others. LVN 23 stated LVN 34 would say such things about Resident 24, such as She is crazy and a complainer for others to hear. LVN 23 stated LVN 34 would refer to Resident 24's room as the special room. LVN 23 stated she have heard LVN 34 say watch out for the resident (Resident 24) as she is crazy, needy, and one should avoid her. LVN 23 stated this created an atmosphere where staff would ignore Resident 24 and not want to help her when Resident 24 called for assistance. LVN 23 stated she reported the incidents to the previous administrator. During an interview on 12/14/2022 at 4:19 p.m. with Certified Nurse Assistant (CNA) 8, CNA 8 stated she heard LVN 34 say one time (date and time unknown), at the nurse's station, during a morning huddle, that Resident 24 was homeless, and her accident was a suicide attempt [sic]. During an interview on 12/14/2022 at 5:58 p.m. with LVN 32 (who works with LVN 34), LVN 32 stated during nursing huddles (date and time unknown) she have heard LVN 34 refer to Resident 24 as Crazy and a homeless suicidal Bitch in ear shot of other staff and residents. LVN 32 stated LVN 34 is very disrespectful and abusive toward Resident 24. During an interview on 12/19/2022 at 2:57 p.m. with LVN 34, LVN 34 stated Resident 24 complained about her discussing that she was homeless in the hallways. LVN 34 stated Resident 24 reported her to the facility's corporate office for calling her names and the director of Nursing (DON) and Administrator (ADM) were made aware. LVN 34 was asked if she verbally abused Resident 24, and she denied verbally abusing the resident. During an interview on 12/19/2022 at 3:28 p.m. with the DON, the DON stated there have been multiple residents' grievances made against LVN 34 by Resident 24 and other staff members complaining about LVN 34. The DON stated LVN 34 has been written up several times for her conduct/behavior and has had multiple in-services regarding customer service. During a review of LVN 34's employee/disciplinary file indicated the following grievance forms against LVN 34: 1. The form dated 8/6/2022, indicated Resident 24 complained LVN 34 spoke unprofessionally. 2. The form dated 9/1/2022, indicated Resident 24 complained about LVN 34 being rude. 3. The form dated 9/13/2022, indicated Resident 9 complained about LVN 34 not providing a follow-up for care of an elbow lesion. 4. The form dated 9/14/2022, indicated Resident 22 complained about LVN 34's conduct of aggressive behavior and not cleaning a wound appropriately. A review of LVN 34's employee file indicated the following in-services were conducted for the LVN's behavior: 1. On 8/11/2022, an in-service titled, Code of Conduct and Approaching Co-workers indicated LVN 34 received training on customer service. 2. On 9/2/2022, an in-service titled, Code of Conduct and Approaching Co-workers LVN 34 received another in-service on customer service (less than a month after the previous in-service). 3. On 9/14/2022, an in-service titled, Code of Conduct and Approaching Co-workers LVN 34 received another training on customer service (12 days after the previous in-service). 4. On 9/17/2022, an in-service titled, Code of Conduct and Approaching Co-workers LVN 34 received another training on customer service (3 days after the previous in-service). During a review of the facility's policy and procedure (P/P) titled, Resident Rights Under Federal Law, dated 11/28/2016, the P/P indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. During a review of the facility's P/P titled, Abuse Prohibition Policy and Procedure, dated 2/23/2021, the P/P indicated verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to ensure the licensed nurses were competent (having the necessary ability and knowledge) and possessed skills to assess and identify wounds at admission and during change in condition ((COC) decline or improvement in a resident's mental or physical functioning), notify the physician of the refusal of care and treatment, develop a plan of care based on the comprehensive assessment and COC to manage the wound, notify the physician of the COC, carry-out the physician order [REDACTED]. Resident 1, who was admitted to the facility on [DATE] with orders for right lower leg wound treatment and wound consultation, was not seen by a wound specialist and had no wound treatment from 11/12/19 through 11/17/19 and from 11/19/19 through 11/22/19 (total of 9 days). The licensed nurses failed to notify Resident 1's physician of the residents' refusal for skin assessment at admission and increase in confusion, lethargy (lack of energy) on 11/21/19 and 11/22/19. These deficient practices resulted in delay in care and treatment, and Resident 1 being admitted to the general acute care hospital (GACH) on 11/22/19 for low blood pressure of 88/58 ((B/P)120/80-140/90 normal reference ranges (NRR)),[MEDICAL CONDITION] (infection in the bloodstream), acute kidney injury (kidneys stop working suddenly with decreased urine output) severe dehydration (not enough fluids in the body), and acute [MEDICAL CONDITION] (temporary confusion and change in consciousness (being alert and aware of surroundings). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of GACH 1's document titled, Patient Transfer Report, dated 11/12/19 and timed at 4 p.m., indicated the report of Resident 1's discharge orders were given to Registered Nurse 3 (RN 3) at the facility over the telephone prior to Resident 1's admission. The report indicated an order for [REDACTED]. A review of Resident 1's History and Physical (H/P), dated 11/13/19, indicated Resident 1 had no cognitive impairment (thought process for daily decision making), but required an extensive assistance (staff provide weight bearing support) of a one-person physical assist for grooming, feeding, bathing, and transferring. The H/P indicated to continue wound care consultation and daily wound dressing changes. A review of Resident 1's H/P, dated 11/18/19 indicated Resident 1 was noted with a large skin tear, after the dressing removal on 11/18/19, (six days after admission) the first time, steri-strips (pieces of medical tape used to close wounds), dried blood and swelling were noted. The H/P indicated to continue with wound care dressing changes daily and keep the steri-strips in place. A review of a Change in Condition Evaluation ((CCE) an internal communication tool), dated 11/18/19 and timed at 11:20 p.m., indicated Resident 1 had a right leg skin tear. The CCE indicated Resident 1's physician was notified on 11/18/19 at 11 a.m., with orders for Keflex (antibiotic) 500 milligrams ((mg) a unit of measurement) by mouth once a day for seven days and Bactrim (antibiotic used to treat infections) by mouth twice a day for seven days. The CCE did not indicate orders for wound consultation. A review of Resident 1's skin check, dated 11/19/19 and timed at 7:30 p.m., indicated discoloration to right lower leg with wound sutures was noted. The review of the chart did not indicate the licensed nurses' identify the discoloration as a change in condition and notify the physician. A review of a physician's telephone order, dated 11/21/19 and timed at 8:45 a.m., indicated for Resident 1 to have ammonia levels (can help identify the cause of changes in behavior and consciousness) checked in the morning for confusion and lethargy. A review of a physician's telephone order, dated 11/22/19 and timed at 2:20 p.m., indicated to transfer Resident 1 to the GACH for [MEDICAL CONDITION] (low blood pressure) and change in level of consciousness. A review of the paramedics run sheet, dated 11/22/19, indicated the paramedics saw Resident 1 at 1:19 p.m. and noted the resident to be lethargic (sluggish). The paramedics transferred the resident to GACH for altered level of consciousness (ALOC). A review of Resident 1's GACH's Emergency Department (ED) nurses progress note, dated 11/22/19 and timed at 2:05 p.m., indicated Resident 1 arrived at the ED with multiple bruises and skin tears. The ED's note indicated Resident 1 was given an aggressive volume of 2,250 milliliters ((ml) a unit of measure) fluid via intravenously ((IV) into the vein) for [MEDICAL CONDITION] of 88/58 ((B/P)120/80 normal reference ranges (NRR)). On 11/28/19 at 10:50 a.m., during an interview and review of Resident 1's wound treatment records with Licensed Vocational Nurse 1 (LVN 1), she stated there were no records found in Resident 1's clinical records for Resident 1's wound treatments. LVN 1 stated there were no treatment orders found because Resident 1 had no wounds and she had been refusing skin assessment since her arrival to the facility on [DATE]. On 12/2/19 at 11:18 a.m., during an interview, Resident 1's Power of Attorney 1 ((POA 1) written authorization to represent or act on another's behalf in private affairs, business, or legal matter) stated he was in the facility with Resident 1 almost all day daily and he never saw staff doing wound dressing changes. POA 1 stated he noticed Resident 1 became lethargic and was different on 11/21/19 and notified the staff, but nothing was done. POA 1 stated he had to call POA 2 to inform him of Resident 1's appearance. POA 1 stated POA 2 had to call the facility once to ask for a nurse to go see Resident 1 due to Resident 1's lethargy and appearance. On 12/2/19 at 1:32 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated she notified the charge nurse of Resident 1's complaints of leg pain on 11/21/19 and 11/22/19. CNA 1 stated on 11/22/19 she gave Resident 1 a bed bath and noticed the dressing on Resident 1's right leg but did not remove it. CNA 1 stated she was not aware if the dressing to the right leg was changed or not since the CNAs were not allowed to remove wound dressings. CNA 1 stated the wound dressing was usually removed by the licensed nurse after the residents were bathe. CNA 1 stated she notified the charge nurse regarding Resident 1 appearing unusual from her normal self. On 12/2/19 at 2:25 p.m., during an interview and review of Resident 1's nurses notes, RN 1 stated Resident 1's wound on the right lower leg was observed on 11/18/19, six days after admission. RN 1 stated there were no records found of Resident 1's skin tear to the right lower leg prior to 11/18/19. RN 1 stated the wound dressing was removed for the first time on 11/18/19 by the nurse practitioner ((NP) advanced practice registered nurse and a type of mid-level practitioner) six (6) days after Resident 1's admission to the facility. On 12/3/19 at 2:38 p.m., during a telephone interview, the NP stated on 11/18/19 during her rounds at the facility she was called to Resident 1's room to see a wound that had not been assessed or had the dressing changed since admission. The NP stated upon assessment, the gauze was difficult to remove from Resident 1's lower leg because it was stuck due to dry blood. The NP stated upon removal of the gauze, the wound was noted in bad condition, with dried blood and steri-strips on the wound. The NP stated part of Resident 1's skin peeled off when the gauze was being removed and small amount of blood was noted with no odor, but swelling was present on the edges of the wound. The NP stated the facility had standing orders for Resident 1's wound treatment and they should had notified the physician if Resident 1 was refusing skin assessments and the facility should have call for a wound consultation per the physician orders. On 12/6/19 at 3:59 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated it was the responsibility of the facility to notify him of Resident 1's refusal for skin assessments. Physician 1 stated he was not made aware Resident 1 had a wound to her right lower leg. On 12/10/19 at 1:50 p.m., during a telephone interview, RN 3 stated she remembered receiving a report from GACH regarding Resident 1's wound treatment but Resident 1 refused skin assessment upon arrival to the facility on [DATE]. RN 3 stated upon resident's admission, the staff receiving the admission was to call the physician and clarify all orders to ensure care was provided to the resident according to their diagnoses. RN 3 stated she did not transcribe (write out notes into ordinary sentences) the physician orders [REDACTED]. On 12/13/19 at 1:23 p.m., during an interview and review of Resident 1's physician orders, the Administrator (ADM) stated there were no orders for wound treatment or wound consultation found prior to 11/18/19. The ADM stated there was no wound assessment, treatment or consultation done for Resident 1. The ADM stated the orders should had been transcribed upon admission and an initial care plan created. The ADM stated there were no notes regarding Resident 1's physician notification of Resident 1's skin assessment refusal. On 12/16/19 at 12:35 p.m., during a telephone interview, the ADM stated there were no progress notes found in Resident 1's clinical record regarding the physician orders [REDACTED]. The ADM stated there was no nurses' documentation of Resident 1's COC found for the 11/21/19. A review of the facility's revised policy on 11/1/19 and titled, Assessment: Nursing, indicated a nursing assessment would be performed by a licensed nurse for all residents within 24 hours of admission to determine resident's condition and clinical needs. The policy indicated a care plan would be created based on the assessment and physician notification of assessment results. A review of the facility's revised policy on 11/1/19 titled, Treatments, indicated the facility staff would perform order treatments per state regulations. The policy indicated if a resident refuses treatment, the staff is to return later and attempt again. The policy indicated to notify physician of any COCs and document in the clinical chart refusal of treatment.

Based on interview and record review, the facility failed to assess a wound upon admission in accordance with the facility's policy and procedure, receive wound care and treatment and wound consultation in accordance with the physician's orders [REDACTED]. Resident 1 was admitted to the facility with a wound to the right lower leg. The licensed nurse did not assess Resident 1 for presence of wounds up to six days (11/12/19 to 11/18/19) from admission, did not implement the physician's orders [REDACTED]. These deficient practices resulted in Resident 1's wounds becoming infected and necrotic (death of cells or tissues from inadequate blood supply of skin) located on bilateral forearms, right lower leg, and sacrum (triangular bone in the lower back) Resident 1 required a transfer to a general acute care hospital (GACH 2) due to altered level of consciousness (ALOC), lethargy (sluggish) and in septic shock (blood pressure fails and the organs of the body fail to receive sufficient oxygen caused by an infection in the bloodstream). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of GACH 1's document titled, Patient Transfer Report, dated 11/12/19 and timed at 4 p.m., indicated the report of Resident 1's discharge orders were given to Registered Nurse 3 (RN 3) at the facility over the telephone prior to Resident 1's admission. The report indicated an order for [REDACTED]. A review of Resident 1's History and Physical (H/P), dated 11/13/19, indicated Resident 1 had no cognitive impairment (thought process for daily decision making), but required an extensive assistance (staff provide weight bearing support) of a one-person physical assist for grooming, feeding, bathing, and transferring. The H/P indicated to continue wound care consultation and daily wound dressing changes. A review of a Change in Condition Evaluation ((CCE) an internal communication tool), dated 11/18/19 and timed at 11:20 p.m., indicated Resident 1 had a right leg skin tear. The CCE indicated Resident 1's physician was notified on 11/18/19 at 11 a.m., with orders for Keflex (antibiotic) 500 milligrams (mg, a unit of measurement) by mouth once a day for seven days and Bactrim (antibiotic used to treat infections) by mouth twice a day for seven days. The CCE did not indicate orders for wound consultation. A review of Resident 1's H/P, dated 11/18/19, indicated Resident 1 was noted with a large skin tear, after the dressing removal on 11/18/19 (six days after admission) for the first time; steri-strips (pieces of medical tape used to close wounds), dried blood and swelling were noted. The H/P indicated to continue with wound care dressing changes daily and keep the steri-strips in place. A review of Resident 1's skin check, dated 11/19/19 and timed at 7:30 p.m., indicated discoloration to right lower leg with wound sutures was noted. A review of a physician's telephone order, dated 11/21/19 and timed at 8:45 a.m., indicated for Resident 1 to have ammonia levels (can help identify the cause of changes in behavior and consciousness) checked in the morning for confusion and lethargy. A review of a physician's telephone order, dated 11/22/19 and timed at 2:20 p.m., indicated to transfer Resident 1 to the GACH for [MEDICAL CONDITION] (low blood pressure) and change in level of consciousness. A review of the paramedics run sheet, dated 11/22/19, indicated the paramedics saw Resident 1 at 1:19 p.m. and noted the resident to be lethargic (sluggish). The paramedics transferred the resident to the GACH for altered level of consciousness (ALOC). A review of Resident 1's GACH's Emergency Department (ED) nurses progress note, dated 11/22/19 and timed at 2:05 p.m. indicated Resident 1 arrived at the ED with multiple bruises and skin tears. The ED's note indicated Resident 1 was given an aggressive volume of 2,250 milliliters ((ml) unit of measure) fluid via intravenously ((IV) into the vein) for [MEDICAL CONDITION] of 88/58 ((a blood pressure, B/P) 120/80 normal reference ranges (NRR)). A review of Resident 1's GACH H/P, dated 11/22/19 and timed at 6:55 p.m., indicated Resident 1 was noted with purpura (rash of purple spots on the skin) on both arms and left upper extremity skin tear with dried blood. A review of Resident 1's GACH Consultation, dated 11/26/19 and timed at 3:30 p.m. indicated Resident 1's right lower extremity wound measured five (5) centimeters ((cm) unit of measure) by 10 cm with multiple moist (humid) partially lifted steri-strips, multiple loose sutures, small amount of cloudy yellowish discharge and with 100% necrotic tissue. A review of Resident 1's GACH document titled, Incision/Wound, indicated Resident 1 presented to the GACH with left forearm, bilateral groin maceration (softening and breakdown of the skin) on the buttocks, and right lower leg injuries. On 11/28/19 at 10:50 a.m., during an interview and review of Resident 1's wound treatment records with Licensed Vocational Nurse 1 (LVN 1), she stated there were no records found in Resident 1's clinical records for Resident 1's wound treatments. LVN 1 stated there were no treatment orders found because Resident 1 had no wounds and she had been refusing skin assessment since her arrival to the facility on [DATE]. On 12/2/19 at 2:25 p.m., during an interview and review of Resident 1's nurses notes, RN 1 stated Resident 1's wound on the right lower leg was observed on 11/18/19, six days after admission. RN 1 stated there were no records found of Resident 1's skin tear to the right lower leg prior to 11/18/19. RN 1 stated the wound dressing was removed for the first time on 11/18/19 by the nurse practitioner ((NP) advanced practice registered nurse and a type of mid-level practitioner) six (6) days after Resident 1's admission to the facility. On 12/3/19 at 2:38 p.m., during a telephone interview, the NP stated on 11/18/19 during her rounds at the facility, she was called to Resident 1's room to see a wound that had not been assessed or had the dressing changed since admission. The NP stated upon assessment, the gauze was difficult to remove from Resident 1's lower leg because it was stuck due to dry blood. The NP stated upon removal of the gauze, the wound was noted in bad condition, with dried blood and steri-strips on the wound. The NP stated part of Resident 1's skin peeled off when the gauze was being removed and small amount of blood was noted with no odor, but swelling was present on the edges of the wound. The NP stated the facility had standing orders for Resident 1's wound treatment and they should had notified the physician if Resident 1 was refusing skin assessments, The NP stated the facility should have call for a wound consultation per the physician orders. On 12/3/19 at 4:50 p.m., during an interview and review of Resident 1's nurses notes, RN 2 stated Resident 1 refused skin assessment upon admission on 11/12/19. RN 2 stated there was no documentation found of the physician notification of Resident 1's refusal for skin assessment. RN 2 stated the staff was to document and notify the physician to attain new orders. On 12/6/19 at 3:59 p.m., during a telephone interview, Resident 1's physician (Physician 1) stated it was the responsibility of the facility to notify him of Resident 1's refusal for skin assessments. Physician 1 stated he was not made aware Resident 1 had a wound to her right lower leg. On 12/10/19 at 1:50 p.m., during a telephone interview, RN 3 stated she remembered receiving a report from the GACH regarding Resident 1's wound treatment but Resident 1 refused skin assessment upon arrival to the facility on [DATE]. RN 3 stated upon resident's admission, the staff receiving the admission was to call the physician and clarify all orders to ensure care was provided to the resident according to their diagnoses. RN 3 stated she did not transcribe (write out notes into ordinary sentences) the physician orders [REDACTED]. On 12/13/19 at 1:23 p.m., during an interview and review of Resident 1's physician orders, the Administrator (ADM) stated there were no orders for wound treatment or wound consultation found prior to 11/18/19. The ADM stated there was no wound assessment, treatment or consultation done for Resident 1. The ADM stated the orders should had been transcribed upon admission and an initial care plan created. The ADM stated there were no notes regarding Resident 1's physician notification of Resident 1's skin assessment refusal. On 12/30/19 at 12:14 p.m., during a telephone interview, the ADM stated of not being aware of Resident 1's multiple injuries to the body. The ADM stated the staff did not mention Resident I had injuries to bilateral arms, sacrum or right leg. A review of the facility's policy and procedure titled, Assessment: Nursing, revised on 11/1/19 indicated the purpose of the police was to determine resident's condition and clinical needs. The policy indicated per standards of practice, upon admission a complete nursing assessment would be perform. The policy indicated an initial nursing assessment within 24 hours of admission and expanded nursing assessment within three to five days and notify physician/NP of the assessment results and document physician/NP response. A review of the facility's policy titled, Treatments, revised on 11/1/19 indicated a licensed nurse or medical technician, per state regulations, will perform ordered treatments. If treatments are refused by resident, attempt again later and notify physician of any significant changes and document on resident's Treatment Administration Record (TAR).

Based on observation, interview and record review, the facility: 1. Failed to secure the main entrance door and Station 2 exit door after business hours. The main exit door and Station 2 exit door had broken locks which could not be locked from the outside, making it easy for an unauthorized persons from entering without notice. 2. Failed to provide adequate training for nursing staff on how to use the appropriate type of keys to lock the exit doors. The licensed staff were unable to demonstrate using the correct keys and the proper method of locking the doors. 3. Failed to have a system in place to ensure persons entering the facility, signed in and were authorized to be in the facility. These deficient practices resulted in; a. Resident 13 stated a Certified Nurse Assistant (CNA) had told him a person was found dead at the back of the facility near the dumpster. The resident stated it bothered me, I thought about it and could not sleep for two nights. The resident stated I have seen a few homeless people walking at the back of the facility, which made him fearful. b. Resident 18 witnessed a transient walking through the front main door of the facility and began to pull his pants down in front of her. Even though the Administrator was informed about the incident, nothing was done. The resident stated I stay up at night for that reason. People are always going in and out the doors of this facility at all hours of the night and nothing is being done about it. and potential for 72 total resident census to be harmed or injured. An Immediate Jeopardy (IJ) was called on 3/11/18 at 12:50 p.m., and on 3/12/18 at 6:47 p.m., the IJ was lifted in the presence of the Center Executive Director (CED). Findings: a. During a resident group meeting on 3/10/18 at 3:13 p.m., three of 6 residents (Resident 13, 18 and 65) stated they had concerns about the exit doors not being locked at night making it easy for an unauthorized persons to come into the facility. Resident 13 stated Station 1 emergency door was unlocked the previous Sunday and did not alarm when people came in and out of the building. Resident 18 stated in (MONTH) of last year at around 11 p.m., she was watching television (TV) in the activity room which was directly in front of the main exit door to the lobby, when a man came into the building and started to drop his pants in front of her. The residents stated they were fearful for their safety. During the interview Resident 65 stated she goes to [MEDICAL TREATMENT] (a process of purifying the blood of a person whose kidneys are not working normally) center at 2 a.m., three times a week with the family member who picks her up from the facility. Resident 65 stated the main exit doors are not locked. The resident stated when she is picked up, there were no alarms when the doors opened. During an unannounced visit to the facility on [DATE] at 12:15 a.m., Station 2's exit doors was unlocked from the outside. There was an audible alarm when the the door was opened. The audible sound stopped when the door closed. There was no staff observed along Station 2's hallway and no staff came to check who was entering the building. The room directly to the left of Station 2's exit door was observed with a family member inside the room. The family member stated both his parents (Resident 27 and Resident 217) were in the room and he was visiting them. There was no facility staff who approached the room to see who entered the facility, while speaking with the family member. On 3/11/18 at 12:22 a.m., when walking down Station 2 hallway, observed Licensed Vocational Nurse (LVN 7) charge nurse sitting at station. LVN 7 stated she worked 3 p.m. to 11 p.m., but was completing her documentation (charting). On 3/11/18 at 12:23 a.m., observed Licensed Vocational Nurse (LVN 8) sitting in Station 1 located in front of the main exit door. On 3/11/18 at 12:25 a.m., a staff was observed sitting in the doctor's (MD) charting room across from Station 3. LVN 1, who was observed sitting at the station stated the staff in the MD charting room was a certified nurse assistant. LVN 1 stated she worked from 3 p.m. to 11 p.m., but stayed to complete her documentation (charting). On 3/11/18 at 12:28 a.m., in the presence of LVN 8, all of the facility's exit doors were inspected. The following were observed: 1. Station 3: The exit door had audible continuous alarm when opened from outside. A code was necessary to stop the alarm from sounding. The door was not locked from the outside. 2. Station 2: The exit door was unlocked. The door had an audible sound but would stop when the door closed. 3. Station 1: The exit door was locked from outside. During a concurrent interview with LVN 8 stated he unlocked the exit door by Station 2 because a family member was visiting and did not want the alarm to go off and bother other residents every time the family member came into the building. During an interview with Certified Nurse Assistant (CNA 3) on 3/11/18 at 12:32 p.m., stated she worked for the facility from 7 a.m. to 3 p.m., but was a private care giver to Resident 27 and Resident 217. CNA 3 stated she worked the previous night from 3 p.m. to 8 p.m., Station 2 doors should be locked at 8 p.m. CNA 3 stated there was a beep when the door opened but not as loud as the one on Station 3. On 3/11/18 at 1:00 p.m. in the presence of the Chief Nursing Executive (NE), the Visitor log book did not show a signature for Resident 27's family member and or Resident 217 for the previous night. On 3/11/18 at 1:13 p.m. during an interview with LVN 6 stated the protocols for visitors was to use the main exit door during off hours. LVN 6 stated visitors were to sign in at the reception area where there was a log book. On 3/11/18 at 3:30 p.m. during a follow interview with LVN 7 stated she first noticed the Surveyor in the unit the previous night (3/10/18) when she walked past Station 2. LVN 7 stated she did hear the door alarm go off but did not check who was at the door. LVN 7 stated she was tired and was trying to go home. LVN 7 stated she could not account for all the CNAs during that time. LVN 7 stated it was a protocol to stand up and check who was at the door when the audible alarm was heard. LVN 7 stated she was aware the family member for Resident 27 and 217 was in the room. LVN stated the family member came in around 10 p.m. and came in through the side door (Station 2). LVN 7 confirmed the door was unlocked at that time but was supposed to have been locked at 8 p.m. LVN 7 stated she had the keys to the door but it skipped her mind to lock the door. During a demonstration of locking Station 2 exit doors on 3/11/18 at 3:37 p.m., LVN 7 was observed to put a key into a metal box between the two doors. After several attempts to lock the doors, LVN 7 stated the key was not turning completely making it unable to lock the doors. During an interview with the maintenance supervisor (MS) on 3/11/18 at 4:42 p.m., stated the metal box between the doors was for the alarm sound box, not a lock. MS was observed to use an Allen wrench (an L-shaped metal bar with a hexagonal head at each end) to turn the lock under the right handle bar in order to lock the door. b. During a witnessed inspection of the exit doors accompanied by maintenance supervisor (MS) and interviews on 3/11/18 at 11:00 a.m., due to Resident 18 complaining about witnessing an unidentified person in the facility at night. During a concurrent interview MS stated the nurses are supposed to lock the door from 7 p.m. to 7 a.m., and the keys were kept in the medication cart. The exit doors to station 1, 2, and 3, were observed on the south back alley of the facility and in close proximity to residential apartments, and a car dealership. The main entrance lobby door opened across from a motor vehicle shop, residential apartments, with a major cross street. During a concurrent interview with Resident 13 also stated the front lobby door had not locked in the past. MS was unable to lock the front lobby door even when using a screw driver and key. The MS confirmed the main entrance double doors failed to lock. During an interview on 3/11/18 at 11:46 a.m., the Center Nursing Executive (CNE) stated the charge nurses had keys to all the exit doors. During an interview on 3/11/18 at 11:53 a.m., Licensed Vocational Nurse (LVN 3) at Station 2 stated she occasionally worked from 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shifts. LVN 3 stated the charge nurse locked the exit door to their stations as soon as it got dark for residents safety. LVN 3 stated if a resident returned from treatment at night, the charge nurse opened the exit door and immediately closed the door. LVN 3 was observed to attempt to lock Station 2 back exit door several times and each time, upon testing, the exit door could be opened from the outside of the building. LVN 3 stated there used to be a key hanging by Station 2 exit door but it was missing. During a review of Resident 13's Admission Records indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a standardized assessment tool and care-screening tool, dated 12/20/17, indicated Resident 13 was cognitively (ability to learn, remember, reason, and make decisions) intact. During an interview on 3/11/18 at 5:15 PM, Resident 13 stated a Certified Nurse Assistant (CNA) had told him a person was found dead at the back of the facility near the dumpster. The resident stated it bothered me, I thought about it and could not sleep for two nights. The resident stated I have seen a few homeless people walking at the back of the facility, which made him fearful. During an interview on 3/11/18 at 5:29 PM, when asked about a body found on the facility's property, along with the front lobby and back exit doors not locking, the Center Executive Director (CED) stated a young man killed himself on this property and there was blood every where. The body had a suicide note. The CED stated a psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of [REDACTED]. The CED stated I could not sleep for two weeks. I slept with my lights on at night. The CED stated neither she nor the staff knew a screw and a wrench were needed to lock the main and back exit doors. The CED stated probably was the reason the doors were not locked. The CED stated both Maintenance Supervisor (MS) and CED tightened some loose screws on the front lobby door before the door could be locked. The CED stated was not aware the doors did not lock and would have gone to the facility in 10 minutes. The CED stated we absolutely deserve the Immediate Jeopardy ((IJ) a non compliance situation likely to cause, result in harm, serious injury, impairment, or death to a resident). The CED stated the facility staff informed her on 3/11/18 at 12:30 a.m., about the lobby and back exit doors which could not be locked and the Surveyor was in the building. c. During a phone interview on 3/12/18 at 7:15 pm., Resident 65 stated my son comes to the facility three times a week at 2:00 a.m. to pick me up for [MEDICAL TREATMENT] treatment scheduled at 4:00 am. He comes through the front door of the facility and the side door next to my room. The doors never were locked and the alarm on the side door or front door never went off. A review of Resident 65's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/27/18 indicated the resident had no cognitive (thought process) impairment. d. During an interview with Resident 18 on 3/11/18 at 9:15 am, stated in (MONTH) around 11:00 p.m., while watching television in the activities room, the resident witnessed a transient walking through the front main door of the facility and began to pull his pants down in front of her. Resident 18 stated, I think he was about to go to the bathroom on the floor, I told him if he did not want to go to jail or be arrested, he should leave. Resident 18 stated luckily he left the facility. The resident stated she informed the Administrator about the incident but nothing was done. The resident stated I stay up at night for that reason. People are always going in and out the doors of this facility at all hours of the night and nothing is being done about it. A review of Resident 18's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/23/17 indicated the resident did not have any cognitive (thought process) impairment. A review of the facility's policy and procedures titled Visitation revised on 11/28/16, indicated that reasonable restrictions shall be imposed, to protect the security of all the center's residents and the center shall be locked at night.

Based on observation, interview, and record review the facility staff failed to ensure 2 of 16 sample residents (10, 2), with a limited range of motion received appropriate treatment and services to increase range of motion and prevent further decrease in range of motion. Resident 10, who was admitted after hip surgery, stated she was not walking with the assistance of the restorative nursing assistant (RNA) as ordered by the physician, and was not receiving pain medications prior to being walked. As a result, the resident declined in the ability to walk at a farther distance, experienced pain when walking, and did not reach maximum rehabilitation potential. The facility staff failed to properly apply Resident 2's hand splints as ordered by the physician, which had the potential to cause further decline in range of motion. Findings: 1. On May 4, 2012, at 6:10 p.m., an interview was conducted with Resident 10 who was alert, oriented and able to make her needs known. She stated there was an order written [REDACTED]. The resident stated after being discharged from physical therapy, she had been assisted with walking only three times. The resident stated her legs felt weak, and her right hip was stiffening up. She stated she was unable to walk for a long period of time because she was experiencing a lot of pain in her legs and left knee, especially when ambulating. She said she was unable to walk without taking pain medications. She stated that she was not medicated daily before attempting to ambulate with the RNA, to enable her to tolerate walking. A review of Resident 10's Face Sheet indicated she was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's Nursing Admission and assessment dated on admission indicated the resident was admitted with surgical staples on the right hip incision site . A review of the resident's Minimum Data Set, dated dated dated [DATE], indicated the resident was assessed with [REDACTED]. In addition, the resident was assessed as requiring extensive assistance in transferring from bed to chair, and extensive assistance in ambulating in and around the corridors in a wheelchair. The resident was assessed as requiring a pain medication regimen, received pain medications as needed having pain at any time of the day, and had limited day-to-day activities because of the pain. A review of a comprehensive pain assessment dated [DATE] indicated the resident had pain related to a history of right [MEDICAL CONDITION]. At the time of the assessment, the resident did not complain of pain. However, on May 3, 2012, another comprehensive pain assessment was completed. On this day, the resident complained of pain to the left knee and rated the pain 6 on a scale of 1 to 10 (10 being the highest rating of pain). The facility utilizes a pain rating scale as follows: 0 to 1(no pain), 2 to 3 (mild pain), 4 to 5 (moderate pain), 6 to 7 (severe pain), 8 to 9 (very severe pain) and 10 (worst possible pain). A review of Resident 10's care plan for Pain dated February 3, 2012, indicated the goal was for the resident to receive pain medication to alleviate pain. In order to achieve this goal, the nurse was to assess the resident's level of pain by using a pain rating scale, administer pain medication as ordered, and evaluate the need to provide pain medications 30 minutes prior to treatment or therapy. A review of Resident 10's recapitulation of physician orders [REDACTED]. On April 13, 2012, an order was written to give the resident [MEDICATION NAME] 7.5 milligrams (mg) twice a day for mild pain of the right hip and knees. A review of the Physical Therapist's discharge summary dated April 11, 2012, indicated on March 5, 2012, the resident was walking at a distance of 20 feet and upon discharge from physical therapy, she was walking a distance of 100 feet. The long-term goal for reaching maximum potential indicated the resident will safely ambulate 100 feet with a front wheel walker on level surfaces and in the hallway with stand by assist having the ability to maintain balance, without losing balance in order to increase independence and safety in room, and increase independence in ambulation. A review of the RNA Care Plan dated April 13, 2012, indicated the resident was at risk for a decline in ambulation. The goal was to maintain ambulation status, by implementation of ambulation by the RNA 5 days a week. However, there was no physican's order until April 24, 2012, at 9:30 a.m., to discontinue physical therapy treatment and for the RNA to ambulate with the resident using a front wheel walker, five times a week. On May 4, 2012, at 6:30 p.m., an interview was conducted with RNA 1 assigned to Resident 10 who stated the RNAs alternate their assignments, and who was not generally assigned to Resident 10. RNA 1 stated whenever she ambulates Resident 10, the resident was unable to walk longer than 5 minutes because she complained of too much pain in the knees and legs. RNA 1 stated that in the past, she informed a charge nurse that resident 10 was in pain whenever she attempts to walk her. RNA 1 was unable to remember when she informed the charge nurse of the resident's pain, and didn't remember which charge nurse it was that she informed. RNA 1 could not provide documentation that the resident was ambulated from April 11, 2012, to April 24, 2012. A review of Resident 10's Pain Assessment Flow Sheet, Controlled Drug Record, and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident ' s pain was relieved after receiving the [MEDICATION NAME] on these occasions. There was no clear documentation that the [MEDICATION NAME] was administered in coordination with ambulation to enable her to tolerate the treatment. A review of the RNA Record indicated there was no documentation to indicate the resident was ambulated from April 11, 2012, to April 24, 2012. The documentation indicated a RNA ambulated Resident 10 using a front wheel walker on April 24, 25, 26, 27, and 30, 2012, and May 1, 2, 3, and 4, 2012. There was no documented evidence that the RNA notified a licensed nurse to premedicate the resident with [MEDICATION NAME] prior to ambulation from April 20, 2012 to May 4, 2012, or any indication the resident was evaluated for the need to received pain medication 30 minutes prior to therapy in accordance with the resident ' s care plan. On May 5, 2012, at 9:30am, a review and comparison of the the RNA documentation, the MAR, Pain Assessment Flow Sheet, and nursing notes was done with the Registered Nurse (RN) Supervisor, revealing there was no clear indication that the RNAs communicated to the licensed staff that Resident 10 was unable to tolerate walking without being premedicated with [MEDICATION NAME]. The RN Supervisor was questioned if Resident 10 was re-assessed for pain management after the comprehensive pain assessment performed on May 3, 2012. The RN Supervisor stated she was unaware that the resident needed pain medication prior to walking, and she was not reassessed for pain management. She also could not provide a MAR indicated [REDACTED]. On May 5, 2012, sometime after the interview, the RN Supervisor re-assessed Resident 10 for pain and completed a comprehensive pain assessment that revealed the resident had hip pain rated 4 to 6 out of 10 when walking less than 70 feet, and bilateral knee pain rated at 9 to 10 out of 10 pain level when walking greater than 70 feet. The assessment also indicated the resident ' s pain was tolerable if medicated before activity. On May 5, 2012, at 1 p.m., an interview was conducted with the Physical Therapist (PT) who stated he received an order to re-evaluate the resident's ability to ambulate. The resident was given pain medication 30 minutes prior to his evaluation. The results of the evaluation revealed the resident was able to walk 90 feet down the corridors of the facility with the use of a front wheel walker. The PT stated when he discharged Resident 10 from physical therapy on April 11, 2012, she was able to walk 100 feet down the corridors, 10 feet farther than at the present time. The goal at that time was for the resident to walk a distance of more than 100 feet if the RNA continued to walk the resident five days a week as ordered. He stated that he discharged Resident 10 to be ambulated by the RNA on April 11, 2012, however he could not provide any documentation that Resident 10 was being ambulated from April 11, 2012 to April 24, 2012, when the physcian wrote an order to discharge the resident to the RNA program. A review of the facility's policy and procedure for Pain Management revised on August 31, 2009, indicated it assessment, management, and documentation of pain will be conducted to provide maximum comfort and enhanced quality of life. Following the initial assessment, the licensed nurse will monitor the resident for pain .... when there is a significant change in condition and with events/treatments likely to produce pain. 2. A review of Resident 2 ' s medical record revealed he had [DIAGNOSES REDACTED]. Resident 2 ' s Minimum Data Set (MDS) assessment dated [DATE], revealed he was alert with confusion, dependent on staff for all his activities of daily living. He was assessed as having limited range of motion to his upper and lower extremities (arms and legs). The plan included applying hand splints. A review of the physician's order [REDACTED]. The Restorative nursing assistant (RNA) to provide range of motion (ROM) services to both upper extremities as tolerated and for bilateral hand splints 4 to 6 hours a day. A review of the care plan dated February 28, 2012, indicated Resident 2 was at risk for further deformity and contracture of the arms and hands. The plan of care included applying the splints to reduce the risk of further decline in range of motion; splints would be applied and monitored every 4 to 6 hours a day as tolerated. During an observation with the MDS Coordinator on May 3, 2012 at 5:45 p.m., Resident 2's hand splints were not in place. The splints were loose and were situated at the resident ' s elbows. The resident ' s fingers and wrists were observed in a closed fist position, and the wrist was turned inward. The splints were missing straps and/or attachment mechanisms. During an interview with MDS Coordinator at the same time as the observation, she stated the splints may not be the right ones for this resident. She stated that due to the resident ' s medical condition, he would not be able to keep the splints on without straps/attachments. She stated she would immediately get an occupational therapist on board to assess the resident. Staff 3 attempted to reapply the bilateral hand splints but they did not fit the resident. A review of the facility ' s policy titled, " Orthotics " dated February 1, 2012, indicated hand splints are used to support or immobilize joints and correct deformities. Ongoing assessment included assessing alignment of the splints and adjusting the straps/attachment mechanisms accordingly to maximize outcome with adequate comfort.

Based on observation, interview and record review, the facility failed to assess and monitor the residents' pain level prior to physical therapy (PT) treatment, prior to application and after removal of bilateral hand splints, failed to administer pain medications as ordered based on the residents' pain scale rating, and to evaluate the resident for the need of routine pain medication for three of ten sample residents (17, 2 and 18). This had the potential for unnecessary pain during treatment and decline in physical function and/or ambulation ability. Findings: a. On June 30, 2012, at 2:30 p.m., Resident 17 was observed lying in bed. During an interview the resident stated that she was admitted to the facility for rehabilitation treatment. She stated she only stood up at her bed side three times on different days, one for three seconds, another day for two minutes, and then three minutes. The resident stated that she was able to walk prior to hospitalization and would like to walk again. When asked if she had pain during the therapy treatment, she stated she had pain to her right leg, with a pain scale rating of 1 to 4 pain (mild pain) before the (PT) treatment. After the PT treatment she had pain at a rating of 7 to 8 (severe pain). The resident stated that she was receiving [MEDICATION NAME] pain medication before PT treatment, however she still had pain. On June 30, 2012, at 3:25 p.m., Registered Nurse 2 (RN 2), was asked to interview the resident regarding her pain during PT treatment. RN 2 stated Resident 17 stated she had pain to her right leg before PT treatment and the pain scale rating was 1 to 4 (mild pain), and after the PT treatment she had pain at a rate of 8 out of 10 (severe pain). According to the admission record, Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognition was intact, required limited to extensive assistance from staff with activities of daily living, and ambulation had not occurred. The care plan for "chronic pain" was initiated on May 5, 2012; however the plan of care did not indicate the cause or source of the chronic pain. The goal was for the resident to achieve a zero pain level. The approaches included to assess the level of pain using a pain rating scale (1 to 10 with 10 being the most severe pain), to administer pain medication as ordered, to monitor response using the pain scale related to medications, treatments, and procedures. Another care plan was initiated on June 25, 2012, for pain medication prior to physical therapy. The goal was for the resident to be able to perform physical therapy treatment without pain. The approaches included [MEDICATION NAME] 50 milligrams (mgs) by mouth three times a day, to educate the resident regarding pain, and to monitor the pain using the pain scale prior to and after rehabilitation treatment. The resident had a physician's orders [REDACTED]. ([MEDICATION NAME] is a narcotic-like pain reliever to treat moderate to severe pain). On May 31, 2012, orders were obtained for [MEDICATION NAME] 5/325 milligrams (mgs) by mouth every six hours as needed (PRN) for pain scale level 7 to 10 (severe pain), ([MEDICATION NAME] is a narcotic pain reliever to treat moderate to severe pain), and Tylenol 325 mgs two tablets by mouth every four hours PRN for pain scale level 1 to 3 (mild pain). The resident had PT treatment daily five times a week. A review of the PT daily documentation from May 30 to June 29, 2012, indicated there was no specific time when the PT treatment was provided to the resident. The PT daily documentation indicated on May 30, 2012 and June 4, 2012, the resident complained of right buttock wound pain. There was no documented pain scale level, whether there was communication between the physical therapist and licensed nurses regarding the resident's pain, or if pain medication was administered when the resident complained of the pain, to ensure a "zero" level of pain as indicated in the care plan. The PT daily note dated June 23, 2012, indicated the resident complained of a pain level of 6 out of 10 (moderate pain) to her right foot. The note indicated the resident was pre-medicated. However, a review of the Medication Administration Record (MAR) revealed there was no documented evidence the resident was pre-medicated. Further review of the PT daily documentation revealed there was no documented evidence the resident was being assessed for pain on a daily basis before the PT treatment was provided, as indicated in the care plan, except on May 30, 2012, June 4, 2012, and June 23, 2012. During a telephone interview on July 5, 2012, at 10 a.m., with the assigned PT staff, he stated he usually provided the PT treatment to the resident between 11 a.m. to 11:30 a.m. He stated the resident "always" complained of pain to her right leg and lower buttock sacral wound, and he stated the pain was a "dull" pain. He stated he did not document it because it was a dull pain and the resident stated she was okay. When asked if he communicated what the resident said during the PT treatment to the licensed nurses, he said that he didn't but he should have. A review of undated rehabilitation department's procedure for "pain proper protocol" indicated if the resident experiences pain, pre-medicate 30 minutes prior. If the pain remains, consult the nurse for additional PRN pain medication for breakout pain, and wait for 30 minutes. If the pain level remains, the nurse must call the physician and the rehabilitation staff must change their treatment activity that day, and consider adding a modality to decrease pain. The procedure also indicated that the daily note must include the pain level during treatment, the pain location, pre-medication timeline and strategies to decrease pain. b. On June 30, 2012, at 9:30 a.m., Resident 2 was observed in the activity room, sitting in a gerichair (reclining chair), with hand splints applied. The resident was not able to be interviewed. According to the admission record the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated April 28, 2012, indicated the resident's cognition was severely impaired and was totally dependent on staff with activities of daily living (walking, transferring, eating and bathing) except with bed mobility. The care plan developed for "pain" revised June 21, 2012, indicated the resident was at risk for discomfort. The approaches included to assess the resident's level of pain using the pain scale (1 to 10, with 10 being the most severe pain), and to monitor the resident's response using the pain scale related to medications, treatments and procedures. The resident had a physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) from June 1 to 30, 2012, reflected the order for Tylenol 650 mgs by mouth daily 30 minutes prior to application of bilateral hand splints, to be applied from 7 a.m. to 3 p.m. However, there was no specific time documented on the MAR as to when the Tylenol was administered. There was no documentation that the resident was assessed and/or monitored for the level of pain prior to application and removal of the hand splints as indicated in the plan of care. During an interview with Registered Nurse 1 on June 30, 2012, at 3 p.m., she stated the licensed nurses should have assessed and monitored the resident for pain prior to and after removal of the hand splints. The facility "Pain Management" policy and procedure revised date of August 31, 2009. The licensed nurse shall administer pain medication as ordered and document on the MAR, the drug, time of administration, dose, pain scale rating pre-medication and the resident's response to medication a minimum of one hour post pain medication, using the pain scale rating. However, this was not followed for Resident 2. c. According to the admission record Resident 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Another order was obtained on the same date for [MEDICATION NAME] two tablets every four hours for severe pain (pain scale level 7 to 10). The facility used a pain level scale of 1 to 10 (10 being the most severe pain). A review of the Medication Administration Record (MAR) pain assessment flow sheet from June 16 to 29, 2012, indicated the following: 1. On June 21, 2012, at 12:35 a.m., the resident complained of knee pain and the pain scale level was assessed as 3 out of 10 (mild pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. 2. On June 26, 2012, at 5:45 a.m. and June 27, 2012, at 12:30 a.m., the resident complained of back pain and the pain scale level was assessed as 6 out of 10 (moderate pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. 3. On June 28, 2012, at 2:50 a.m., the resident complained of back pain and the pain scale level was assessed as 5 out of 10 (moderate pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. Further review of the MAR from June 16 to 29, 2012, indicated the resident received [MEDICATION NAME] two tablets 22 times and [MEDICATION NAME] 5/325 mgs two tablets six times. The pain care plan was initiated on June 29, 2012, for pain related to right knee joint replacement. The approaches included to administer pain medication as ordered and to evaluate the resident's need for "routinely scheduled" medication rather than as needed (PRN) pain medication. There was no documented evidence that the resident was assessed, monitored and evaluated for the need for routine pain medication as indicated in the care plan. Additionally, the resident was not assessed for the need of breakthrough pain medication for pain scale rating 1 to 4 (mild pain) and 5 to 6 (moderate pain), and to notify the physician. On June 30, 2012, at 1:40 p.m., the resident was playing BINGO in the activity room and was not able to be interviewed. During an interview with Registered Nurse 2 on June 30, 2012, at 2:50 p.m., she had no explanation as to why the licensed nurses had not assessed, monitored and evaluated Resident 18 for routine pain medications as indicated in the plan of care. The facility "Pain Management" policy and procedure with revised date of August 31, 2009, indicated to provide guidelines for assessment, management and documentation of resident's pain in an attempt to provide maximum comfort and enhanced quality of life. Points to consider listed are to provide around the clock dosing, to get an order for [REDACTED]. The policy and procedure are referring to follow World Health Organization (WHO) Step Ladder approach, however the policy did not address the WHO step ladder approach and what is the pain scale rating level for mild, moderate and severe pain.

Based on interview and record review, the facility failed to ensure that 2 of 16 sampled residents (1 and 10) were provided with the necessary care and services to ensure that they attained optimal improvement in condition and did not deteriorate outside the limits of normal and recognized processes. Resident 1 was not administered pain medication as ordered by the physician, resulting in Resident 1 ' s pain and suffering. Resident 10, who had pain in the lower extremities (legs), was not premedicated prior to treatment, nor reassessed for pain resulting in pain during treatment and a decline in the distance and/or ability she could ambulate. Findings: 1. A review of the General Acute Care Hospital (GACH) records indicated Resident 1 was admitted to the GACH on May 1, 2012, due to a fall which had resulted in an incomplete [MEDICAL CONDITION] hip (previously replaced). Surgery was not indicated at this time. A review of the "Post-Acute admission orders [REDACTED]'s admission. The orders included Tylenol 325 milligrams (mg) 2 tablets by mouth every 6 hours as needed (prn) for mild pain (1 to 3), [MEDICATION NAME] 1 tablet by mouth every 4 hours prn for moderate pain (4 to 6), and [MEDICATION NAME] 3 mg intravenously (IV (through the vein)) every 4 hours prn for severe pain (7 to 10). The facility utilizes a pain rating scale as follows: 0 to 1(no pain), 2 to 3 (mild pain), 4 to 5 (moderate pain), 6 to 7 (severe pain), 8 to 9 (very severe pain) and 10 (worst possible pain). A review of the Admission Face Sheet revealed Resident 1 was admitted to the facility on [DATE], at 2:25 p.m. A record review of the Nursing Admission and Assessment document dated May 1, 2012, at 5:05 p.m., revealed Resident 1 was alert, verbal, oriented, and cooperative. Resident 1 ' s [DIAGNOSES REDACTED]. Resident 1 had an IV site in place (heplock). The resident had no pain at the time of assessment. The Minimum Data Set (MDS) Assessment and Care Plans for Resident 1 were incomplete because she was newly admitted . A review of Resident 1 ' s admission orders [REDACTED]. The order for [MEDICATION NAME] was not included in the admission orders [REDACTED] The History and Physical completed May 2, 2012, indicated the resident had the capability to understand and make decisions. At the time of the physical exam (1:30 p.m. according to nurses notes), Resident 1 complained of pain in her right hip that she rated at 8 out of 10. According to the documentation, the physician updated the daughter of a change in the resident ' s treatment plan. There was a physician's order [REDACTED]. A review of the " Physical Therapy PT HMO Evaluation & Plan of Treatment " form dated May 2, 2012, at 5:27 p.m., indicated that Resident 1 ' s lower extremity (legs) range of motion was limited by pain and required premedication (pain medications given prior to evaluation). Resident 1 had pain of 10 out of 10 to the right hip during the evaluation that worsened with movement and was alleviated by rest and medications. A review of the Comprehensive Pain assessment dated [DATE], (no time noted) revealed Resident 1 had previously sustained a [MEDICAL CONDITION] due to a fall, with a " history of pain. " She complained of current right hip pain rated as 9 to 10 out of 10, with an onset date of May 1, 2012. Resident 1 stated her pain varied, but it intensified when she moved in bed, and is relieved with rest and medications. The assessment indicated "Accompanying symptoms" of pain included decreased appetite and mobility, and sadness. The " Plan " was to implement current pain management as ordered by the physician and initiate/update the care plan. There was a care plan for Pain developed on May 3, 2012, over 24 hours after Resident 1 complained of moderate to severe pain. The goal was fore the resident to verbalize 0 out of 10 for a pain level. Interventions included administering pain medications as ordered by the physician. A review of the " Daily and Q Shift Charting " and " Pain Assessment Flow Sheet " forms from May 1, 2012, to May 4, 2012, revealed the following series of events: On May 1, 2012, at 11:15 p.m., Resident 1 complained of pain of 4 out of 10, was given Tylenol 2 tabs, with relief to 2 out of 10. On May 2, 2012 at 6:30 a.m., the licensed nurse answered Resident 1 ' s call light. Resident 1 complained of pain to the right hip (no level noted), and requested [MEDICATION NAME] for her pain. Tylenol 2 tablets was given because there was no [MEDICATION NAME] available, and the followup for the [MEDICATION NAME] was endorsed to the 7 a.m. to 3 p.m. nurse, according to the documentation. At 7:30 a.m. the resident complained of right hip pain (no rating). Tylenol was offered but the resident refused the Tylenol. At 9:45 a.m., the resident complained of right hip pain rated at 6 out of 10. [MEDICATION NAME] 1 tablet was given, with relief. At 2 p.m., the physician examined the resident (and ordered [MEDICATION NAME] 3 mg every 4 hours prn via IV). On May 3, 2012, at 9 a.m., the resident complained of right hip pain rated at 7 out of 10, [MEDICATION NAME] 1 tablet was given (instead of [MEDICATION NAME]). At 12 p.m., the resident complained of pain (no rating), and the physician was paged. At 1 p.m., [MEDICATION NAME] 1 tablet was given for right hip pain rated as 7 out of 10. At 1:30 p.m., a new order for [MEDICATION NAME] 2 tablets (every 6 hours as needed) for moderate pain was received. However, when the nurse offered the second [MEDICATION NAME] tablet, the resident refused and stated that she was still waiting for the [MEDICATION NAME] to arrive, according to the documentation. At 3:15 p.m., the [MEDICATION NAME] was received from the pharmacy. A " new " IV was started. The resident complained of right hip pain rated at 10 out of 10. [MEDICATION NAME] via IV was given, with relief of pain rated at 3 out of 10. At 5:30 p.m., the resident was seen by the physician. At 7 p.m., the resident complained of right hip pain rated at 6 out of 10, and [MEDICATION NAME] 1 tablet was given (instead of 2 tablets as ordered). At 11 p.m., the resident complained of right hip pain rated at 6 out of 10, and [MEDICATION NAME] 1 tablet was given (instead of 2 tablets as ordered), and documented that relief was 0 out of 10 at 11:30 p.m. On May 4, 2012, at 12 a.m., the resident complained of pain rated at 10 out of 10. [MEDICATION NAME] was given via IV, and the pain was relieved to 2 out of 10. At 7 a.m., the resident complained of right hip pain rated at 8 out of 10, [MEDICATION NAME] 2 tablets was given (instead of [MEDICATION NAME] as ordered). At 3 p.m., the resident was seen by the physician. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the [MEDICATION NAME] label indicated that it was " filled on May 2, 2012. " During an interview with the nurse consultant and the Minimum Data Set Coordinator (MDSC) on May 4, 2012, between 6:35 p.m. and 8 p.m., they were asked why the [MEDICATION NAME] order was not carried over from the GACH when Resident 1 was transferred to the SNF. They stated they could not explain why the orders on the form " Post Acute admission orders [REDACTED]. The MDSC stated it may have been a transcription mistake on the facility's part. She stated that although Resident 1 had a physician's orders [REDACTED]. She stated that Resident 1 badly wanted her pain medications. The nurse consultant stated the pharmacy had implemented a new system of delivering pain medications, causing a delay in getting the [MEDICATION NAME] and the [MEDICATION NAME] to the resident timely. During the interview, the MDSC stated she could not explain why Tylenol was given when the resident stated she had a pain level of 4. She stated the resident should have received something stronger for pain. She stated Resident 1 had a physician's order [REDACTED]. During the interview the nurse consultant agreed that Tylenol should not have been given. She stated for a pain level of 4, [MEDICATION NAME] was the pain medication ordered by the physician. She stated staff could not give the [MEDICATION NAME] because it was not available. A review of a memorandum document from the pharmacist titled " Controlled Substances in Contingency Box/E-Kit/Starter Kit/Automated Dispensing Machines " dated March 23, 2012, revealed the following: The Drug Enforcement Administration (DEA) in accordance with 21 Code of Federal Regulations 1306.11 and 1306.21, indicates a controlled substance can only be dispensed pursuant to either a valid signed written prescription by the practitioner; a facsimile of a written, signed prescription transmitted by the practitioner or his/her agent to the pharmacy. The DEA has interpreted these regulations to mean that the nurse at the skilled nursing facility cannot remove a Schedule II-V controlled substance medication from the supply until the pharmacist confirms that the pharmacy has received a valid written, faxed or verbal prescription from the individual prescribing practitioner. When a nurse is discussing a resident ' s pain needs with the practitioner, the nurse should encourage the prescribing practitioner to fax a valid written prescription to the pharmacy. During an interview with the Licensed Vocational Nurse (LVN 1) on May 5, 2012, at 10:50 a.m., she stated the memorandum was given to the facility on [DATE], stating that the procedure was to begin on May 1, 2012. She stated the facility had over 5 weeks to prepare for the new rules, and it is a combined effort between the pharmacy and the skilled nursing facility to ensure the pain medications are available so that a resident does not have to suffer unnecessarily. She stated that because the licensed nurses and other staff did not follow the memorandum, the pharmacy was unable to dispense the pain medications timely. She stated the pharmacy was not able to dispense the [MEDICATION NAME] until May 3, 2012, at 11 a.m. and provided the evaluator with an invoice. She stated the facility should have received the [MEDICATION NAME] a day earlier on May 2, 2012, when it was ordered by the physician had they followed proper protocol. She stated it was the licensed nurses who were at fault, not the pharmacy, for " not following the procedure and not having the physician on board in a timely manner." During an interview with Resident 1 on May 4, 2012, at 7:15 p.m., and on May 5, 2012, at 12:30 p.m., she stated she had been experiencing severe pain and that staff did not have her pain medications available. She stated they kept giving her Tylenol because they did not have [MEDICATION NAME] or [MEDICATION NAME] available. She stated she was receiving [MEDICATION NAME] at the GACH because it was the medication that worked to relieve her pain. She stated the [MEDICATION NAME] relieved her pain somewhat but that the side effects made her nauseated and she preferred [MEDICATION NAME] for pain. She stated that from May 1, 2012, to May 3, 2012, the facility staff gave her Tylenol or [MEDICATION NAME] for pain because they did not have [MEDICATION NAME] available. Staff told her she had to wait for the [MEDICATION NAME] to arrive from the pharmacy. She stated she cried and begged staff to get her [MEDICATION NAME] pain medication but they said they could not borrow the medication from another resident and that she needed to be patient as it would be arriving soon. She stated staff kept offering her Tylenol or [MEDICATION NAME] and she continued to tell them her pain was too severe and that she needed [MEDICATION NAME] to relieve the pain. She stated it was the worst experience of her life and she felt like a " wounded animal, left to die. " A review of the facility ' s Incident/Accident Investigative report dated May 3, 2012, revealed that on May 1, 2012, revealed it was documented that "the attending physician ordered [MEDICATION NAME] during the routine visit and [MEDICATION NAME] was administered as ordered. " However, a review of the physician's order [REDACTED]. During an interview with the Licensed Vocational Nurse (LVN 1) on May 5, 2012, at 10:50 a.m., she stated she worked on May 3, 2011, on the 3 p.m. to 11 p.m. shift. She stated that when she got report from LVN 2 who worked the 7 a.m. to 3 p.m. shift, she was informed that Resident 1 was extremely upset, crying, and that she was in severe pain. She stated the facility had problems getting Resident 1 her pain medication due to poor communication between the staff and the physician. LVN 2 had informed her that Resident 1 had been crying and begging for her [MEDICATION NAME] pain medication. LVN 2 told her the [MEDICATION NAME] would be arriving soon from the pharmacy. The facility ' s policy and procedure titled " Pain Management " dated August 31, 2009, indicated assessment, management, and documentation of pain will be conducted to provide maximum comfort and enhanced quality of life. Implementation included providing around the clock dosing, getting an order for [REDACTED]. It is the responsibility of the licensed nurse to notify the physician of pain assessment findings and obtain orders for pharmacological interventions, and the licensed nurse shall administer pain medication as ordered . If pain is of new onset, changed in nature, not relieved with current medications, the nurse will notify the physician for a review of the medication and pain management plan. During an interview with the MDSC on May 5, 2012 at 1:55 p.m., she stated she did not develop a care plan for Resident 1 on May 1, 2012, because she was newly admitted . However, she stated the plan of care for a resident in pain is to relieve their pain and to make them comfortable. She stated she was disappointed staff did not medicate the resident according to the physician's order [REDACTED]. During an interview with Physician B on May 5, 2012, at 2:15 p.m., he stated both the resident and the family member called his office complaining about the resident ' s level of pain. He stated the family member was extremely upset and that when he spoke to the facility, a licensed staff told him they had trouble getting the pain medications and the resident was in pain. He stated he was not aware that the resident had to wait so long for her pain medications. He stated he thought it had been resolved on May 1, 2012, and was disappointed when he got another call from the family member on May 3, 2012, complaining that the facility ' s staff were not managing the resident ' s pain effectively because the pain medications arrived late to the facility. He stated it was unnecessary for the resident to suffer like that. During an interview with Resident 1 ' s family member on May 5, 2012, at 2:10 p.m., she stated she spoke in length to the case manager regarding her anger and frustration that Resident 1 had to suffer because staff did not have the pain medication that had been ordered available. She stated that the case manager told her she had heard about the mistake the nurses had made by not notifying the physician in a timely manner and for not following up on the pain medication. She stated the case manager apologized to her for the mix-up. During the interview, the family member provided a written letter dated May 5, 2012, stating the facility staff had so much trouble and confusion getting Resident 1 her [MEDICATION NAME] pain medication, which resulted in the resident experiencing " severe " pain. She stated Resident 1 had been suffering and in pain since she got to the SNF. She stated the facility staff were not medicating the resident like they should be. She stated that when the resident was at the GACH, she was medicated well and she did not suffer, and prior to leaving the GACH, Resident 1 received a dose of [MEDICATION NAME] for her transport to the SNF. However, since she got transferred to the facility, staff did not have her pain medication available so they were compensating by giving her other over the counter pain medications that were not effective. She stated she complained to the Administrator and that he apologized for the confusion and ineffective pain management of Resident 1. The family member stated when Resident 1 started crying again, begging for her pain medication, and complaining that staff were ignoring her because they knew she was asking for her pain medications, she immediately called the case manager. The case manager visited them and apologized for the emotional and physical pain Resident 1 was experiencing. The family member stated that what they did to Resident 1 was cruel and the fact that they tried to juggle around not giving the pain medications she wanted and needed, because it was not available, was " borderline criminal. " 2. On May 4, 2012, at 6:10pm, an interview was conducted with Resident 10 who was alert, oriented and able to make her needs known. During the interview, Resident 10 stated she recently had hip surgery and received Physical Therapy at the facility. After receiving Physical Therapy, the physician ordered to walk five days a week with the assistance of the Restorative Nursing Assistant (RNA). However, the resident complained that she was not walked in accordance with the physician's orders [REDACTED]. She stated that she was not medicated daily before attempting to ambulate with the RNA. A review of Resident 10's Face Sheet indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Nursing Admission and assessment dated on admission indicated the resident was admitted with surgical staples on the incision site of the resident's right hip from surgery. A review of the resident's Minimum Data Set, dated dated dated [DATE] indicated the resident was assessed with [REDACTED]. In addition, the resident was assessed as requiring extensive assistance in transferring from bed to chair, and extensive assistance in ambulating in and around the corridors in a wheelchair. The resident was assessed as requiring a pain medication regimen, received pain medications as needed having pain at any time of the day, and had limited day-to-day activities because of the pain. A review of a comprehensive pain assessment dated [DATE] indicated the resident had pain related to a history of right [MEDICAL CONDITION]. At the time of the assessment, the resident did not complain of pain. However, on May 3, 2012, another comprehensive pain assessment was completed. On this day, the resident complained of pain to the left knee and rated the pain 6 on a scale of 1 to 10 (10 being the highest rating of pain). The facility utilizes a pain rating scale as follows: 0 to 1(no pain), 2 to 3 (mild pain), 4 to 5 (moderate pain), 6 to 7 (severe pain), 8 to 9 (very severe pain) and 10 (worst possible pain). A review of Resident 10's care plan for Pain dated February 3, 2012, indicated the goal was for the resident to receive pain medication to alleviate pain. In order to achieve this goal, the nurse was to assess the resident's level of pain by using a pain rating scale, administer pain medication as ordered, and evaluate the need to provide pain medications 30 minutes prior to treatment or therapy. A review of Resident 10's recapitulation of physician orders [REDACTED]. On April 13, 2012, the physician ordered [MEDICATION NAME] 7.5 milligrams (mg) twice a day for mild pain of the right hip and knees. A review of Resident 10's physician's orders [REDACTED]. On May 4, 2012, at 6:30 p.m., an interview was conducted with RNA 1 assigned to Resident 10 who stated the RNAs alternate their assignments, and who was not generally assigned to Resident 10. RNA 1 stated whenever she ambulates Resident 10, the resident was unable to walk longer than 5 minutes because she complained of too much pain in the knees and legs. RNA 1 stated that in the past, she informed a charge nurse that resident 10 was in pain whenever she attempts to walk her. RNA 1 was unable to remember when she informed the charge nurse of the resident's pain, and didn't remember which charge nurse it was that she informed. A review of Resident 10's Pain Assessment Flow Sheet, Controlled/Antibiotic Drug and Medication Administration records for April 2012 indicated the resident was given [MEDICATION NAME] two tablets on April 2, 3, 4, 10, 12, 13, 15, 16, 17, and 20, 2012, on the 7 a.m. to 3 p.m. shift, for pain on the right leg and right hip, with pain levels ranging from 4 to 9 out of 10. It was documented that the resident ' s pain was relieved after receiving the [MEDICATION NAME] on these occasions. However, there was inconsistent documentation to indicate Resident 10 received [MEDICATION NAME] after April 20, 2012, and after being discharged from Physical Therapy to the RNA services, making it difficult to reconcile whether Resident 10 was premedicated prior to ambulation by the RNA. The "Controlled/Antibiotic Drug record indicated that the [MEDICATION NAME] was taken from the locked narcotics cart through April 20, 2012, however, there was no documentation on the MAR indicated [REDACTED]. During the review, the RN Supervisor could not provide a completed MAR indicated [REDACTED]. A review of the RNA Record indicated a RNA walked with Resident 10 using a front wheel walker on April 24, 25, 26, 27, and 30, 2012, and May 1, 2, 3, and 4, 2012. The inconsistent documentation on the above listed records made it difficult to reconcile whether the nurses assessed or evaluated Resident 10 for the need to premedicate her with [MEDICATION NAME] 30 minutes prior to ambulation after discharge from Physical Therapy, from April 24, 2012, to May 4, 2012, in accordance with the resident ' s care plan. On May 5, 2012, at 9:30am, a review and comparison of the the RNA documentation, the MAR, Pain Assessment Flow Sheet, and nursing notes was done with the Registered Nurse (RN) Supervisor, revealing there was no clear indication that the RNAs communicated to the licensed staff that Resident 10 was unable to tolerate walking without being premedicated with [MEDICATION NAME]. The RN Supervisor was questioned if Resident 10 was re-assessed for pain management after the assessment performed on May 3, 2012. The RN Supervisor stated she was unaware that the resident needed pain medication prior to walking, and she was not reassessed for pain management. She also could not provide a MAR indicated [REDACTED]. On May 5, 2012, the RN Supervisor re-assessed Resident 10 for pain and completed a comprehensive pain assessment that revealed the resident had hip pain rated 4 to 6 out of 10 when walking less than 70 feet, and bilateral knee pain rated at 9 to 10 out of 10 when walking greater than 70 feet. The assessment also indicated the resident ' s pain was tolerable if medicated before activity. A review of the facility's policy and procedure for Pain Management revised on August 31, 2009, indicated it is the policy of the facility that residents are assessed for pain and a plan of care developed to manage pain. Assessment, management, and documentation of pain will be conducted to provide maximum comfort and enhanced quality of life. Following the initial assessment, the licensed nurse will monitor the resident for pain .... weekly, quarterly, with a significant change in condition and events/treatments likely to produce pain.

Based on observation, interview and record review, the facility failed to assess and monitor the residents' pain level prior to physical therapy (PT) treatment, prior to application and after removal of bilateral hand splints, failed to administer pain medications as ordered based on the residents' pain scale rating, and to evaluate the resident for the need of routine pain medication for three of ten sample residents (17, 2 and 18). This had the potential for unnecessary pain during treatment and decline in physical function and/or ambulation ability. Findings: a. On June 30, 2012, at 2:30 p.m., Resident 17 was observed lying in bed. During an interview the resident stated that she was admitted to the facility for rehabilitation treatment. She stated she only stood up at her bed side three times on different days, one for three seconds, another day for two minutes, and then three minutes. The resident stated that she was able to walk prior to hospitalization and would like to walk again. When asked if she had pain during the therapy treatment, she stated she had pain to her right leg, with a pain scale rating of 1 to 4 pain (mild pain) before the (PT) treatment. After the PT treatment she had pain at a rating of 7 to 8 (severe pain). The resident stated that she was receiving [MEDICATION NAME] pain medication before PT treatment, however she still had pain. On June 30, 2012, at 3:25 p.m., Registered Nurse 2 (RN 2), was asked to interview the resident regarding her pain during PT treatment. RN 2 stated Resident 17 stated she had pain to her right leg before PT treatment and the pain scale rating was 1 to 4 (mild pain), and after the PT treatment she had pain at a rate of 8 out of 10 (severe pain). According to the admission record, Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognition was intact, required limited to extensive assistance from staff with activities of daily living, and ambulation had not occurred. The care plan for "chronic pain" was initiated on May 5, 2012; however the plan of care did not indicate the cause or source of the chronic pain. The goal was for the resident to achieve a zero pain level. The approaches included to assess the level of pain using a pain rating scale (1 to 10 with 10 being the most severe pain), to administer pain medication as ordered, to monitor response using the pain scale related to medications, treatments, and procedures. Another care plan was initiated on June 25, 2012, for pain medication prior to physical therapy. The goal was for the resident to be able to perform physical therapy treatment without pain. The approaches included [MEDICATION NAME] 50 milligrams (mgs) by mouth three times a day, to educate the resident regarding pain, and to monitor the pain using the pain scale prior to and after rehabilitation treatment. The resident had a physician's orders [REDACTED]. ([MEDICATION NAME] is a narcotic-like pain reliever to treat moderate to severe pain). On May 31, 2012, orders were obtained for [MEDICATION NAME] 5/325 milligrams (mgs) by mouth every six hours as needed (PRN) for pain scale level 7 to 10 (severe pain), ([MEDICATION NAME] is a narcotic pain reliever to treat moderate to severe pain), and Tylenol 325 mgs two tablets by mouth every four hours PRN for pain scale level 1 to 3 (mild pain). The resident had PT treatment daily five times a week. A review of the PT daily documentation from May 30 to June 29, 2012, indicated there was no specific time when the PT treatment was provided to the resident. The PT daily documentation indicated on May 30, 2012 and June 4, 2012, the resident complained of right buttock wound pain. There was no documented pain scale level, whether there was communication between the physical therapist and licensed nurses regarding the resident's pain, or if pain medication was administered when the resident complained of the pain, to ensure a "zero" level of pain as indicated in the care plan. The PT daily note dated June 23, 2012, indicated the resident complained of a pain level of 6 out of 10 (moderate pain) to her right foot. The note indicated the resident was pre-medicated. However, a review of the Medication Administration Record (MAR) revealed there was no documented evidence the resident was pre-medicated. Further review of the PT daily documentation revealed there was no documented evidence the resident was being assessed for pain on a daily basis before the PT treatment was provided, as indicated in the care plan, except on May 30, 2012, June 4, 2012, and June 23, 2012. During a telephone interview on July 5, 2012, at 10 a.m., with the assigned PT staff, he stated he usually provided the PT treatment to the resident between 11 a.m. to 11:30 a.m. He stated the resident "always" complained of pain to her right leg and lower buttock sacral wound, and he stated the pain was a "dull" pain. He stated he did not document it because it was a dull pain and the resident stated she was okay. When asked if he communicated what the resident said during the PT treatment to the licensed nurses, he said that he didn't but he should have. A review of undated rehabilitation department's procedure for "pain proper protocol" indicated if the resident experiences pain, pre-medicate 30 minutes prior. If the pain remains, consult the nurse for additional PRN pain medication for breakout pain, and wait for 30 minutes. If the pain level remains, the nurse must call the physician and the rehabilitation staff must change their treatment activity that day, and consider adding a modality to decrease pain. The procedure also indicated that the daily note must include the pain level during treatment, the pain location, pre-medication timeline and strategies to decrease pain. b. On June 30, 2012, at 9:30 a.m., Resident 2 was observed in the activity room, sitting in a gerichair (reclining chair), with hand splints applied. The resident was not able to be interviewed. According to the admission record the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated April 28, 2012, indicated the resident's cognition was severely impaired and was totally dependent on staff with activities of daily living (walking, transferring, eating and bathing) except with bed mobility. The care plan developed for "pain" revised June 21, 2012, indicated the resident was at risk for discomfort. The approaches included to assess the resident's level of pain using the pain scale (1 to 10, with 10 being the most severe pain), and to monitor the resident's response using the pain scale related to medications, treatments and procedures. The resident had a physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) from June 1 to 30, 2012, reflected the order for Tylenol 650 mgs by mouth daily 30 minutes prior to application of bilateral hand splints, to be applied from 7 a.m. to 3 p.m. However, there was no specific time documented on the MAR as to when the Tylenol was administered. There was no documentation that the resident was assessed and/or monitored for the level of pain prior to application and removal of the hand splints as indicated in the plan of care. During an interview with Registered Nurse 1 on June 30, 2012, at 3 p.m., she stated the licensed nurses should have assessed and monitored the resident for pain prior to and after removal of the hand splints. The facility "Pain Management" policy and procedure revised date of August 31, 2009. The licensed nurse shall administer pain medication as ordered and document on the MAR, the drug, time of administration, dose, pain scale rating pre-medication and the resident's response to medication a minimum of one hour post pain medication, using the pain scale rating. However, this was not followed for Resident 2. c. According to the admission record Resident 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Another order was obtained on the same date for [MEDICATION NAME] two tablets every four hours for severe pain (pain scale level 7 to 10). The facility used a pain level scale of 1 to 10 (10 being the most severe pain). A review of the Medication Administration Record (MAR) pain assessment flow sheet from June 16 to 29, 2012, indicated the following: 1. On June 21, 2012, at 12:35 a.m., the resident complained of knee pain and the pain scale level was assessed as 3 out of 10 (mild pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. 2. On June 26, 2012, at 5:45 a.m. and June 27, 2012, at 12:30 a.m., the resident complained of back pain and the pain scale level was assessed as 6 out of 10 (moderate pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. 3. On June 28, 2012, at 2:50 a.m., the resident complained of back pain and the pain scale level was assessed as 5 out of 10 (moderate pain). The resident received [MEDICATION NAME] two tablets that were ordered for severe pain. Further review of the MAR from June 16 to 29, 2012, indicated the resident received [MEDICATION NAME] two tablets 22 times and [MEDICATION NAME] 5/325 mgs two tablets six times. The pain care plan was initiated on June 29, 2012, for pain related to right knee joint replacement. The approaches included to administer pain medication as ordered and to evaluate the resident's need for "routinely scheduled" medication rather than as needed (PRN) pain medication. There was no documented evidence that the resident was assessed, monitored and evaluated for the need for routine pain medication as indicated in the care plan. Additionally, the resident was not assessed for the need of breakthrough pain medication for pain scale rating 1 to 4 (mild pain) and 5 to 6 (moderate pain), and to notify the physician. On June 30, 2012, at 1:40 p.m., the resident was playing BINGO in the activity room and was not able to be interviewed. During an interview with Registered Nurse 2 on June 30, 2012, at 2:50 p.m., she had no explanation as to why the licensed nurses had not assessed, monitored and evaluated Resident 18 for routine pain medications as indicated in the plan of care. The facility "Pain Management" policy and procedure with revised date of August 31, 2009, indicated to provide guidelines for assessment, management and documentation of resident's pain in an attempt to provide maximum comfort and enhanced quality of life. Points to consider listed are to provide around the clock dosing, to get an order for [REDACTED]. The policy and procedure are referring to follow World Health Organization (WHO) Step Ladder approach, however the policy did not address the WHO step ladder approach and what is the pain scale rating level for mild, moderate and severe pain.

Based on interview and record review, the facility failed to ensure that 2 of 16 sampled residents (1 and 10) were provided with the necessary care and services to ensure that they attained optimal improvement in condition and did not deteriorate outside the limits of normal and recognized processes. Resident 1 was not administered pain medication as ordered by the physician, resulting in Resident 1 ' s pain and suffering. Resident 10, who had pain in the lower extremities (legs), was not premedicated prior to treatment, nor reassessed for pain resulting in pain during treatment and a decline in the distance and/or ability she could ambulate. Findings: 1. A review of the General Acute Care Hospital (GACH) records indicated Resident 1 was admitted to the GACH on May 1, 2012, due to a fall which had resulted in an incomplete [MEDICAL CONDITION] hip (previously replaced). Surgery was not indicated at this time. A review of the "Post-Acute admission orders [REDACTED]'s admission. The orders included Tylenol 325 milligrams (mg) 2 tablets by mouth every 6 hours as needed (prn) for mild pain (1 to 3), [MEDICATION NAME] 1 tablet by mouth every 4 hours prn for moderate pain (4 to 6), and [MEDICATION NAME] 3 mg intravenously (IV (through the vein)) every 4 hours prn for severe pain (7 to 10). The facility utilizes a pain rating scale as follows: 0 to 1(no pain), 2 to 3 (mild pain), 4 to 5 (moderate pain), 6 to 7 (severe pain), 8 to 9 (very severe pain) and 10 (worst possible pain). A review of the Admission Face Sheet revealed Resident 1 was admitted to the facility on [DATE], at 2:25 p.m. A record review of the Nursing Admission and Assessment document dated May 1, 2012, at 5:05 p.m., revealed Resident 1 was alert, verbal, oriented, and cooperative. Resident 1 ' s [DIAGNOSES REDACTED]. Resident 1 had an IV site in place (heplock). The resident had no pain at the time of assessment. The Minimum Data Set (MDS) Assessment and Care Plans for Resident 1 were incomplete because she was newly admitted . A review of Resident 1 ' s admission orders [REDACTED]. The order for [MEDICATION NAME] was not included in the admission orders [REDACTED] The History and Physical completed May 2, 2012, indicated the resident had the capability to understand and make decisions. At the time of the physical exam (1:30 p.m. according to nurses notes), Resident 1 complained of pain in her right hip that she rated at 8 out of 10. According to the documentation, the physician updated the daughter of a change in the resident ' s treatment plan. There was a physician's order [REDACTED]. A review of the " Physical Therapy PT HMO Evaluation & Plan of Treatment " form dated May 2, 2012, at 5:27 p.m., indicated that Resident 1 ' s lower extremity (legs) range of motion was limited by pain and required premedication (pain medications given prior to evaluation). Resident 1 had pain of 10 out of 10 to the right hip during the evaluation that worsened with movement and was alleviated by rest and medications. A review of the Comprehensive Pain assessment dated [DATE], (no time noted) revealed Resident 1 had previously sustained a [MEDICAL CONDITION] due to a fall, with a " history of pain. " She complained of current right hip pain rated as 9 to 10 out of 10, with an onset date of May 1, 2012. Resident 1 stated her pain varied, but it intensified when she moved in bed, and is relieved with rest and medications. The assessment indicated "Accompanying symptoms" of pain included decreased appetite and mobility, and sadness. The " Plan " was to implement current pain management as ordered by the physician and initiate/update the care plan. There was a care plan for Pain developed on May 3, 2012, over 24 hours after Resident 1 complained of moderate to severe pain. The goal was fore the resident to verbalize 0 out of 10 for a pain level. Interventions included administering pain medications as ordered by the physician. A review of the " Daily and Q Shift Charting " and " Pain Assessment Flow Sheet " forms from May 1, 2012, to May 4, 2012, revealed the following series of events: On May 1, 2012, at 11:15 p.m., Resident 1 complained of pain of 4 out of 10, was given Tylenol 2 tabs, with relief to 2 out of 10. On May 2, 2012 at 6:30 a.m., the licensed nurse answered Resident 1 ' s call light. Resident 1 complained of pain to the right hip (no level noted), and requested [MEDICATION NAME] for her pain. Tylenol 2 tablets was given because there was no [MEDICATION NAME] available, and the followup for the [MEDICATION NAME] was endorsed to the 7 a.m. to 3 p.m. nurse, according to the documentation. At 7:30 a.m. the resident complained of right hip pain (no rating). Tylenol was offered but the resident refused the Tylenol. At 9:45 a.m., the resident complained of right hip pain rated at 6 out of 10. [MEDICATION NAME] 1 tablet was given, with relief. At 2 p.m., the physician examined the resident (and ordered [MEDICATION NAME] 3 mg every 4 hours prn via IV). On May 3, 2012, at 9 a.m., the resident complained of right hip pain rated at 7 out of 10, [MEDICATION NAME] 1 tablet was given (instead of [MEDICATION NAME]). At 12 p.m., the resident complained of pain (no rating), and the physician was paged. At 1 p.m., [MEDICATION NAME] 1 tablet was given for right hip pain rated as 7 out of 10. At 1:30 p.m., a new order for [MEDICATION NAME] 2 tablets (every 6 hours as needed) for moderate pain was received. However, when the nurse offered the second [MEDICATION NAME] tablet, the resident refused and stated that she was still waiting for the [MEDICATION NAME] to arrive, according to the documentation. At 3:15 p.m., the [MEDICATION NAME] was received from the pharmacy. A " new " IV was started. The resident complained of right hip pain rated at 10 out of 10. [MEDICATION NAME] via IV was given, with relief of pain rated at 3 out of 10. At 5:30 p.m., the resident was seen by the physician. At 7 p.m., the resident complained of right hip pain rated at 6 out of 10, and [MEDICATION NAME] 1 tablet was given (instead of 2 tablets as ordered). At 11 p.m., the resident complained of right hip pain rated at 6 out of 10, and [MEDICATION NAME] 1 tablet was given (instead of 2 tablets as ordered), and documented that relief was 0 out of 10 at 11:30 p.m. On May 4, 2012, at 12 a.m., the resident complained of pain rated at 10 out of 10. [MEDICATION NAME] was given via IV, and the pain was relieved to 2 out of 10. At 7 a.m., the resident complained of right hip pain rated at 8 out of 10, [MEDICATION NAME] 2 tablets was given (instead of [MEDICATION NAME] as ordered). At 3 p.m., the resident was seen by the physician. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the [MEDICATION NAME] label indicated that it was " filled on May 2, 2012. " During an interview with the nurse consultant and the Minimum Data Set Coordinator (MDSC) on May 4, 2012, between 6:35 p.m. and 8 p.m., they were asked why the [MEDICATION NAME] order was not carried over from the GACH when Resident 1 was transferred to the SNF. They stated they could not explain why the orders on the form " Post Acute admission orders [REDACTED]. The MDSC stated it may have been a transcription mistake on the facility's part. She stated that although Resident 1 had a physician's orders [REDACTED]. She stated that Resident 1 badly wanted her pain medications. The nurse consultant stated the pharmacy had implemented a new system of delivering pain medications, causing a delay in getting the [MEDICATION NAME] and the [MEDICATION NAME] to the resident timely. During the interview, the MDSC stated she could not explain why Tylenol was given when the resident stated she had a pain level of 4. She stated the resident should have received something stronger for pain. She stated Resident 1 had a physician's order [REDACTED]. During the interview the nurse consultant agreed that Tylenol should not have been given. She stated for a pain level of 4, [MEDICATION NAME] was the pain medication ordered by the physician. She stated staff could not give the [MEDICATION NAME] because it was not available. A review of a memorandum document from the pharmacist titled " Controlled Substances in Contingency Box/E-Kit/Starter Kit/Automated Dispensing Machines " dated March 23, 2012, revealed the following: The Drug Enforcement Administration (DEA) in accordance with 21 Code of Federal Regulations 1306.11 and 1306.21, indicates a controlled substance can only be dispensed pursuant to either a valid signed written prescription by the practitioner; a facsimile of a written, signed prescription transmitted by the practitioner or his/her agent to the pharmacy. The DEA has interpreted these regulations to mean that the nurse at the skilled nursing facility cannot remove a Schedule II-V controlled substance medication from the supply until the pharmacist confirms that the pharmacy has received a valid written, faxed or verbal prescription from the individual prescribing practitioner. When a nurse is discussing a resident ' s pain needs with the practitioner, the nurse should encourage the prescribing practitioner to fax a valid written prescription to the pharmacy. During an interview with the Licensed Vocational Nurse (LVN 1) on May 5, 2012, at 10:50 a.m., she stated the memorandum was given to the facility on [DATE], stating that the procedure was to begin on May 1, 2012. She stated the facility had over 5 weeks to prepare for the new rules, and it is a combined effort between the pharmacy and the skilled nursing facility to ensure the pain medications are available so that a resident does not have to suffer unnecessarily. She stated that because the licensed nurses and other staff did not follow the memorandum, the pharmacy was unable to dispense the pain medications timely. She stated the pharmacy was not able to dispense the [MEDICATION NAME] until May 3, 2012, at 11 a.m. and provided the evaluator with an invoice. She stated the facility should have received the [MEDICATION NAME] a day earlier on May 2, 2012, when it was ordered by the physician had they followed proper protocol. She stated it was the licensed nurses who were at fault, not the pharmacy, for " not following the procedure and not having the physician on board in a timely manner." During an interview with Resident 1 on May 4, 2012, at 7:15 p.m., and on May 5, 2012, at 12:30 p.m., she stated she had been experiencing severe pain and that staff did not have her pain medications available. She stated they kept giving her Tylenol because they did not have [MEDICATION NAME] or [MEDICATION NAME] available. She stated she was receiving [MEDICATION NAME] at the GACH because it was the medication that worked to relieve her pain. She stated the [MEDICATION NAME] relieved her pain somewhat but that the side effects made her nauseated and she preferred [MEDICATION NAME] for pain. She stated that from May 1, 2012, to May 3, 2012, the facility staff gave her Tylenol or [MEDICATION NAME] for pain because they did not have [MEDICATION NAME] available. Staff told her she had to wait for the [MEDICATION NAME] to arrive from the pharmacy. She stated she cried and begged staff to get her [MEDICATION NAME] pain medication but they said they could not borrow the medication from another resident and that she needed to be patient as it would be arriving soon. She stated staff kept offering her Tylenol or [MEDICATION NAME] and she continued to tell them her pain was too severe and that she needed [MEDICATION NAME] to relieve the pain. She stated it was the worst experience of her life and she felt like a " wounded animal, left to die. " A review of the facility ' s Incident/Accident Investigative report dated May 3, 2012, revealed that on May 1, 2012, revealed it was documented that "the attending physician ordered [MEDICATION NAME] during the routine visit and [MEDICATION NAME] was administered as ordered. " However, a review of the physician's order [REDACTED]. During an interview with the Licensed Vocational Nurse (LVN 1) on May 5, 2012, at 10:50 a.m., she stated she worked on May 3, 2011, on the 3 p.m. to 11 p.m. shift. She stated that when she got report from LVN 2 who worked the 7 a.m. to 3 p.m. shift, she was informed that Resident 1 was extremely upset, crying, and that she was in severe pain. She stated the facility had problems getting Resident 1 her pain medication due to poor communication between the staff and the physician. LVN 2 had informed her that Resident 1 had been crying and begging for her [MEDICATION NAME] pain medication. LVN 2 told her the [MEDICATION NAME] would be arriving soon from the pharmacy. The facility ' s policy and procedure titled " Pain Management " dated August 31, 2009, indicated assessment, management, and documentation of pain will be conducted to provide maximum comfort and enhanced quality of life. Implementation included providing around the clock dosing, getting an order for [REDACTED]. It is the responsibility of the licensed nurse to notify the physician of pain assessment findings and obtain orders for pharmacological interventions, and the licensed nurse shall administer pain medication as ordered . If pain is of new onset, changed in nature, not relieved with current medications, the nurse will notify the physician for a review of the medication and pain management plan. During an interview with the MDSC on May 5, 2012 at 1:55 p.m., she stated she did not develop a care plan for Resident 1 on May 1, 2012, because she was newly admitted . However, she stated the plan of care for a resident in pain is to relieve their pain and to make them comfortable. She stated she was disappointed staff did not medicate the resident according to the physician's order [REDACTED]. During an interview with Physician B on May 5, 2012, at 2:15 p.m., he stated both the resident and the family member called his office complaining about the resident ' s level of pain. He stated the family member was extremely upset and that when he spoke to the facility, a licensed staff told him they had trouble getting the pain medications and the resident was in pain. He stated he was not aware that the resident had to wait so long for her pain medications. He stated he thought it had been resolved on May 1, 2012, and was disappointed when he got another call from the family member on May 3, 2012, complaining that the facility ' s staff were not managing the resident ' s pain effectively because the pain medications arrived late to the facility. He stated it was unnecessary for the resident to suffer like that. During an interview with Resident 1 ' s family member on May 5, 2012, at 2:10 p.m., she stated she spoke in length to the case manager regarding her anger and frustration that Resident 1 had to suffer because staff did not have the pain medication that had been ordered available. She stated that the case manager told her she had heard about the mistake the nurses had made by not notifying the physician in a timely manner and for not following up on the pain medication. She stated the case manager apologized to her for the mix-up. During the interview, the family member provided a written letter dated May 5, 2012, stating the facility staff had so much trouble and confusion getting Resident 1 her [MEDICATION NAME] pain medication, which resulted in the resident experiencing " severe " pain. She stated Resident 1 had been suffering and in pain since she got to the SNF. She stated the facility staff were not medicating the resident like they should be. She stated that when the resident was at the GACH, she was medicated well and she did not suffer, and prior to leaving the GACH, Resident 1 received a dose of [MEDICATION NAME] for her transport to the SNF. However, since she got transferred to the facility, staff did not have her pain medication available so they were compensating by giving her other over the counter pain medications that were not effective. She stated she complained to the Administrator and that he apologized for the confusion and ineffective pain management of Resident 1. The family member stated when Resident 1 started crying again, begging for her pain medication, and complaining that staff were ignoring her because they knew she was asking for her pain medications, she immediately called the case manager. The case manager visited them and apologized for the emotional and physical pain Resident 1 was experiencing. The family member stated that what they did to Resident 1 was cruel and the fact that they tried to juggle around not giving the pain medications she wanted and needed, because it was not available, was " borderline criminal. " 2. On May 4, 2012, at 6:10pm, an interview was conducted with Resident 10 who was alert, oriented and able to make her needs known. During the interview, Resident 10 stated she recently had hip surgery and received Physical Therapy at the facility. After receiving Physical Therapy, the physician ordered to walk five days a week with the assistance of the Restorative Nursing Assistant (RNA). However, the resident complained that she was not walked in accordance with the physician's orders [REDACTED]. She stated that she was not medicated daily before attempting to ambulate with the RNA. A review of Resident 10's Face Sheet indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Nursing Admission and assessment dated on admission indicated the resident was admitted with surgical staples on the incision site of the resident's right hip from surgery. A review of the resident's Minimum Data Set, dated dated dated [DATE] indicated the resident was assessed with [REDACTED]. In addition, the resident was assessed as requiring extensive assistance in transferring from bed to chair, and extensive assistance in ambulating in and around the corridors in a wheelchair. The resident was assessed as requiring a pain medication regimen, received pain medications as needed having pain at any time of the day, and had limited day-to-day activities because of the pain. A review of a comprehensive pain assessment dated [DATE] indicated the resident had pain related to a history of right [MEDICAL CONDITION]. At the time of the assessment, the resident did not complain of pain. However, on May 3, 2012, another comprehensive pain assessment was completed. On this day, the resident complained of pain to the left knee and rated the pain 6 on a scale of 1 to 10 (10 being the highest rating of pain). The facility utilizes a pain rating scale as follows: 0 to 1(no pain), 2 to 3 (mild pain), 4 to 5 (moderate pain), 6 to 7 (severe pain), 8 to 9 (very severe pain) and 10 (worst possible pain). A review of Resident 10's care plan for Pain dated February 3, 2012, indicated the goal was for the resident to receive pain medication to alleviate pain. In order to achieve this goal, the nurse was to assess the resident's level of pain by using a pain rating scale, administer pain medication as ordered, and evaluate the need to provide pain medications 30 minutes prior to treatment or therapy. A review of Resident 10's recapitulation of physician orders [REDACTED]. On April 13, 2012, the physician ordered [MEDICATION NAME] 7.5 milligrams (mg) twice a day for mild pain of the right hip and knees. A review of Resident 10's physician's orders [REDACTED]. On May 4, 2012, at 6:30 p.m., an interview was conducted with RNA 1 assigned to Resident 10 who stated the RNAs alternate their assignments, and who was not generally assigned to Resident 10. RNA 1 stated whenever she ambulates Resident 10, the resident was unable to walk longer than 5 minutes because she complained of too much pain in the knees and legs. RNA 1 stated that in the past, she informed a charge nurse that resident 10 was in pain whenever she attempts to walk her. RNA 1 was unable to remember when she informed the charge nurse of the resident's pain, and didn't remember which charge nurse it was that she informed. A review of Resident 10's Pain Assessment Flow Sheet, Controlled/Antibiotic Drug and Medication Administration records for April 2012 indicated the resident was given [MEDICATION NAME] two tablets on April 2, 3, 4, 10, 12, 13, 15, 16, 17, and 20, 2012, on the 7 a.m. to 3 p.m. shift, for pain on the right leg and right hip, with pain levels ranging from 4 to 9 out of 10. It was documented that the resident ' s pain was relieved after receiving the [MEDICATION NAME] on these occasions. However, there was inconsistent documentation to indicate Resident 10 received [MEDICATION NAME] after April 20, 2012, and after being discharged from Physical Therapy to the RNA services, making it difficult to reconcile whether Resident 10 was premedicated prior to ambulation by the RNA. The "Controlled/Antibiotic Drug record indicated that the [MEDICATION NAME] was taken from the locked narcotics cart through April 20, 2012, however, there was no documentation on the MAR indicated [REDACTED]. During the review, the RN Supervisor could not provide a completed MAR indicated [REDACTED]. A review of the RNA Record indicated a RNA walked with Resident 10 using a front wheel walker on April 24, 25, 26, 27, and 30, 2012, and May 1, 2, 3, and 4, 2012. The inconsistent documentation on the above listed records made it difficult to reconcile whether the nurses assessed or evaluated Resident 10 for the need to premedicate her with [MEDICATION NAME] 30 minutes prior to ambulation after discharge from Physical Therapy, from April 24, 2012, to May 4, 2012, in accordance with the resident ' s care plan. On May 5, 2012, at 9:30am, a review and comparison of the the RNA documentation, the MAR, Pain Assessment Flow Sheet, and nursing notes was done with the Registered Nurse (RN) Supervisor, revealing there was no clear indication that the RNAs communicated to the licensed staff that Resident 10 was unable to tolerate walking without being premedicated with [MEDICATION NAME]. The RN Supervisor was questioned if Resident 10 was re-assessed for pain management after the assessment performed on May 3, 2012. The RN Supervisor stated she was unaware that the resident needed pain medication prior to walking, and she was not reassessed for pain management. She also could not provide a MAR indicated [REDACTED]. On May 5, 2012, the RN Supervisor re-assessed Resident 10 for pain and completed a comprehensive pain assessment that revealed the resident had hip pain rated 4 to 6 out of 10 when walking less than 70 feet, and bilateral knee pain rated at 9 to 10 out of 10 when walking greater than 70 feet. The assessment also indicated the resident ' s pain was tolerable if medicated before activity. A review of the facility's policy and procedure for Pain Management revised on August 31, 2009, indicated it is the policy of the facility that residents are assessed for pain and a plan of care developed to manage pain. Assessment, management, and documentation of pain will be conducted to provide maximum comfort and enhanced quality of life. Following the initial assessment, the licensed nurse will monitor the resident for pain .... weekly, quarterly, with a significant change in condition and events/treatments likely to produce pain.