Every finding on record at Beacon Harbor Healthcare and Rehabilitation

Based on observation, interview, and record review, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for three (Resident #1, #2, and #3) of ten residents reviewed for food preferences. The facility failed to provide hot palatable oatmeal at the breakfast meal for Residents #1, # 2, 3, and #4. This deficient practice could put residents at risk of weight loss, an increase of feelings of self-worth, and a decreased quality of life. Findings included: Record Review of Resident #1's quarterly MDS assessment, dated 03/10/2026, revealed a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included: cerebral infarction (stroke), chronic respiratory failure (lungs are very weak), and atrial fibrillation (irregular fast heart rate). Resident #1 had severe cognitive impairment and required assistance of one staff for activities of daily living. Record Review of Resident #2's quarterly MDS assessment, dated 01/12/2026, revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: cerebral infarction (stroke), hypertension (high blood pressure), and edema (fluid in lower legs). Resident #2 was alert and oriented and able to make decisions. He required assistance of one staff for activities of daily living. Record Review of Resident #3's quarterly MDS assessment, dated 01/05/2026, revealed an [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: chronic obstructive pulmonary disease (congested lungs), heart failure (weak heart), and congestive heart failure (heart and lungs are weak). Resident #3 was alert and oriented and able to make decisions. He required assistance of one staff for activities of daily living. Record Review of Resident #4's quarterly MDS assessment, dated 03/06/2026, revealed an [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: cerebral infarction (stroke), hypertension (high blood pressure), and muscle weakness (weakness). Resident #4 was alert and oriented and able to make decisions. She required assistance of one staff for activities of daily living. During an observation and interview on 03/24/2026 at 8:45 a.m., revealed on Hall 200 the residents were eating breakfast. Resident #1 was assisted to eat her breakfast in her room, while in bed. Resident #1 stated she knew the oatmeal was cold and lumpy but she was hungry and was eating it anyway. The oatmeal did appear to be sticky and when the bowel was touched it was cold. During an observation and interview on 03/24/2026 at 9:00 a.m., revealed Resident #2 in the room with Resident #1. He was eating his breakfast and the oatmeal was left in his bowl. Resident #2 had completed the rest of his breakfast. Resident #2 stated he would not touch the oatmeal, it was sticky, cold and lumpy and looked disgusting. Resident #2 stated the oatmeal was always that way. Resident #2 pulled the oatmeal out of the bowl with his spoon as one whole piece. In an interview on 03/24/2026 at 03/24/2026 at 9:00 a.m., with CNA A at 9:00 a.m., revealed, CNA A stated the oatmeal was always served lumpy, it was always cold and she had a lot of residents that complained. CNA stated she told the kitchen about the oatmeal, but it had not changed. CNA A stated Resident #1 always eats all her breakfast, including oatmeal, the CNA stated she tries to mix it with the eggs that are warm, so she will eat it. CNA stated she offers fresh oatmeal, but the residents say it will just be the same. CNA A stated that breakfast is the only served meal when all the residents are on the hallway, but by lunch time there are very few residents, they all eat in the dining room, except for maybe two or three residents. During an observation and interview on 03/24/2026 at 9:10 a.m., revealed Resident #3 had completed his breakfast. He had eaten his eggs and his toast, but the oatmeal bowl had not been touched. Resident #3 stated he could not eat the oatmeal, it was terrible. He stated it was always thick and cold. Resident #3 took his spoon, placed it in the bowl of oatmeal attempting to stir it and the entire bowl of oatmeal came out for the bowl in one piece. Resident #3 stated he had told the staff about it, but nothing had changed. During an interview on 03/24/2026 at 9:15 a.m., Resident #1 stated she did not mind cold food, and she will try and eat anything, but Resident #2 likes his food warm. Resident #1 stated she did know that the oatmeal would taste better if it were warm. During an observation and interview on 03/24/2026 at 9:35 a.m., Resident #4 was eating her breakfast. The resident stated she did not want to get anyone in trouble, but she sure would like her oatmeal to be warm and edible Resident #4 stated she likes oatmeal, but not cold and sticky and one big lump. Resident #4 stated the oatmeal was aways served the same, so she asked for extra toast. Resident #2 stated she had told the CNAs, but she did not like to make a fuss, and the rest of the meals are warm and good. During an interview on 03/24/2026 at 1:37 p.m., with the Dietary Manager revealed the oatmeal left the kitchen warm, and she did not know what happened after that. The Dietary Manager stated she did not recall any grievances concerning cold inedible oatmeal. During an interview on 03/24/2026 at 3:00 p.m. with the Administrator and the DON revealed they were unaware of any problems with the oatmeal that was served at breakfast. The Administrator stated they would be looking into the problem. The DON stated if that was all the residents would eat it could lead to weight loss. Record Review of the facility Dietary Services Meal and Food policy dated June 2022 reflected It is the policy to ensure dietary services are provided to our residents. 9. Food prepared for consumption by our residents is prepared according to all applicable food services regulations.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life threatening conditions or clinical complications for 1 of 3 residents (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when Resident #1 was found sitting up in bed with his midline IV (flexible catheter inserted into a vein in the arm) removed from his left arm on 12/03/25, which resulted in his arm having to be elevated and wrapped to lessen any swelling and bleeding. This failure could place residents at risk of their RP not being aware of conditions that may require them to make medical decisions. Findings include:Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Atherosclerotic cardiovascular disease (caused by plaque buildup in arterial walls), Chronic Kidney Failure (gradual loss of kidney function over time), Dementia (loss of thinking, remembering, and reasoning skills), and Malignant Neoplasm of Brain (cancer that grows aggressively, and can spread). Record review of Resident #1's admission MDS, dated [DATE], indicated he had a BIMS score of 5, which indicated severe cognitive impairment. Record review of Resident #1's Care Plan, dated 11/20/2025, indicated At risk for impaired cognitive function/dementia or impaired thought processes. Record review of Resident #1's SBAR Communication Form, dated 12/3/2025 at 11:00 AM, and completed by RN B, reflected Resident #1 had a change in skin color that started on 12/3/25. Under section Name of Family/Health Care Agent Notified was FM [Name]. Record review of Resident #1's Skin Check, dated 12/3/25 at 19:57 (7:57 PM) and completed by LVN B, reflected Resident #1 had a new skin tear on his left outer forearm that was acquired in-house. The Skin Check further revealed Resident #1's skin was not warm and dry, his skin color was not within normal limits, and his skin turgor (skin's elasticity, its ability to snap back after being stretched) had decreased. Record review of Resident #1's Progress Notes, dated 12/03/2025 at 11:22 AM and written by RN B, revealed Midline observed out of pt's arm during this shift. Catheter tip was intact. Plan of care ongoing. Record review of Resident #1's Progress Notes, dated 12/03/2025 at 11:29 AM and written by RN B, revealed eINTERACT SBAR Summary for Providers: The Change in Condition/s [sic] reported on this CIC Evaluation are/were: Change in skin color or condition. Primary Care Provider responded with the following feedback: A. Recommendations: Wound care order. Record review of Resident #1's Progress Notes, dated 12/03/2025 at 13:20 (1:20 PM) and written by RN B, revealed Monitor PIV / PICC / Midline / Central Line For S/S Of Infection/Infiltration Every Shift **Notify Provider If Present every shift. Record review of Resident #1's Progress Notes, dated 12/04/2025 at 11:34 AM and written by RN B, revealed Pt transfered [sic] to [Hospital] ER per family - [RP]'s [Name] request. Pt is stable at time of transfer. [FM], [Name] at bedside. In an interview on 12/09/25 at 5:47 PM with the RP, she stated the facility removed Resident #1's midline IV from his left arm on 12/3/2025 without informing her. The RP stated she visited Resident #1 on 12/2/2025 and he was fine with no issues. The RP stated FM visited Resident #1 on 12/3/2025 and he was told the facility removed the midline IV. The RP stated FM said he observed Resident #1 sitting up in his chair with his arm wrapped. The RP stated on 12/4/2025, a male staff member called her and asked if they could insert another midline IV in his right arm. In an interview on 12/10/25 at 3:05 PM with LVN A, she stated if there was any type of change in condition, they contacted the NP or the doctor to get orders. She stated they also notified the DON and the RP. LVN A stated the RP must always be contacted for any change in condition. LVN A stated she should had contacted the RP. She stated she was trained on changes in conditions and proper notifications by the ADONs and the DON. In an interview on 12/11/25 at 11:00 AM with ADON C, she stated when a resident had a change in condition, they assessed the resident and contacted the doctor or the NP and shared their findings and then notified the RP. ADON C stated they processed any orders (medications, lab work, etc.). ADON C stated once they received the results, they informed the doctor and NP and implemented any new orders given. ADON C stated they updated the RP as soon as possible to get approval and if the RP was not in agreement, they notified the doctor. In an interview on 12/11/25 at 11:45 AM with ADON D, she stated when there was a change in condition, if the resident did not have a cognitive diagnosis, she discussed the lab results with the resident. ADON D stated they notified the resident, the RP, the physician, the NP and the DON. ADON D stated after a change in condition, the physician would give new orders, continue with existing orders, repeat lab work, or order an x-ray. ADON D stated they updated the family and the DON. ADON D stated if a family member was present at the facility, she reviewed the face sheet to confirm if they were able to release information, because the resident may not want that person to be informed. ADON D stated if the person was on the face sheet as an emergency contact, she would inform them too. ADON D stated she still notified the RP and never relied on a family member to inform the RP. In an interview on 12/11/25 at 12:25 PM with RN B, she stated when there was a change in condition, they notified the doctor, the RP and the DON. RN B stated if there were new orders, they informed the RP prior to implementation and if the RP consented, they proceeded. RN B stated if the RP was not in agreement, they updated the doctor. RN B stated they also completed the Change of Condition Form in the EMR. RN B stated Resident #1 had a change in condition on 12/3/2025 which consisted of his midline IV being observed out of his left arm with visible bleeding. RN B stated she found the midline IV out of Resident #1's arm, and she informed the FM when he arrived to visit Resident #1. RN B stated she did not inform the RP due to telling the FM. RN B stated they were supposed to notify the RP to ensure the RP was made aware. RN B stated due to the FM not being the RP, she should have notified the RP herself. RN B stated by not informing the RP, prevented the RP from being aware of any change in condition. RN B stated she was trained on changes in conditions and proper notifications by the ADONs and the DON. In an interview on 12/11/25 at 1:40 PM with NP E, she stated RN B informed her Resident #1 pulled out his midline IV. NP E stated RN B notified her on 12/3/25 that there was bleeding from Resident #1's arm. NP E stated she put in an order to cleanse the arm and an order for a wound care assessment due to it being opened. NP E stated the next day on 12/4/25, the RP requested Resident #1 be sent out to the hospital for further evaluation. In an interview on 12/11/25 at 2:05 PM with the MD, she stated it was believed Resident #1 pulled out the midline IV as it was not removed by staff. The MD stated RN B notified her the midline IV was out and there was a change in condition which included a skin tear. The MD stated Resident #1 was a [AGE] year-old male, on a blood thinner and had a long-term use of steroids. The MD stated in addition to Resident #1's serious co-morbidities all contributed to him having thin skin. The MD stated NP E put in a new order to Cleanse left arm wounds with NS, pat dry, apply xeroform (mesh gauze dressing), cover with ABD and secure with kerlix (woven gauze bandage) every day shift every Tuesday, Thursday, Saturday for Wound care. In an interview on 12/11/2025 at 2:30 PM, the DON stated his expectation was for nursing to notify the family and the MD of any change in condition. The DON stated RN B should have notified Resident #1's RP as soon as possible when he first had a change in status on 12/3/25. In an interview on 12/11/2025 at 3:20 PM with the ADM, he stated he expected staff to follow policy which included notifying the RP. The ADM said they coached the nurses on what the policy was, so they had an understanding. The ADM stated staff could not be expected to do something they did not know. The ADM stated his expectation was if there was a change of condition, the family and the RP should be notified as soon as possible. The ADM stated it was important for the family and the RP to know what was going on with the resident. The ADM stated nurses were educated on when to notify and to not deviate from the facility's policy. Record review of the facility's policy, Change in Condition, with a revision date of April 2025, reflected .5.The resident/resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety.1. The facility failed to correctly discard food by the use by date for 1 storage bag of cheese.2. The facility failed to discard a dented can of soup.3. The facility failed to use or discard a tray with four containers of sliced/chopped vegetables by the discard dateThese failures could place residents at risk for food-borne illness and cross contamination.Findings included:Observation of the kitchen on 09/23/2025 at 9:40 a.m., revealed in the walk in refrigerator a storage bag containing sliced cheese was observed with a use by date of 09/21/2025. Observation of the walk refrigerator on 09/23/2025 at 9:45 a.m. revealed a tray with 4 containers, one with sliced onions, one with sliced pickles, one with lettuce, and another with sliced tomatoes. This tray had plastic wrap covering it with a use by date of 09/21/2025. Observation of the dry storage room on 09/23/2025 at 10:00 a.m. reveal a dented can of soup on the bottom row of a storage rack. In an interview with the DM on 09/23/2025 at 10:15 a.m., she revealed that she received orders every week and she usually made sure items were labeled with received and use by dates. She stated that someone must have re-used the plastic wrap on the sliced vegetables. She stated because the burger condiments were just put in there. She stated that she doesn't know what happened with the cheese and the date on the package. She stated that the dented can just got past her eyes. She stated they usually don't have dented cans and she will just discard them. During an interview with the Administrator on 09/23/2025 at 2:10 p.m. He stated that that Dietary Manager has done a tremendous job getting the kitchen in order. He stated that he was surprised we found anything because she has done a very good job in the kitchen. Record review of Facility Policy, undated. Policy:The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.Definitions: Time/temperature control for safety food (formerly potentially hazardous food) includes an animal food that is raw or heat-treated; a plant food that is heat-treated or consists of raw seed sprouts, cut melons, cut leafy greens, cut tomatoes or mixtures of cut tomatoes that are not modified in a way so that they are unable to support pathogenic microorganism growth or toxin formation; or garlic-in-oil mixtures that are not modified in a way so that they are unable to support pathogenic microorganism growth or toxin formation.Policy Explanation and Compliance Guidelines for Staffing:1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days.2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday.)6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed.8. Note: prepared foods that are delivered to the nursing units shall be discarded within two hours, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. Review of the U.S. FDA Food Code 2022 reflected: Chapter 2 . section 2-301 Hands and Arms. 2-301.11 Clean Condition. Food Employees shall keep their hand and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (C). To avoid recontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a Handwashing Sink or the handle of a restroom door. 2-201.14 When to Wash. Food Employees shall clean their hands and exposed portions of their arms as specified under section 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles. and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. Section 2-301.15 Where to Wash. Food Employees shall clean their hands in a Handwashing Sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. Chapter 3 . section 3-201.11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in LAW, including 21 CFR 101 Food Labeling [*.(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Section 3-302.12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section 3-501.13 Thawing. Except as specified in (D) of this section, Time/Temperature Control for Safety Food (TCS) shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF) , or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41oF). Section 3-501.17. Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 5 . Section 5-205.11 Using a Handwashing Sink (A) A Handwashing Sink shall be maintained so that it is accessible at all times for Employee use. Section 5-501.16 Storage Areas, Rooms, and Receptacles, Capacity and Availability . (B) A receptacle shall be provided in each area of the Food establishment or premises where refuse is generated or commonly discarded, or where recyclables or returnables are placed. (C) If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories. Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . www.fda.gov eCFR- Code of Federal Regulations are indicating within the text by an *- www.ecfr.gov

Based on interviews and record reviews, the facility failed to provide each resident with a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 5 residents (Resident #13) reviewed for resident rights.1. The facility failed to remove Resident #13 from contact isolation as ordered. Failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. findings included: Record review of Resident #13's face sheet, dated 09/25/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing inflammation and narrowing of the airways, making it difficult to breath), dysarthria following other cerebrovascular disease (slurred, slow, or unclear speech resulting from brain damage caused by stroke or other blood vessel problem in the brain), muscle weakness, cognitive communication deficit (difficulty in communication caused by impairment in brain function like memory, attention and problem-solving, rather than a primary language or speech problem) and major depressive disorder.Record review of Resident #13's Quarterly MDS assessment, dated 09/01/2025, reflected Resident #13 had a BIMS score of 15 indicating he was cognitively intact. The MDS assessment reflected Resident #13 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing, lower body dressing, putting off footwear and personal hygiene. Record review of Resident #13's comprehensive care plan, revised on 07/31/2024, reflected Resident #13 was dependent on staff to assist him to and with activities. The care plan goal included resident will attend/participate in activities of choice and will choose and participate in his preferred leisure activities daily. The interventions included the following: All staff to converse with resident while providing care; Assistance with ADLs as required during activity; it is very important to do his favorite activities, bible study, social events, and BINGO; Needs assistance to activity functions; provide who activities calendar and notify of any change to the calendar of activities. Record review physician order for Resident #13 revealed contact isolation start date of 2//21/2025 through the duration of 3/3/2025. Record review of nurse's progress note revealed Resident #13 showed no sign of diarrhea on 2/26/2025, 2/27/2025 and 2/28/2025. During an interview on 09/23/2025 at 10:09 AM, Resident #13 he stated that back in February he had contracted C-DIFF and was placed on contact isolation. Resident #13 stated that per CDC guidelines he was only supposed to be on contact isolation for three days after the last symptom. Resident #13 had his last symptom on 2/28/2025 but remained on contact isolation until 3/10/2025. Resident #13 stated that when he was on contact isolation he missed group activities such as church, BINGO, blackjack and eating with the other residents. Resident # 13 stated the facility provided one-on-one activities, but it was not the same. During an interview on 9/24/2025 at 3:00 PM, with the physician she revealed that residents are kept in contact isolation according to the symptoms and the type of bacteria they are treating. The physician stated Resident #13 needed to be in contact isolation for a longer period of time (no specific dates or times were provided) due to his inconsistent diarrhea and facility would have to contact her to take any resident out of contact isolation. The physician did not recall the order for discontinuing isolation but did state that the staff should have contacted her if the resident had been asymptomatic for greater than 72 hours, so they could discuss the resident's course of treatment. During an interview on 9/23/2025 at 12:32 PM, with the DON stated residents were placed on contact isolation by a physician's orders. The DON stated that the facility's' goal was to remove the contact isolation once they were no longer contagious and that the facility did not have to wait until the treatment/antibiotic were completed. The DON stated that residents are no longer contagious after no signs of diarrhea for 72 hours, but their policy was to refer to the physicians for final decision.During interview with the DON he said it was his expectation for the facility staff to follow the physician orders. Record review of Infection Prevention and Control Measure for Common Infections in LTC Facilities dated 10/07/22 stated duration of precaution is the duration of illness. Record review IPCP Standard and Transmission-Based Precautions dated 6/2021 revied 3/2024 stated under e. Termination of Contact Precautions: may be discontinued when the resident becomes asymptomatic: i. It is not necessary to wait until the completion of the antibiotic.ii. Assess the resident for clinical improvement which is evident be resolution of symptoms.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (MA A) staff members and 3 of 4 residents (Residents #21, #91, and #42) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #21, #91, and #42. These failures could place residents at risk for cross contamination and infections.Findings included: Record review of Resident #91's annual MDS assessment, dated 08/06/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Cardiovascular accident (stroke), and hypertension (high blood pressure). Resident #91 was moderately cognitively impaired and unable to make decisions. He required assistance from one staff for activities of daily living. Record review of Resident #91's physician orders dated 08/16/25 (open ended) reflected, Amlodipine tablet (high blood pressure) 2.5 mg give one tablet by mouth one time a day, and losartan potassium-HCTZ (high blood pressure) 100-12.5 mg one tablet by mouth one time a day. Obtain blood pressure one time a day on each shift. Record review of Resident #42's quarterly MDS Assessment, dated 09/08/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #42 had diagnoses which included: hypertension (increased blood pressure), and cerebrovascular accident (stroke). Resident #42 was cognitively intact and able to make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #42's physician orders dated 08/16/2025 (open ended) reflected, Lisinopril (high blood pressure) 10 mg give one tablet by mouth one time a day. Obtain blood pressure one time a day on each shift. Record review of Resident #21's quarterly MDS Assessment, dated 07/14/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #21 had diagnoses which included: hypertension (increased blood pressure), and cerebrovascular accident (stroke), and hemiplegia (one arm does not work) Resident #21 was cognitively intact and able to make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #21's physician orders dated 08/16/2025 (open ended) reflected, Amlodipine tablet (high blood pressure) 2.5 mg give one tablet by mouth one time a day, and losartan potassium-HCTZ (high blood pressure) 100-12.5 mg one tablet by mouth one time a day. Obtain blood pressure one time a day on each shift. Observation on 09/23/2025 at 9:30 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #91. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #91. Observation on 09/23/2025 at 9:39 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #42, using the same blood pressure cuff used on Resident #91. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #42. Observation on 09/23/2025 at 9:55 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #21, using the same blood pressure cuff used on Resident #42. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #21. In an interview on 09/23/2025 at 12:30 p.m., MA B stated she did not think about cleaning the blood pressure cuff between usage, and she had been in-serviced on that. MA B stated if the cuff was on the residents and then not cleaned it could spread germs to others. In an interview with the DON, who was the infection control preventionist on 09/25/2025 at 1:39 p.m., the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated he had just had an in-service on 08/25/2025, presenting step by step the cleaning of equipment and infection control. The DON stated during the in-service the staff did not ask any questions and appeared to understand and indicated they knew everything. The DON stated MA A had been trained multiple times about cleaning the blood pressure cuff between each usage, in fact he just had spoken to her today about it, that is how he found out she had forgotten to clean the cuff. The DON stated if they do not clean the blood pressure cuffs appropriately and clean the shower rooms after each use when they should, they could spread germs to themselves and the residents. Record review of an in-service log dated 08/25/2025 revealed entire direct care staff and MA A, had received in-service on cleaning and properly storing equipment after each use and how to prevent the spread of infection. Record review of the Facility's Policy titled Cleaning and Disinfection of Resident-Care Items and Equipment undated, reflected: Policy Statement Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected . (c). non-critical items are those that come in contact with intact skin but not mucus membranes. (1) Non-critical resident-care items include . blood pressure cuffs. (2) Most non-critical reusable items can be decontaminated where they are used . 4. Reusable resident equipment will be decontaminated and/or sterilized between residents

Based on observation, interview, and record review the facility failed to the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one (Resident#1) of four reviewed for environment. The facility failed to ensure Resident #1's sheets were clean and free of any stains. This failure could place residents at risk for a reduced quality of life and unsanitary and hazardous living conditions. Findings included: Record review of Resident #1's Face Sheet printed 12/04/2024, reflected a [AGE] year-old female who was admitted to the facility initially 06/02/2022 and readmitted on [DATE] and 12/11/2022 with diagnoses to include but not limited to Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance (term used to describe a group of symptoms affecting memory, thinking and social abilities), high blood pressure and heart failure. Record review of Resident #1's quarterly l MDS, dated [DATE], reflected a BIMS score of 10 which indicated moderate cognitive impairment. Record review of Resident #1s care plan revised 06/15/2024reflected, Resident #1 at risk for impaired cognitive function/dementia or impaired thought processes regarding UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE. Intervention included: COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Engage in simple, structured activities that avoid overly demanding tasks. Observation and interview on 12/04/2024 at 1:30PM with Resident #1 revealed the sheets on the bed were largely stained with a light brown substance that appeared to be food. Resident #1 stated she may have spilled something a few days ago and the sheets were not changed. Resident #1 stated she would have liked to have the sheets changed on the bed however staff had not done it yet. Resident #1 stated maintenance was supposed to change out her mattress today(12/04/2024) and had come in the room to look at the mattress but had not returned with the mattress yet. Interview on 12/04/2024 at 2:40PM with CNA A revealed she worked the hall for Resident #1's room however she did not change the sheets. CNA A stated she did not notice that the sheets needed to be changed. CNA A stated the sheets were typically changed on shower days or as needed. Interview on 12/04/2024 at 4:16PM with the Director of Nursing revealed CNA's or any staff who noticed that bed linens needed to be changed were able to do so. The Director of Nursing stated there had not been issues with bed linens being changed in the facility. The Director of Nursing stated Resident #1 did have dementia and may not have been aware of timeframes however he was not disregarding her concerns. The Director of Nursing stated Resident#1 received a new mattress today (12/04/2024) and the sheets were changed after she got the new mattress. Review of the facility policy Resident Rights dated amended July 13, 2017, revealed You have a right to a safe, clean, comfortable and homelike environment, and use of your personal belongings to the extent possible, including but not limited to receiving treatment and supports for daily living safely.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed Resident #1's care plan quarterly. This failure could affect residents by placing them at risk for not having their individual needs met. Findings included: Record review of Resident #1's Face Sheet printed 12/04/2024, reflected a [AGE] year-old female who was admitted to the facility initially 06/02/2022 and readmitted on [DATE] and 12/11/2022 with diagnoses to include but not limited to dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance ( term used to describe a group of symptoms affecting memory, thinking and social abilities), high blood pressure and heart failure. Record review of Resident #1's quarterly l MDS, dated [DATE], reflected a BIMS score of 10 which indicated moderate cognitive impairment. Record review of Resident #1s care plan revised 06/15/2024reflected, Resident #1 at risk for impaired cognitive function/dementia or impaired thought processes regarding UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE. Intervention included: COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. Engage in simple, structured activities that avoid overly demanding tasks. Review of Resident #1's care plan conference revealed the last care plan was held 5/03/2024. Interview on 12/04/2024 at 3:05 PM with the social worker revealed care plan conferences were held quarterly. She stated she did reach out to Resident #1's family member today (12/04/2024) to schedule the care plan meeting however the family member was not available for a meeting until after Christmas. The Social worker stated she had not contacted the family member prior to today (12/04/2024) to schedule the meeting. The Social worker stated the electronic system the facility was using had not prompted her that the care plan was due. The Social Worker stated she had known the care plan meeting was due for about 3 weeks. The Social Worker stated she did could not say whether or not there was a risk to the resident due to the care plans not being completed because staff see the residents on a regular basis however, she was aware that the care plan conference has to be done quarterly. Interview on 12/04/2024 at 4:16PM with the Administrator revealed the care plan had not been updated due to the electronic system not informing staff that the care plan was due. The Administrator stated this was the first time the system had failed and now the Social Worker was auditing resident files to ensure care plans were up to date. The Administrator stated the care plan was a formal setting in which family and residents had the opportunity to voice concerns however residents were asked daily about needs. The Administrator stated the care plan conference was a formality and resident care did not lack due to a care plan conference not being held. Review of the facility care plan policy Policy / Procedure - Nursing Administration, Subject -Comprehensive Person-Centered Care Planning revised 05/2021 revealed The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment as indicated.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #2) of 4 residents reviewed for accuracy of medical records. The facility failed to ensure the nursing notes accurately reflected Resident #2's condition. The nursing notes dated 08/17/2024 indicated the resident had old bruises to the bilateral upper arms, chest area and knees that were old however those bruises were new following the fall on 08/17/2024. These failures could place residents at risk for medication and /or treatment errors and omissions in care. Findings included: Review of Resident #2's electronic face sheet printed 12/04/2024 revealed a [AGE] year- old female admitted to the facility initially on 03/30/2023 and re admitted on [DATE] with diagnoses that included but not limited to dementia(term used to describe a group of symptoms affecting memory, thinking and social abilities), Stroke(when the blood supply to part of the brain is blocked or reduced.), and Parkinson(a movement disorder of the nervous system that worsens over time.) Review of Resident #2's care plan revised 6/28/2024 Has had an actual fall with No Injury, regarding Poor Balance, Poor communication/comprehension, Unsteady gait Falls:1/6/24, 2/15/24, 04/27/24 and 06/25/24, intervention included - Neuros initiated, therapy screen. Resident educated on call light and asking for assistance when needed, Resident redirected and educated to use walker to ambulate. Resident and staff educated to ensure w/c are locked during transfers, Monitor/document /report to medical doctor for signs/symptoms: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 07 which indicated mild cognitive impairment. Review of Resident #2's incident report authored by LVN B dated 08/17/2024 revealed Resident was assisted back in bed x 2 staff members, assessment done, skin warm and dry to touch, old bruises noted to Bilateral upper arms, chest area and knees. bed in the lowest position, fall mat in place, resident brought to nurse's station for close observation, Resident educated to call for assistance, Call placed to [Hospice} and notified [family member] of the fall. [director of nursing], [doctor] and [family member]. Review of Resident #2's incident report dated 08/12/2024 authored by LVN C revealed - Nursing description- CNA [name] told writer that resident was sitting on the floor. Went in room and resident was up from the floor and walking in. Assessment performed ROM on all extremities, scratch on right arm, vital signs 137/61, 88, 18, 97%, 98.2. NP.Description: Assessment performed ROM on all extremities, scratch on right arm, first aide given, vital signs 137/61, 88, 18, 97%, 98.2. Neuro checks initiated. Resident educated to use the call light system for help, therapy screen, resident brought to the nurse's station for close monitoring. Injury type- no injury observed at the time of the incident. No injures observed post incident. Review of Resident #2's incident report dated 8/11/2024 authored by LVN D Resident Nurse heard uh [sic] nurse's station, stand up to see and saw resident lying on the floor in front of nurse's station.Nurse went to see the noise and notice resident is on the floor, Head to toe assessment completed, no physical injury noted. Pull up by nurse and walk her down to her room. DON, hospice, MD notified, RP Sunny called and informed also. Neuro checks initiated. Resident is non- complaint with instruction but educated to use walker and to ask for assistance, therapy screen, medications reviewed. No injures noted at the time of the incident. No injuries observed post incident. Review of nursing note dated 8/12/2024 authored by LVN E revealed post fall neuro checks in progress, no injury noted, resident denied any pain, sitting at nursin station at lunch time, took all her prescribed meds without any issues. Review of the skin assessment dated [DATE] revealed document all ulcers, wounds, and other skin problems- Bruising BUE d/t recent fall. Review of the skin assessment dated [DATE] revealed document all ulcers, wounds, and other skin problems- no new skin issues noted. Review of the skin assessment dated [DATE] revealed document all ulcers, wounds, and other skin problems- no new skin issues noted. Review of the skin assessment dated ,d+[DATE]/ 2024 Review of the skin assessment dated [DATE] revealed document all ulcers, wounds, and other skin problems- bruises on face from post fall, no new skin issues noted. Attempted call to LNV B on 12/04/2024 at 4:00PM was unsuccessful. Interview on 12/04/2024 at 4:16 PM with the Director of Nursing and administrator revealed the Director of nursing stated LVN B completed the nursing notes and incident report incorrectly and the notes should have indicated that bruises to the bilateral upper arms, chest and knees were new. The Administrator stated he could not say if there was a risk to residents or not if documentation was not correct and followed up. The administrator stated there could have been an issue however documentation was not a end all be all. A policy regarding documentation was requested from the administrator and Director of Nursing on 12/04/2024 at 3:20PM however was not provided prior to exit.

Based on observations, record reviews and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #139) resident of three residents reviewed for assisted transfer. The facility failed to ensure on 02/01/2024 PT K used the Hoyer lift ( mechanical/patient lift designed to assist caregivers move patients from one place to another) correctly, attach the Hoyer lift sling pad and condcuted with assistance of a second person as care planned, when he transferred Resident #139 from his wheelchair to the bed. On 02/01/2024 Resident #139 fell from the Hoyer lift sling pad while in use fracturing the right clavicle (right shoulder), right femoral neck (hip), right proximal tibia fracture (long bone in the right lower leg) and sustained an intraventricular hemorrhage (bleeding into the brain). The noncompliance was identified as PNC (past non-compliance). The Immediate Jeopardy(IJ) began on 02/01/2024 and ended on 02/03/2024. The facility had corrected the noncompliance before the survey began. The failures placed residents at risk for harm and/or serious injury, hospitalization , a decline in health, and death. Findings included : Record review of Resident #139's quarterly MDS assessment, dated 04/25/2024 reflected the Resident was a [AGE] year-old-male who admitted to the facility on [DATE] and discharged on [DATE]. The resident had diagnoses which included: Diabetes (increased blood sugar), dialysis (kidneys do not function have to have machine to cleanse blood), osteoporosis (brittle bones), left above knee amputation (leg missing from above the knee downward) and Protein malnutrition (poor nutrition). The MDS reflected he had a BIMs score of 12, which indicated moderate cognitive impairment and the resident was dependent on two or more staff members to transfer him from bed to wheelchair. Record review of Resident #139's care plan, dated with a review/revise date of 06/13/2022, addressed the resident's activities of daily living needs, requiring mechanical aide for transfers for chair/bed transfers (requiring two staff), and risk for falls and assistance required for activities of daily living. Further review of the clinical record reflected, the care plan was updated quarterly, addressing the transfer bed/chair needs requiring mechanical assistance and two staff members, until discharge on [DATE]. Record review of Resident #139's Fall Risk Assessment completed 06/09/2022 and quarterly thereafter scored Resident #139 as high risk. Further review of the clinical record reflected on 02/06/2024 a follow-up fall risk assessment was completed after hospitalization ; Resident #139 was still a high risk for falls. Record review of the Provider Investigation Report, dated 02/02/2024 and completed on 02/07/2024, revealed Resident #139 was total assist for activities of daily living and had fallen during a Hoyer lift transfer with the Physical Therapist K on 02/01/2024 at approximately 4:00 p.m. Resident #139 had been transferred by PT K without any assistance from other staff and the PT knowingly attached the Hoyer lift sling/pad incorrectly. The transfer resulted in Resident #139's injuries: 1) right distal clavicle fracture, 2) the right proximal tibia fracture, 3) right intertrochanteric femoral neck fracture, and 4) intravascular hemorrhage of the brain. Resident #139 had to be transferred from the local ER to a larger hospital for further evaluations of his injuries. The Provider Investigation Report reflected a finding of confirmed (incident). The facility suspended the physical therapist and then later terminated,due to the PT admited he did not follow the policy for mechanical transfer (Hoyer lift). The facility started an in-service on fall prevention, transfer, and abuse/neglect policy and procedure with all staff and conducted competencies for mechanical lift training, Hoyer lift competency check off, and transfer training with a gait belt, was performed on all staff who transfer residents prior to returning to care with all staff. Review of the Provider Investigation Report dated 02/01/2024 and completed on 02/07/2024, reflected a finding of substantiated for an incident based on the Physical Therapist's interview. The physical therapist in the interview admitted the Hoyer lift transfer of Resident #139 was conducted without following policy of the facility, including two staff members for the transfer, and attaching the Hoyer lift pad/slip correctly. Review of the External/Internal/Systemic Approach Investigation Summary dated 02/02/2024 completed on 02/07/2024 reflected: There was an emergency QAPI meeting was held on 02/02/2024 with Medical Director in attendance. The meeting concluded all residents had a safe survey interview completed with BIMs score greater than 10 (no concerns about transfers noted), staff interview initiated, facility inspected lift sling and equipment to check for failure. (No failures of equipment or sling were identified), in-services began on all staff that care directly for residents, concerning Hoyer lift transfer, gait belt transfers, falls, abuse, and neglect. Who was responsible for in-servicing: Nurse Management. Who will monitor: Regional Director of Clinical Services/Director of Nursing. In additional meeting the QAPI decided, The Nursing Administration, including the ADON and DON will randomly select five staff for Hoyer lift transfers demonstration each week to continue since February 2024. The DON will monitor for compliance for 8 weeks and then on 04/02/2024 QAPI decided to continue the five employee's observation of transfer training a week ongoing basis. This training is including new hires, CNAs, Nurses, MAs, and therapists. Who will monitor: The Administrator will continue to monitor and oversee the training by reviewing with the DON the weekly trainings in the morning meeting. Resident care plans will be reviewed and updated about the transfer needs. Audits will be ongoing basis and compiled into a binder that the DON maintains. The binder was reviewed with the DON and the Surveyor. Further review of the Provider Investigation Report reflected monitoring and audits by the designated staff (the DON and Nurse Managers) had occurred. Record review of the nursing progress notes reflected on 02/01/2024, the PT reported to and doucmeneted by RN L at approximately 4:30 p.m. that Resident #139 had slipped from the Hoyer lift during a transfer. RN L observed Resident #139 in the room lying on the floor, next to the bed with a pillow under his head. The RN assessed the resident due to complaint of pain to his bilateral (both) hips, right toe, right temporal mandibular joint (right cheek), and right shoulder. The RN called the family and the physician ordered x-rays. Further review of the progress note reflected Resident #139's x-rays results at 5:46 p.m. were questionable for a right distal fracture and proximal tibia fracture, positive for right intertrochanteric femoral neck fracture, and right clavicle fracture. The physician was notified of the results of the x-rays, orders were given to transfer the resident to the local hospital. The family was notified of the results and the transfer to the hospital. Record review of the nursing progress notes dated 02/06/2024, at aporximalty 2:20 p.m. documented by RN L reflected Resident #139 on 02/06/2024 returned from the hospital with a right hip fracture and right shoulder fracture. Orders noted for Physical Therapy, Occupation therapy, and Speech therapy. Resident #139 remained a total assist for transfer with two staff members using a Hoyer lift. In an interview on 08/20/2024 with PT K at 9:30 a.m. revealed PT K knowingly with no assistance from another staff member, transferred Resident #139 using the Hoyer lift. PT K stated no other staff was asked to assist with the Hoyer lift transfer. PT K stated there was plenty of staff and a CNA assigned to Resident #139. PT K stated the Hoyer lift sling pad was not hooked appropriately, the sling pad was not fully clipped to the sling loop onto the lift hook, causing the loop to slip off. The sling pad became undone, and the resident slipped out and was eased to the floor. PT K could not explain if the resident was eased to the floor how so many injuries had occurred. PT K stated that Resident #139 hit the floor hard. The PT stated a pillow was placed under the resident's head and the nurse was informed. PT K admitted to knowing and understanding that the facility policy and the training specified that lift transfers required at least two staff, but he did not offer any reason as to why he did not follow policy for a safe transfer. PT K stated he could not come back until the investigation was completed. PT K stated he made a very poor decision, but it was an accident. PT K stated the facility terminated his position in the facility. The PT stated he was a four-year degreed PT with a doctorate degree and he knew the importance of a safe Hoyer lift transfer. The PT stated in-services were given concerning Hoyer lift transfer and how to appropriately perform them, by PT K, at this facility. An observation on 08/20/2024 at 11:00 a.m. revealed Resident #140 was transferred by Hoyer lift. CNA M and CNA N transferred Resident #140 appropriately to the wheelchair with no pain or anxiety related to the resident. CNA M and CNA N both stated there had been multiple in-services on Hoyer lift transfers, including appropriately securing the lift sling/pad. Both CNAs stated they had been tested after the training and one of the CNAs stated there was random competency testing. In an interview on 08/20/2024 with RN L at 1:45 p.m. revealed the PT came and reported Resident #139 had slipped out of the Hoyer lift , while being transferred. The RN stated there was no other staff in the room when Resident #139 was being assessed for injuries. The family and the physician were notified, x-rays were ordered, and the result of the x-rays indicated there were fractures to the shoulder and possible tibia and possible hip, all on the right side. Resident #139 was sent to the hospital when the results of the x-ray came back. RN L stated PT K stated Resident #139 was transferred in the Hoyer lift by the PT with only one person and the sling/pad had come undone and the resident had slid out of the Hoyer lift onto the floor. Resident #139 was hurting all over and denied hitting his head. RN L stated when a resident had a fall the resident was assessed, and the physician and responsible party were informed. They followed physician's orders and then reassessed according to the physician's orders and the injures. The RN stated the ADON, and the DON would be notified when a resident had a fall and had to go to the hospital. The RN sated the entire staff had to have the transfer in-service concerning gait belts and Hoyer lifts before working on the floor after Resident #139 fell from the Hoyer lift. The RN stated the facility had in-serviced the entire care staff and the therapists, and the facility had continued to randomly select staff and have them Hoyer lift transfer a resident or another staff member. In an interview on 08/22/24 at 10:00 a.m. with the DOR revealed the PT had been trained on all transfer methods including the use of the Hoyer lift. The PT had even given in-services concerning the Hoyer lift and how to transfer a resident safely and appropriately. The DOR could not recall how long ago. The DOR stated the PT had worked at the facility for 7 years as a Physical Therapy Assistant, then got accepted into therapy school completed and gotten his doctorate and passed the board. The DOR stated it was shocking to hear how the PT had transferred Resident #139. In an interview on 08/22/2024 with the DON at 4:00 p.m. revealed the RN had contacted the physician and the responsible party when Resident #139 had fallen. The x-rays were positive for injuries and the investigation was started by the Administrator and DON. The DON stated the PT admitted to inappropriately transferring the resident and not following the company policy for Hoyer lift transfer. The resident's family was contacted, and the family had decided to bring the resident back to the facility as they were satisfied with how the facility had conducted the investigation and the outcome. The DON stated the PT had been trained on the policy and procedure for Hoyer lift transfers and had even given some of the in-services at the facility. In an interview on 08/22/2024 with the Administrator at 4:15 p.m. revealed the staff had all been in-serviced on Hoyer lift transfers, gait belt transfer, and abuse and neglect starting on 02/02/2024 and the in-services continued for the nursing and therapy departments given by the DON and ADON with competency testing. The DON and ADON choose five different staff off different shifts during the week to perform Hoyer lift testing. He stated the Quality Assurance team decided in April 2024 to continue with that part of the plan. The Administrator stated the PT had been suspended on 02/01/24 and had immediately been dismissed, as soon as the injuries were verified. The PT admitted completing the Hoyer lift transfer and not following the company policy of always having two staff and using appropriate safety concerning the Hoyer lift sling pad. The Administrator stated the staff had been in-serviced on safe transfers and the expectations of the Administrator. In an interview on 08/23/2024 at 1:00 p.m. with LVN O revealed Resident #139 had been on the rehab hallway. LVN O stated Resident #139 was a very pleasant man, who had originally admitted to the facility to get stronger and learn to use a sliding board since his left leg was an above the knee amputation. Resident #139 did not accomplish the sliding board safely and then had to be transitioned to a Hoyer lift transfer and remained a Hoyer lift transfer the entire stay at the facility. The resident was not on the rehab hallway the entire time. LVN O stated after the fall occurred the entire direct care staff had been in-serviced with competency testing on different types of transfers to include Hoyer lifts. The Hoyer lift required two staff members, it always had. The LVN stated the testing continued by the DON and ADON even now for Hoyer lift transfers, to make sure the staff understood the safety measures and always had two staff members, as well appropriate use of the lift sling pads. The LVN stated it was shocking that the PT had not gotten assistance to transfer Resident #139. In an interview on 08/22/2024 at 3:30 p.m. with the Medical Director revealed the facility had been contacted when Resident #139 had fallen and had serious injuries. The Medical Director stated there was a QAPI meeting the next day and was plan was put into place to educate and prevent a similar incident from happing again. The PT was terminated, and it was suggested that the PT be referred, which is in agreement. The Medical Director stated the facility was very good about communicating to him concerning changes of conditions with the residents. Review of the incident and accident logs dated 01/01/2024 through 08/20/2024 reflected no other incident /accidents related to the Hoyer lift transfers. Resident #139 had no other incidents or accidents related to transfer with a Hoyer lift. Review of an in-service dated 02/02/2024 reflected all staff attended and the subject matter was regarding the facility policy on falls, Hoyer lift transfers, and gait belt transfers with the competency testing for each transfer by each individual staff member. Further review reflected additional continued random testing one time a week for random selected staff for Hoyer lift transfers and education. Review of the Facility's Policy titled Hoyer Lift revised and dated May 2024 reflected: It is the policy of this facility that the Hoyer lift will be utilized for resident transfers only. It will not be used to transport resident to another location. Assistance of two personnel will be used with Hoyer Lift Equipment . Hoyer lift , Hoyer Lift sling 6. Position seat sling .8. Attach S/hooks of the lift to the holes in the Hoyer sling. Insert hooks away from the resident to outside of sling .9. Count links to be sure there are the same number on each side. Check to see that S/hooks are hooked all the way into the loops and that the sling is closed to the knees for safety .11. Check S/hooks to makes are properly positioned

Based on observation, interview, and record review, the facility failed to ensure personal privacy during incontinent care for 4 (Residents#78,#71,#38, and #3) of 15 residents reviewed for privacy. The facility failed to ensure Residents#78,#71,#38, and #3 were not put at risk of being exposed to view from the outside of the facility and to other windows of the facility during incontinent care or getting dressed. This failure could place other residents at risk for embarrassment and loss of self-esteem and dignity. Findings included: Review of the Admission Record indicated Resident #78 was [AGE] years old female admitted on [DATE]. Review of the MDS assessment dated [DATE] indicated Resident #78 had diagnoses of cerebral vascular accident (stroke) and generalized muscle weakness and was dependent on staff for toileting, and hygiene. During an observation on 08/20/24 at 1:16 p.m., revealed Resident #78 was observed receiving incontinence care by LVN C. Resident #78's bed was located beside a window that had vertical blinds with slats. The blinds were missing multiple slats, leaving large areas where the resident could be visible to anyone outside the building, or anyone looking out the windows of the part of the building facing directly across from Resident #78's room. The window itself did not have a curtain. The privacy curtain had been pulled in the middle of the room to provide privacy between roommates and to block the view of anyone entering the room. The privacy curtain did not block the view of the window. Resident #78 was observed being turned on her left side with the complete back part of her body unclothed and facing the window. In an interview on 08/20/24 at 01:20 p.m., with LVN C, when asked about the gapping blinds in Resident #78's room, the incontinence care that he had just provided, and the lack of resident privacy, LVN C stated, Of course, privacy was going to be a concern and that it could have negatively affected the resident. He reported all staff were responsible for ensuring the privacy of residents during personal care. In an interview on 08/20/24 at 01:22 p.m., Resident #78 stated she had difficulty with her vision and had not been able to tell that the blinds did not cover the window. She reported that made her feel uncomfortable. In an interview on 08/20/24 at 01:25 p.m., CNA B reported that she had worked at the facility for 1 year. She reported that staff had knocked on residents' doors and utilized the privacy curtains in the rooms to protect residents' privacy. She stated that window blinds were broken throughout the facility. She stated that if someone had walked by the window while a resident had been changed, it was very concerning for privacy. She stated staff had tried to use the curtains. She reported she had reported the broken blinds to maintenance a month or two ago. She stated that some residents had received better blinds (the horizontal blinds), but that many of them had not. In an interview and observation on 08/20/24 at 01:13 p.m., Resident #3 stated that her blinds had been broken since her admission two years ago. She stated she had submitted a request to the DON that they be fixed but did not know the exact date. The lateral blinds were observed to have approximately 13 slats which were not enough to fully cover the window. The window did not have a curtain. Resident #3 stated anyone could see in the window. She reported the window showed into the dining room across the way. She was noted with a privacy curtain in her room but stated she did not use it. She stated she turned off the lights when she needed to change clothes. She was noted with a roommate. She stated, you don't like to have people looking in on you and you can't tell. In an interview and observation on 08/20/24 at 01:25 p.m., Resident #38 stated he had lived at the facility for 7 years. The lateral blinds in his room (approximately20 individual slats) did not cover the entire window at their widest. The window did not have a curtain. The window directly faced the parking lot. He reported he was legally blind and was not aware of that. He stated he always wore a hospital gown. He stated he was not aware of the privacy issue. He laughed and stated, I hope I gave them a good show! The privacy curtain that was in use was providing privacy between him and his roommate. In an interview on 08/20/24 at 05:20 p.m., MA A stated he had worked at the facility for 8 years. He reported that when providing personal care, the curtain should be drawn, and the blinds should be closed to protect residents' privacy. In an interview on 08/20/24 at 05:25 p.m, CNA D reported she had worked at the facility for 3 weeks. She stated that to protect the privacy of residents the blinds needed to be closed and a curtain could also be used to block the resident from any roommates and anyone coming in the room during personal care. She reported that providing privacy was a dignity issue. In an interview on 08/20/24 at 05:40 p.m., LVN E reported that the windows needed to be covered to provide residents with privacy for personal care. She reported that not providing privacy could result in resident embarrassment. In an interview on 08/20/24 at 05:50 p.m., CNA F stated she had worked at the facility for ten months. She reported that to protect the privacy of residents, staff closed the blinds, pulled the curtain, and shut the door prior to providing any personal care. In an interview on 08/21/24 at 12:00 p.m., DON reported he expected staff to have closed the blinds or used the privacy curtain hanging from the ceiling when they provided residents with personal or incontinence care. He reported that failure to do that could affect the residents' privacy and dignity but that it would depend on the situation, noting that some residents' windows faced a brick wall. He reported that all staff were responsible for maintaining the privacy of residents. He stated the facility was currently under construction and that there was a plan to replace the blinds in resident rooms. In an interview on 08/22/24 at 12:56 p.m., RN G reported that regarding privacy and providing personal care to residents, she expected that staff would provide privacy, making sure that the blinds were closed to ensure the privacy and dignity of residents. She reported that if this had not occurred, what the resident could experience would depend on what care had been provided to the resident. In an interview and observation on 08/22/24 at 01:02 p.m., Resident #71 stated, I've been asking for blinds since I got here in October (2023). I have been mostly asking DON. He said they are ordering them and going to put them all in at one time. They are those long vertical blinds. They don't work. You can't close them. I have just been getting dressed without them closed. My window faces the gazebo and courtyard. We close the door. We don't use the curtain because it blocks the air conditioner. Observation during the interview revealed there were no blinds on Resident #71's window. Resident #71 had hung personal decorative curtains which were tied back to the sides of the window away from the air conditioner. In an interview on 08/22/24 at 01:22 p.m., LVN H reported when providing residents with personal care, the staff, usually the first thing is, they have to close the curtain. Close the door. Close the blinds. To keep the resident's privacy. No one wants to show their privacy. To respect the resident. If this is not done, some residents would not notice, but some would be angry, feel embarrassed, or unsafe because we are not keeping their dignity. Review of facility policy titled, Policy/Procedure-Nursing Clinical, Section: Routine Procedures, Subject: Incontinence Care with revision date of 5/2007, reflected that #1 for providing incontinence care stated, Assemble equipment. Explain procedure. Provide privacy by closing door and securing privacy curtain.

Based on observation, interview, and record review the facility failed to provide a resident has a right to a safe, clean, comfortable and homelike environment for three of six resident halls (100, 200 hall and 300 hall) reviewed for physical environment. 1. The facility failed to ensure the intake vent at beginning of 100 hall was kept clean. 2. The facility failed to ensure resident rooms (102, 106 and 133) had a complete set of lateral blinds. 3. The facility failed to ensure resident room [ROOM NUMBER] was maintained with baseboards in place and the wall not exposed. 4. The facility failed to ensure hall 300 had safe handrails. These failures placed residents at risk for an unsanitary, unsafe, and uncomfortable environment. Findings included: 1. Observation of the 100 hall on 08/20/24 at 10:22 AM revealed the intake vent was covered in dust. 2. Observations of resident rooms 102, 106 and 133 08/20/24 at 11:00 AM revealed multiple missing vertical blinds. An interview on 08/20/24 at 11:05 AM with Resident #3 revealed her blinds were broken and the resident had requested they be fixed, because the blinds did not fully cover the window. She stated that anyone could see in the window if they were in the dining room. An interview on 08/20/24 at 11:22 AM with LVN C revealed when asked about the gapping blinds and privacy, stated, Of course, privacy is concerning, because the gaps between the blinds in the window allowed exposure to people looking into residents' rooms. 3. Observation of room [ROOM NUMBER] on 08/20/24 at 1:30 PM revealed a base board approximately 8 inches was completely detached, which exposed the wall and approximately 2 feet of base board pulled away from wall located under the wall air condition unit. An interview on 08/22/24 at 11:45 AM, CNA I stated she had not noticed any baseboards that peeled or were missing. CNA I stated if she had any maintenance issues, she would report them to the nurse to put in a maintenance request on the computer. Interview on 8/22/24 at 3:24 PM LVN J stated no resident or CNA had informed her of missing or peeling baseboards. LVN J stated that if she had seen or if someone reported to her that there were missing baseboards or peeling baseboards, she would put in a maintenance request through TELS (computer maintenance work order system) on the computer. 4. Observation of hall 300 on 08/20/24 at 10:22 AM revealed broken plastic handrails outside room [ROOM NUMBER] and room [ROOM NUMBER] that exposed sharp edges. Interview on 08/22/24 at 1:40 PM with the Maintenance Director, he stated he was not informed of the issues with the intake vent or baseboards. He stated the facility had been going through complete renovations, which included all vents being replaced throughout the facility from metal vents to plastic vents and each resident room was being updated. If the staff had a maintenance request, they would put them in through TELS. The Maintenance Director stated that he checked TELS daily, the staff could see when work orders were being processed and once, they were completed. The Maintenance Director stated he was aware there were handrails that were broken but covered them with tape to prevent injury to residents and the blinds that were missing, he had them replaced . Observation of rooms 102, 106 and 133 on 08/22/24 at 3:22 PM revealed blinds were no longer missing any vertical blinds. An interview on 08/22/24 at 3:35 PM with the DON,revealed The facility is currently being remodeled, floors are done and once the painting of the halls are complete then each of the residents' rooms will be remodeled. The DON stated he was not aware there were any rooms with baseboards that were missing. The DON stated the facility changed out most vertical blinds to horizontal blinds, the rooms who still had vertical blinds, if they were to break, the facility would intermittingly replace the broken/missing blinds. The DON stated the staff put in all maintenance request through TELS. Review of facility's undated policy Physical Environment/Homelike Environment reflected It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Resident rooms must be designed and equipped for adequate nursing care, comfort and privacy of residents.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety. 1. The facility failed to ensure food items in the refrigerators, freezer and dry storage room were labeled with the item description, the received by date, the opened date, the discard by and or expiration dates; stored in accordance with the professional standards for food service. 2. The facility failed to discard opened items stored in refrigerator, freezers and dry storage that were not properly labeled with the opened or prepped by date and or past the 'best buy', consume by or the manufacturer's expiration dates. 3. The facility failed to ensure multiple food items stored in a bin/container were each clearly identifiable. 4. The facility failed to ensure the handwashing sink #1's garbage receptacle was used for only paper towels. 5. The facility failed to ensure the eyewash station bowl was clean and fully functional. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the Kitchen on [DATE] at 09:24 AM revealed the following: - The long prep table next to the ice machine, where the juice machine also sat. Next to the juice machine were two square clear containers with lids, one labeled coffee, dated [DATE] the other labeled tea, dated [DATE] with 3 extra-large tea bags inside. There was no discard by or expiration date. -The kitchen floor was slippery even with non-skid shoes on, but it was dry to the appearance. -Handwashing sink #1's garbage receptacle has trash other than paper towels. There was a large sized cardboard carton that was sticking up from the garbage receptacle. -On the steam table, on top were four foam to-go containers with lids, which contained leftover breakfast (scrambled eggs, small pancakes, sausage links). The containers were unlabeled with an item description, no prep date, no discard by or expiration date. -On the steam table, there were two small bowls with lids, containing oatmeal. There were no item descriptions, no prep dates and no discard by or expiration dates. -On the steam table, there was a small stack of bread slices wrapped in foil. There was no item description, no prep date and no discard by or expiration date. -The prep table across from the stove, on the bottom shelf was a tray with ten bowls with lids containing various cereals. The bowls were labeled: RC (rice cereal), CH (whole grain cereal o's) and CF (cornflakes). There were various prep dates ranging from ,d+[DATE] and ,d+[DATE] (out dated) ,d+[DATE] and ,d+[DATE]. There was no discard by or expiration dates. -1 Extra-large bin with a lid labeled cornmeal dated [DATE], no discard by date. -,d+[DATE] lbs. 5 oz container with lid of mashed potatoes granules, previously opened, dated [DATE]. There was no open date, the manufacturer's expiration date was [DATE]. -1-Extra-large bin with a lid labeled sugar dated [DATE], no discard by date. -1-Extra-large bin with lid labeled thickener dated [DATE], no discard by date. -The eyewash station bowl had dust and debris inside and there was a substantial crack in the bowl nearest the side where the wall was. The crack was wide enough to see through it toward the floor (wide enough a dime or penny could fit through). Observations of the Walk-in refrigerator on [DATE] at 09:52 AM revealed the following: -Left side: 1 small square bin labeled dressing, dated [DATE]. There were 5 small individual containers of ranch dressing, 2 small individual containers of balsamic vinegar dressing and 2 yogurts (manufacturer expirations [DATE] & [DATE]). No labels for the yogurts were noted. -Right side: 1 extra-large zip top bag with shredded cheese dated [DATE], no discard by date. -1 medium metal pan labeled mix veggies dated [DATE], expiration date [DATE]. -2 plates with garden salads wrapped in plastic wrap dated [DATE], no discard by date. -1 medium zip top bag with chips, a sandwich, a pastry and bottled water, dated [DATE]. There was no patient name on the bag, no item description, no discard by date. -1 large zip top bag containing previously opened turkey deli meat, dated [DATE], no discard by date. -1 large zip top bag containing previously opened ham deli meat date [DATE], no discard by date. Observation of the Walk-in freezer on [DATE] at 10:19 AM revealed the following: -1 Extra-large zip top bag labeled chicken dated [DATE] and had a moderate amount of ice crystals in the bag. The meat was darkened and had a dried appearance in some areas. Observations of the Dry Storage Room on [DATE] at 10:27 AM revealed the following: -Left back corner of room: -1 extra-large bin with lid, labeled flour, dated [DATE], expiration date [DATE]. It was left open to air. - 1 extra zip top bag of crispy rice cereal date [DATE], opened [DATE], no discard by date. -1 extra large bag of cornflakes cereal dated [DATE], opened [DATE] had plastic wrap draped over it (not securely wrapped); product left open to air. -,d+[DATE].7 oz bottle of previously opened caramel sauce, no received by date, opened [DATE], no discard by date. -1 plastic bag of 3 hamburger buns, previously opened, no received by date, no opened date, no discard by date. Observation of Dining room on [DATE] at 09:50 AM, revealed the following: -Near Kitchen entry door: -1 large drink dispenser containing dark colored liquid, no label of item description, no prep. date, not discard by date. In an interview on [DATE] at 09:39 AM with the DM, she stated leftovers were kept for 3 days in refrigerator unless it was something they generally kept longer. The DM stated the dry goods were kept ,d+[DATE] days once opened. She stated items like cereal were kept 3 months, when opened then they were kept 1 month but then once they transferred to the cereal containers, they only kept for 10 days. The DM stated she did a walkthrough of the kitchen after the surveyors left the kitchen on the first day and noted some of the things that had been brought to her attention. She stated when items in the big bins run low or are out, they wash the bin, dry it, then put new product inside and label it. The DM stated when written the labels should be legible not hard to read, smeared or not visible as noted during our walk through. She stated that not putting the end dates (expiration/discard dates) could cause something that is outdated to be served or not having the dates legible could cause the staff to not know when something had expired, these things could lead to food born-illness. She stated she would do an in-service with staff on the labeling of food items and the discard by dates. Review of the facility's Dietary Services Food Storage Policy, Date Revised [DATE], reflected Policy: It is the policy of this facility to prevent contamination of food products and therefore prevent foodborne illness. Procedures: 1. Director of food Service Responsibilities .E. Provide for the proper receipt and storage of all food supplies. 5. Food Storage. C. All non-food items must be properly labeled and stored away from labeled food products. G. Old stock is rotated and used first. 6. Proper Handling. K. Leftovers must be dated, labeled, covered, cooled and stored (within ,d+[DATE] hour) in a refrigerator, not at room temperature. P. Foods that have stood for several hours at room temperature cannot be considered safe and free from contamination and cannot be made so by refrigeration, especially during the summer season. They must be discarded. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 . section ,d+[DATE].11 Compliance and Food Law: . C. Packaged Food shall be labeled as specified in Law, including 21 CFR 101 Food Labeling [* .(b) A food which is subject to the requirements of section 403(k) of the act shall bear labeling, even though such food is not in package form. (c) A statement of artificial flavoring, artificial coloring, or chemical preservative shall be placed on the food or on its container or wrapper, or on any two or all three of these, as may be necessary to render such statement likely to be read by the ordinary person under customary conditions of purchase and use of such food. The specific artificial color used in a food shall be identified on the labeling when so required by regulation in part 74 of this chapter to assure safe conditions of use for the color additive.], 9 CFR 317 Labeling, [*(a) When, in an official establishment, any inspected and passed product is placed in any receptacle or covering constituting an immediate container, there shall be affixed to such container a label .Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S ,d+[DATE].18. Section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food: Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. Section ,d+[DATE].17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Chapter 6 .Section ,d+[DATE].20 Disposable Towels, Waste Receptacle. Waste receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents www.fda.gov

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (CNA M, CNA P, and CNA Q) of 3 staff members for infection control procedures. CNA M, CNA P and CNA Q failed to perform hand hygiene after direct contact with Residents #3, #31, and #76 while serving meals on the hallways. This failure could place residents at risk for healthcare associated cross contamination and infections. Findings included : Record review of Resident #3's annual MDS assessment, dated 06/21/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: Dementia (brain disease that effects memory), Parkinson's Disease (uncontrollable or unintended movements), and atrial fibrillation (irregular heartbeat). Resident #3 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #31's annual MDS Assessment, dated 06/16/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31 had diagnoses which included: dementia (brain disease that effects memory), hypertension (increased blood pressure), and chronic venous peripheral insufficiency (blood pooling in the legs). Resident #31 was still cognitive and required one staff for assistance with activities of daily living. Record review of Resident #76's annual MDS Assessment, dated 01/22/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #76 had diagnosis which included: Dementia (brain disease that effects memory), Hyperlipidemia (high cholesterol), hypertension (high blood pressure), and hypothyroidism (low thyroid level). Resident #76 was moderately impaired for cognition and required one staff for assistance with activities of daily living. Observation on 08/20/24 at 12:16 p.m., revealed CNA M, walked up with the lunch tray cart, and served a lunch tray to Resident #3. CNA M entered Resident #3's room touched, and moved the overbed table in the resident's room, opened the lid of Resident #3's meal tray, setting up the meal to tray for the resident to eat the lunch. CNA M did not have on gloves. CNA M was observed to not wash her hands or use hand sanitizer, available in the hallway prior to getting the next tray for another resident. Observation on 08/20/24 at 12:17 p.m., revealed CNA P entered Resident's #76's room with the lunch tray. CNA P set up the resident's lunch tray, adjusted the overbed table, unwrapped the utensils, and removed the tops off drinks. CNA P did not complete hand hygiene after leaving Resident #76's room. CNA P returned to the tray cart to get a tray for another resident. Observation on 08/21/24 at 12:12 p.m., revealed CNA Q had rolled the meal cart up the hallway to Resident #31's room. CNA Q served a lunch tray in Resident #31's room. CNA Q set up the resident's lunch tray, adjusted the overbed table, unwrapped the utensils, and removed the tops off the drinks. CNA Q did not complete hand hygiene before serving or after leaving Resident #31's room. CNA Q returned to the tray cart to get a tray for another resident. An interview on 08/21/24 at 12:33 p.m., with CNA M revealed she was aware she had not performed hand hygiene after direct contact with residents, during the lunch meal service on 08/20/2024. CNA M stated the staff was supposed to use the hand sanitizer in between serving each tray or wash their hands with soap and water. CNA M stated there had been an in-service given on hand washing and infection control. CNA M stated the in-service was given recently on using hand sanitizer, wearing gloves, and washing hands including return demonstration. CNA M stated, she had just forgotten to sanitize her hands. The CNA stated if hands were not washed and sanitized, or hand gel was used it could spread germs. An interview with the DON on 08/22/24 at 9:00 a.m., revealed that all staff must complete hand hygiene after having contact with residents. The CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray and wash hands upon completion. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. Record review of an undated in-service log revealed CNA M, CNA P, and CNA Q received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted on 07/15/2024 reflected: when passing trays in the hallways, sanitize after going in every room , that CNA M, CNAP, and CNA Q had received the in-service. Record review of the Facility's Policy titled Hand Hygiene August 2014 reflected: the facility considers hand hygiene the primary means to prevent the spread of infecitons.1. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Wash hands with soap . water .a. when hands are visibly soiled . b. after contact with a resident with infectious . 4. use alcohol-based hand rub c . or alternative soap . and water b. before and after direct contact with residents . l. after contact with objects in the immediate vicinity of the resident; . o. before and after eating or handling food .

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications. The facility failed to ensure Resident #1 was provided his medications and not the medications of Resident #2, when he went on therapeutic leave on 06/02/24. This failure placed residents at risk of consuming unprescribed medications, harm, and hospitalization . The findings included: Record review of Resident #1's face sheet, printed on 06/25/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of atherosclerosis of native arteries of extremities with gangrene, right leg (narrowing and hardening of the arteries that supply the legs and feet), muscle weakness, muscle wasting and atrophy (loss of muscle tissue), and abnormalities of gait and mobility. Record review of Resident #1's quarterly MDS assessment, dated 06/03/24, reflected Resident #1 had a BIMS score of 09, which indicated Resident #1 had a moderate cognitive impairment. Record review of Resident #1's care plan, revised on 06/03/24, reflected the following: Focus: [Resident #1] Has hypertension . INTERVENTIONS: Give anti-hypertensive medications as ordered . FOCUS: [Resident #1] Has Diabetes Mellitus . INTERVENTIONS: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . FOCUS: Anti-anxiety medication uses r/t anxiety disorder INTERVENTIONS . Give anti-anxiety medications ordered by physician . FOCUS: Antidepressant medication use r/t Depression .INTERVENTIONS . Give antidepressant medications ordered by physician. Monitor/document side 1effects and effectiveness .FOCUS . [Resident #1] Has acute/chronic pain . INTERVENTIONS . Administer analgesia medication as per orders . Record review of the physician orders tab of Resident #1's electronic health record revealed the following evening orders: - Atorvastatin Calcium Oral Tablet 40 MG - Give 1 tablet by mouth at bedtime related to HYPERLIPIDEMIA, UNSPECIFIED, start date of 04/17/23 - Melatonin Oral Tablet 3 MG - Give 3 mg by mouth at bedtime for insomnia, start date of 04/18/23 - traZODone HCl Oral Tablet 50 MG - Give 2 tablet by mouth at bedtime related to UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39);SLEEP DISORDER, UNSPECIFIED (G47.9);ANXIETY DISORDER, UNSPECIFIED, start date of 10/13/24 - Brilinta Oral Tablet 90 MG (Ticagrelor)- Give 1 tablet by mouth two times a day for Atrial Thromboembolism, start date of 04/18/23 - Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) - Give 250 mg by mouth two times a day related to UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39), start date of 09/06/23 - Famotidine Tablet 20 MG - Give 1 tablet by mouth two times a day for GERD, start date of 07/15/23 - Gabapentin Oral Capsule 100 MG -Give 1 capsule by mouth two times a day for pain, start date of 03/28/23 - Lovaza Oral Capsule 1 GM (Omega-3-acid Ethyl [NAME]) - Give 2 capsule by mouth two times a day for supplement, start date of 06/09/23 - Metoprolol Tartrate Tablet 25 MG - Give 0.5 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold B/P less than 100/60 or HR less than 60, start date of 04/18/23 - Sacubitril-Valsartan Oral Tablet 49-51 MG (Sacubitril-Valsartan) - Give 0.5 tablet by mouth two times a day for HTN HOLD IF SBP less than 110, start date of 04/19/23 Record review of Resident #2's face sheet, printed on 06/26/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, cognitive communication deficit, pain in unspecified shoulder and hypotension. Record review of the physician orders tab of Resident #2's electronic health record revealed the following evening orders: - Neurontin Oral Capsule 300 MG - Give 300 mg by mouth at bedtime related to CHRONIC PAIN SYNDROME, start date of 05/01/24 - Senna-Docusate Sodium Tablet 8.6-50 MG - Give 1 tablet by mouth at bedtime for constipation, start date of 08/14/22 -Zoloft Oral Tablet 25 MG (Sertraline HCl) - Give 3 tablet by mouth at bedtime for Dysthymia, start date of 05/08/24 -Depakote Oral Tablet Delayed Release125 MG (Divalproex Sodium) - Give 1 tablet by mouth two times a day for Anxiety and agitation, start date of 05/08/24 - Memantine HCl Tablet 5 MG - Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, start date of 08/14/22 - Gabapentin Capsule 100 MG - Give 1 capsule by mouth three times a day for neuropathic pain, start date of 08/14/22 - Midodrine HCl Tablet 5 MG - Give 2 tablet by mouth three times a day for hypotension 1 hour before Dialysis Hold for BP of greater than 120/90, start date of 08/16/22 - Renvela Oral Tablet 800 MG (Sevelamer Carbonate) - Give 1 tablet by mouth with meals for related to END STAGE RENAL DISEASE, start date of 03/07/24 In a telephone interview on 06/24/24 at 3:49 p.m., Resident #1's family member stated on 06/02/24, Resident #1 was provided the incorrect medications by LVN A when he went on therapeutic leave. The family member stated they received several calls after he left from LVN A, stating Resident #1 was given another residents medications and not to take the medications provided. The family member stated Resident #1 was not provided his insulin as well. The family member stated the medications were not double checked at the facility because they were in a rush. The family member stated Resident #1 did not take any of the medications provided to Resident #1 when he left the facility. In an interview on 06/25/24 at 1:16 p.m., Resident #1 stated he did not recall an instance where he was provided another residents medications or that he received a call stating he was provided another residents medications. Resident #1 stated he had no concerns regarding his medications. In an interview on 06/25/24 at 2:50 p.m., LVN A stated she was Resident #1's nurse when he went on therapeutic leave on 06/02/24. LVN A stated she recalled having to call Resident #1's family member to report the incorrect medications. LVN A stated MA B prepared the medications for Resident #1's leave, which she provided to the resident as his family member signed him out of the facility. She stated roughly 30 minutes after his departure, MA B notified her that she had prepared Resident #2's medication for Resident #1 in error. LVN A stated she immediately began to call Resident #1 and his family member to report the error. LVN A stated when she was able to speak with Resident #1's family member, she was able to confirm he did not take the medications. LVN A stated she offered to prepare Resident #1's evening medications, but the family member declined to pick them up. LVN A stated if Resident #1 would have taken the medications, they could have had adverse effects to the resident. LVN A stated she reported the situation to LVN C, who was the supervisor, and he took over the situation. LVN A stated by her next shift, which was the following weekend, she was in serviced on medication administration and leave of absence medication procedures. In a telephone interview on 06/26/24 at 10:51 a.m., MA B stated LVN A notified her on the morning of 06/02/24 to prepare the evening medications for Resident #1, but she heard Resident #2, whose names were similar. MA B stated she prepared the medications, gave them to LVN A a little after lunch and continued to administer medications to her assigned halls. MA B stated roughly 30 minutes later she saw Resident #2 in the facility, and she immediately realized her error and reported to LVN A. MA B stated LVN A stated she would call Resident #1's family and report to the supervisor. MA B stated she was not certain how the medications would have affected Resident #1, but she knew Resident #2 had a kidney medication that Resident #1 was not on, so she believed it could have harmed him. MA B stated she had an one-on-one in-service with the DON when she returned to work regarding medication administration, the 10 rights of medication administration and leave of absence medication procedures. Telephone interviews were attempted with the weekend supervisor, LVN C on 06/26/24 at 11:00 a.m., 11:23 a.m., 1:28 p.m., and 3:30 p.m., but were unsuccessful. In an interview on 06/26/24 at 1:33 p.m., the DON stated Resident #1's family member reported the incident to him roughly a week and a half prior to the investigation. The DON stated Resident #1's family member saw him in the facility the week of Father's Day and told him she wanted to speak with him, but she did not have time to speak at that moment. The DON stated about a week later he saw the family member again in the facility and she reported the wrong medications were provided on 06/02/24. The DON stated the family member had the medications with her and he was able to confirm they were the medication of Resident #2, and the medications were destroyed. The DON stated he conducted one-on-one in services with LVN A, MA B, and LVN C regarding incident reporting, medication administration, the 10 rights of medication administration, leave of absence medication procedures and documentation. The DON stated he also in serviced all nursing staff on the 10 rights of medication administration, incident reporting and leave of absence medication procedures. In an interview on 06/26/24 at 2:47 p.m., the ADMIN stated he was aware of the medication mix-up with Resident #1. He stated after the family member reported the incident to the DON, he investigated and found there was a miscommunication between LVN A and MA B. The ADMIN stated staff were able to identify the error and avoid a medication diversion. The ADMIN stated the DON immediately re-trained the involved staff and in-serviced all nursing staff on medication administration, the 10 rights of medication administration, incident reporting, leave of absence medication procedures and documentation to ensure the situation did not occur again. The ADMIN stated the medications could have harmed Resident #1 if had taken them. Record review of Inservice documentation dated 6/22/24 through 6/24/24, revealed all nursing staff, including LVN A, MA B, and LVN C were in serviced on the 10 rights of medication administration, leave of absence medication procedures and incident reporting. Record review of the facility's policy entitled Medication Administration, revised in 02/2007, read in part: POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . 2. Medications must be administered in accordance with the written orders of the attending physician .

Based on interview and record review the facility failed to ensure if a hospice care was furnished through an agreement, a provision that the LTC facility immediately notified the hospice about a significant change in the resident's physical, mental, social, or emotional status for 1 of 1 resident (Resident #1) reviewed for hospice care. The facility failed to immediately notify Resident #1's hospice agency of falls and change of condition that occurred on 2/22/24 and 2/25/24. This failure could place residents at risk to a decline in health. Findings include: Record review of Resident #1's electronic face sheet, dated 02/28/2024, reflected a [AGE] year-old male who was admitted to the facility 08/30/22. Resident #1 had diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #1's comprehensive care plan, revised 01/18/2024, reflected Resident #1 had a terminal prognosis regarding Alzheimer's(type of dementia) and was on hospice. Interventions listed on Resident #1's care plan included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were being met. Record review of Resident#1's quarterly MDS, dated [DATE], reflected the BIMS was not completed. Record review of the nursing note, authored by LVN A, dated 02/22/24 at 3:45 PM, reflected Nurse called to room by ADON observed resident laying on fall mat beside bed. Residents bed in lowest position. Resident confused/disoriented head to toe assessment neurological checks able to [NAME](sic) noted 1cm bruise under right eye 1.5 cm skin tear to right forearmno (sic) signs/symptoms of pain or discomfort resident assisted back in bed incontinent care provided. Bed in lowest position fall mat in place cleansed skin tear right forearm with n/s tao dressing applied. NP/DON/wife notified skull xray ordered. Record review of nursing note, authored by LVN A, dated 02/22/24 at 3:45 PM, reflected Change in Condition : Symptoms or signs noted of Condition change: Falls Refer to elNTERACT Change in Condition for Full Evaluation Vital Signs: Blood pressure 124/74 - 2/22/2024 15:45 [ 3:45PM] Position: Lying Ieft/arm Pulse 74 - 2/22/2024 15:45[3:45PM] Pulse Type: Regular Rate 18.0 - 2/22/2024 15:45 Temperature 97.5 - 2/22/2024 15:45 Route: Forehead (non-contact) 02 97.0 % - 2/22/2024 15:45[3:45PM] Method: Room Air Notifications: Reported to primary care clinician: [ Nurse practitioner ] Date and time of clinician notification: 02/22/2024 4:00 PM Name of family member or resident representative notified: [family member] Date and time family or representative notified: 02/22/2024 4:30 PM Record review of nursing notes, authored by LVN B, dated 2/25/24 at 8:33PM, reflected Refer to elNTERACT Change in Condition for Full Evaluation Vital Signs: BP 120/74 - 2/25/2024 20:45 Position: Standing I/arm P 72 - 2/25/2024 20:45 Pulse Type: Regular R 18 - 2/25/2024 20:45 T 97.4 - 2/25/2024 20:47 Route: Forehead (non-contact) 02 95 % - 2/25/2024 20:46 Method: Room Air Notifications: Reported to primary care clinician: [ NP] Date and time of clinician notification: 02/25/2024 8:50 PM Name of family member or resident representative notified: [family member] Date and time family or representative notified: 02/25/2024 9:00 PM Review of the nursing notes, authored by LVN B dated 2/25/24 at 21:01 [9:01PM], reflected Resident found on the floor mattress x 3 episodes this evening no injuries apparent. patient is fighting, staff when they attempt to place him back in bed. will continue to monitor closely. Review of the incident report authored by LVN B dated 02/25/24 with no time refelcted , resident found on mattress, head to toe assessement completed, placed back in bed , large body pilow placed in bed with resident to aid fall. Bed lowered to lowest level, floor mattress placed besided bed neurological check and frequent montioring began. notified wife, DON and Nurse practioner Interview on 02/28/24 at 10:00 Am with Hospice Supervising Nurse revealed she was not informed by the facility regarding Resident#1's fall however was informed by the hospice aide. The Hospice Supervising nurse stated the facility should be calling to inform of any falls or change in condition even it a hospice aid is in the facility daily. Interview on 02/28/24 at 10:50 AM with LVN C revealed if a resident was receiving hospice services, hospice, the family, the doctor and the DON all should be notified of any fall or change in condition that occurred with the resident. LVN C revealed once hospice was notified it should be documented in the nursing notes. Interview on 02/28/24 at 11:00 AM with LVN D revealed if a resident was receiving hospice services, then hospice, the DON, the doctor and the family should all be notified if there was a fall or change in condition regarding the resident. LVN D revealed notification of falls or change in condition should have been documented in the nursing notes. Interview on 02/28/24 at 2:14 PM with the DON revealed the nursing staff did not document hospice was notified of the falls that occurred on 02/22/24 and 02/25/24, however he was notified as well as the physician and the family member. The DON stated he verbally notified the hospice nurse on 02/26/24 of both falls, however it was not documented. The DON stated the nursing staff should have notified hospice immediately regarding any change in condition regarding residents who received hospice services. The DON stated there was no risk to residents due to hospice not being notified due to the physician being notified. Record review of the facility policy Significant change in condition, response, revised 2022, reflected The Nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. Record review of the facility policy End of life care, hospice and/or palliative care, revised 2023, reflected It is the policy of this facility to provide dignified and compassionate end of life care for terminally ill or dying residents. Through continuing interdisciplinary assessment, individualized plans will be developed and implemented to address prevention and relief of symptoms and the resident's physical, intellectual, emotional, social, spiritual, and practical needs. Support and reassurance for family and friends close to the resident will be an integral part of the plan.

Based on observation, interview, and record review, the facility failed to honor the resident right to choose his or her attending physician for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility did not honor Resident #1's right to choose his primary care physician as his attending physician when readmitted to the facility on [DATE]. This deficient practice could place residents at risk of decreased quality care and treatment due to their lack of free choice for their attending physician care while in the facility. Findings included: Record review of Resident #1's Admission Record, revealed an [AGE] year-old female, who admitted to the facility on [DATE] from a short-term (acute) hospital with the following diagnoses: Anemia; unspecified Dementia; Chronic Diastolic (Congestive) HF (occurs if the left ventricle muscle becomes stiff or thickened); CKD, Stage 3 (kidneys have mild to moderate damage); Other lack of coordination; and T2DM. The Admission Record reflected MD G as Resident #1's attending physician. Record review of Resident #1's 5-Day (conducted between days one to eight after the resident enters the facility) MDS Assessment, dated 01/22/24, revealed Resident #1 had a BIMS of 10 which suggested moderately impaired cognition. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was frequently incontinent of bladder and had a colostomy appliance to collect bowel wastes. Record review of Resident #1's Hospital Medicine Discharge Summary dated 01/19/24 reflected encounter dates 1/15/24 - 01/18/24. The Hospital Medicine Discharge Summary (01/18/24) reflected discharge disposition to SNF, recommended diet, and other discharge instructions: Follow-Up: Your Appointments (scheduled at discharge by hospital): 02/19/24 at 1:30 PM with MD D at Cardiac Clinic Follow-Up Appointments to be scheduled (discharge: 01/18/24): Hepatology in 1 - 2 weeks Gastroenterologist in 2 weeks Cardiology in 2 weeks Discharge History by Follow-Ups reflected: Follow up with Internal Medicine with MD B Follow up with Gastroenterology with MD C Follow up with cardiovascular disease in 2 weeks (02/01/24) with MD E Follow with Internal Medicine (PCP) with MD A Follow with Endocrinology with MD E Follow up with Nephrology with MD F The discharge follow-up provider list revealed Resident #1's primary providers that included the primary care physician (MD A) and other responsible care professionals. During an observation and interview on 02/16/24 at 1:09 PM revealed Resident #1 up to wheelchair. Resident #1 appeared clean and groomed. There were no visible injuries or behavior suggestive of abuse, neglect, or sub-quality care. Resident #1 was awake, alert, and oriented to self-awareness, place, surroundings, time of day [with prompts/cues], and situation. Resident #1 received 1 LPM oxygen via nasal cannula by concentrator. Resident #1 presented with a flat affect congruent with mood. Resident #1 spoke in an appropriate volume and tone, at a moderate pace with pausing affected by breathing or word selection. Resident #1 had good recall of immediate and past events. Resident #1 said that her family member visited but had a lot going on and was unable to take care of her at home or manage her appointments. Resident #1 stated that she needed to follow up with her PCP and cardiologist and have not since she returned to the SNF. Resident #1 indicated that she was concerned because she recently had a heart attack. Resident #1 could not immediately recall her PCP's name but was able to state the name and location of the clinic her appointments were scheduled with her PCP. During an interview on 02/16/24 at 3:45 PM, the RP said that Resident #1 appointments were not scheduled and did not receive services by the facility to ensure continuity of care. The RP said that Resident #1 was assigned a doctor provided by the facility as a primary physician. The RP said that he was concerned because Resident #1 was closely followed by providers outside the facility and the facility provider was not familiar with Resident #1's care needs. The RP said that Resident #1 needed to follow up with her PCP but was told that Resident #1 would be followed by the facility physician. The RP said that he requested a care plan meeting to discuss his concerns about upcoming appointments that were not scheduled per the hospital discharge summary (01/18/24) and transportation needs. The RP stated that he was told by the LSW during the meeting that he would first need to complete release of information forms for each of Resident #1's specialty providers before appointments could be scheduled. The RP said that when asked about transportation arrangements, the LSW informed that the RP could take [Resident #1] to appointments. The RP said that Resident #1 had an appointment the day of the care plan meeting and [the RP] took her to the appointment. During an interview on 02/16/24 at 4:28 PM, the SSA said she was not involved in the admission process with residents. The SSA said that she was not familiar with the facility responsibility to notify a resident about the right to choose a primary physician or if required to use the facility physician. During a phone interview on 02/16/24 at 4:46 PM, the LSW said that he worked remotely and was familiar with Resident #1 when attended a care plan meeting with the RP and facility management to discuss the RP's concerns. The LSW said that he was responsible for scheduling follow-up appointments if outlined in the discharge instructions when a resident was admitted to the facility. The LSW said sometimes the admitting nurse would schedule appointments if needed and communicate with the LSW. The LSW said that new admissions were discussed during morning meetings with a focus on appointment(s) scheduling and/or transportation needs. The LSW said that there was an Admission Director who would coordinate appointments when the hospital clinical records were reviewed, but the Admission Director no longer worked at the facility. The LSW said that the RP asked about AEM and Resident Rights. The LSW said that the RP was provided a copy of the AEM application and policy. The LSW said he discussed Resident Rights with the RP. The LSW said that the RP said that Resident #1 wanted to see her outside PCP and not the facility provided physician and an appointment needed to be scheduled. The LSW said that he explained that the facility had to first check with the selected PCP if they would follow the resident while resided at the SNF. The LSW indicated that the RP had to complete and return to the facility a release of information form for each provider Resident #1 wanted to see. The LSW said that the RP asked about transportation and was informed that the facility could provide transportation or arrange with a transportation service provider. The LSW stated that the concerns the RP voiced during the meeting suggested a grievance should be filed and followed up by the facility. The LSW said he had not initiated the grievance. During a phone interview on 02/16/24 at 5:18 PM, the Marketing Specialist (MS) stated that she assessed the clinical needs of potential and existing residents to assure the facility had the clinical capability to treats the resident. The MS said that she did not initially admit Resident #1 but currently filled the role of the Admissions Director. The MS said that she informed residents about certain forms that required signature at admission. The MS said that forms that required signature included consent to treat, an Admission Agreement, and Resident Rights. The MS said there were a lot of pages in the admission packet and could not say for sure which documents required signature without the packet in front of her. The MS said the resident or RP was offered the opportunity to read the admission packet in its entirety before signing and informed could receive a printed copy as an alternative to the digital copy reviewed on a computer tablet. The MS said that she has never verbalized in detail that a resident had the right to choose their own primary care physician. The MS said in [AGE] years, she did not recall a resident asking about a primary care physician specifically because a physician is provided by the facility. The MS said that she would be sure to review the packet and become familiar with important details. The MS said that when she reviews the admission packet with a potential resident, she would be sure to inquire if the resident had a PCP and to communicate the terms of the admission agreement in a way the resident or RP understood before they sign. Record Review of the facility's Resident Rights and Responsibilities, Notice of policy revised 01/2022 reflected: Policy: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as, the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility. Procedure: Prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights and a copy of all rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility. The resident will be required to sign a statement acknowledging that he/she was informed of his/her rights and responsibilities. The facility will inform the resident of his/her rights and responsibilities in a language that is both clear and understandable to the resident. Written copies of resident rights and responsibilities are available upon request and may be obtained from the social services department during normal office hours (8:00 a.m.- 5:00 p.m., Monday-Friday (except holidays). The resident will be promptly informed, both orally and in writing, of a change in resident rights and when changes occur in facility rules that govern the resident's conduct or responsibilities.

Based on interview and record the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 5 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 was accurately assessed, monitored, and treated for a change of condition when the resident was found to be in pain on 09/10/23 at approximately 10:30 PM. Resident #7 was not immediately sent to the hospital for emergency medical care. She was sent to the hospital on 09/11/23 after therapy staff notified the nurse of a leg deformity. At the hospital, Resident #7 was diagnosed with fractures of her left tibula and fibula (two bones in the lower leg, calf/shin area). This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe injury and pain, hospitalization , or even death. Findings include: A record review of Resident #7's face sheet, dated 09/13/23, reflected Resident #7 was an 81-year- old female, who originally admitted to the facility on [DATE] ad readmitted on [DATE]. Resident #7had diagnoses which included: cognitive communication deficit, contracture unspecified ankle (a chronic loss of ankle joint motion due to structural changes in muscle), muscle weakness, reduced mobility, need for assistance with personal care, abnormal posture, pain in unspecified joint, muscle wasting and atrophy multiple sites, lack of coordination, unsteadiness on feet, falls, chronic kidney disease, unspecified fracture of shaft of left femur (thigh bone) with routine healing, and dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #7's Quarterly MDS Assessment, dated 08/30/23, indicated Resident #7's BIMS score was 0, which indicated the resident's condition was severely impaired. Resident #7 required extensive physical assistance of two or more staff for bed mobility, transfers, and toilet use. Resident #7's was not on a scheduled pain medication regimen and the other sections which referenced pain, were not competed and had dashes in the spaces. A record review of Resident #7's Care Plan, initiated date 05/24/22 and revision date 08/27/23, reflected she had acute/chronic pain. The interventions included Administer analgesic medication as per orders. Give 1/2 hour before treatments or care. Anticipate need for pain relief and respond immediately to any complaint of pain. Follow pain scale to medicate as ordered. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Pain assessment every shift. A record review of Resident #7's Progress Notes, written by LVN F on 09/11/23 at 12:37 PM reflected, Around 12:15 pm, this Nurse was doing dining room duties when staff therapy stated that resident needs to be checked to her lower extremity. This Nurse went into the residents' room and upon assessment, observed that resident's left lower leg below the knee was bent. Resident groaned in pain when leg was moved. Unable to rate pain due to baseline confusion. PRN pain meds tramadol 50 mg admin per MAR. [Physician] informed, came to assess resident and ordered that resident be sent to ER for further medical treat and eval. Resident is alert with baseline confusion. 911 called and resident picked up to ER via stretcher [hospital]. RP [family member] informed. Record review of the facility's incident and accident log for September 2023 revealed Resident #7 had a physician diagnosed fracture on 09/11/23 at 12:23 PM. A record review of Resident #7's hospital records revealed she entered the hospital on 09/11/23 at 2:21 PM with chief complaint of leg injury and the following information provided by EMS Patient presents due to left tib (tibia) fib (fibula) deformity. Patient is from [Facility's name] nursing facility. EMS was called due to deformity of left tib fib. Patient is bed bound and nonverbal at baseline. She has a history of dementia. EMS reports that nursing staff at [Facility's Name] claim they found her in bed that way today. Last night her leg was normal. She is acting like her baseline mental status. The physical exam revealed . Musculoskeletal: Comments: Mid left tib fib has obvious deformity, distal portion of leg freely mobile and wobbly. Palpable pulse. Neurological: Moving all extremities except left leg. Makes eye contact. Shakes her head no to certain questions. The hospital records indicated x rays were conducted at 2:49 PM and Resident #7's final diagnosis included Closed displaced comminuted fracture of shaft of left fibula, initial encounter; Closed displaced comminuted fracture of shaft of left tibia, initial encounter. In a phone interview on 09/18/23 at 12:03 PM, OT K stated she worked with Resident #7 on 09/10/23. She stated it was her first time working with Resident #7. OT K stated Resident #7 had a therapy goal of feeding herself, so she went to work with her during lunch. OT K stated she arrived at Resident #7's room about 11AM. She stated Resident #7 was wet, so she changed her brief, got her dressed, and put her in her wheelchair. OT K stated she transferred Resident #7 by herself. She stated she took Resident #7 to the dining room and worked with queuing her while eating her lunch. OT K stated Resident #7 was in good spirts, talked some during her meal, and majority of her food. OT K stated after lunch she took her to the nurse's station, locked her wheelchair, and let the nurse know she was leaving. She stated that was about 12:30/1:00PM. OT K stated there was no indication the resident was in any pain. In a phone interview on 09/18/23 at 11:06 AM, CNA H stated she was assigned to Resident #7's hall on 09/10/23 from 2PM-10PM. CNA H stated when she started her shift at 2PM, Resident #7 was at the nurse's station and was there until dinner, which was about 5:30 PM. CNA H stated she checked her brief right before dinner, about 5PM, and she was dry. She stated she assisted her with eating dinner in the dining room and then brought her back to the nurse's station. CNA H stated she sat at the nurse's station until about bedtime. CNA H stated about 9/9:30PM, she checked Resident #7, and she was wet. CNA H stated she took Resident #7 to her room, transferred her from her wheelchair to the bed by herself , changed her brief, put her night gown on, and put her to bed. CNA H stated Resident #7 seemed fine and was not grimacing in pain when she transferred and changed Resident #7's brief. CNA H stated she worked a double, so when her 10PM- 6AM shift started she was assigned to a different hall. She stated about 10:30 PM she did her final rounds and when she went to check on Resident #7, she was holding her left hip area and her face was grimacing in pain. CNA H stated she told the 10:00 PM to 6:00 AM nurse, LVN I, Resident #7 looked as if she was in pain and was holding her hip. She stated she did not know if LVN I assessed Resident #7 because she went to start the next shift on another hall. In a phone interview on 09/18/23 at 2:24 PM, LVN I stated he was assigned to Resident #7's hall on 09/10/23 from 10PM to 6AM. LVN I stated at the beginning of his shift CNA H stated Resident #7 was holding her hip and her face looked as if she was in pain, so he did a head-to-toe assessment. LVN I stated the assessment consisted of him looking for swelling and redness and he used his hand to push down on Resident #7's hip and thigh area. He stated he did not see any swelling or redness and Resident #7 did not grimace in pain, yell or groan, nor attempted to move his hand when he pushed down on her hip and thigh area. LVN I stated based on this assessment, he felt the resident was not in pain and was fine . LVN I stated he did not observe Resident #7's leg distorted or unaligned. LVN I stated he did not push down on the resident's leg and only focused on the hip/thigh area because CNA H reported that was the area Resident #7 was holding. He stated he did not attempt to move Resident #7's leg or check for ROM . When LVN I was asked if he was supposed to check for ROM and attempt to move Resident #7's leg as a part of a head-to-toe assessment, he stated yes. LVN I stated he did not document that CNA H reported resident was in pain nor did he document the assessment he completed on Resident #7. He stated he was supposed to document the incident. LVN I stated he did not re-assess Resident #7 at any time during his shift because the first time he assessed her she did not show she was in any pain. LVN I stated he did not monitor Resident #1 for pain throughout his shift, but the CNAs did round and had not reported any signs of pain. In an interview on 09/18/23 at 10:58 AM, CNA G stated she was assigned to Resident #7's hall on 09/11/23 from 6AM-2PM. She stated she did rounds about 6:30 AM. CNA G stated Resident #7 was still asleep but she checked her brief, and it was dry. CNA G stated Resident #7 had breakfast and seemed normal. She stated Resident #7 never complained of any pain or appeared to be in pain. CNA G stated she checked Resident #7 about 11:00 AM and her brief was wet. She stated she noticed as soon as she moved Resident #7, she grimaced in pain. CNA G stated she told nurse, LVN F, Resident #7 seemed to be in pain. In an interview on 09/20/23 at 3:15 PM, OT J stated on 09/11/23 around lunch time, she went to Resident #7's room to do therapy. She stated the resident was laying on her right side, which was rare. OT J stated when she went to reposition her, and Resident #7 groaned loudly and her face was grimacing in pain. She stated once Resident #7 was laying flat on her back, she noticed her leg was bent and distorted. OT J stated she could clearly see it was fractured. She stated she went to get LVN F. In a phone interview on 09/18/23 at 11:38 AM, LVN F stated he was assigned to Resident #7's hall on 09/11/23 from 6AM to 2PM. LVN F stated around lunch time CNA G and Occupational Therapist (OT) J told him resident was in pain when they provided care. LVN F stated he went to complete a head-to-toe assessment on the Resident #7. He stated as soon as he pulled back the covers, he immediately noticed Resident #7's left leg was unaligned. LVN F stated he gently attempted to move the resident's leg and she groaned really loud in pain. He stated the facility doctor was at the facility, so he went to get her. LVN F stated the doctor assessed Resident #7 and gave an order to send her to the hospital. He stated she had a PRN order for Tramadol, so he gave her the pain medication and called 911. LVN F stated as long as Resident #7 did not move, she was ok. In a phone interview on 09/18/23 at 1:20 PM, the facility's Physician stated on 09/11/23 she was at the facility doing rounds and LVN F called her to Resident #7's room. She stated LVN F reported Resident #7 was in pain and her leg was unaligned. The Physician stated she went to assess Resident #7 and immediately saw her left leg was unaligned. She stated she did not attempt to move the leg because it was clearly fractured. She stated any nurse should have been able to immediately recognize the leg was unaligned. In an interview on 09/19/23 at 10:24 AM, the DON stated if a resident reported pain, it was his expectation that the nurse completed a head-to-toe assessment. The DON stated LVN I reported to him he completed a head-to-toe assessment on Resident #7, after CNA H reported seeing Resident #7 in pain. The DON stated LVN I reported Resident #7 did not seem to be in any pain during the assessment. He stated when completing a head-to-toe assessment checking ROM and attempting to move the extremities were a part of the assessment. The DON stated he was not aware LVN I did not complete these tasks during his assessment . A record review of the facility's, undated, Head to Toe Assessment- Skills Checklist reflected Charting Instructions: Document the Head-to-Toe Assessment findings in PCC Progress Note under Nursing. If a resident presents a change in condition during the assessment, follow the Change in Condition Guidelines . Head to Toe Assessment Guidelines . Bilateral Checks: Bilateral checks for comparison need to be done for . Leg Strength- place your hands on the patient's thighs. Have the patient push legs against the resistance of your hands. Check for equality in strength A record review of the facility's policy titled, Significant Change in Condition, Response, revised January 2022, reflected Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) . new complaints of pain or worsening of pain . 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of exiting orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3 . Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs . 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report . 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly In interviews on 09/20/23 between 1:45 PM and 3:25 PM, staff interviews with LVN D, LVN F, LVN I, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q LVN R, RN S, LVN T, LVN U, ADON, and DON were conducted. All staff were able to articulate what they were taught, policies, protocols, and procedures related to pain assessments, head to toe assessments, change of condition, and injuries of unknown origin. In interviews on 09/20/23 with the ADON at 3:23 PM and the DON at 2:47 PM, they both stated they were responsible for verifying staff competency with staff weekly using the pain competency checklists, reviewing all residents with injury or pain each week in the clinical meeting to assure pain assessments were completed timely, and ensuring at each shift change nursing staff were trained on the assessment of residents for pain assessments and head-to-toe assessments prior to the start of their shift . A record review of the resident's electronic medical records revealed facility nurses had completed resident's pain assessments by 09/19/23 and there were no acute pain or major changes of condition identified. Record review of in-services titled Assessing for Pain and Head to Toe Assessment revealed LVN D, LVN F, LVN I, LVN L, LVN M, LVN N, LVN O, LVN P, RN Q LVN R, RN S, LVN T, LVN U, ADON, and DON signed the facility's in-serviced logs, completed competency tests. A record review of the in-service log titled Subject: F684 Plan of Removal - Ad Hoc QAPI, dated 09/19/23, revealed signatures by the Medical Director, Clinical Resource Manager, DON, and the Administrator. A record review of the in-serve log titled F684 Plan of Removal by the Clinical Market Lead, revealed the DON & Clinical Resource Manager received training on the assessment of residents for pain assessments and head-to-toe assessments.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident #1, Resident #2, Resident #3) reviewed for ADL care. The facility failed to ensure Resident #1, Resident #2 and Resident #3 received timely incontinent care. This failure could put residents at risk of impaired skin integrity and decreased feelings of self-worth and dignity. Findings include: 1. Record review of Resident #1's electronic face sheet, dated 09/07/23, reflected the resident was admitted to the facility on [DATE] and was an [AGE] year-old female with a diagnoses which included age-related osteoporosis (causes bones to become weak and brittle) with current fracture, unspecified lack of coordination, unspecified dementia , and chronic pain. Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/23, indicated a BIMS score of 2, which indicated the resident's cognition was severely impaired. Resident #1 required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected Resident #1 was always incontinent of urine and bowel. Record review of Resident #1's Care Plan, dated 09/02/23, indicated a focus on area of bowel and bladder incontinence due to impaired mobility. The Care Plan interventions did not address peri care. 2. Record review of Resident #2's electronic face sheet, dated 09/08/23, reflected a female admitted to the facility on [DATE], who was [AGE] years old with diagnoses which included abnormalities of gait and mobility, unspecified lack of coordination, need for assistance with personal care, weakness, unsteadiness of feet, and muscle wasting and atrophy. Record review of Resident #2's Quarterly MDS Assessment, dated 04/02/23, indicated a BIMS score of 13, which indicated the resident's cognition was intact. She required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected she was occasionally incontinent of urine and always incontinent of bowel. Record review of Resident #2's care plan, dated 08/31/23, indicated a care area/problem of bladder and bowel incontinence due to history of UTI and impaired mobility with an intervention to Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. 3. Record review of Resident #3's electronic face sheet, dated 09/08/23, reflected a male resident who admitted to the facility on [DATE] and was [AGE] years old with diagnoses which included lack of coordination, difficulty in walking, pain in joint, right shoulder, and foot, history of falls, muscle weakness, and abnormalities of gait and mobility. Record review of Resident #3's Comprehensive MDS Assessment, dated 06/23/23, indicated a BIMS score of 5, which indicated the resident's cognition was severely impaired. He required extensive assistance with bed mobility, transfers, and with toilet use. Further review reflected he was occasionally incontinent of urine and always incontinent of bowel. Record review of Resident #3's care plan, dated 07/07/23, indicated a care area/problem of occasional bladder and bowel incontinence. The Care Plan interventions did not address peri care. In a phone interview on 09/06/23 at 4:50 PM, Resident #1's family member (FM) stated Resident #1 had a camera in her room and on 09/02/23 at 1:50 PM the FM checked the camera and saw Resident #1 had not been changed since 2:15 AM. The FM stated she went to the facility about 2:30/3:00 PM and saw Resident #1 still had not been changed. The FM stated they spoke to LVN A about Resident #1 not being changed since 2:15 AM and asked who was Resident #1's CNA. The FM stated LVN A told her she was not sure who the CNA was for Resident #1. The FM stated she asked LVN A for help because she was going to change Resident #1 themselves. The FM stated eventually a CNA (did not remember their name) came to help change Resident #1. The FM stated it was about 3:30 PM before Resident #1 was changed, which meant she had not been changed for about 13 hours . In an interview on 09/07/23 at 10:53 AM, Resident #2 stated there were a few times per week she waited several hours to be changed. Resident #2 stated she would press her call light and it would take 2-3 hours before someone would answer and change her. She stated she reported this several times to the nurses who were covering her hall . Resident #2's FM was visiting and stated this happened because she would check the camera in her room. The FM stated on the weekend it was really bad. The FM stated she usually visited on weekends, and she had witnessed it took 3 to 4 hours before staff would respond to the call light to change Resident #2. In a phone interview on 09/07/23 at 2:17 PM, LVN A stated on 09/02/23 Resident #1's FM went to the facility and stated Resident #1 had not been changed for several hours and she was extremely wet. LVN A stated she told the FM she did not know who the CNA was for Resident #1, because it was around shift change and she did not know which CNA took over Resident #1's hall. LVN A stated she learned CNA B was assigned to Resident #1's hall from 6AM to 2PM. She stated CNA C was assigned to Resident #1's hall from 2PM to 10PM. LVN A stated CNA C went to change Resident #1. She stated CNA C stated Resident #1 was extremely saturated. LVN A stated she spoke to CNA B and asked her why she had not changed Resident #1. LVN A stated CNA B did not provide a direct answer and said, she had to do this and that. LVN A stated CNA C went to her very upset because while she was doing rounds, there were several residents who were extremely wet. LVN A stated she did rounds with CNA C to help her. LVN A stated she could not remember everyone who was extremely wet, but she definitely remembered Resident #3 because he had dried feces and a brown circle on his sheets. She stated this was an indication he had not been changed for several hours. LVN A stated she worked on the weekends and there were issues with CNAs because a lot of them were agency. She stated she received complaints from resident's that they would turn on call lights to be changed and no one would come for hours. LVN A stated she would have to go look for the CNAs who were usually in the breakroom or hiding in the front lobby because the receptionist left at 4PM. She stated she reported this issue to the Weekend Supervisor (WS ), the Staffing Coordinator (SC), and the DON. She stated the WS would say he would inform the SC to stop scheduling those CNAs, the SC would stop scheduling those CNAs, but the new agency staff would come in and do the same thing. LVN A stated the DON would tell her they were working towards getting the agency staff out of the building. In an interview on 09/08/23 at 11:30 AM, the SC stated she worked on 09/02/23 because she had two people call out and one person did not show up. She stated it was very chaotic. The SC stated she received complaints from the residents and nurses there were issues with residents not being changed in a timely manner. She stated residents were complaining they had not been changed for several hours and after pressing call lights they had to wait about 2 hours to be changed. The SC stated this was an issue in the facility during the 2PM to 10PM shift during the week and on the weekends. She stated the facility was staffing appropriately but it's a lot of agency from 2PM to 10PM and on the weekends and they were not on the floor. The SC stated she received calls from the weekend nurses who stated they could not find the CNAs and they were hiding, or on occasions they had left the building. She stated when this happened, she would not put them back on the schedule. In an interview on 09/08/23 at 1:08 PM, LVN D stated she worked Monday thru Friday from 6AM to 2PM. She stated on Wednesday (09/06/23) she received a complaint from Resident #2 when she answered her call light. LVN D stated Resident #2 stated she had not received incontinence care for a while and put on her call light. She stated Resident #2 stated her call light had been on for two hour. She stated she sent a CNA to change her, but she could not recall who. LVN D stated Resident #2's FM called and stated it had been about two hours when she checked the cameras. In an observation and attempted interview on 09/08/23 at 1:45 PM with Resident #3, he was observed to be in and out of a state of confusion. Resident #3 was asked if he received timely incontinence care, and his roommate, Resident #4 responded and stated no he did not. Resident #4 stated staff would not change Resident #3 for a while , so he would tell Resident #3 to press his call light, or he pressed his own call light for Resident #3. Resident #4 stated on the weekends it would take several hours before Resident #3 would be changed, even after pressing the call light. In an interview on 09/08/23 at 1:55 PM, the DON stated he had not received any complaints from residents or staff regarding timely incontinence care. He stated he had not received any complaints from weekend nurses of issues with CNAs not being on the floor or hiding. The DON stated his expectations were for staff to provide timely incontinence care. In a phone interview on 09/08/23 at 3:54 PM, CNA B stated she was assigned to Resident #1's on 09/02/23 from 6AM to 2PM. CNA B stated she could not remember if she changed Resident #1 during her shift on 09/02/23. She stated she could not remember if she checked in on her to see if she was wet during her entire shift on 09/02/23. CNA B stated she was supposed to do rounds to check residents to see if they needed to be changed but it was extremely busy her entire shift. CNA B stated she could not remember if LVN A asked her about not changing Resident #1. She stated she remembered her telling her she should have gotten her up for the day. In a phone interview on 09/13/23 at 11:28 AM, CNA C stated on 09/02/23 she worked a double shift from 6AM to 10PM. CNA C stated when the 2PM to 10PM started she was assigned to Resident #1 and Resident #2's hall. CNA C stated towards the beginning of her shift she heard Resident #1's FM telling LVN A she checked her camera and Resident #1 had not been changed all morning. CNA C stated LVN A told her to go change Resident #1. CNA C stated Resident #1 was wet and she believed it had been a while since she had been changed because some parts of the brief were dry. CNA C stated during her rounds she saw the residents were saturated and seemed as if they had not been changed for a while. CNA C stated when she got to Resident #3, it was really bad, so she called LVN A into the room. She stated she did not want to get blamed for him being in that condition. CNA C stated Resident #3's brief and bed sheet were saturated in urine, and he had dried up feces stuck to his bottom, so she knew he had not been changed during the 6AM to 2PM shift. CNA C stated she had to take Resident #3 to the shower . A record review of the facility's policy titled Incontinence Care, dated 03/2022, reflected Policy: It is the policy of this facility to provide incontinence care for those residents requiring assistance with bladder and/or bowel incontinence. Staff providing incontinence care will do so while maintaining the dignity of the resident and providing care in a respectful manner. Procedure . 7. Check the resident for further incontinence regularly.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 7 of 10 resident rooms (Rooms #114, #118, #124, #131, #203, #219, and #223) reviewed for environment. The facility failed to ensure resident rooms were cleaned daily, and in accordance with the facility's 5- Step Daily Housekeeping Procedure. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas. Findings Include: In interview and observation on 09/07/23 at 10:07 AM of room [ROOM NUMBER] revealed food crumbs, crumbled paper napkins, and three patches of a gray sticky substance on the floor around the bed. A dead cricket was on the floor by the window. Resident #5 stated housekeeping (HK) had not been in his room all week to clean. He stated the last time his room was cleaned was last week either Tuesday (08/29/23) or Wednesday (08/30/23). Resident #5 stated HK used to come every other day and clean his room, but for the last month in a half, they may come once per week . In interview and observation on 09/07/23 at 10:11 AM of room [ROOM NUMBER] revealed food crumbs, food wrappers, crumbled napkins, and patches of visible brown dirt spots were all over the floor. Resident #6 stated she was not sure of the last time HK came into her room to clean. She stated she knew for sure no one had come the last two days. Resident #5 stated HK emptied her trash earlier in the morning, but they did not clean. An observation on 09/07/23 at 10:38 AM of room [ROOM NUMBER] revealed food crumbs around bed B, food wrappers under the bed, with dust visibly under the bed, sticky brown spots on the floor beside the bed and trashcan. The floors were very sticky. An observation on 09/07/23 at 10:43 AM of room [ROOM NUMBER] revealed crumbled paper on the floor near the trash can, crumbled napkins on the floor by the bed and two patches of dried sticky red stains on the floor near the side of the bed. The floor was very sticky . An observation on 09/07/23 at 10:46 AM of room [ROOM NUMBER] revealed pieces of paper and dust was under bed B. There were two large spills of light brown substance, one near the bed by the trash and one near the nightstand. The spill near the nightstand was dried up and the one near the trashcan was dry in some spots. The substance appeared to be chocolate milk or coffee with cream. There were visible patches of dirt on the floor that were grayish/blackish in color . In an interview on 09/07/23 at 10:24 AM, the HK Manager stated on Thursday (08/31/23), he had only been working at the facility for one week. The HK Manager stated he realized the building was not in very good shape. The HK Manager stated he received several complaints from the residents that their rooms had not been cleaned for several days and to him, the rooms appeared as if they had not been cleaned for several days . The HK Manager stated he believed there were staffing issues prior to him starting, but now they were fully staffed. He stated HK was supposed to clean resident rooms daily, which consisted of emptying the trash, cleaning the bathroom, disinfect things that were touched daily such as bed side tables, sweep, and mop. The HK Manager stated they used a 5-Step Daily Housekeeping Procedure to ensure the rooms were cleaned appropriately. The HK Manager stated each room was supposed to be deep cleaned twice per month. He stated he was in the process of getting every room deep cleaned and then he would do routine cleaning and deep cleaning twice per month . An interview and observation on 09/07/23 at 10:52 AM of room [ROOM NUMBER] revealed food crumbs and crumbled paper debris around the resident's bed. Under the resident's bed was dust. The floor was sticky and had visible patches of grayish/blackish dirt stains. Resident #2 stated it had been about three days since HK cleaned her room. She stated HK did not clean daily. Resident #2 stated HK cleaned her room about 1-2 times per week. In a follow up interview and observation on 09/08/23 at 12:15 PM of room [ROOM NUMBER] revealed the room still had not been cleaned. The same observations from 09/07/23 at 10:07 AM were still present in room [ROOM NUMBER]. Resident #5 stated HK did not clean his room yesterday nor so far today. An interview and observation on 09/08/23 at 1:45 PM of room [ROOM NUMBER] revealed crumbled paper towels and small bits of trash sporadically over the floor. The floor was sticky. Resident #4 stated HK did not clean their room often. He stated the last time they cleaned was on Tuesday (09/05/23). Resident #4 stated HK did not generally come until his or Resident #3's FM complained . In an interview on 09/08/23 at 2:14 PM, the Administrator stated he started at the facility on 08/28/23 and realized HK was an issue. He stated resident's rooms were supposed to be cleaned daily but that was not happening. The Administrator stated there were issues with staffing when he first started at the facility. He stated there were 2 or 3 HK staff who could only work on certain days. The Administrator stated he hired a new HK Manager about one week ago and they were fully staffed. He stated the new HK Manager had prepared a schedule to provide consistency and to ensure the rooms were going to be cleaned daily . A record review of the facility's, undated, HK procedures titled 5-Step Daily Housekeeping Procedure, reflected Step 1: Empty trash and check supplies. Trash: Add liners to receptacles and sanitized as needed. Supplies: paper towels, toilet paper, and soap. Step 2: Clean (dust) all horizontal surfaces using 200 disinfectants. Horizontal Surfaces: picture frames, dressers, bed-side tables, TV, beds, handrails, sink, toilet, mirror & lights. Step 3: Spot clean walls and check privacy curtains. Step 4: Sweep/dust mop. Move furniture & sweep under beds. Step 5: Damp mop, mop under bed. A record review of the facility's policy titled Resident Rights, dated 05/2007, reflected Policy: It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. A record review of the facility's policy titled Environmental Services- Housekeeping, dated 2022, reflected Policy: Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit. Procedures: 1. All rooms of residents will be cleaned regularly. These duties include: a. Sweeping and mopping of the resident's room and restroom . e. Properly dispose of any trash in the room (declutter) . h. Frequently change mop water as to not transfer any infectious materials/substances from room to room .

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to administer Resident #1's tramadol HCI oral tablet on 09/02/23 at 1:00 PM and 09/03/23 at 1:00 PM for pain. This deficient practice could place residents at risk of not receiving the therapeutic effect of medications and a drug diversion. The findings include: Record review of Resident #1's electronic face sheet, dated 09/07/23, reflected a female who admitted to the facility on [DATE] and was [AGE] years old. Resident #1 had diagnoses which included age-related osteoporosis (causes bones to become weak and brittle) with current fracture and chronic pain. Record review of Resident #1's Quarterly MDS Assessment, dated 08/31/23, indicated a BIMS score of 2, which indicated the resident's cognition was severely impaired Resident #1 was to receive a scheduled pain medication regimen. Record review of Resident #1's care plan, dated 09/02/23, reflected a focus that Resident #1 had acute/chronic pain due to age related osteoporosis. The Care Plan reflected the intervention included Administer [pain] medication as per orders. A record review of Resident #1's Order Summary, dated 09/07/23, reflected a physician order for Tramadol HCl Oral Tablet 50 MG (Tramadol HCI) Give 1 tablet orally three times a day for pain. Start date 03/14/23. A record review of Resident #1's MAR, dated September 2023, reflected the following: Tramadol HCl Oral Tablet 50 MG (Tramadol HCI) Give 1 tablet orally three times a day for pain. Start date 03/14/23 5:00 PM. The MAR reflected the hours for the medication were 9:00 AM, 1:00 PM, and 5:00 PM. There were no initials or check marks, which indicated the medication was not administered for the following times: 09/02/23 at 1:00 PM and 09/03/23 at 1:00 PM. In a phone interview on 09/06/23 at 4:50 PM, Resident #1's family member (FM) stated over the weekend (09/02/23 and 09/03/23) Resident #1 received all her doses of tramadol. The FM stated while at the facility on 09/02/23 they spoke to the Med Aide assigned to Resident #1's hall about 4PM. The FM stated they could not recall the Med Aide's name, but they pointed out Resident #1 did not receive her afternoon dose of Tramadol. The FM stated they reviewed the camera in Resident #1's room and saw she did not receive the medication. The FM stated the Med Aide said she was new and got behind. The FM stated Resident #1 did receive her 5PM dose. In a phone interview on 09/07/23 at 2:17 PM, LVN A stated on 09/02/23 Resident #1's FM went to the facility and stated Resident #1 had not received her tramadol medication. She stated Med Aide E was new and it was her first weekend working by herself. LVN A stated Resident #1's FM wanted to know who the Med Aide was on Resident #1's hall. LVN A stated she advised the FM that Med Aide E was assigned to Resident #1's hall and told the FM Med Aide E was new and behind. She stated one of the other Med Aides went to help her. LVN A stated she knew several medications were late, but she was not aware medications were missed . In an interview on 09/07/23 at 3:25 PM, Med Aide E stated Saturday, 09/02/23, was her first day passing medications by herself and there were a lot of issues. Med Aide E stated she fell behind and another Med Aide had to help her. She stated Resident #1's FM told her she did not receive her tramadol. The Med Aide stated she told Resident #1's FM that it was her first day and she had fallen behind. She stated she was not aware Resident #1 did not receive the medication at all. Med Aide E stated she thought it was just late. She stated shortly after that conversation with Resident #1's FM, another Med Aide started helping her and there could have been a mix up between them. Med Aide E stated she may have thought the other Med Aide gave her the meds and she missed it. In an interview on 09/08/23 at 1:55 PM, the DON stated there had not been any issues reported to him regarding medications over the weekend (09/02/23 and 09/03/23). He stated there was a new Med Aide who started over the weekend, but nothing had been reported to him that resident's medications were late or not administered. The DON stated his expectation was for medications to be administered per physician orders. He stated the adverse actions would depend on the type of medication, but in general there were concerns residents would not receive the desired effect the medication was intended to provide. A record review of the facility's policy, titled Medication Administration, dated 05/2007, revealed It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: 2. Medications must be administered in accordance with the written orders of the attending physician . 8. Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled. 9. The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication. 10. The nurse administering the medications must initial the resident's MAR, on the appropriate line and date for that specific day.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 1 (Resident #133) reviewed for accidents hazards/supervision. The facility failed to implement interventions to prevent elopement and failed to adequately supervise Resident #133 to prevent him from leaving the facility on 06/05/2023 without staff knowledge. Resident #133 was located 0.4 miles away from the facility. This failure could place residents requiring supervision at risk for serious injury and death. In Immediate Jeopardy (IJ) was identified to have existed from 06/05/2023 to 06/05/2023. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. The facility took the following actions to correct the non-compliance: moved Resident #133's room close to the nurse's station and placed a wanderguard bracelet on Resident #133. The facility Administrator was provided the IJ template on 06/30/2023 at 12:24 PM. Findings included: Record review of Resident #133's face sheet, dated 06/30/2023, revealed he was a [AGE] year-old male admitted to the facility on [DATE] from a skilled nursing facility with a primary diagnosis that included surgical aftercare following surgery on the digestive system and other diagnoses that included muscle weakness, abnormalities of gait and mobility, cognitive communication deficit, alcoholic cirrhosis of liver without ascites, heart failure, hypotension, acute kidney failure, and benign prostatic hyperplasia. Record review of Resident #133's MDS, dated [DATE], revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #133 had wandering behavior 1-3 days upon assessment and required extensive one person assist for bed mobility, toileting, and personal hygiene and required the use of a walker and wheelchair for mobility. Record review of Resident #133's care plan, dated 06/03/2023, revealed Resident #133 had an indwelling catheter, was an elopement risk with history of attempts to leave the facility unattended x1 on 06/05/2023, and at risk for falls. Record review of Resident #133's Nurse note on admitted d 06/02/23 at 8:35 PM by LVN T revealed he was alert and oriented x 2 at times . but very confused . had a healing surgical wound to his abdominal area with a Jackson Pratt drain present . foley-cath . with urine dark [NAME] with traces of blood and bruising to both hands, arms, and lower abdominal area. Record review of Resident #133's Nurse Note dated 06/05/23 at 8:30 AM by LPN L revealed the resident in bed holding [Jackson Pratt] JP drain after self removal. Record review of Resident #133's Nurse Note dated 06/05/23 at 11:45 AM by DON revealed IDT team note: resident with a BIMS of 10 . Resident states 'I left to go get some food from one of my favorite restaurants.' Physician and LVN D and was at bedside and completed head to toe assessments. No injuries noted at this time. Resident had a few episodes of minimal low-level confusion. New order for wander guard placed. Wander guard placed at this time. Resident is cooperative and not attempting to wander or elope at this time . Resident being moved to a room close to nurse station for increased observation. Record review of Resident #133's Nurse Note dated 06/05/23 at 12:48 PM by LPN L revealed Notified of resident being out of the building this AM. Code green activated. Resident returned to building via staff via wheelchair. Head to toe assessment performed no new injury noted no decrease in ROM noted. Wander guard attached to right ankle. Resident stated, 'I don't like the food and went to go get something to eat.' Record review of Resident #133's Nurse Note dated 06/06/23 at 1:30 AM by RN O revealed Patient found lying on the floor next to his bed, appeared confused, unable to describe what he was trying to do. Patient might have slid off the bed with bed in the lowest position, no complaint of pain, no injuries this time, vital signs stable, neuro checks started . Record review of Resident #133's Nurse Note entries dated 06/06/2023 at 7:23 AM and 06/07/2023 at 7:07 AM by RN G revealed Continues to exit seek . no late injury noted . Record review of Resident #133's elopement/wandering evaluation, dated 06/02/2023, revealed a score of 28 out of 55, indicating a high [elopement] risk. Record review of Resident #133's elopement/wandering evaluation completed after elopement, dated 06/05/2023, revealed a score of 17 out of 55 indicating a high risk. Record review of Resident #133's June 2023 TAR reflected, monitor placement and functioning of wander guard every shift, if wander guard is nonfunctioning replace immediately -Order Date- 06/05/2023. Record Review of 24-hour report dated 06/02/2023 reflected, Admissions - Resident #133, [room number] full code, Dx hernia repair, Abd - JP drain empty every shift, Foley Catheter 16Fr/10mL, Alert and Oriented x2 forgetful, assist x1, P.O. med. Record Review of 24-hour report, dated 06/04/2023, reflected Resident #133 .repeat BMP, low/decreased Sodium. Record Review of 24-hour report, dated 06/05/2023, reflected Resident #133 JP out, moved, eloped, wanderguard, room number]. Record Review of the Provider Investigation Report (PIR) revealed based on camera surveillance, around 09:50 AM on 6/05/23, patient wheeled himself out of his room, down the hall toward the short-term care nurses' station. At 9:53 AM, Resident #133 goes out of camera view as he entered a foyer/sitting area for the short-term care entrance to the facility. At that point he is no lover visible by camera surveillance. Around 10:45 AM Resident #133's roommate (from his home residence) called the facility to inform us that Resident #133 was at a neighboring restaurant. At that point in time the facility was alerted to a Code Green elopement . Around 10:50 the Administrator and DON found Resident #133 at the restaurant and asked if he was okay. He explained he lives nearby and likes this restaurant and would stop by to get something to eat. Investigation notes revealed Resident #133 responded that he did not want to go back to the facility and was going to have his roommate come pick him up, but the roommate was in a meeting and could not come right now but was hopeful he could get a ride later. At this point Resident #133's second resident representative and her husband showed up at the restaurant to help persuade the resident to return to the facility. Further review of the PIR revealed resident returned to the facility in the facility van. The Facility Investigation Summary reflected, investigation found that Resident #133's medical records did not indicate any previous elopement attempts or wandering behaviors at [hospital/facility names]. The investigation found that Resident #133 had a change in condition with improved mobility, increased confusion and exit seeking desires . Observation of facility grounds when exiting the main door and rehab door revealed the outside area and parking lot was unsecured and led to residential streets and a major highway. [restaurant name] was located 0.4 miles away from the facility. Observation and interview of Resident #133 on 06/28/2023 at 04:16 PM, revealed the resident was well groomed and dressed, lying in bed, wearing nonskid socks and a gray ankle bracelet. When asked about the elopement, Resident #1 stated that he does not normally act like that, they [staff] were very concerned and did those tests and found he had a UTI. Resident #133 said the staff would not let him go outside now because they think he would run away. Resident #133 stated he actually thought he was somewhere else, and he was trying to leave because he was hungry and knew of a place close by. Resident #133 said the day he left, 4 people came to the restaurant to get him, 2 guys that worked at the facility and 2 of his friends. Resident #133 said he was not injured that day. Resident #133 said the ankle bracelet was to keep track of him. Interview with LVN F on 06/28/2023 at 04:26 PM, revealed he remembered the incident, but it happened on the first shift when he was not there, and since then they have monitored Resident #133 every 2 hours, and his wander guard would set off the alarm if he left the building. LVN F stated the resident has been very compliant and has not tried to get out since. LVN F said Resident #133 did not try to leave before that incident. LVN F stated if a resident was an elopement risk they have alarms and staff check on them. When asked what you do when a resident elopes, LVN F stated once identified the resident has left, check all the rooms and facility, if we don't find them, we make an announcement so everyone tries to find the person, go outside and look around. When we find them, bring them in, inform family, let the DON know and an incident report. LVN F said we want to make sure the person is ok and no harm, let the doctor know and if the doctor wants labs, psych evaluation or whatever is necessary. LVN F said they use wander guards if the resident was a risk, get a doctor order and explain to the resident that it was a little gadget to allow staff to know where they were at all times and if they try to leave the alarm would go off. LVN F said some residents understand it was for their safety but some get confused. Interview with Resident #133's Emergency Contact/Representative on 06/29/2023 at 10:23 AM, revealed Resident #133 lived independently prior to being at the facility, had been in the hospital since 04/11/2023, and she was aware of the elopement incident. She stated Resident #133 had wheeled himself out of the facility, and at the time was on his meds, had a UTI and was trying to escape. He was trying to get home or a place where he would go quite frequently, something familiar. She said Resident #133 thought he left his truck there [at the restaurant] and could not find it so called one of his friends to pick him up. She said that friend knew better so he called another friend (Resident #133's second listed representative) and that representative called the facility. The Emergency Contact stated Resident #133 had no past wandering or elopement behaviors, but he had liver disease and when on the UTI meds he started imagining things and remembering things from before and just got confused. Interview with LVN D on 06/29/2023 at 10:50 AM, revealed he was not able to answer what elopement interventions/monitoring were in place for Resident #133 upon admission, but the wanderguard was put on after the fact. When asked what you do if an elopement risk was high, LVN D stated that was evaluated when they came in and the wanderguard was not put on at first but at attempt or when they have made an attempt to leave. LVN D said he was not on the floor and was in the morning meeting when Resident #133 left and was later told he went out about 15 feet from here (he pointed at the rehab entrance and not main building entrance) and exited the door from the lobby. LVN D stated there was a code to enter before leaving but were also fire doors so if pushed long enough the door would open. LVN D stated he saw Resident #133 lying in bed about 9:30 am on 06/05/2023 on his last round before going to the morning meeting. LVN D stated when a resident elopes and gets out, a code green was called, they search the building and then if they cannot find the resident, they work the surrounding area. LVN D stated the had a code green drill last month. LVN D stated he does not usually do elopement assessments because admissions come in on the evening shifts but during the day if he notices wandering or exit seeking behaviors, he would let the ADON or DON know and it was communicated on shift change. Interview with Resident #133 on 06/29/2023 at 11:10 AM, revealed when he admitted he was in another room and the morning he left there was a receptionist sitting in the lobby and told her he was going to get something from the truck and opened the door or went out with some other people, and did not remember if the door alarm went off. Resident #133 stated this happened about 10:15 AM, and he did not know the names of the streets he took but took the side and residential roads because he did not want to take the highway. He said he was tired when he got there, was not scared, and was going to come back. He said he thought he could come and go but they changed hisroom when he came back. Interview with CNA E on 06/29/2023 at 11:34 AM revealed he worked that day (06/05/2023) and was doing something for another resident when Resident #133 was gone and all the people tried to find him. CNA E stated the alarm was currently working on the door and after the resident came back, he was moved to his (CNA E's) assigned hall because the resident was trying to go outside. CNA E stated if a resident eloped he would report to the nurse, search all the rooms, closets and outside the building. Interview with CNA C on 06/29/2023 at 12:16 PM revealed she worked with Resident #133 on 06/05/2023. She stated she did rounds from down the hall, got him dressed and in his wheelchair around 9:45 or 9:50 AM and asked him if he was going up front. The resident said yes, he was going to roll up their himself and she went to another room to assist another resident and that was when they got the alert. CNA C stated the last time she saw him he was going to do therapy and did not see him leave the facility and did not see any exit seeking or wandering behaviors that day and put a wanderguard after the incident. CNA A stated they make sure to keep an eye on him, have a routine, walk back and forth down the hall and check on them to make sure everybody was fine. She stated she did get training on elopements before the incident and if a resident tried to leave how to alert everybody, how to approach the resident and try to get them back in. CNA A stated Resident #133 did have a catheter and she put it on his chair with a privacy bag that morning and therapy was always in that area because they sit there and work with residents, but no one was assigned to sit at the entrance. She stated they did complete a code green drill before the incident and where they told us how to get the resident in, what areas to look and that everybody has to look. Interview with DON on 06/29/2023 at 01:12 PM revealed the DON, ADONs, and Clinical Resources do quarterly elopement drills and then review. He stated they had an elopement incident on 06/05/2023 and the drill was a week earlier on 05/25/2023 so they reviewed and had an in-service. He stated we go over the process and take a resident in an office or conference room therefore providing a live demonstration. He stated if a resident was an elopement risk they do a new assessment, and if they are confused the first intervention was the wanderguard but if not confused, do other interventions, because we cannot use a wanderguard on an alert and oriented resident as it would be considered a restraint. Other interventions included talking with them, frequent checks, assess, move the resident closer to the nurses' station and alert staff of needing to watch the person, talk with the family, and care plan. The DON stated the administrator did the investigation, and they do have cameras in the building, but do not cover every exit and the door he went out does not have a camera. He stated there is a code to open the door, and the alarm was currently functioning. He stated there was a front entrance way that therapist's work by but it was not their job to monitor who comes in and out and there was no receptionist at that entrance. The DON said the elopement drills included other departments, they call code green on the intercom, and everyone stops what they are doing to look for the resident. The DON stated Resident #133 admitted on the 2 to 10 shift and the nurse did an inaccurate assessment for elopement that included mental illness, but the resident did not have mental illness. The DON stated he redid the assessment after the elopement and it scored in the 20s but it was a horrible assessment because you can be an 11 and be high risk, there was not middle. There could be a lot of people that score high who are not appropriate. The DON stated Resident #133 had slight confusion at the time of elopement. When asked what interventions were done at the time prior to elopement, the DON said frequent monitoring, assess the patient check frequently and make sure they are OK but the monitoring was not charted. The DON said Resident #133 had a catheter at time of elopement and transported in a wheelchair. He said the resident lived in the neighborhood and went to his favorite restaurant and post elopement interventions included head to toe assessment with no injuries, physician and family notification, got an order for the wanderguard and moved to room [ROOM NUMBER] by the nurses' station, education, monitoring and a care plan meeting. The DON stated Resident #133 did have a fall on 06/06/2023 about 15 hours after elopement in the middle of the night. He said fall precautions were in place that included low bed, call light in reach, checking on him and not low on staff that night. After the fall, an Xray showed an injury that was found to be chronic and the family confirmed that he had a problem with the hip, if he had an acute injury the CT scan would have showed that. The DON said since elopement, Resident #133 did not have any other elopements or falls. The DON stated his expectation was for nurses to alert him when residents were exit seeking. Attempted interview with LVN T on 06/29/2023 at 02:15 PM by telephone was unsuccessful. Interview with Weekend Supervisor on 06/30/2023 at 10:08 AM revealed he worked the weekend on 06/03/2023 and 06/04/2023 and did not observe any wandering behaviors from Resident #133. He said he did check on Resident #133 that weekend, and all staff check on our residents, make sure the doors are not beeping, especially new residents on that hall they monitor closely but he did not get any reports from the nurses that Resident #133 was close to the door. He stated when he came back the next weekend the resident was moved. He said according to the assessment, if the resident was a high elopement risk and they were confused they use a wanderguard and made sure it was in place every shift, but if not confused they closely monitor behaviors like exit seeking, keep eyes on them and monitor. He said if the person has a wanderguard they are monitored every 2 hours and if no wanderguard then every hour. Interview with Administrator, DON and Clinical Resources on 06/30/2023 at 12:24 PM, they said up until the point Resident #133 eloped, he had not tried to. Record reveiw of Emergency Prepardeness DRILL - Missing Person/Elopement dated 05/25/2023, revealed LVN D, CNA C, and CNA E participated in the drill. Review of the drill further reflected the following: .2. Locations searched within the facility and any pertinent details for each: Entire facility 3. Time when search of facility grounds was initiated and any pertinent details: Resident was located inside the facility x2 . 6. Location of Resident when found: 1) Education room [ROOM NUMBER]) Private dining room * Describe staff response to drill: Both shifts responded and systematically searched the building unitl the residents were located . Record review of Elopement In-Service, dated 06/05/2023, revealed LVN F and LVN T signed the attendance sheet. The inservice futher reflected: 1. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions. 2. If a resident is missing it is a facility-wide emergency. Code Green will be announced. The missing resident procedures will be initiated: A. Determine if the resident is out on an authorized leave or pass. B. If the resident was not authorized to leave, institute a search of the premises. C. If the resident is unaccounted for after a thorough search of the building and grounds, immediately notify: Administrator Director of Nursing Services Residents legal representative or emergency contact Attending physician Law Enforcement Officials D. Provide search teams with resident identification information and begin extensive search of the surrounding territory. 3. When the resident returns to the facility: A. An assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. B. Notify search teams that the resident has been located C. The attending Physician and Resident Representative will be notified of the resident's return and the resident status. D. Document relevant information in the resident's medical record. 4. An Elopement/Wandering Evaluation will be completed post elopement incident with follow up documentation for a minimum of 72 hours following the incident. Record review of policy titled Wander System Monitoring Program revised 09/2007, reflected It is the policy of this facility that all new residents will be evaluated with initial assessment process as to whether he or she presents a wondering risk . any resident previously identified as a wandering risk will be reassessed quarterly, and with changes in behavior, all residents identified to be at risk for wondering, will have a wonder monitoring bracelet . Procedures: 1. An initial wondering assessment will be completed on all new residence on admission. See Elopement Risk Assessment. 2. Any resident displaying significant change of status or change of behavior pattern will be reevaluated for potential wondering . Record review of policy titled Elopement/Unsafe Wandering, revised 06/2018, reflected It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement . Procedures: 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an elopement/wondering evaluation completed to determine risks for elopement and unsafe, wondering on admission, and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors identified on an elopement/wondering evaluation are considered at risk and will have an individual individualized care plan developed that includes miserable objectives, and time frames for the care plan interventions will consider the particular elements of the evaluation that put the resident at risk and the observations of wondering behavior .

Based on interview and record review the facility failed to ensure residents were free of significant medication errors for one (Resident # 1) of one resident reviewed for significant medication errors. LVN A failed to administer Resident # 1's [MEDICATION NAME] 5000U (units) 1 Milliliter (ml) subcutaneously and instead administered Insulin 70/30 100 units subcutaneously. Resident #1 was sent to the emergency room for treatment related to the medication error of 100 units Insulin 70/30 injection. This was determined to be past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the beginning of the survey. The failures placed residents at risk of not receiving the correct medications as ordered by the physician. Findings included: Review of Resident # 1's face sheet, dated 04/30/18 reflected she admitted to the facility on [DATE] and she was an [AGE] year-old female. Review of Resident # 1's MDS dated [DATE] reflected her [DIAGNOSES REDACTED]. Her functional status reflected she required extensive assistance of two plus staff for Activities of daily living (ADL's) and she was severely cognitively impaired. Resident # 1's Care Plan dated 07/10/18 reflected she was receiving an anticoagulant. Measurable goals and interventions were in place. Review of Medication Error report dated 04/28/18 revealed LVN A had given Resident #1 Insulin 70/30 instead of [MEDICATION NAME] 5000U 1ml. Resident #1 was given orange juice, checked the blood sugar and sent her to the hospital. LVN A was educated immediately on the 10 Rights of Drug Administration, Sharpening Critical Thinking education and then resigned the same evening. The attending physician and family were notified. Review of emergency room (ER) records dated 04/28/18 revealed Resident #1 arrived at 9:05 PM with a [DIAGNOSES REDACTED]. At 10:22 PM she was given D50W ([MEDICATION NAME] 50%) 1 amp, IV pump and at 10:44 PM she was given D5-1/2 NS (5% [MEDICATION NAME] in half amount of normal saline) 1000 ml per IV, (Intravenously) 100 ml per hour. Resident #1's blood sugars were checked at the following times: 9:07 PM - 156 10:01 PM - 66 11:12 PM - 120 She was also given [MEDICATION NAME] 2 mg (milligrams) one time. She was discharged back to the facility at 11:30 PM with a [DIAGNOSES REDACTED]. Review of Discharge orders dated 04/28/18 revealed the following: Diagnosis: [REDACTED]. - check glucose every hour till 7 AM - if sugar less than 80 then give oral glucose and recheck -return to ER if unable to correct sugar. Review of the Charge nurses notes dated 04/29/18 revealed the following blood sugar readings: 12:00 AM: 52, administered [MEDICATION NAME] 15 mg 1:00 AM: 44, pudding and apple juice given 2:00 AM: 61 3:00 AM: 90 4:00 AM: 87 5:00 AM: 58, apple juice and 2 packets of sugar 6:00 AM: 91 7:00 AM: 60 Review of In-services on 04/28/18 for all Registered Nurses and Licensed Vocational Nurses revealed they were given training on the 10 Rights of Medication Administration by the DON. Observation on 03/01/19 from 6:00 AM to 8:00AM of Medication administration by the surveyor revealed there were no errors observed with Insulin or [MEDICATION NAME] administration. Interview with the DON on 02/28/19 at 5:15 PM revealed on 04/28/18, LVN A had given Resident #1 Insulin instead of [MEDICATION NAME]. He stated she realized her mistake almost immediately after giving the medication. Resident #1 was given orange juice, they checked her blood sugar, it was 119 and called 911. The attending physician and family were notified. LVN A was educated immediately on the 10 Rights of Drug Administration, Sharpening Critical Thinking education and then resigned the same evening. Interview with the DON on 03/01/19 at 3:45 PM revealed they do not have a policy for checking blood sugars; they follow the Physician Orders. .

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #15) of 21 residents reviewed for their medication regimen was free of significant medication errors. LVN L failed to determine if the resident could be adminstered a PRN dose of [MEDICATION NAME] 10-325 mg prior to [MEDICAL TREATMENT]. LVN Unit Manager failed to intervene when the resident requested her routinely scheduled dose of [MEDICATION NAME] 10-325 mg be given to her to take with her to [MEDICAL TREATMENT]. LVN Unit Manager M also failed to determine if the resident could be administered a PRN dose of pain medication prior to [MEDICAL TREATMENT]. The facility failed to write a Physician's Telephone Order when Resident #15's physician changed the frequency of her [MEDICATION NAME] 10-325 mg from four times a day to six times a day. The facility failed to have Resident #15's PRN [MEDICATION NAME] 10-325 mg available for the resident in case of breakthrough pain. These failures resulted in Resident #15 going to [MEDICAL TREATMENT] in pain on 10/30/13, and the facility running out of Resident #15's [MEDICATION NAME] 10-325 mg. She missed 18 routinely scheduled doses of her pain medication from 10/18/13 through 10/21/13. These failures could affect the 78 residents, who had moderate/severe pain, by placing them at risk for [MEDICAL CONDITION], refusal to go to adhere to treatments/plans of care such as [MEDICAL TREATMENT], reduced ability to move and perform ADLs, a decline in mood, or social engagement, and an increase in maladaptive behaviors. Findings included: Resident #15 was a [AGE] year-old female originally admitted to the facility on [DATE], per the undated Face Sheet. Resident #15 was recently re-admitted on [DATE] from an acute hospital setting, per the quarterly MDS assessment, dated 10/06/13. The MDS assessment reflected her [DIAGNOSES REDACTED]., Depression (other than [MEDICAL CONDITION]), Hyperpotassemia, [MEDICAL CONDITION] in Diabetes and [MEDICAL CONDITION]. She was moderately cognitively impaired and needed the assistance of one person with transfers, dressing, toileting, and personl hygiene. Resident #15 used a wheelchair for mobility and was able to self propel the wheelchair. She was occasionally incontinent of bowel and bladder. Resident #15 was on a scheduled pain medication regimen over the past five days from the ARD 10/06/13, and she had not received any PRN pain medication or non-medication interventions for pain over the past five days. The interview to assess pain was conducted and revealed the occasional presence of pain. The intensity of the resident's pain was rated four on a scale of zero to ten, with ten being the worst pain. Review of all available care plans revealed, "Problem Onset: 07/14/2013 Resident complaining of pain, discomfort, nausea, related to [MEDICAL CONDITION], leg pain etc. - requiring medication for pain relief." The short term goal reflected, "Resident has pain relief of 3 or less, 1-2 hours after pain medication administered." The long term goal reflected, "Resident has increased comfort and pain is controlled by next 180 days." The Approaches were "Complete pain assessment routinely as instructed. For a score of 5 or greater notify MD, evaluate pain medications, and re-evaluate care plan. Assess and document for pain and response to pain relief measures. Ask resident to rate pain using 0-10 (0=no pain, 10=worst pain). Be alert to verbal and nonverbal cues regarding level of pain experienced by resident. Offer position change, back rubs, relaxation techniques as supplements to medication for pain relief, as appropriate for level of pain identified. Explain reason for pain medication and instruct resident to ask for pain medication before pain becomes too severe, prior to activities/procedures, as needed. Effectiveness of pain medication or interventions will be evaluated per episode and MD notified if action, medication or intervention is not effective. Licensed nurse to evaluate via pain assessment tool on admissions, readmissions, significant changes in condition, quarterly assessments and prn. Notify MD if score is greater than 5. Assess for condition/[DIAGNOSES REDACTED]. MD to review pain medication and adjust as needed. Resident's pain threshold is 6-8. Resident loves playing the piano." This care plan was signed and dated 08/15/13. Interview on 10/31/13 at 3:20 PM with MDS LVN U revealed pain assessments were completed quarterly by the charge nurses and the MDS nurses completed pain assessments as part of the MDS assessment. When asked if he was aware of the pain Resident #15 experienced and possible causes, MDS LVN U replied he did not. When asked about care plans regarding the management of Resident #15's pain, MDS LVN U replied the care plan dated 07/14/13 was the most current care plan. The Admission Nursing Evaluation dated 09/24/13 reflected Resident #15 experienced pain frequently and she verbalized a numeric value of her pain as a "5 to 8." A nursing progress note, dated 09/25/13 and timed 12:00 AM, reflected Resident #15 was at the nurse's station in her wheelchair complaining of generalized pain rated eight of ten, and routine pain medication was administered and at 1:00 AM, which was effective. There was no documentation reflecting the resident's physiciam was notified. (Note: Resident #15's, Care Plan dated 07/14/13, reflected to notify the physician if the resident's pain score was greater than five.) Review Resident #15's consolidated October 2013 physician's orders [REDACTED]. A nursing progress note, dated 10/07/13 and timed 12:00 AM, reflected Resident #15 complained of pain to her bilateral lower extremities and "Routine meds given per orders...." Review of the [MEDICAL TREATMENT] center documentation dated 10/07/13 and authored by the [MEDICAL TREATMENT] RN Nurse Manager revealed, "Pt's (Resident #15's) CVC (Central Venous Catheter) has been in place for over a year. Pt had previous graft to left upper arm and pt developed arterial ulcers to left hand secondary to poor profusion to hand. Pt was referred to vascular surgeon and graft was ligated to save the left hand. Pt also had AVF (Arteriovenous Fistula) placed to right arm and did not mature as expected. Every month Physician reviews the importance of placing an access in her arm and pt is refusing to place an access and go through surgery again at this time." During an interview on 10/31/13 at 3:50 PM with LVN Unit Manager M she revealed Resident #15's shoulder pain was secondary to the arteriovenous shunt that had been removed from her left arm due to circulation complications approximately five to seven months ago. She stated currently Resident #15 had a port catheter inserted in her upper chest. When asked about pain secondary to arthritis, LVN Unit Manager M revealed she had not heard that. Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/09/13 timed at 3:58 PM, reflected, "Complained of usual pain on both legs and right shoulder secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/11/13 timed at 11:11 AM, reflected, "...c/o (complaint of) ongoing right shoulder pain, pt is on routine pain meds at Rehab...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/11/13 timed at 3:22 PM, reflected, "Complained of usual pain on legs and right shoulder secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/21/13 timed at 3:31 PM, reflected, "Complained of usual pain on both ankle (sic) and right shoulder pain secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/23/13 timed at 3:10 PM, reflected, "Complained of usual right shoulder pain and pain on both ankles d/t (due to) arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/25/13 timed at 1:23 PM, reflected, "Complained of usual right shoulder pain secondary to arthritis and pain on ankles...." Observation on 10/30/13 at 10:15 AM at the nurse's station revealed Resident #15 was seated at the nurse's station in her wheelchair holding her arm and repeatedly telling anyone who would listen that she was "hurting." Approximately four nursing staff members were present at the nurse's station, including Resident #15's charge nurse, LVN L. LVN L responded she would look into it, but at that moment she had to go to the kitchen and retrieve Resident #15's lunch to take to [MEDICAL TREATMENT]. LVN L then proceeded to the kitchen. After LVN L left, Resident #15 continued to hold her arm. She was tearful, grimacing and kept repeating she was hurting. LVN Unit Manager M approached the nurse's station and asked MA O if she had administered Resident #15's routine pain medication. MA O replied she had and the resident was not scheduled for another dose until noon. Resident #15, who was listening to the exchange between LVN Unit Manager M and MA O asked if she could take her noon dose of pain medication to [MEDICAL TREATMENT] with her. MA O told Resident #15 she could not take the medication to [MEDICAL TREATMENT] because the doctor at the [MEDICAL TREATMENT] center and the doctor at the facility said she could not. Resident #15 tearfully stated, "I guess I will just have to suffer today." Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed when asked what pain management measures were in place for Resident #15 on her [MEDICAL TREATMENT] days, LVN Unit Manager M stated the [MEDICAL TREATMENT] center would not allow the facility to send medications with the resident. She revealed to her knowledge long acting pain medications or timing of medication administration had not been discussed. When asked why Resident #15's complaints of pain were not addressed on 10/30/13, LVN Unit Manager M stated she should have checked to see if the resident had something ordered for PRN pain or she should have called the physician. Interview on 10/31/13 at 1:30 PM with LVN L revealed quarterly pain assessments were completed by the charge nurses. At this time LVN L looked through Resident #15's entire clinical record and stated she was unable to locate any pain assessments for the resident. Interview on 10/30/13 at 10:30 AM with LVN L revealed rountine pain medications were kept in the MA's medication cart and were administered by the MAs. PRN pain medications were kept in the nurse's medication cart and were administered by the nurses. Review of Resident #15's daily pain flow sheet, located with the nurse's MARs for October 2013 revealed everyday in October and on every shift Resident #15's pain level was zero. On 10/30/13 for the 6:00 AM to 2:00 PM shift, LVN L documented a zero for the resident's pain level. Review of the MA MAR for October 2013 revealed [MEDICATION NAME] 10/325 mg 1 tablet by mouth every four hours (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM) while awake. The MAR indicated [REDACTED]. Further review of the October 2013 MA MAR indicated [REDACTED]. The MAs wrote and circled their initials on the following dates at the corresponding times: 10/18/13 at 4:00 PM; 8:00 PM 10/19/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM; 4:00 PM; 8:00 PM 10/20/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM; 4:00 PM; 8:00 PM 10/21/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM and there was no documentation on the back of the MAR, or anywhere else to indicate why the initials were circled. Interview on 10/31/13 at 2:30 PM with MA P revealed she was Resident #15's MA on 10/18/13 and administered the resident's routine medications, including [MEDICATION NAME]. MA P stated she informed LVN C Resident #15 missed two doses of [MEDICATION NAME] on 10/18/13 at 4:00 PM and 8:00 PM because the resident ran out of medication. MA P stated she assumed LVN C would get [MEDICATION NAME] from the E-kit and re-order the medication from the pharmacy. Interview on 10/31/13 at 2:50 PM with LVN C revealed when he was notified about Resident #15's [MEDICATION NAME] a dose was taken from the E-kit for the resident or a dose was administered from Resident #15's PRN supply in the nurse's medication cart. LVN C finally stated he could not recall what happened. Review of the 24 Hour Nursing Report for the month of October 2013 revealed no documentation reflecting Resident #15 had run out of [MEDICATION NAME]. On 10/30/13 at 11:30 AM the surveyor and MA O reviewed Resident #15's MA October 2013 MAR. When asked why the dose of Resident #15's rountine [MEDICATION NAME] had not been initialed on the MAR, MA O stated she forgot. Observation on 10/30/13 at 11:30 AM of the MA's medication cart contents with MA O revealed a bubble pack of Resident #15's [MEDICATION NAME] with a prescription label that reflected the prescription was filled on 10/21/13 and was for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every six hours while awake (Note: Resident #15's October 2013 physician's orders [REDACTED]. When asked if she compared the label on the bubble pack to the MAR indicated [REDACTED]. When asked if she had informed the charge nurse of the discrepancy, MA O did not reply. Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed if the label on the bubble pack for routine medications did not match the MAR indicated [REDACTED]. Interview on 10/31/13 at 12:30 PM with the DON revealed attempts were being made to locate a Physician's Telephone Order, dated 09/06/13, changing the [MEDICATION NAME] from 10/325 mg 1 tablet by mouth every six hours while awake to [MEDICATION NAME] 10/325 mg 1 tablet by mouth every four hours while awake. Interview on 10/31/13 at 1:20 PM with the DON revealed an order was never written and faxed to the pharmacy regarding the changes made to Resident #15's [MEDICATION NAME] 09/06/13. She stated it was written on the 24 Hour Nursing Report. The DON stated it was because of this that Resident #15 ran out of [MEDICATION NAME] too soon. Interview on 10/31/13 at 10:30 AM with LVN L revealed since the changes to Resident #15's routine [MEDICATION NAME] to every four hours the resident had not been complaining of pain as often. Before the changes, Resident #15 asked for pain medication "right on the clock." LVN L stated the resident's pain was usually to the right upper quadrant including her shoulder and back. LVN L stated she did not know the cause of the resident's pain, but had been taking care of Resident #15 since May 2013 and the resident always had the same pain. Review of the Nurse's MAR for October 2013 revealed [MEDICATION NAME] 10/325 mg 1 tablet by mouth every six hours as needed for pain. The MAR indicated [REDACTED]. Observation on 10/30/13 at 10:30 AM with LVN L of the nurse's medication cart contents did not reveal a bubble pack of [MEDICATION NAME] for Resident #6. LVN L stated at that time Resident #15 did not have any PRN [MEDICATION NAME] because the facility had not re-ordered it. LVN L stated Resident #15 could not take a narcotic with her to [MEDICAL TREATMENT]. She stated the resident would return from [MEDICAL TREATMENT] at around 4:00 PM. LVN L offered no explaination regarding the unavailability of the PRN [MEDICATION NAME]. Observation on 10/30/13 at 3:40 PM revealed Resident #15 had returned from [MEDICAL TREATMENT] and was self-propelling her wheelchair down the corridor toward her room. Interview on 10/30/13 at 3:45 PM with Resident #15 revealed she had chronic pain to her right shoulder and back and her legs hurt. She said sometimes there was a sharp, shooting pain in her right leg. Resident #15 revealed the pain had become more manageable since her pain medication was administered more frequently, however on [MEDICAL TREATMENT] days she experienced more pain because the facility would not allow her to take the noon dose of pain medication to the [MEDICAL TREATMENT] center. Resident #15 stated sometimes they gave her Tylenol at [MEDICAL TREATMENT] and it helped some. When asked if she received Tylenol at [MEDICAL TREATMENT] on 10/30/13, Resident #15 stated she did. She stated it brought her pain level to a four of ten. Resident #15 stated she would rate her current pain level twelve of ten. When asked about her compliance with going to [MEDICAL TREATMENT], Resident #15 stated she refused to go when she was not feeling well. During the interview the MA entered the room to administer Resident #15 pain medication. Review of a nursing progress note, dated 10/30/13 and timed 3:45 PM, revealed when Resident #15 returned from [MEDICAL TREATMENT] on 10/30/13, she complained of right shoulder pain that rated ten of ten. The note reflected, "Routine pain medication ([MEDICATION NAME] 10/325 mg) given po by CMA (sic) per doctor's orders." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/31/13 timed at 8:51 PM reflected, "Late entry for 10/30/13; pt (Resident #15) arrived incenter (sic) with c/o back pain (chronic) rated a 10/10; medicated with [MEDICATION NAME] 500 mg po; pt was sleeping throughout tx (treatment); no further c/o." Telephone interview on 10/30/13 at 4:30 PM with the [MEDICAL TREATMENT] RN Nurse Manager revealed Resident #15 had chronic pain and complained during every [MEDICAL TREATMENT] treatment of [REDACTED]. When asked about the cause of the shoulder pain, the [MEDICAL TREATMENT] RN Nurse Manager stated it was arthritis. The [MEDICAL TREATMENT] RN Nurse Manager stated 500 mg of Tylenol was offered to the resident only when the resident specifically asked for it. She stated the resident received routine pain medication at the facility. The [MEDICAL TREATMENT] RN Nurse Manager revealed, "The facility needs to schedule her pain medication around [MEDICAL TREATMENT] treatments." She stated any time Tylenol was administered at the [MEDICAL TREATMENT] center it was documented in the [MEDICAL TREATMENT] records and was communicated to the facility on the Pre/Post [MEDICAL TREATMENT] Communication Report. Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed the [MEDICAL TREATMENT] center never communicated to the facility Resident #15 was experiencing pain while at [MEDICAL TREATMENT] or that Tylenol was ever administered at the [MEDICAL TREATMENT] center. Interview on 10/31/13 at 1:05 PM with Psychiatrist T revealed he was unaware of Resident #15's increased pain or that the pain medication regimen had been changed. He stated he learned about the changes on 10/31/13. Psychiatrist T stated he recommended a pain patch because the levels of medication in the resident's system would be maintained evenly without peaking and falling. A pain Evaluation dated 10/31/13 reflected Resident #15 experienced pain occasionally and the intensity was 4-5 on a scale of 0 to 10. The current plan as reflected on the evaluation was scheduled and PRN medication. A nurse's progress note dated 10/31/13 and timed 6:30 AM reflected the DON discussed Resident #15's pain level in her shoulder and the level of pain the resident was able to tolerate. The documentation reflected Resident #15 reported having bilateral shoulder pain that was on-going. Tolerable pain indicated by Resident #15 was 5/10. The documentation reflected Resident #15 was alert and oriented to person, place and time. It was reflected Resident #15 had full range of motion of bilateral upper extremities with increasing pain to her right shoulder with raising her arms over her head. The resident stated left shoulder pain was not expressed with any particular movement. The resident reported having a shooting pain down her legs. The note reflected, "Patient stating on exam shoulder pain is bad." The resident verbalized she could request pain medication as needed with pain not relieved by routine pain medication. A nurse's progress note dated 10/31/13 and timed 7:30 AM reflected the DON notified Resident #15's attending physician about pain management. The documentation reflected to continue [MEDICATION NAME] routine and PRN and not to exceed 4000 mg of Tylenol in a 24 hour period. The physician was informed of 5/10 pain scale. A nurse's progress note dated 10/31/13 and identified as a late entry reflected a clarification not to exceed 3000 mg of Tylenol in a 24 hour period. A nurse's progress note dated 10/31/13 and timed 1:51 PM reflected Resident #15 was at the nurse's station complaining of pain to her right shoulder and right knee with an intensity of 8 out of 10. PRN [MEDICATION NAME] 10/325 was administered at this time. The CMS form 802 Roster/Sample Matrix, provided to the surveyors on 10/28/13 by the DON reflected a total of 78 residents identified by the facility has having moderate/severe pain.

Based on observation, interview and record review, it was determined the facility failed to ensure necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #15) of 13 residents reviewed for pain management. LVN L failed to assess Resident #15 when the resident tearfully complained of pain on 10/30/13. LVN L failed to determine if the resident could be adminstered a PRN dose of [MEDICATION NAME] 10-325 mg prior to [MEDICAL TREATMENT]. LVN Unit Manager M also failed to assess Resident #15 when the resident tearfully complained of pain on 10/30/13. She did not intervene when the resident requested her routinely scheduled dose of [MEDICATION NAME] 10-325 mg be given to her to take with her to [MEDICAL TREATMENT]. LVN Unit Manager M also failed to determine if the resident could be administered a PRN dose of pain medication prior to [MEDICAL TREATMENT]. The facility failed to write a Physician's Telephone Order when Resident #15's physician changed the frequency of her [MEDICATION NAME] 10-325 mg from four times a day to six times a day. The facility failed to have Resident #15's PRN [MEDICATION NAME] 10-325 mg available for the resident in case of breakthrough pain. These failures resulted in Resident #15 going to [MEDICAL TREATMENT] in pain on 10/30/13, and the facility running out of Resident #15's [MEDICATION NAME] 10-325 mg. She missed 18 routinely scheduled doses of her pain medication from 10/18/13 through 10/21/13. These failures could affect the 78 residents, who had moderate/severe pain, by placing them at risk for [MEDICAL CONDITION], refusal to go to adhere to treatments/plans of care such as [MEDICAL TREATMENT], reduced ability to move and perform ADLs, a decline in mood, or social engagement, and an increase in maladaptive behaviors. Findings included: Resident #15 was a [AGE] year-old female originally admitted to the facility on [DATE], per the undated Face Sheet. Resident #15 was recently re-admitted on [DATE] from an acute hospital setting, per the quarterly MDS assessment, dated 10/06/13. The MDS assessment reflected her [DIAGNOSES REDACTED]., Depression (other than [MEDICAL CONDITION]), Hyperpotassemia, [MEDICAL CONDITION] in Diabetes and [MEDICAL CONDITION]. She was moderately cognitively impaired and needed the assistance of one person with transfers, dressing, toileting, and personl hygiene. Resident #15 used a wheelchair for mobility and was able to self propel the wheelchair. She was occasionally incontinent of bowel and bladder. Resident #15 was on a scheduled pain medication regimen over the past five days from the ARD 10/06/13, and she had not received any PRN pain medication or non-medication interventions for pain over the past five days. The interview to assess pain was conducted and revealed the occasional presence of pain. The intensity of the resident's pain was rated four on a scale of zero to ten, with ten being the worst pain. Review of all available care plans revealed, "Problem Onset: 07/14/2013 Resident complaining of pain, discomfort, nausea, related to [MEDICAL CONDITION], leg pain etc. - requiring medication for pain relief." The short term goal reflected, "Resident has pain relief of 3 or less, 1-2 hours after pain medication administered." The long term goal reflected, "Resident has increased comfort and pain is controlled by next 180 days." The Approaches were "Complete pain assessment routinely as instructed. For a score of 5 or greater notify MD, evaluate pain medications, and re-evaluate care plan. Assess and document for pain and response to pain relief measures. Ask resident to rate pain using 0-10 (0=no pain, 10=worst pain). Be alert to verbal and nonverbal cues regarding level of pain experienced by resident. Offer position change, back rubs, relaxation techniques as supplements to medication for pain relief, as appropriate for level of pain identified. Explain reason for pain medication and instruct resident to ask for pain medication before pain becomes too severe, prior to activities/procedures, as needed. Effectiveness of pain medication or interventions will be evaluated per episode and MD notified if action, medication or intervention is not effective. Licensed nurse to evaluate via pain assessment tool on admissions, readmissions, significant changes in condition, quarterly assessments and prn. Notify MD if score is greater than 5. Assess for condition/[DIAGNOSES REDACTED]. MD to review pain medication and adjust as needed. Resident's pain threshold is 6-8. Resident loves playing the piano." This care plan was signed and dated 08/15/13. Interview on 10/31/13 at 3:20 PM with MDS LVN U revealed pain assessments were completed quarterly by the charge nurses and the MDS nurses completed pain assessments as part of the MDS assessment. When asked if he was aware of the pain Resident #15 experienced and possible causes, MDS LVN U replied he did not. When asked about care plans regarding the management of Resident #15's pain, MDS LVN U replied the care plan dated 07/14/13 was the most current care plan. The Admission Nursing Evaluation dated 09/24/13 reflected Resident #15 experienced pain frequently and she verbalized a numeric value of her pain as a "5 to 8." A nursing progress note, dated 09/25/13 and timed 12:00 AM, reflected Resident #15 was at the nurse's station in her wheelchair complaining of generalized pain rated eight of ten, and routine pain medication was administered and at 1:00 AM, which was effective. There was no documentation reflecting the resident's physiciam was notified. (Note: Resident #15's Care Plan dated 07/14/13, reflected to notify the physician if the resident's pain score was greater than five.) Review Resident #15's consolidated October 2013 physician's orders [REDACTED]. A nursing progress note, dated 10/07/13 and timed 12:00 AM, reflected Resident #15 complained of pain to her bilateral lower extremities and "Routine meds given per orders...." Review of the [MEDICAL TREATMENT] center documentation dated 10/07/13 and authored by the [MEDICAL TREATMENT] RN Nurse Manager revealed, "Pt's (Resident #15's) CVC (Central Venous Catheter) has been in place for over a year. Pt had previous graft to left upper arm and pt developed arterial ulcers to left hand secondary to poor profusion to hand. Pt was referred to vascular surgeon and graft was ligated to save the left hand. Pt also had AVF (Arteriovenous Fistula) placed to right arm and did not mature as expected. Every month Physician reviews the importance of placing an access in her arm and pt is refusing to place an access and go through surgery again at this time." During an interview on 10/31/13 at 3:50 PM with LVN Unit Manager M she revealed Resident #15's shoulder pain was secondary to the arteriovenous shunt that had been removed from her left arm due to circulation complications approximately five to seven months ago. She stated currently Resident #15 had a port catheter inserted in her upper chest. When asked about pain secondary to arthritis, LVN Unit Manager M revealed she had not heard that. Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/09/13 timed at 3:58 PM, reflected, "Complained of usual pain on both legs and right shoulder secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/11/13 timed at 11:11 AM, reflected, "...c/o (complaint of) ongoing right shoulder pain, pt is on routine pain meds at Rehab...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/11/13 timed at 3:22 PM, reflected, "Complained of usual pain on legs and right shoulder secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/21/13 timed at 3:31 PM, reflected, "Complained of usual pain on both ankle (sic) and right shoulder pain secondary to arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/23/13 timed at 3:10 PM, reflected, "Complained of usual right shoulder pain and pain on both ankles d/t (due to) arthritis...." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/25/13 timed at 1:23 PM, reflected, "Complained of usual right shoulder pain secondary to arthritis and pain on ankles...." Observation on 10/30/13 at 10:15 AM at the nurse's station revealed Resident #15 was seated at the nurse's station in her wheelchair holding her arm and repeatedly telling anyone who would listen that she was "hurting." Approximately four nursing staff members were present at the nurse's station, including Resident #15's charge nurse, LVN L. LVN L responded she would look into it, but at that moment she had to go to the kitchen and retrieve Resident #15's lunch to take to [MEDICAL TREATMENT]. LVN L then proceeded to the kitchen. After LVN L left, Resident #15 continued to hold her arm. She was tearful, grimacing and kept repeating she was hurting. LVN Unit Manager M approached the nurse's station and asked MA O if she had administered Resident #15's routine pain medication. MA O replied she had and the resident was not scheduled for another dose until noon. Resident #15, who was listening to the exchange between LVN Unit Manager M and MA O asked if she could take her noon dose of pain medication to [MEDICAL TREATMENT] with her. MA O told Resident #15 she could not take the medication to [MEDICAL TREATMENT] because the doctor at the [MEDICAL TREATMENT] center and the doctor at the facility said she could not. Resident #15 tearfully stated, "I guess I will just have to suffer today." Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed when asked what pain management measures were in place for Resident #15 on her [MEDICAL TREATMENT] days, LVN Unit Manager M stated the [MEDICAL TREATMENT] center would not allow the facility to send medications with the resident. She revealed to her knowledge long acting pain medications or timing of medication administration had not been discussed. When asked why Resident #15's complaints of pain were not addressed on 10/30/13, LVN Unit Manager M stated she should have checked to see if the resident had something ordered for PRN pain or she should have called the physician. Interview on 10/31/13 at 1:30 PM with LVN L revealed quarterly pain assessments were completed by the charge nurses. At this time LVN L looked through Resident #15's entire clinical record and stated she was unable to locate any pain assessments for the resident. Interview on 10/30/13 at 10:30 AM with LVN L revealed rountine pain medications were kept in the MA's medication cart and were administered by the MAs. PRN pain medications were kept in the nurse's medication cart and were administered by the nurses. Review of Resident #15's daily pain flow sheet, located with the nurse's MARs for October 2013 revealed everyday in October and on every shift Resident #15's pain level was zero. On 10/30/13 for the 6:00 AM to 2:00 PM shift, LVN L documented a zero for the resident's pain level. Review of the MA MAR for October 2013 revealed [MEDICATION NAME] 10/325 mg 1 tablet by mouth every four hours (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM) while awake. The MAR indicated [REDACTED]. Further review of the October 2013 MA MAR indicated [REDACTED]. The MAs wrote and circled their initials on the following dates at the corresponding times: 10/18/13 at 4:00 PM; 8:00 PM 10/19/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM; 4:00 PM; 8:00 PM 10/20/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM; 4:00 PM; 8:00 PM 10/21/13 at 12:00 AM; 4:00 AM; 8:00 AM; 12:00 PM and there was no documentation on the back of the MAR, or anywhere else to indicate why the initials were circled. Interview on 10/31/13 at 2:30 PM with MA P revealed she was Resident #15's MA on 10/18/13 and administered the resident's routine medications, including [MEDICATION NAME]. MA P stated she informed LVN C Resident #15 missed two doses of [MEDICATION NAME] on 10/18/13 at 4:00 PM and 8:00 PM because the resident ran out of medication. MA P stated she assumed LVN C would get [MEDICATION NAME] from the E-kit and re-order the medication from the pharmacy. Interview on 10/31/13 at 2:50 PM with LVN C revealed when he was notified about Resident #15's [MEDICATION NAME] a dose was taken from the E-kit for the resident or a dose was administered from Resident #15's PRN supply in the nurse's medication cart. LVN C finally stated he could not recall what happened. Review of the 24 Hour Nursing Report for the month of October 2013 revealed no documentation reflecting Resident #15 had run out of [MEDICATION NAME]. On 10/30/13 at 11:30 AM the surveyor and MA O reviewed Resident #15's MA October 2013 MAR. When asked why the dose of Resident #15's rountine [MEDICATION NAME] had not been initialed on the MAR, MA O stated she forgot. Observation on 10/30/13 at 11:30 AM of the MA's medication cart contents with MA O revealed a bubble pack of Resident #15's [MEDICATION NAME] with a prescription label that reflected the prescription was filled on 10/21/13 and was for [MEDICATION NAME] 10/325 mg 1 tablet by mouth every six hours while awake (Note: Resident #15's October 2013 physician's orders [REDACTED]. When asked if she compared the label on the bubble pack to the MAR indicated [REDACTED]. When asked if she had informed the charge nurse of the discrepancy, MA O did not reply. Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed if the label on the bubble pack for routine medications did not match the MAR indicated [REDACTED]. Interview on 10/31/13 at 12:30 PM with the DON revealed attempts were being made to locate a Physician's Telephone Order, dated 09/06/13, changing the [MEDICATION NAME] from 10/325 mg 1 tablet by mouth every six hours while awake to [MEDICATION NAME] 10/325 mg 1 tablet by mouth every four hours while awake. Interview on 10/31/13 at 1:20 PM with the DON revealed an order was never written and faxed to the pharmacy regarding the changes made to Resident #15's [MEDICATION NAME] 09/06/13. She stated it was written on the 24 Hour Nursing Report. The DON stated it was because of this that Resident #15 ran out of [MEDICATION NAME] too soon. Interview on 10/31/13 at 10:30 AM with LVN L revealed since the changes to Resident #15's routine [MEDICATION NAME] to every four hours the resident had not been complaining of pain as often. Before the changes, Resident #15 asked for pain medication "right on the clock." LVN L stated the resident's pain was usually to the right upper quadrant including her shoulder and back. LVN L stated she did not know the cause of the resident's pain, but had been taking care of Resident #15 since May 2013 and the resident always had the same pain. Review of the Nurse's MAR for October 2013 revealed [MEDICATION NAME] 10/325 mg 1 tablet by mouth every six hours as needed for pain. The MAR indicated [REDACTED]. Observation on 10/30/13 at 10:30 AM with LVN L of the nurse's medication cart contents did not reveal a bubble pack of [MEDICATION NAME] for Resident #6. LVN L stated at that time Resident #15 did not have any PRN [MEDICATION NAME] because the facility had not re-ordered it. LVN L stated Resident #15 could not take a narcotic with her to [MEDICAL TREATMENT]. She stated the resident would return from [MEDICAL TREATMENT] at around 4:00 PM. LVN L offered no explaination regarding the unavailability of the PRN [MEDICATION NAME]. Observation on 10/30/13 at 3:40 PM revealed Resident #15 had returned from [MEDICAL TREATMENT] and was self-propelling her wheelchair down the corridor toward her room. Interview on 10/30/13 at 3:45 PM with Resident #15 revealed she had chronic pain to her right shoulder and back and her legs hurt. She said sometimes there was a sharp, shooting pain in her right leg. Resident #15 revealed the pain had become more manageable since her pain medication was administered more frequently, however on [MEDICAL TREATMENT] days she experienced more pain because the facility would not allow her to take the noon dose of pain medication to the [MEDICAL TREATMENT] center. Resident #15 stated sometimes they gave her Tylenol at [MEDICAL TREATMENT] and it helped some. When asked if she received Tylenol at [MEDICAL TREATMENT] on 10/30/13, Resident #15 stated she did. She stated it brought her pain level to a four of ten. Resident #15 stated she would rate her current pain level twelve of ten. When asked about her compliance with going to [MEDICAL TREATMENT], Resident #15 stated she refused to go when she was not feeling well. During the interview the MA entered the room to administer Resident #15 pain medication. Review of a nursing progress note, dated 10/30/13 and timed 3:45 PM, revealed when Resident #15 returned from [MEDICAL TREATMENT] on 10/30/13, she complained of right shoulder pain that rated ten of ten. The note reflected, "Routine pain medication ([MEDICATION NAME] 10/325 mg) given po by CMA (sic) per doctor's orders." Resident #15's [MEDICAL TREATMENT] Treatment Record, dated 10/31/13 timed at 8:51 PM reflected, "Late entry for 10/30/13; pt (Resident #15) arrived incenter (sic) with c/o back pain (chronic) rated a 10/10; medicated with [MEDICATION NAME] 500 mg po; pt was sleeping throughout tx (treatment); no further c/o." Telephone interview on 10/30/13 at 4:30 PM with the [MEDICAL TREATMENT] RN Nurse Manager revealed Resident #15 had chronic pain and complained during every [MEDICAL TREATMENT] treatment of [REDACTED]. When asked about the cause of the shoulder pain, the [MEDICAL TREATMENT] RN Nurse Manager stated it was arthritis. The [MEDICAL TREATMENT] RN Nurse Manager stated 500 mg of Tylenol was offered to the resident only when the resident specifically asked for it. She stated the resident received routine pain medication at the facility. The [MEDICAL TREATMENT] RN Nurse Manager revealed, "The facility needs to schedule her pain medication around [MEDICAL TREATMENT] treatments." She stated any time Tylenol was administered at the [MEDICAL TREATMENT] center it was documented in the [MEDICAL TREATMENT] records and was communicated to the facility on the Pre/Post [MEDICAL TREATMENT] Communication Report. Interview on 10/30/13 at 6:30 PM with LVN Unit Manager M revealed the [MEDICAL TREATMENT] center never communicated to the facility Resident #15 was experiencing pain while at [MEDICAL TREATMENT] or that Tylenol was ever administered at the [MEDICAL TREATMENT] center. Interview on 10/31/13 at 1:05 PM with Psychiatrist T revealed he was unaware of Resident #15's increased pain or that the pain medication regimen had been changed. He stated he learned about the changes on 10/31/13. Psychiatrist T stated he recommended a pain patch because the levels of medication in the resident's system would be maintained evenly without peaking and falling. A pain Evaluation dated 10/31/13 reflected Resident #15 experienced pain occasionally and the intensity was 4-5 on a scale of 0 to 10. The current plan as reflected on the evaluation was scheduled and PRN medication. A nurse's progress note dated 10/31/13 and timed 6:30 AM reflected the DON discussed Resident #15's pain level in her shoulder and the level of pain the resident was able to tolerate. The documentation reflected Resident #15 reported having bilateral shoulder pain that was on-going. Tolerable pain indicated by Resident #15 was 5/10. The documentation reflected Resident #15 was alert and oriented to person, place and time. It was reflected Resident #15 had full range of motion of bilateral upper extremities with increasing pain to her right shoulder with raising her arms over her head. The resident stated left shoulder pain was not expressed with any particular movement. The resident reported having a shooting pain down her legs. The note reflected, "Patient stating on exam shoulder pain is bad." The resident verbalized she could request pain medication as needed with pain not relieved by routine pain medication. A nurse's progress note dated 10/31/13 and timed 7:30 AM reflected the DON notified Resident #15's attending physician about pain management. The documentation reflected to continue [MEDICATION NAME] routine and PRN and not to exceed 4000 mg of Tylenol in a 24 hour period. The physician was informed of 5/10 pain scale. A nurse's progress note dated 10/31/13 and identified as a late entry reflected a clarification not to exceed 3000 mg of Tylenol in a 24 hour period. A nurse's progress note dated 10/31/13 and timed 1:51 PM reflected Resident #15 was at the nurse's station complaining of pain to her right shoulder and right knee with an intensity of 8 out of 10. PRN [MEDICATION NAME] 10/325 was administered at this time. The CMS form 802 Roster/Sample Matrix, provided to the surveyors on 10/28/13 by the DON reflected a total of 78 residents identified by the facility has having moderate/severe pain.

Based on observation, interview, and record review, the facility failed to ensure two (Residents #1 and #2) of eight residents reviewed for falls received adequate supervision and assistance devices to prevent falls. 1. Resident #1 had a history of [REDACTED]. 2. When Resident #1 was identified as a high risk for falls on admission, a chair/bed alarm was the only intervention ever implemented to assist with the prevention of falls until surveyor intervention. 3. Resident #1 had physical therapy from June 2013 through the middle of August 2013, but there was never a change in the treatment plan and no interventions were recommended for implementation to assist with the prevention of falls. 4. Resident #2 was identified as a high fall risk on admission (05/16/13), but no fall precautions were implemented, and she fell on [DATE] sustaining a fracture of the left hip. . 5. Fall precautions for Resident #2 were not implemented after she fell on [DATE] with the exception of a bed/chair alarm. On 08/25/13, the alarm was disconnected and the resident fell again. 6. "On-going" in-services for staff on fall prevention were not being conducted as indicated for the facility action post-investigation. The failures to implement interventions to assist with the prevention of falls when residents have been identified as fall risks could affect the 45 residents who had fallen and the 23 who sustained fractures, including Residents #1 and #2 placed them at risk for further falls with further injury such as fractures, hematoma's and pulmonary emboli, which could result in death. Findings included: 1. During observation rounds conducted on 09/04/13 at 10:30 AM, Resident #1 was observed climbing over the side rail on her bed. Her left leg and left arm were hanging over the right side rail. When asked where she was going, she said she did not know. The resident's bed alarm was sounding as the string attached to the resident's clothing and the alarm box had become disconnected. The resident did not have a low bed, and there were no floor mats on the floor next to Resident #'s bed. Further observation of Resident #1's room revealed there were no special chairs such as a Broda wheelchair (a wheelchair with a high back, which can be tilted) or any other assistive devices (e.g., floor mats, a low bed, hip padding or pommel cushion), which could have been in use to prevent the resident from falling and/or falling with an injury. Resident #1's hospital H & P dated 05/31/13 reflected the resident fallen from a chair in her home without injury. The H & P reflected the resident had a low sodium level, which was treated. The physician indicated on the H & P the resident was severely demented. Resident #1's Initial Assessment for Physical Therapy dated 06/03/13 reflected the evaluation was referred for therapy due to muscle weakness from her recent hospitalization and she would benefit from skilled intervention. The assessment reflected Resident #1 would be provided: Therapeutic exercise, Neuromuscular re-education, Gait training and therapeutic activities five times a week for 30 days with a long term goal date of 07/02/13. Precautions identified by the Physical Therapist included: falls, dementia and confusion. Resident #1's PT Therapist Progress Notes dated 06/09/13 reflected the resident was responding well with improvement in strength and mobility tasks. The MDS assessment dated [DATE] reflected Resident #1, a [AGE] year-old female, was admitted to the facility on [DATE]. The MDS assessment reflected she was severely impaired cognitively and required the extensive assistance of two plus staff for transfers, ambulation, dressing and hygiene/bathing. Resident #1 was frequently incontinent of bladder and bowel. [DIAGNOSES REDACTED]. Resident #1's Comprehensive Plan of Care dated 06/02/13 reflected the resident was at risk for falls as evidenced by her cognitive impairment and unsteady gait. Interventions included: 1) Encourage resident to ask for assistance of staff 2) Ensure call light is in reach, answer promptly. 3) Therapy to eval and treat per orders. 4) Anticipate needs, provide prompt assistance. 5) Assure lighting is adequate and areas are free of clutter. 6) Encourage socialization and activity attendance - as tolerated. 7) Falling star program 8) Personal alarm. Review of the facility's Incident/Accident Reports since June 2013 revealed since her admission on 06/02/13, Resident #1 had ten falls on 06/15/13, 07/06/13, 07/13/13, 07/25/13, 08/01/13, 08/02/13, 08/12/13, 08/15/13, 08/20/13 and 09/04/13. An Incident/Accident Report dated 06/15/13 reflected Resident #1 fell in her room on 06/15/13 at 6:30 AM. Resident #1 was not injured. Resident #1's PT Therapist Progress Notes dated 06/16/13 reflected the resident was making progress prior to her fall on 06/15/13 and when she attempted to stand on Monday, 06/17/13, she could not bear weight on her right leg. There was no change in treatment plan. Resident #1's PT Therapist Progress Notes dated 06/23/13 reflected she had demonstrated a sever decline in her functional ability since her fall (on 06/15/13) and subsequent right hip pain, although she was showing some improvement with weight bearing. There was no change in her treatment plan. Resident #1's PT Therapist Progress Notes & Discharge Summary dated 06/24/13 reflected Discharge plans indicated she was discharged due to a decline in her medical status. A Physical Therapy Initial assessment dated [DATE] was conducted with recommendations to provide Therapeutic exercise, Neuromuscular re-education, Gait training and Therapeutic activities five times a week for 12 weeks. There were no recommendations for interventions to be implemented to assist with preventing falls. A PT - Therapist Progress Note dated 07/04/13 reflected Resident #1's cognitive impairment made for slow progress. Precautions included: Diabetic, Dementia, Right Hip Pain, Confused and Fall Precautions. The MDS assessment dated [DATE] reflected a change in that Resident #1 required the extensive assistance of staff to eat when she was assessed as only required cueing previously. An Incident/Accident Report dated 07/06/13 reflected Resident #1 fell in her bathroom and was not injured. A PT - Therapist Progress Note dated 07/11/13 reflected Resident #1 had a lot of difficulty with balance, which required additional assistance with standing, transfers and gait. Improvement was noted in Resident #1's ability to bear and shift weight. Despite the resident's fall, there was no change in her treatment plan. An Incident/Accident Report dated 07/13/13 at 2:10 PM reflected Resident #1 fell in her room and sustained a laceration on her head, which required treatment at the ER. Her laceration required staples. A PT - Therapist Progress Note dated 07/18/13 reflected Resident #1 was showing improvement with balance. Despite the resident's fall, there was no change in her treatment plan. A PT - Therapist Progress Note dated 07/25/13 at 8:00 AM reflected Resident #1 showed some improvement in standing balance and gait. There was no change in her treatment plan. An Incident/Accident Report dated 07/25/13 reflected Resident #1 fell in her room on 07/25/13 at 2:20 PM and did not sustain an injury. . Resident #1's Comprehensive Plan of Care dated 07/25/13 and was reviewed on 08/01/13 and 08/02/13 reflected the resident was at risk for falls as evidenced by her cognitive impairment and unsteady gait. Interventions included: 2) Ensure call light is in reach, answer promptly. (updated 08/02/13) 3) Therapy to eval and treat per orders. 5) Assure lighting is adequate and areas are free of clutter. (updated 08/02/13) 7) Falling star program. (updated 08/01/13 and 08/02/13) Previous interventions indicated on 06/02/13 were not identified on this care plan, the resident's personal alarm was not included and there were no new interventions identified on this care plan. Resident #1's Fall Risk Evaluation dated 07/19/13 reflected a score of 20. This indicated she was at high risk for falling. The legend on the form reflected, "A resident who scores a 10 or higher is at risk. Consider Environmental risk factors in resident's interventions." A PT - Therapist Progress Note dated 07/28/13 reflected Resident #1's standing balance had improved with intervention. There was no change in her treatment plan. A PT - Therapist Progress Note dated 08/01/13 reflected Resident #1 continued to need skilled therapy due to muscle weakness, balance issues and cognition, which influenced her ability to perform safe gait and transfers. There was no change in her treatment plan. An Incident/Accident Report dated 08/01/13 reflected Resident #1 fell at the Nurses Station on 08/01/13 at 6:20 PM. She sustained a hematoma (area of injury not identified). X-rays were negative for a fracture. An Incident/Accident Report dated 08/02/13 reflected Resident #1 fell in her room on 08/02/13 at 2:15 PM. She received a skin tear on her left arm. A PT - Therapist Progress Note dated 08/08/13 reflected Resident #1 required more assistance than last week. She demonstrated difficulty processing verbal, tactile or visual instructions. The note further reflected due to Resident #1's poor cognition, 24 hour assistance was required for her safety. There was no update to the resident's treatment approach. An Incident/Accident Report dated 08/08/13 reflected Resident #1 fell in her room on 08/08/13 at 4:50 PM, which resulted in a skin tear on the resident's right humerus (upper arm). A PT - Therapist Progress Note dated 08/12/13 reflected Resident #1's dementia had been worse and impacted her motor planning and function. Resident #1 required constant supervision for well being. The Discharge Plan reflected Resident #1 was to remain on "nursing for medical." An Incident/Accident Report dated 08/15/13 reflected Resident #1 fell in her room on 08/15/13 at 7:00 PM, requiring an x-ray with negative results. The Report did not indicate the location of the body needing x-ray. Resident #1's Nursing to Therapy note dated 08/15/13 reflected a request for Physical Therapy and Occupational Therapy. The note reflected on 08/21/13 therapy was not warranted at that time, because no treatment was appropriate due to Resident #1's significantly impaired cognition and the resident required the assistance of two staff. At 12:30 PM on 09/05/13, the DON and the Rehab Vice President of Operations provided Resident #1's Nursing To Therapy form. The areas checked on the form under Physical Therapy were Coordination, Falls, Safety awareness and Balance. Under Occupational Therapy were Feeding self, and safety awareness. The comments section reflected Resident #1 slid out of the wheelchair and was dated 08/15/13. Therapists Recommendations reflected no treatment was appropriate due to Resident #1's significantly impaired cognition and the resident requiring the assistance of two staff, which was signed by the Director of Rehab. An Incident/Accident Report dated 08/20/13 reflected Resident #1 attempted to transfer herself when the CNA was in the bathroom. She fell on the floor, hit her back and left ribs on the trash can on 08/20/13 at 10:00 AM, while CNA A was in her bathroom. An x-ray dated 08/20/13 indicated Resident #1 fractured her left 5th, 6th, and 7th ribs. The facility's Provider Investigation Report for Resident #1's fall on 08/20/13 reflected the resident was admitted to the facility for rehabilitation after falling at home. She was assessed as being a high risk for falls with chair and bed alarms placed. Resident #1 had completed her physical therapy sessions due to being "unable to participate due to cognitive status. Patient has fallen at facility 6/15, 7/6, 7/13, 7/25, 8/1, 8/2, 8/15, &8/20, with appropriate interventions in place for prevention of injuries...." At the time, the resident still had the bed/chair alarm, which she had since admission. No new interventions were identified. "Physical therapy to evaluate again for possible interventions. This fall from 08/20/13 X-ray findings reveal rib fractures of 5th, 6th, 7th, left side. No pain noted form fractures. Continue with pain management & fall precautions, including within eye view while out of bed." Provider action taken post-investigation included: "Continue interventions for patient, will not leave in room unattended while out of bed. ...Revise plan of care...." Resident #1's Comprehensive Plan of Care dated 09/03/13 reflected the resident was at risk for falls as evidenced by her cognitive impairment, impulsiveness and unsteady gait. The interventions to use were not identified, but the falling star program was crossed out and no new interventions were added. Neither the resident's personal alarm was included, nor was the action to not leave Resident #1 unattended in her room while out of bed or to keep Resident #2 within eye view when she was out of bed on the resident's care plan. An Incident/Accident Report dated 09/04/13 reflected Resident #1 fell in her room on 09/04/13 at 6:45 PM. The fall had just occurred and the Incident/Accident Report was still being written and indicated Resident #1 had not been injured. On 09/04/13 at 1:30 PM, PT H, PT I, and PT J were interviewed regarding the physical therapy evaluation ordered after the resident's fall on 08/20/13. All three PTs stated the evaluation had not been done or ordered. When queried about evaluating residents with a history of falls for interventions to prevent falls, all three PTs were surprised to hear of such a program unless it was ordered by the resident's physician as part of the resident's rehabilitation program. When the three therapist were asked if anyone thought to suggest a low bed, floor mats, a special chair such as a Broda chair or Geri-Chair, PT H said, "We have limited funds." At 11:45 AM on 09/05/13, the information from the meeting with the three Physical Therapists on 09/04/13 at 1:30 PM was shared with the Rehab Vice President of Operations. On 09/04/13 at 2:00 PM, the surveyor discussed Resident #1 with the DON and the Investigation Summary on the Provider Investigation Report for Resident #1's fall on 08/20/13. The surveyor showed the DON where it was referenced in the Provider Investigation Report. The DON stated she would look into it. On 09/04/13 at 3:30 PM, the DON told the surveyor the physical therapy evaluation was not done. The DON stated there would be a physical therapy evaluation done "today" (09/04/13). It was at that time the surveyor discussed with the DON regarding the preventive measures implemented for Resident #1, which was the bed/chair alarm, which was initiated on 06/02/13, the resident's date of admission. The surveyor told the DON staff did try to keep Resident #1 at the Nursing Station when she was up in the wheelchair and keep her within "eye view." The surveyor and the DON discussed their observation of Resident #1 trying to climb over the side rails that morning. The surveyor queried why other preventive measures had not been tried such as a low bed, floor mats, or a special wheelchair. The surveyor also asked about a device to add to a wheelchair to remind the resident not to get out of the chair or to slow her escape from the chair so staff could get to the resident before she fell . The DON responded she would get a low bed, floor mat, and try a high back wheelchair. Observation of Resident #1's room with LVN A on 09/05/13 at 11:05 AM revealed Resident #1 was asleep in a low bed. A mat was on the floor on the left side of the bed between the bed and the wall. There was approximately 5 to 6 feet between the right side of the bed and Resident #1's roommate's bed. There was no mat on the floor on the right side of the bed, even though the right side of the bed was the side the resident had used to try and climb over the side rail. This was also the side of the room where the bathroom and hallway were located. The surveyor discussed with LVN A the idea of pushing Resident #1's bed against the wall with the floor mat placed on the right side of the bed. 2. Resident #2's MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The MDS assessment reflected Resident #2 had vision impairment and used corrective lenses and was severely impaired cognitively. Resident #2 required the extensive assistance of two staff to assist with bed mobility, transfers, ambulation, dressing and toileting. Resident #2 required the assistance of one staff for personal hygiene and bathing. Resident #2 used a wheelchair for mobility and required one person's assistance. she was frequently incontinent of bowel and bladder. The Care Assessment Summary in the MDS assessment reflected falls were triggered and there was a need for a plan for falls. [DIAGNOSES REDACTED]. Review of Resident #2's Fall Risk Evaluation dated 05/16/13 revealed her score was a 22. The evaluation reflected: "A resident who scores a 10 or higher is at risk. Consider Environmental risk factors in resident's interventions." Physical Therapy notes were reviewed. It was identified that PT was declined due to the resident's cognition per the PT note dated 06/18/13. Resident # 2's care plan dated 05/29/13 reflected the problem was "Resident has been identified as at high risk for falls." Goals included the resident will have less falls daily for 90 days and she will keep her optimum level of functional independence safely for the next 180 days. Approaches included: --Therapy to evaluate for decreased motor strength. -- Review labs and medications for potentiating factors. -- Assess for a change in condition, and alert staff to Resident's increased needs. -- Fall risk assessment on admission, readmission, quarterly, and with significant (change),assess. -- Therapy to eval for need for assistive devices. -- Monitor and eliminate potential hazards. -- Monitor for side effects of medications in relation to falls. -- Assist with ambulation and transfers. -- Monitor degree of disorientation to determine safety needs. The following approaches were crossed out on the care plan. The care plan was also marked as being revised on 08/08/13 by the DON. -- Evaluate for use of siderails, low bed; or personal alarm. -- Assess for an implement if appropriate: Need for a toileting schedule, or a BSC. -- Monitor for pattern of risk factors, or tendency to fall. -- Analyze previous falls to determine causative factors, and implement changes. -- Instruct and encourage call light use and request for assistance. During initial tour rounds on 09/04/13 at 9:58 AM, Resident #2 was observed sitting in a wheelchair in the Physical Therapy Department hitting a ball with the therapist. Observation of Resident #2's room while she was in therapy on 09/04/13 at 10:10 AM revealed a regular bed with side rails (not a low bed), no floor mats in the room or any other padded devices. The bed was in the high position. Resident #2's care plans dated 08/14/13 included the following problems/needs: 1) Cognitive Impairment related to sort term memory deficit, long term memory deficit, impaired ability to understand others, and impaired ability to make daily decisions; 2) Actual/Potential impaired communication related to hearing loss, language barrier, slurred speech, expressive aphasia or dementia, 3) Resident has [DIAGNOSES REDACTED]. 4) Resident has impaired communication evidenced by reduced ability to be understood by others, reduced ability to understand others, Impaired daily decision making abilities. Review of Resident #2's Fall Risk Evaluation revealed on 08/08/13, her score was 8, and on 8/24/13 her score was 22. "A resident who scores a 10 or higher is at risk. Consider Environmental risk factors in resident's interventions." Review of Resident #2's Incident/Accident Report dated 08/08/13 revealed Resident #2 was found in a sitting position on the floor. Resident #2 complained of pain in her left hip. The report indicated Tylenol 2 tablets were administered and an X-ray of both of Resident #2's hips was ordered. The Incident/Accident Action Plan for Resident #2's fall on 08/08/13 was: 1) Review incident report, 2) Educate resident about safety concerns, 3) Educate resident about ways to fall, and 4) Resident will need to use call light to ask for assistance. Appropriate safety precautions and devices - yes Positioning devices - yes Toileting program - NA Rehab/restorative program - yes Behavioral program - NA Review of the Provider Investigation Report for Resident #2's fall on 08/07/13 revealed the resident was a high fall risk from the facility's admission assessment with a care plan in place for interventions. Resident #2 was found sitting on her buttocks in her room at 5:30 AM. She complained of pain to her left leg and was given Tylenol. There were no witnesses. An x-ray of the left leg reflected there was an acute fracture impacted subcapital fracture of the left femur (left hip fracture). The Provider Action Taken Post-Investigation was for a revision of her care plan upon her return to the facility from the hospital and an on-going in-service with staff regarding fall prevention. The DON signed the Provider Investigation Report on 08/12/13. Review of Resident #2's x-ray results dated 08/08/13 revealed the resident had an acute impacted subcapital fracture of the left femur. Review of an undated witness statement signed by RN G revealed RN G wrote that LVN B was walking down the hall. At that time, LVN B saw Resident #2 sitting on the floor complaining of left leg pain. The physician was notified. Resident #2 was transferred to a wheelchair and then from the wheelchair to the bed. Tylenol 650 mg was given for the pain. Resident #2 was also assessed to have an open wound on her left elbow. Resident #2's left elbow wound was cleaned with normal saline and a Steri-Strip dressing was applied to the wound. Review of Resident #2's progress note dated 08/08/13 revealed the Resident complained of left hip pain. Using a pain scale where 0 was no pain and 10 was the worst pain,Resident #2's pain was documented as "8/10." Resident #2 was transferred to the hospital for evaluation. Interview on 09/05/13 at 12:10 PM with the DON revealed Resident #2 was not on a high fall risk when she was admitted to the facility on [DATE]. The DON stated when Resident #2 fell on [DATE], the DON added a chair and bed alarm. The DON stated staff were supposed to check to see if Resident #2's alarm was functioning. When asked if the resident had floor mats, the DON replied, "There was no need for that." Interview on 09/05/13 at 11:17 AM with LVN B revealed LVN B was the charge nurse for Resident #2 when the fall occurred on 08/07/13. LVN B stated CNA C informed him Resident #2 fell . LVN B stated when he got to Resident #2's room, he found her on the floor next to her roommate's bed. LVN B stated Resident #2 had a bump on her forehead and skin tear on her elbow. LVN B stated he asked Resident #2 if she was in pain and she said, "No." LVN B stated he cleaned Resident #2's skin tear on the elbow with normal saline and applied Steri-Strips. LVN B stated he went back in 30 minutes and asked Resident #2 if she was in pain and she said, "Yes." LVN B said he then gave Resident #2 Tylenol 325 mg, 2 tablets and applied an ice pack to her forehead. LVN B stated he notified the physician and the physician ordered x-rays. LVN B stated Resident #2 fell 2 months ago and sustained a fracture. When LVN B was questioned regarding fall precautions/preventative measures in place, LVN B stated Resident #2 did not have a bed alarm. She did not have a low bed and the regular bed was in a high position with bilateral side rails up. LVN B stated Resident #2 did not have a floor mat. LVN B stated after Resident #2 fell , he and CNA C put the resident back to bed, then applied a bed alarm to Resident #2. LVN B stated if Resident #2 would have had a bed alarm, it would have alerted staff when she was attempting to get out of bed. LVN B said if Resident #2 would have had a floor mat, it might have prevented injuries. LVN B stated he had told management Resident #2 needed a low bed after the fall on 08/08/13. During an interview on 09/05/13 at 12:15 PM with CNA C, CNA C stated when she went into Resident #2's room, the resident was on the floor in a sitting position. CNA C stated she noticed Resident #2's left leg was bent and her right leg was underneath her. CNA C stated the resident did not have a bed alarm or floor mats. Review of nurses notes dated 08/25/13 revealed Resident #2 fell at 11:30 PM. There was no evidence of fall precaution/prevention measures implemented prior to the fall despite the resident being a high risk for falls. The notes indicated a skull X-ray and X-ray of both the resident's hips had been done. The x-ray results were pending. Resident #2 sustained "a bump to her forehead and skin tear x 3 to her left hand." Tylenol 650 mg (milligram) was given and neuro checks were done. During an interview on 09/05/13 at 12:15 PM with CNA C, CNA C stated Resident #2 had fallen again (on 08/25/13). CNA C stated she went and got the charge nurse. CNA C stated the charge nurse assessed Resident #2 and found a skin tear on her left arm and a bump on her left forehead. CNA C stated after she and LVN B put Resident #2 to bed, she attached a bed alarm to the resident. Resident #2 was complaining of pain and LVN B got an ice pack and applied it to Resident #2's forehead. CNA C stated Resident #2 climbed out of bed and fell . When asked if any fall prevention/precaution was in use, CNA C stated the resident did not have a bed alarm on, a floor mat on the floor, and the resident's bed should be pushed close to the wall. Interview on 09/05/13 at 12:32 PM with CNA D revealed she worked 10:00 PM to 6:00 AM shift on 09/24/13. CNA D stated from 10:00 PM to 10:49 PM, Resident #2 was not assigned to her. CNA D stated she was assigned to Resident #2 after she had the fallen at 10:50 PM. CNA D stated she asked LVN B for her assignment, and he told her to wait. CNA D stated she was working on B hall before she was assigned to Resident #2 at 10:50 PM. CNA D stated when she went to Resident #2's room, there was an alarm on the bed. The part of the alarm that was supposed to sound when Resident #2 got out of bed was hanging from the night stand. CNA D stated when Resident #2 got out of the bed, the reason the alarm did not sound was because it was disconnected. CNA D stated when the resident had an alarm, the staff was supposed to check to see if the alarm was functioning. On 09/05/13 at 11:30 AM, Resident #2's bed had been pushed away from the wall. There was no floor mat in the room and the regular bed was in high position Review of the facility's in-service records for the months of June through September 5, 2013 revealed the most current or last in-service on Falls/Fall Protocol, Assessment, Fall Care Plans, and s/p (status [REDACTED]. This was the day prior to the fall of Resident #2's fall. There were no in-services for staff following Resident #2's fall on 08/07/13. 3. The facility's current policies and procedures entitled Falls - Clinical Protocol with a revised date of April 2007, was provided by the DON on 09/05/13. The policies/procedures reflected the following: "Assessment and Recognition ...a. Staff will ask the resident and the caregiver or family about a history of falling... 2. In addition, the nurse shall assess and document/report the following: ...g. Frequency and number of falls since last physician visit h. Precipitating factors, details on how fall occurred... ...5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. a. Falls should be categorized as a) from a sitting or lying to an upright position, b) those that occur while upright and attempting to ambulate, and c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor...." "Cause Identification For an individual who has fallen, staff will attempt to define possible causes of the resident's fall within 24 hours of the fall. ...2. If the cause of the fall is unclear ...or if the individual continues to fall despite attempted interventions... a. After more than one fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling...." "Treatment/Management "1. ...the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious subsequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, use of hip protectors, addressing medical issues such as hypotension and dizziness, and tapering, discontinuing, or changing problematic medications...." "Monitoring and Follow-up 1. The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematoma's or other intracranial bleeding could occur up to several weeks after a fall...." The facility's current policy/procedure entitled Falls and Fall Risk, Managing, with a revised date of December 2007, reflected the following: "Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls... ...4. If falling recurs despite initial interventions, staff will implement additional or difference interventions... 5. ...staff will try various interventions... until falling is reduced or stopped... 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. ...3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions...." The facility's current policy/procedure entitled Fall Risk Assessment, with a revision date of December 2007, reflected the following: "Policy Statement The nursing staff, in conjunction with the Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls." The facility's current policy/procedure entitled Assessing Falls and Their Causes with a revision date of December 2007, reflected the following: "Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying the causes of falls... ...5. Residents must be assessed in a timely manner for potential ca