Every finding on record at Blackfeet Care Center

Based on interviews and record review, the facility failed to ensure residents were free from neglect of care for 2 (#s 1 and 3) of 6 sampled residents. This deficient practice resulted in resident #1 being left in a urine-saturated bed overnight, and a staff member making an inappropriate gesture to resident #2 and not answering his call light. The facility identified the neglect of care and carried out corrections for the deficient practices; therefore, F600 was cited as Past Non-Compliance. Findings include:Review of the facility-reported incident, dated 7/20/26, showed resident #1 had been left in a saturated bed and brief during the nightshift. The report indicated the facility camera footage confirmed staff members N and O took multiple breaks for 15-30 minutes and remained away from their assigned resident care areas for extended periods. The report showed the camera footage confirmed staff members N and O failed to complete resident rounding responsibilities. The report indicated the facility determined staff members N and O did not complete assigned resident care and routine rounding responsibilities in accordance with facility protocol. The facility reported staff members N and O had been removed from resident care pending investigation and staff members N and O were being terminated. Review of the facility's Abuse/Incident Investigation Packet for resident #s 1 and 2, dated 7/20/26, showed:- Staff member N was interviewed and stated he and staff member O went outside to smoke four to five times during the overnight shift. Staff member N stated he had one mixed alcohol drink prior to the overnight shift. Staff member N stated resident #1 was changed at bedtime, checked again at 2:00 a.m. and, was still good. (not requiring a brief change)- Staff member O was interviewed and stated she left the facility to smoke four or five times and went to [convenience store name] for snacks. Staff member O stated she was aware resident #1 was found soaked with urine on the morning of 7/20/26. - Staff member G was interviewed and stated she had noticed resident #1 was not up for breakfast on the morning of 7/20/26 and went to check on her. Staff member G stated resident #1 sounded like she was going to cry and asked to be changed (brief change). Staff member G stated resident #1 reported to her she had asked the nightshift staff to change her and they told her no and moved her wheelchair by the door. Staff member G stated resident #3 reported to her he had rang his call light for assistance and staff member O came to the room, flipped him off, and shut his door. - Resident #2 reported to staff member I she had smelled alcohol on staff member N. Resident #2 reported she asked staff member N if he was drunk and he replied, Yeah, [staff member O] brought us something to drink for our break. Resident #2 reported staff member N was elaborating his words and red eyes. -Staff member I reported she observed staff member N appeared to be intoxicated when she arrived on shift the morning of 7/20/26. Staff member I reported she noted staff member N smelled of alcohol, bloodshot eyes, had different mannerisms, euphoric behavior, and odd verbiage. During an interview on 8/20/26 at 7:27 a.m., staff member I stated resident #1 reported to her resident #1's wheelchair was pulled away from her bed preventing her from getting up and was left in bed soaked with urine all night by staff member N and O. Staff member I stated resident #3 reported to her staff member O had flipped him off. Staff member I stated resident #2 reported to her staff member O was drunk. Staff member I stated she reported to her nurse on duty. During an interview on 8/20/26 at 9:50 a.m., resident #2 stated staff member N smelled of alcohol and told her staff member O had brought alcohol to work for them to drink on their breaks. During an interview on 8/20/26 at 10:20 a.m., resident #3 stated staff member O had flipped him off and closed his door on night shift when he used his call light. Resident #3 stated he reported it to the morning CNA the next day. Resident #3 thought this incident occurred a couple of weeks ago but did not know the exact day. During an interview on 8/20/26 at 11:55 a.m., resident #1 stated she had pressed her call light for help to the toilet. Resident #1 stated staff member O came to the room and moved her wheelchair out of her reach and closed her door without assisting her to the toilet. Resident #1 stated she soaked her bed, all bedding, and her clothing until the morning shift came in to help her. Resident #1 reported staff member O refusing to assist her to staff member G.During an interview on 8/20/26 at 10:54 a.m., staff member B stated the facility substantiated the neglect of care for staff members N and O based on the resident and staff interviews and camera footage. Staff member B stated the facility was in the process of terminations when both staff member N and O resigned. Staff member B stated the facility had involved the Interdisciplinary team and QAPI team in developing a plan for education, audits and follow-up after the incident. Review of the facility's Quality Assurance Performance Improvement monthly meeting minutes, dated 7/30/26, showed the QAPI team had discussed a plan for nursing supervisors to conduct night shift rounding and audits, terminations were being processed for staff members N and O, and abuse/neglect education was being completed.Review of the facility's In Service Education, dated 7/29/26, showed the facility did complete re-education on the topics of employee professionalism conduct and break expectations, drug and alcohol policy, reporting policy (neglect and abuse), transportation, and grievance processes. Review of the facility's policy, Abuse Prevention Policy and Procedures, dated 10/2025, showed:- . Neglect- failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .Due to the facility's actions with identifying the neglect of care, protecting the resident, reporting timely, and carrying out corrective actions, the facility utilized their abuse prevention process to correct the deficient practices; therefore, the corrections were completed before the survey.

Based on interview and record review, the facility failed to identify risks, provide training for van drivers, and ensure the safety of two unrestrained residents who fell to the floor when the van made abrupt stops for 2 (#s 1 and 2) of 9 sampled residents. This deficient practice increased the risk of negative outcomes and injury for residents required to use the facility van.On 7/9/26 at 9:55 a.m., an Immediate Jeopardy (IJ) was announced to the Administrator and Director of Nursing related to F689-Free of Accidents and Hazards and Supervision affecting two residents. The Severity and Scope identified for the Immediate Jeopardy were identified to be at the level of J, and upon verification for the removal of the immediacy, lowered to a D. An acceptable plan for the Removal of Immediacy was approved by the State Survey Agency on 7/9/26 at 1:30 p.m. Surveyors were on-site and verified the removal of immediacy on 7/9/26. 1. During an interview on 7/8/26 at 9:46 a.m., staff member B stated that during an out-of-town trip, the facility van was stopped, and the driver was looking to turn out onto a main street. An oncoming car with its blinker on indicated it was turning in front of them. The facility van started to pull forward, but the other car kept driving straight, so the brakes were applied, which caused the van to stop abruptly. This caused resident #1 to fall out of her wheelchair. Staff member B stated resident #1 was on her knees on the ground and was pinned up between the backseat and her wheelchair. Staff member B stated the resident's wheelchair had been secured, but her lap belt was not. Staff member B stated, to their knowledge, the van driver was responsible for securing the resident's belts. During an interview on 7/8/26 at 10:00 a.m., staff member C stated they had never heard of a specific rule on who was responsible for securing residents' wheelchairs and seatbelts during a transport, and it was just common sense that the person driving should be the one to secure the seatbelts. During an observation and interview on 7/8/26 at 10:17 a.m., resident #1 showed bruising on her knees from her fall during the transport. Resident #1 stated she was worried about other residents getting hurt in the same manner. Resident #1 stated she had been in a prior car accident, which led to her disability. Review of resident #1's Medical Diagnoses showed a history of diffuse traumatic brain injury. Resident #1 was mostly wheelchair bound. During an interview on 7/8/26 at 1:41 p.m., staff member F stated not everyone was aware lap belts were in the van. Staff member F stated they had taken it upon themselves to scan the code for training in the back of the van and watch the tutorial, but that had not been a facility-wide practice. Staff member F stated staff member H had commented to her that she was not aware there were lap belts. Staff member F stated staff member H had been driving for quite a while at that point, and stated, I'm not sure where the ball was dropped there (for lack of training). During an interview on 7/8/26 at 2:51 p.m., staff member H stated their training for the van included using the lift to raise and lower the back ramp and the paperwork needed for resident appointments. Staff member H stated they had zero knowledge that the resident was supposed to be strapped in by using the lap and shoulder belts, as the previous driver had not explained that. Staff member H stated they did not initially know how to use the wheelchair locking restraints. Staff member H stated later that they had completed a brief online training, but there was no hands-on experience, and the use of the restraints was mostly self-taught through trial and error. Staff member H stated they were still working through how to place the belts over or under the wheelchair arms and how far forward or backwards the chair should be for the shoulder strap. Staff member H stated that each of the facility vans was different in how the restraints and belts were set up. During an interview on 7/8/26 at 3:27 p.m., staff member A stated new employee orientation should include safety and accident prevention and involve how to hook up the van's seat belts. Staff member A stated the maintenance supervisor signed off on that portion of the checklist; each van had its own checklist, and everyone who drove the van should sign off on the checklist. Staff member A stated that after the turnover of the maintenance supervisor's position, she did not think the employee checklists had been formally signed off, and it was more verbal confirmation. Staff member A stated they had looked through multiple employee files and had not been able to locate signed-off competencies for the van driving. Review of the Facility Transportation Vehicle Policy, not dated, showed, Residents will be transported using appropriate safety measures based on their individual needs and equipment available. Staff will ensure residents are appropriately positioned and prepared for transport prior to departure . The facility will provide orientation and education to staff assigned transportation responsibilities as appropriate to their job duties. A review of the facility schedules, dated April 2026 – July 2026, listed one staff member having the title of Driver. Review of the facility transport log for the last two months showed multiple staff members outside of the designated driver taking residents on local and out-of-town transports. 2. During an interview on 7/8/26 at 2:51 p.m., staff member H said there had been at least one other resident fall on the van during a transport. Staff member H said about a week after a fall on 6/12/26, another resident (later identified as resident #1) fell out of her van seat onto the floor. Staff member H said she did not know the name of the resident who fell or the exact date. During an interview on 7/8/26 at 4:14 p.m., staff member J said she was a Helping Aide and was not a Certified Nurse Assistant. Staff member J said she was alone driving the van with two residents on board. They were returning home from a larger nearby city (250 miles round trip). Staff member J said they arrived back in town and another car pulled out in front of the van. Staff member J said resident #2 fell off the seat and slid to the floor of the van when it stopped. Staff member J said resident #2 must have removed her seatbelt sometime on the drive home. Staff member J said she was unable to monitor and supervise the residents in the van to ensure their safety, as she was driving. Staff member J said resident #2 said she was not hurt. Staff member J said she was not trained and could not take resident #2's vital signs or provide any care assistance. She brought the resident into the building and told the nurse that resident #2 had fallen while in the van. Staff member J said she had not received any training on the seat belt or shoulder harness system when using the van to ensure proper anchorage (of wheelchairs). Review of resident #2's nursing note, dated 6/18/25 at 5:00 p.m., showed the driver said the van stopped fast and resident #2 moved around on the seat. The staff member wrote, When I spoke with the resident, she states she didn't fall and didn't hit anything. During an observation and interview on 7/9/26 at 8:27 a.m., resident #2 was sitting up independently on the side of her bed, eating breakfast. When asked about the fall she had in the van, resident #2 said, Oh, it was nothing. Resident #2 said she released her seat belt so she could lie down on the seat in the van. Resident #2 said the van driver stopped fast, and she (the resident) slipped off the seat onto the floor. Resident #2 denied any injuries. During an interview on 7/9/26 at 11:46 a.m., staff member K said the van driver told her resident #2 fell in the van and hit her knee. Staff member K said resident #2 told her the van had to stop abruptly and she slid off the seat, landing on the van floor. Resident #2 told staff member K she hit her knee but was not hurt.

Based on observation, interview, and record review, the facility failed to develop and implement an effective training program for all staff who transported residents in the facility vans to ensure the residents were safe when transported and seat belts and safety harnesses were secured properly. This failure contributed to the Immediate Jeopardy situation(s) identified in F869 - Accidents and Hazards, and if not corrected, this failure may affect any resident not transferred properly by untrained staff. Findings include: During an interview on 7/8/26 at 9:45 a.m., staff member B said resident #1 fell out of her wheelchair because staff member H tethered resident #1's wheelchair to the van but did not place a waist/lap belt on resident #1 for resident safety. Staff member B said she could be asked to drive the van if needed and she did not have training on the van or aspects related to safety with the use of the van. Staff member B said any staff member could put the safety harnesses on the residents in the van, but the ultimate responsibility for that, and the safety of the resident, should fall to the van driver.During an interview on 7/8/26 at 10:00 a.m., staff member C said the facility took a copy of her driver's license, but she did not have any training for the use of the facility van(s) seat belts or placement of the harness straps when a transfer occurred. Staff member C said the facility recently got a couple of new vans, and there was no training for the seat belts or harness safety.During an observation and interview on 7/8/26 at 10:16 a.m., resident #1 showed the healed abrasion scar on her right knee from falling in the van on 6/12/26. Resident #1 said the vans need more seat belts. Resident #1 said she was not secured with the seat belts tight enough, and she slid out of her chair under the seatbelt.During an interview on 7/8/26 at 10:30 a.m., resident #4 said the van driver drives too fast, and she was upset by her driving. Resident #4 said that when she went on the van on 6/12/26, the van was traveling at a fast speed, which caused her to bounce up and down in her wheelchair, causing her to get bruises. Resident #4 said she was not secure enough in her seat belt. During an interview on 7/8/26 at 1:40 p.m., staff member F said not all the staff were aware there were lap seat belts on the van. Staff member F said the van had QR codes that could be scanned on the phone, and then a video would show how the seat and harness belts were to be used. Staff member F said strapping and securing the resident was the most important task to be done before the van was taken on an outing. Staff member F said she thought the training she completed that morning was not very effective because staff were standing outside, to the side of the van, so you could not see to observe the demonstration. Staff member F said if staff watched the video or practiced placing the seatbelts themselves, the training would be more effective. Staff member F said not everyone was aware of the lap belts, including staff member H, who was the designated van driver. Staff member F stated all residents who used wheelchairs should wear a lap belt and a shoulder harness when riding in the van for safety.During an interview and record review on 7/8/26 at 2:51 p.m., staff member H said on the first day of her employment, the training to be a facility driver consisted of making sure the resident's medical information was taken to physician appointments and how to lower and raise the wheelchair ramp in the old van. Staff member H said she did not receive any other training until after she was suspended; then she watched a video. Review of the employee's training record showed staff member H completed a video-type training on 6/22/26 related to driving safety. The education was not van-specific, nor did it contain seat belt and harness application. Staff member H said she still had not received any hands-on training or competency evaluations for seat belt application. Staff member H said there was only one (red) seat belt for the waist restraint in each van, but multiple residents in wheelchairs go in the vans at one time. Staff member H said she worked one day with the prior driver. During that day of training, staff member H said the prior van driver didn't place the required four tether straps on the wheelchair (2 in front and 2 in back); rather, he placed one in back and one in front, and no seatbelt was placed on the resident.During an interview and record review on 7/8/26 at 3:27 p.m., staff member A said the facility was short staffed for van drivers. Staff member A said the facility had to make other staff drive the van to get residents to their medical appointments. Review of the facility transportation log from 6/9/26 to 6/23/26 showed 13 different staff initials showing those staff drove residents in the van. Staff member A said the maintenance department tracked education for the van's lifts and seat belts. Staff member A said she looked for return demonstrations and education for the 13 staff listed and no education could be found for van safety, restraint use, or and seat belt education.During an interview on 7/8/26 at 4:14 p.m., staff member J said she was not a certified nurse assistant. Staff member J said she drove the van on occasion but not routinely. Staff member J said the van safety education consisted of how to lower and raise the lift gate on the big van. Staff member J said she had some education on locking wheelchairs when in the van(s) but had no training in securing seat belts or shoulder harnesses.During an interview on 7/9/26 at 9:28 a.m., staff member E said he was informed that resident #1 fell out of her wheelchair on the van. Staff member E said the staff told him the van was traveling too fast and resident #1 was not properly secured with a lap seat belt.

Based on interview and record review, the facility failed to ensure a system was in place for grievances to be filed orally, and the facility staff failed to address or act upon a grievance submitted for 1 (#4) of 9 sampled residents. This deficient practice resulted in the resident's ongoing feelings of fear during van transports. Findings include: During an interview on 7/8/26 at 10:30 a.m., resident #4 said she was afraid to ride in the van when staff member H was the driver. Resident #4 said staff member H drives too fast on the highway, doing 70 or 80 miles an hour. Resident #4 said that during the trip she went on in June, she bounced around in her chair, and she got bruises all over her arms. Resident #4 said the bruises were there, and staff member C took pictures of the bruises. Resident #4 said she made a complaint to staff member F right after this trip. Resident #4 said she told staff member F about her fear and the safety concerns with staff member H's driving too fast. Resident #4 said she had post-traumatic stress disorder (PTSD) because of a car wreck in her past and said: They don't care about me; nothing had been done.During an interview on 7/8/26 at 1:40 p.m., staff member F said resident #4 told her the other day that staff member H drives too fast. Staff member F told resident #4, who had minimal movement in her arms, that she would need to write up a statement and type it. Once that was done, she would give the grievance to management before anything could be done. Staff member F said resident #4 told her she does not feel safe with the driver. Staff member F said resident #4's disability was caused by a traffic accident, and she developed PTSD.Grievances were requested for the last six months on 7/7/26. No grievances were provided by the end of the survey on 7/9/26 for the event.

Based on interview and record review, the facility failed to submit an incident for a Facility Reported Incident timely to the State Survey Agency for 1 (#1) of 9 sampled residents. Findings include: Review of a Facility Reported Incident submitted to the State Survey Agency on 6/15/26, involving resident #1, showed that on 6/12/26, resident #1 was riding in the facility van and the driver of the van slammed on the brakes, which caused the van to come to an abrupt stop. This caused resident #1 to fall out of her wheelchair and onto the van floor. The initial report of this incident was not submitted to the State Survey Agency within the required reporting timeline. During an interview on 7/8/26 at 3:27 p.m., staff member A stated, I was not told about the incident (with resident #1 falling in the van) until late on Monday 6/15/26. Staff member A said that when she became aware of the situation, three days after the event, the staff member (driving the van) was suspended pending investigation of the event. Staff member A said she reported the incident to the State Survey Agency on 6/15/26.

Based on interview and record review, the facility failed to ensure that a resident did not experience re-traumatization during transports, for 1 (#4) of 9 sampled residents by use of the individualized care plan and interventions. This deficient practice resulted in a resident being fearful of transportation in the facility van. Findings include:During an interview on 7/8/26 at 10:30 a.m., resident #4 stated, [Staff member H's] driving gives me PTSD. Resident #4 stated that when the van moved too fast on the highway, she was bumped around in her wheelchair and got bruised all over her arms. Resident #4 stated she had told staff before that she was uncomfortable in the facility van when staff drove too fast but said, nobody cares. During an interview on 7/8/26 at 1:41 p.m., staff member F stated resident #4's disability had happened because of a car accident, and they had stressed with staff that resident #4 experienced PTSD from that. Staff member F stated resident #4 had mentioned multiple times that she felt unsafe when the van was traveling at high speeds.During an interview on 7/8/26 at 2:35 p.m., staff member D stated resident #4 was seeing a counselor related to her traumatic car wreck. Staff member D stated there was a long period of time when resident #4 would not talk about her car accident with anyone.Review of resident #4's Medical Diagnoses, dated 6/5/24, showed an admitting diagnosis of quadriplegia C1-C4.Review of resident #4's care plan, with a recent revision date of 7/6/26, failed to include concerns related to the resident's PTSD and her car accident or fear of being transported.

Based on interview and record review, the facility nursing staff failed to ensure a resident's anticoagulant medication was clarified on admission for 1 (#36) of 19 sampled and supplemental residents, and the resident received a medication that was discontinued while in the hospital before being admitted . Therefore, the medication was unnecessary and should not have been provided to the resident. The resident experienced a significant change and decline in status due to the medication being given, which resulted in a low hemoglobin of 6.9 g/dl and required a blood transfusion. On 3/25/26 at 4:22 p.m., the facility Administrator and Office Manager were notified of an immediate jeopardy situation for F757. This involved one resident, #36. The severity and scope were identified at the level of J, and when the immediacy was removed, lowered to a G. The facility provided an acceptable plan to remove the immediacy, which was verified at 1:11 p.m. on 3/26/26. The IJ pertained to resident#36, receiving an anticoagulant medication that was discontinued before the admission, and the resident had a decline and was hospitalized for ongoing acute care. Findings include:A review of a complaint received by the State Survey Agency, on 3/4/26, showed that resident #1 was provided an unnecessary medication, as it was discontinued while in the hospital, and the resident had a negative outcome and was hospitalized as a result. A review of resident #1's medical record showed no admission orders for the date the resident was admitted on [DATE]. During an interview on 3/26/26 at 12:03 p.m., staff member N stated he expected the nurses to call and clarify physician orders for any re-admissions or new admissions. Staff member N stated it was the expectation for nurses to follow the physician's orders. Staff member N stated he was usually available via text for any medication concerns. During an interview on 3/25/26 at 1:58 p.m., NF2 stated resident #36 was residing at the facility since 2024 and had not had any concerns until this incident. NF2 stated the resident was in the hospital from [DATE] through 2/18/26. On 2/18/26 the family of resident #36 picked her up from the hospital and transported the resident to the facility. NF2 stated the resident's anticoagulant was supposed to be discontinued on admission. NF2 stated the resident had received a blood transfusion at the hospital. NF2 stated that following the administration of the anticoagulant, the resident's nephrostomy bag had blood in it. NF2 stated resident #36 was aware there was blood in her urine drainage bag and was aware she was not supposed to have the anticoagulant medication. On 2/22/26, NF2 stated the family decided the resident would not go back to the facility, due to concerns for her health, and the staff had not been following the physician's orders. NF2 stated when the resident was first admitted , the care was good. Review of resident #36's After Visit Summary, dated 2/18/26, page one, showed instructions to pause the medication, apixaban (blood thinner). Review of the After Visit Summary, page four, showed the medication was paused until the physician started it again. Review of resident #36's Emergency Department provider note, dated 2/22/26, page two, showed the resident presented to the ER with hypoxia, hypotension, and hematuria. The resident was pale and sleepy, but easily arousable. Page 10 showed the resident had hypotension, profound weakness, respiratory distress, and received two units of blood.Review of resident #36's Hospital History and Physical, dated 2/22/26, page 11, showed the resident presented to the hospital with profound weakness, anemia, hypoxia, and acute kidney injury. The resident had been admitted on [DATE] for hematuria and received three units of blood. During the 2/8/26 admission, the resident had gone into renal failure.Review of resident #36's Emergency Department to Hospital Admission, dated 2/22/26, showed the resident had a low hemoglobin level of 6.9 (critical), had received an anticoagulant, and had gross hematuria (blood in the urine). The resident was experiencing hypotension and symptoms of weakness and respiratory distress. The resident received two units of packed red blood cells. The resident's medical record showed the anticoagulant was supposed to have been paused on the previous admission date of 2/18/26. Page 20 of the document showed that apixaban, the anticoagulant, was discontinued. Review of resident #36's Root Cause Analysis, dated 2/25/26, for the resident's hospitalization, showed the resident was discharged back to the facility on 2/18/26. The apixaban physician's order showed it was to be paused, without a duration noted, and there was no restart date or physician clarification completed for the medication. The medication was restarted when the resident was re-admitted to the facility on [DATE]. The documentation showed:- 2a. Why do you think this event occurred? The response was it was due to ambiguity in the discharge communication and medication reconciliation workflow.- Section 2b. showed What could have been done to prevent the event? The response was clear discharge orders from the hospital. The document also showed that medication was paused. The order was not complete, and there was no documented duration for the medication. The corrections showed to prevent an event from occurring again, the facility need to get clarification of orders before administering the medication.- Section 3c. showed it was now going to be recommended that two nurses need to review discharge orders and medication reconciliations.Review of resident #36's Medication Administration Record, dated 2/1/26-2/28/26, showed the resident received seven doses of apixaban after re-admission to the facility on 2/18/26.Review of resident #36's care plan, with an admission date of 2/18/26, did not show any identified problems, goals, and interventions for anticoagulant medications, safety related to the use of anticoagulants, or monitoring side effects. Review of resident #36's nursing progress notes, dated 2/18/26 through 2/22/26, showed:- The resident was readmitted to the facility after hospitalization on 2/18/26. The resident was on enhanced barrier precautions related to right-sided nephrostomy and colostomy. There was yellow urine observed from the right-sided nephrostomy tube draining into the drainage bag.- On 2/20/26, there was blood observed from the right-sided nephrostomy tube draining into the resident's drainage bag. There was no documentation that the provider was contacted regarding the blood in the urine- On 2/21/26, blood was observed from the right-sided nephrostomy tube draining into the drainage bag. There was no documentation that the provider was contacted regarding the blood in the urine.- The resident's oxygen saturation was 85%. Her oxygen was raised to 3L and her oxygen level only came up to 87%. The resident had been weak and had not been eating. She was unable to stay in a sitting position and would fall back or sideways on the bed. The resident was transported to the local hospital via ambulance at 9:50 a.m. The family was notified that the resident had been sent to the ER.- On 2/26/26, the following late entry was noted in resident #36's nurse's progress note, Communicated with physician regarding the resident's recent hospitalization for blood transfusion. When the resident returned to the facility, the discharge summary was overlooked and the order to hold apixaban was not implemented. As a result, the resident continued receiving apixaban and was readmitted to the hospital and was administered a blood transfusion. [sic]Review of resident #36's nursing progress notes showed the resident had hematuria in her nephrostomy bag two days before transfer to the hospital on 2/22/26, without physician notifications made, and action taken to address it by the facility. The facility did document in the medical record the blood in the resident's nephrostomy bag but failed to take measures to identify the cause or intervene for the resident's health and safety.

Based on interview and record review, the facility failed to ensure the accuracy of staffing data submitted to CMS (the Centers for Medicare and Medicaid Services) through the PBJ (Payroll-Based Journal) system for October 1, 2025, through December 31, 2025. Findings include:Review of the PBJ Staffing Data Report for quarter 1 (10/1/25-12/31/25) showed the facility failed to include all nursing staff hours when compared to facility staffing schedules and payroll records for six days in October 2025, six days in November 2025, and three days in December 2025.During an interview on 3/25/26 at 11:10 a.m., staff member B stated she was responsible for submitting PBJ data and submitted the PBJ information on a quarterly basis. Staff member B stated once she inputs all the data, she will run off a copy of the information and check for any errors. Staff member B was uncertain why nursing hours were not correctly reflected on the PBJ information. Staff member B stated she did not compare the information submitted with the nursing department schedule.

Based on interview and record review, the facility failed to complete a thorough investigation, monitoring, and documentation for allegations of staff-to-resident abuse for 1 (#28), resident-to-resident physical abuse for 2 (#s 40 and 41), and resident-to-resident sexual abuse for 2 (#s 6 and 40) of 17 sampled residents. This deficient practice had the potential to place all residents at risk of abuse. Findings include:1. Review of a Facility Reported Incident reported to the State Survey Agency, dated 10/9/25, showed resident #28 had reported to staff member P that staff member O had blown marijuana vape smoke in his face.Review of the investigation completed by the facility showed staff member O admitted to vaping marijuana in the resident's room and stated, That was me I did not think my pen was that strong. [sic] Staff member O resigned from the facility.Review of resident #28's nursing progress notes, dated 10/9/25-10/20/25, showed no nursing documentation of the incident or monitoring of resident #28 post-incident.During interviews on 3/24/26 at 9:11 a.m., 3/24/26 at 2:21 p.m., and 3/26/26 at 9:18 a.m., resident #28 refused to talk about the incident involving staff member O.During an interview on 3/26/26 at 10:29 a.m., staff member D stated he spoke to resident #28 about the incident, and resident #28 told him that staff member O had blown marijuana smoke in his face. Staff member D stated resident #28 did not want to report the incident right away because staff member O was his friend. Staff member D stated he did not interview staff member O or any other staff who were on shift on that date. Staff member D stated he did not complete the ongoing follow-up with resident #28 to monitor for any changes, but he had completed a psychosocial impact assessment tool. Staff member D stated that no abuse education was provided after the incident.Review of a facility form titled Psychosocial Impact Assessment Tool, dated 10/22/25, showed: . Has ALERT Charting been done by Nursing and Social Services? NO . was marked. Review of staff member O's personnel file showed she had acknowledged and signed the facility's abuse and prevention policy on 1/22/25 and 10/7/25.Staff member P was not available for an interview during the survey.2. Review of a Facility Reported Incident reported to the State Survey Agency, dated 10/18/25, showed resident #40 was sitting in a wheelchair by the nurse's station when resident #40 stated to staff member Q that resident #41 had hit him. Staff member Q assessed resident #40 and saw a red mark on his head. Staff member Q notified resident #40's family, and they requested an evaluation at the emergency room. Staff member Q sent resident #40 to the emergency room for evaluation.Review of nursing progress notes, dated 10/18/25-10/25/25, showed no documentation of the incident involving resident #40, and no post-incident monitoring.Review of nursing progress notes, dated 10/18/25-10/25/25, showed no documentation of the incident involving resident # 41, and no post-incident monitoring.During an interview on 3/26/26 at 10:29 a.m., staff member D stated staff member Q called and notified him on 10/25/25 of the incident involving residents #40 and #41. Staff member D stated he had come to the facility to initiate the investigation. Staff member D stated he had watched video footage of the incident and concluded resident #s 40 and 41 had gotten their wheelchair wheels locked together, and both residents were trying to get the wheels unlocked when resident #41 struck resident #40 with an open hand on the left side of his head. Staff member D stated he had interviewed both residents about the incident, but it was only documented in the incident report. Staff member D stated resident #41 was placed on one-on-one care for a while and educated not to hit other residents, but there was no monitoring of resident #40 after. Staff member D stated he did not interview other staff on shift or other residents. Staff member D stated there was no education provided to staff on abuse after the incident.3. Review of a Facility Reported Incident reported to the State Survey Agency, dated 11/11/25, showed resident #6 was found in the room of resident #40 by staff. When staff entered the room, resident #40 was seen removing his hands from inside resident #6's pants and shirt. Staff removed resident #6 from resident #40's room, and resident #6 told staff, It hurts down there. Resident #6 was sent to the emergency room for an evaluation.Review of resident #6's medical diagnosis list showed, Unspecified symptoms and signs involving cognitive functions and awareness, anxiety, depression, and cerebral infarct.Review of resident #40's Brief Interview for Mental Status (BIMS) score was 14, showing he was cognitively intact.During an interview on 3/23/26 at 3:41 p.m., NF1 stated she was notified of an incident where resident #6 was sent to the emergency room because another resident had sexually assaulted her. NF1 stated resident #6 had a developmental delay and had the mentality of an 8-year-old. NF1 stated she felt resident #6 was safer after the other resident left the facility.Review of resident #6's nursing progress notes dated 11/11/25-11/26/25 showed no documentation of the incident involving residents #6 and #40, and no post-incident monitoring.Review of resident #40's nursing progress notes dated 11/11/25-11/26/25 showed no documentation of the incident involving residents #40 and 6, and no post-incident monitoring.During an interview on 3/26/26 at 10:29 a.m., staff member D stated he was called in about the incident. Staff member D stated he had watched the video, and what resident #6 had told staff matched what was on the video. Staff member D stated Law Enforcement was notified and came out to the facility, and interviewed resident #40. Law enforcement was unable to determine if a sexual assault had occurred or not. Staff member D stated he had educated resident #40 on not touching female residents and let him know that he could not be alone with other female residents. Staff member D stated he checked on resident #6 post-incident, but had not completed any documentation. Staff member D stated he did not interview staff on shift or other residents for the investigation. Staff member D stated there was no education provided to staff on abuse after the incident or for protecting the resident. During an interview on 3/26/26 at 11:48 a.m., staff member A stated the expectation for all investigations was for all staff on shift to be interviewed, residents to be interviewed, have social services and nursing staff monitor and assess the affected residents for a period of time to ensure there were no adverse effects from the incidents, and all information, assessments, and monitoring needed to be documented in the medical record.Review of a facility document titled Abuse Prevention Policy and Procedures, with a revision date of 10/2025, showed: . G. Investigation.3. Retrieve written statements. that are signed and dated along with titles.4. The actual investigation will include:a. Date, time, location;. e. Interviews with all people involved;f. Interview residents and/or family member(s). Obtain signed statements regarding the incident, as well as their reaction, who was involved, and what they hope the outcome will be. [sic]

Based on observation, interview and record review, the facility failed to revise an individualized, comprehensive care plan to address end-of-life/comfort care needs for 1 (#8); failed to revise a resident's care plan addressing a suprapubic catheter, and interventions for a suprapubic catheter for 1 (#5); and failed to address psychotropic medication use for 1 (#6) of 17 sampled residents. This deficient practice increased the risk for resident #8 not receiving proper catheter care/services, for resident #5 not receiving necessary care/services for the suprapubic catheter, and for resident #6 to have unmet care needs related to end-of-life care and services. Findings include: 1. During an observation on 3/24/26 at 8:50 a.m., resident #5 was sitting in a wheelchair. Catheter tubing was observed, with a catheter bag, and was draining clear, yellow urine. Review of resident #5's care plan with a revision date of 2/26/26, failed to address resident #5's suprapubic catheter. There were no focus, goals, or interventions related to catheter care, scheduled catheter changes, or monitoring for signs or symptoms of infection related to catheter use. 2. Review of resident #6's care plan, with a revision date of 3/10/26, failed to include the use of mirtazapine for depression. There were no focus, goals, or interventions related to non-pharmacological interventions, signs or symptoms of increased depression, or monitoring for any adverse side effects from the medication taken by the resident. During an interview on 3/25/26 at 10:15 a.m., staff member H stated all the staff had access to resident care plans. Staff member H stated she does not look at the care plans for any changes. Staff member H stated if she needed to know about what side effects to look for with medication or a change with a resident's feeding or transfer status, she would just ask another staff member. During an interview on 3/25/26 at 10:20 a.m., staff member J stated that all staff have access to the care plans and should review them for any resident changes. Staff member J stated the nursing staff had the ability to update care plans, but most of the time, the interdisciplinary team made the updates and revisions to the care plans. Staff member J stated if there was a change in medication or status for a resident, she would notify a member of the interdisciplinary team so they could revise the care plan. Review of a facility policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, showed: . 11. Assessments of the residents are ongoing, and care plans are revised as the information about the residents and the residents' conditions change. [sic] 3. During an interview on 3/26/26 at 12:05 p.m., staff member C stated there are no Hospice providers available in their area, and the facility provided end-of-life/comfort care for resident #8. Staff member C stated that comfort care should have been included on resident #8's care plan. Staff member C stated she did not know why end-of-life/comfort care was not included on resident #8's care plan. Staff member C stated, It may have just been missed. A review of resident #8's care plan showed that end-of-life/comfort care was not addressed in the resident's care plan, and there were no end-of-life/comfort care-specific interventions documented on the care plan. Resident #8's care plan did not include a focus that showed a shift in treatment or the approach to provide comfort care. Resident #8's care plan did not list interventions to address fears about dying, terminal restlessness, positioning related to comfort, changes in cognitive status, increased sleeping, reorientation needs, or education of the resident and family related to the dying process. A review of resident #8's Medical Visit, dated 1/9/26 at 2:56 p.m., showed: A. Reason for visit End of Life Care . I. Plan I spoke with [Residents name]'s [family member] . she agreed to comfort care measures. [sic] A review of resident #8's Care Area Assessment Worksheet, dated 1/9/26, showed: . 2. Cognitive Loss/Dementia . Mood and Behavior . She has been increasingly agitated according a charge nurse. . Medical Problems that can impact cognition . End of life [indicated with a check mark] . Other Considerations . Staff had said that [Resident Name] is sleeping more and needs more reorientation. . 9. Behavioral Symptoms . Analysis of Findings . Nature of the Problem/Condition: . expressed that she wants to rest more often, but at night she stays awake fearing she will die. [sic]

Based on interview and record review, the facility failed to ensure residents were seen by a physician within required timeframes (at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter) for 6 (#s 1, 3, 5, 6, 15, and 28) of 17 sampled residents. This deficient practice had the potential for an increased risk of unidentified changes in condition, delayed treatment, worsening of medical conditions, avoidable complications, or decline in resident health and safety. Findings include:Review of resident #1's medical visit note showed the last documented physician visit was on 6/11/25. The resident had not been seen by a physician for 227 days, exceeding the required frequency.Review of resident #3's medical visit note showed the last documented physician visit was on 6/3/25. The resident had not been seen by a physician for 235 days, exceeding the required frequency.Review of resident #5's medical visit note showed the last documented physician visit was undated. There was no documentation to confirm compliance that resident #5 had been seen by a physician within the last 60 days, exceeding the required frequency. Review of resident #6's medical visit note showed the last documented physician visit was on 6/13/25. The resident had not been seen by a physician for 225 days, exceeding the required frequency.Review of resident #15's medical visit notes showed resident #15 had been seen on 7/24/25 and again on 2/26/26. There were 155 days between physician visits, exceeding the required frequency.Review of resident #28's medical visit note showed the last documented physician visit was on 6/2/25. The resident had not been seen by a physician for 236 days, exceeding the required frequency. During an interview on 3/23/26 at 3:41 p.m., NF1 stated resident #6 had not seen a physician in the facility for many months and was concerned because of resident #6's ongoing medical conditions.During an interview on 3/25/26 at 12:04 p.m., staff member N stated he did not have a set schedule for seeing residents; his visits depended on his hospital schedule. Staff member N stated he was unsure if any other providers assessed residents between his visits.During an interview on 3/25/26 at 11:33 a.m., staff member A stated physicians were expected to evaluate residents when due and document the visit in the medical record.

Based on interview and record review, the facility failed to ensure the resident's representative was provided information necessary to make an informed decision, including the risks, benefits, and alternatives, before the initiation of psychotropic medications; and the facility failed to obtain informed consent for the use of the medications, for 1 (#6) of 17 sampled residents. Findings include:During an interview on 3/23/26 at 3:41 p.m., NF1 stated resident #6 was prescribed medications for depression and anxiety. NF1 stated she was notified when medications were started or discontinued but the facility did not explain the risks, benefits, or alternatives of the medications prior to initiation. NF1 stated she had been asked to sign forms on occasion, but the medications were not explained to her.A review of resident #6's pharmacy medication regimen review, dated 3/4/26, showed: [Resident Name] receives an antidepressant, mirtazapine, but no informed consent found in chart. Also need consent for clonazepam (recently re-started) [sic]Review of resident #6's electronic medical record showed no documentation of informed consent forms for mirtazapine (an antidepressant) or clonazepam (an antianxiety) before initiation of the medications.Review of resident #6's physician orders showed mirtazapine was started on 2/24/26, and clonazepam was started on on 3/16/26.During an interview on 3/24/26 at 3:10 p.m., staff member A stated informed consent forms were expected to be completed before the initiation of all psychotropic medications.During an interview on 3/26/26 at 12:25 p.m., staff member J stated informed consent forms should be completed when psychotropic medications were initiated or changed.Review of a facility policy titled Psychotropic Medication Use, with a revision date of July 2022, showed: . 4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications.a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Based on observation, interview and record review, the facility failed to afford residents the right to receive visitors at a time of their choosing for 2 (#s 15 and 23) of 17 sampled residents. This deficient practice placed residents at risk for social isolation and or decreased quality-of-life due to unnecessary limitations on visitation and interference with their ability to maintain relationships with family or others. Findings include:During an observation on 3/23/26 at 11:22 a.m., a facility sign posted above the double doors to the left of the security desk showed, Resident Visiting Hours 8:00 A.M. - 8:00 P.M. During an interview on 3/25/26 at 10:44 a.m., resident #15 stated she did not like the limitations on visiting hours. Resident #15 stated she thought she should be able to have visitors at a time she chose.During an interview on 3/26/26 at 9:16 a.m., staff member G stated residents were not allowed to have visitors before 8:00 a.m. or after 8:00 p.m.During an interview on 3/26/26 at 9:20 a.m., staff member F stated visiting hours were between 8:00 a.m. and 8:00 p.m. Staff member F stated visitors were not allowed to come into the facility outside of those times. Staff member F stated if visitors came to the facility outside of visiting hours, they would need to ring the doorbell and would be told to come back during visiting hours. Staff member F stated, We are strict about our (visiting) hours.During an interview on 3/26/26 at 10:24 a.m., staff member C stated the facility did not have a separate policy regarding visiting hours, but stated it was included in the admission agreement. Staff member C stated visiting hours were from 8:00 a.m. to 8:00 p.m.During an interview on 3/26/26 at 10:37 a.m., resident #23 stated the facility did not allow visitors outside of the posted visiting hours. Resident #23 stated she thought residents should be allowed to decide when they have visitors. Resident #23 stated she likes to sleep late, and the visiting hours restricted her from having visitors later in the evening. Resident #23 stated It would be better for me to decide.Review of a facility document titled, [Facility name] admission Agreement, reviewed 1/26, showed: . Visitation Rights and Limitations7.1 Right to visitation- All residents have the right to visit anyone during visiting hours. [sic]

Based on interview and record review, the facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) in accordance with the Resident Assessment Instrument (RAI) Manual for 1 (#5) of 17 sampled residents. Findings include:Review of resident #5's MDS with an ARD (Assessment Reference Date) of 2/7/26, showed under Section N (Medications) item N300 (number of injections received in the last 7 days) was coded as 1, and item N350 (number of days insulin injections were received in the last 7 days) was coded as 1.Record review of resident #5's physician's orders, dated 11/17/25, showed, Ozempic, inject 1mg subcutaneously every Monday for Diabetes. Ozempic is a GLP-1 (Glucagon Like Peptide-1) which is a hormone that is used for weight loss and diabetes and is not considered insulin.During an interview on 3/26/26 at 9:40 a.m., staff member C stated she was responsible for completing Section N of the MDS and acknowledged she coded Ozempic as insulin because it was used to treat diabetes. Staff Member C stated she had not received formal training on MDS completion and was not familiar with the RAI Manual.Review of a facility policy titled, Resident Assessments, with a revision date of March 2022, showed: . All persons who have completed any portion of the MDS resident assessment must sign the document attesting to the accuracy of such information.Review of the facility policy titled Resident Assessments, revised March 2022, revealed the policy had not been updated to reflect current RAI Manual guidance for accurate coding of medications, including differentiation between insulin and non-insulin injectable medications.

Based on interview and record review, the facility failed to ensure physician services provided appropriate assessment and adjustment of treatment for a resident's medical condition for 1 (#15) of 17 sampled residents. This deficient practice resulted in frequently elevated blood sugar levels. Findings include: During an interview on 3/24/26 at 10:44 a.m., resident #15 stated her blood sugars had frequently been running high. Resident #15 stated her blood sugars were over sometimes over 300 mg/dL. During an interview on 3/25/26 at 12:12 p.m., staff member N stated he would consider day-to-day blood sugar readings of 150-200 mg/dL acceptable in geriatric residents. Staff member N stated if a resident was frequently having a blood sugar reading above 200 mg/dL their insulin regime should be evaluated for adjustment. Staff member N stated he was aware resident #15's blood sugars had been above 200 mg/dL, and he felt it was due to the amount of snack foods she consumed. Staff member N stated he did not feel resident #15's diabetes was adequately controlled and stated resident #15's insulin should have been adjusted due to her high blood sugars. Staff member N stated resident #15 did not have orders for sliding scale insulin. Staff member N stated resident #15 should have been evaluated for sliding scale insulin due to snacks being part of the cause of her elevated blood sugars. Staff member N stated his evaluation of residents in the facility was not as often as it should be.During an interview on 3/26/26 at 11:43 a.m., staff member C stated resident #15's blood sugars were not well controlled. Staff member C stated the dietician visited with resident #15 and educated her on selecting healthy snacks but resident #15 continued to eat foods that contributed to increased blood sugar levels. Staff member C stated resident #15 had not been ordered sliding scale insulin in the past and did not currently have an order for sliding scale insulin. Staff member C stated she was not sure if staff member N had reviewed resident #15's blood sugars or if nursing staff had asked him to review them. Staff member C stated she felt resident #15's blood sugars and insulin regime should have been evaluated for needed changes.Review of resident #15's physicians' orders showed: There were no sliding scale insulin orders for resident #15. The last adjustment made to resident #15's insulin orders was on 12/8/25 at 2:57 p.m.Review of resident #15's blood sugars for the period (prior to staff member N's assessment) from 1/30/26 to 2/26/26 showed:- 8 blood sugar readings recorded under 200 mg/dL- 47 blood sugar readings recorded over 200 mg/dL- 4 blood sugar readings over 300 mg/dLReview of resident #15's Medical Visit, dated 2/26/26 at 1:28 p.m., showed: A. Reason for VisitAssessment. D. Record Review1. Medications Reviewed [indicated with a check mark]. E. Systems Review. 11. Endocrine [fields blank with no information filled in]. F. Physical Exam.1e. Most recent blood sugarBlood Glucose: 205.0 mg/dL Date: 2/26/26 06:04 [a.m.]. I. Plan[Residents Name] has been a long term patient of the Care Center. She is doing well. [sic]A review of resident #15's blood sugars for the period (after staff member N's assessment) from 2/27/26 to 3/25/26 showed:- 9 blood sugar readings recorded under 200 mg/dL- 47 blood sugar readings recorded over 200 mg/dL- 9 blood sugar readings over 300 mg/dLThere was an increase in blood sugar readings over 300 mg/dL after staff member N's assessment on 2/26/26 at 1:28 p.m.

Based on observation, interview, and record review, the facility failed to ensure expired medications and medical supplies were removed from the medication and supply rooms and that medications and biologicals were stored securely in 1 of 1 sampled medication room and 1 of 2 sampled supply rooms. Findings include:During an observation on 3/23/26 at 11:30 a.m., the medical supply room door was propped open with an ice chest and left unsupervised, allowing residents access. During an observation on 3/24/26 at 10:38 a.m., in the medication supply room, one vial of Tuberculin Purified Protein Derivative was labeled with an open date of 1/26/26 and a discard date of 2/25/26.During an observation on 3/24/26 at 10:49 a.m., the medical supply room door was unlocked and unsupervised. The following items were not in a locked cabinet:1 box of 25-gauge 1-inch needles, and1 box of 1cc, 27-gauge 1/2 inch needles and syringes.During an observation on 3/24/26 at 10:51 a.m., the following expired items were found in the medical supply room:Four blue top blood tubes with an expiration date of 1/31/26,Three green top blood tubes with an expiration date of 7/31/25, and eight of them with an expiration date of 12/31/25; and, 47 Xeroform petrolatum dressings with an expiration date of 1/2026.During an interview on 3/24/26 at 11:18 a.m., staff member H stated she does not look at expired medications or supplies. Staff member H stated that either a nurse or a pharmacy staff member would look through the medications and supplies.During an interview on 3/25/26 at 10:58 a.m., staff member J stated the nursing staff would look for expired medications and supplies. Staff member J stated the night shift staff would look for expired medications and supplies, but medications and supply expirations should be checked before the item was used.Review of a facility policy titled Medication Labeling and Storage, dated February 2023, showed: The facility stores all medications and biologicals in locked compartments. Only authorized personnel have access to keys. 3. If the facility has discontinued, outdated, or deteriorated medications . the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.4. Compartments (including, but not limited to, drawers, cabinets, rooms.) containing medications and biologicals are locked when not in use, . items are not left unattended if open or potentially available to others. 5. Multi-dose vials that have been open or accessed (needle punctured) are dated and discarded within 28 days .

Based on interview and record review, the facility failed to ensure the medical director was active in his role for QAPI and review, development, and revision of the facility policies and procedures. Findings include:During an interview on 3/26/26 at 10:50 a.m., staff member A stated the medical director was not always at their QAPI meetings. Staff member A stated staff member N did not always participate in reviewing and revising the policies and procedures for the facility but did sometimes. Staff member A stated there was a new medical director starting with the facility (in the near future). During an interview on 3/26/26 at 12:03 p.m., staff member N stated he was not the medical director but was the medical provider. Staff member N stated he works full-time at another healthcare entity and comes to see residents about every other week. Staff member N stated he just got access to the facility's electronic medical record. Information was requested for the medical director's involvement in QAPI activities and policy reviews. The facility did not provide documentation to show staff member N's involvement (or any other medical director) related to QAPI or policy and procedure reviews and or development, before the end of the survey. Review of a QAPI at Risk Meeting document, not dated, showed the medical director's name was not present on the list of IDT members who attended.

Based on observation and interview, the facility staff failed to ensure staff adhered to accepted infection control standards, including proper hand hygiene and glove use, during a medication pass for 2 (#s 3 and 5) of 17 sampled residents. This deficient practice had the potential for an increased risk of the transmission of infections. Findings include:During an observation on 3/24/26 at 8:35 a.m., staff member H was observed at the medication cart preparing medications. Staff member H donned a pair of nitrile gloves without performing hand hygiene prior to donning the gloves. While wearing gloves staff member H touched multiple potentially contaminated surfaces including the medication cart, computer, computer mouse, personal hair, shirt pocket, medication keys, and door handles. Staff member H removed packaged medication cards and bottles and placed them on top of the medication cart and prepared the medications into a clear plastic cup. Staff member H doffed her gloves and donned a new pair without performing hand hygiene between glove changes.Staff member H pushed the medication cart down the hallway, knocked on resident #3's door and entered the room, after touching the door handle. Staff member H administered medications to resident #3 without performing hand hygiene prior to administering the medications.Staff member H exited resident #3's room doffed her gloves, performed hand hygiene and donned a new pair of gloves. Staff member H touched the medication cart, computer, and computer mouse then prepared resident #5's medications. Staff member H entered resident #5's room after touching the door handle without performing hand hygiene. Staff member H administered medication to resident #5 without performing hand hygiene prior to administration.During an interview on 3/24/25 at 10:22 a.m., staff member H stated she had been educated on proper hand hygiene and stated she should have performed hand hygiene in between donning and doffing gloves, prior to administering medications, and in between residents.Review of a facility policy titled, Administering Medications, undated, showed: . Staff follows infection control procedures (e.g., handwashing, antiseptic technique, gloves.) for the administration of medications.According to guidance from the Centers for Disease Control and Prevention (CDC), hand hygiene should be performed before touching a patient, after contact with a patient, after contact with potentially contaminated surfaces, and before preparing or administering medications.https://www.cdc.gov/infection-control/hcp/core-practices/

Based on observation, interview, and record review, the facility failed to complete thorough incident investigations and address psychosocial impacts of abuse for those affected, for (#s 3, 7, 31, 32, and 34) of 9 sampled resident abuse allegations and investigations. Resident #32 was then reportedly afraid, #31 was uncomfortable with the employee's actions and lack of follow up by the facility, and #3 was tearful during the investigation. Findings include: 1. Review of a Facility Reported Event, submitted to the State Survey Agency on 2/4/25, showed resident #34 reported NF3 refused to change her soiled brief. During an interview on 6/18/25 at 3:25 p.m., staff member B stated he investigated the incident. Staff member B stated NF3 was sent home pending investigation and CNAs were interviewed. Staff member B stated he determined the incident to be a personality conflict between resident #34 and NF3. Staff member B stated his investigation did not include interviews with any other residents cared for by NF3, and did not include an assessment of any psychosocial impact for resident #34 following the incident. 2. Review of a Facility Reported Event, submitted to the State Survey Agency on 2/12/25, showed resident #3 reported NF1 was rude, abrupt, and rough with her care. The investigation documentation showed resident #3 was tearful when discussing the incident with staff member C. During an interview on 6/18/25 at 3:25 p.m., staff member B stated his investigation did not include interviews with any other residents cared for by NF1, and did not include an assessment of any psychosocial impact for resident #3 following the incident. 3. Review of a Facility Reported Event, submitted to the State Survey Agency on 2/12/25, showed staff member B had learned of a second incident involving NF1, while investigating another incident on the same date. The investigative report showed resident #32 reported that NF1 was rough with her care and caused an abrasion to her lower left leg. The investigation documentation showed resident #32 stated several times she was afraid of NF1 and was subsequently hesitant to receive showers. During an interview on 6/18/25 at 12:12 p.m., staff member D stated She (NF1) was not a good (stated position). You could tell she was just here for the paycheck. She was lazy and rough with the residents and made fun of them . She (Resident #32) was tearful and afraid to take a shower for a while after that (incident). During an interview on 6/18/25 at 3:25 p.m., staff member B stated he investigated the report regarding NF1, was very concerned regarding the allegations, and NF1's contract was terminated on 2/12/25. Staff member B stated his investigation did not include interviews with any other residents cared for by NF1, and did not include an assessment for any psychosocial harm for resident #32. 4. Review of a Facility Reported Event, submitted to the State Survey Agency on 3/27/25, showed resident #31 reported concerns regarding a staff member possibly taking pictures of him while he was showering on 3/27/25. During an observation and interview on 6/17/25 at 4:45 p.m., resident #31 was seated in a wheelchair in his room. Resident #31 stated he had reported a concern to the facility when NF2 remained in the shower room while he showered independently, and she was holding her phone up facing him. Resident #31 stated the encounter made him uncomfortable, and he stated, . because I felt like she was filming or taking pictures. Resident #31 held his phone up several times during the conversation to demonstrate the position NF2 held her phone up at eye level, facing him. Resident #31 stated, They (facility staff) told me they doubt she was taking pictures, but with these phones, you just don't know, and I don't know if they ever found out. I don't think that girl works here anymore. no one came back to talk to me about it; haven't heard anything. During an interview on 6/18/25 at 3:45 p.m., staff member B stated the investigation and reporting of incidents in the facility was the responsibility of either himself or staff member A. Staff member B stated he investigated the 3/27/25 reportable incident, and he was unable to interview the accused staff member, as she had already been terminated. Staff member B stated his investigation did not include interviews with any other residents cared for by NF2, and did not include an assessment for psychosocial harm for resident #31. Staff member B stated, I just talked to him to see what happened. Review of all staff education between January and June of 2025, showed staff most recently received abuse refresher training on 3/19/25; over one month after the 2/12/25 incidents. 5. Review of a Facility Reported Event, submitted to the State Survey Agency on 3/15/25, showed resident #7 was sprayed intentionally in the face by a staff member, with water, during a shower. The temperature was up and this made the resident yell out. This was reported to have happened on 2/15/25. Review of the facility findings showed, Once administration learned of this incident, [staff member F] was taken off the schedule, his company was notified and his contract terminated. Review of the nursing schedule for June 2025 showed staff member F was still working in the facility. During an interview on 6/18/25 at 3:25 p.m., staff member B stated, The process for investigation of incidents would be that the charge nurse would inform the DON of the incident, the DON would contact the Administrator, and the administrator would inform social services. Social services would then report it to the BOUNDS system and proceed with gathering information for the investigation. In most cases, if a staff member is involved, they will be sent home until the investigation is complete. We reported the incident as soon as we found out about it. We were not sure of the exact date of the incident so I picked a day that both staff members were scheduled to work together. Review of resident #7's bath log showed her bath days were on Wednesday and Sunday, and 2/15/25 was on a Saturday. Review of the nursing staff schedule for February and March showed Wednesday, March 5th was the only date the two staff members worked together which correlated to resident #7's bath schedule. During an interview on 6/18/25 at 4:10 p.m., staff member B stated, I remember closing out a lot of bounds that day, and the recommendation was to let that staff member go. Under the direction of staff member A, I went and interviewed other staff about the incident. I did not interview other residents. After talking to other staff, I did not substantiate the incident and never went back in to update my findings. I did not talk to that staff member directly; I think he was out on days off. The resident involved does not remember the incident. I never thought of looking at the bath schedule during the investigation. The investigation submitted to the State Survey Agency did not show the employee received abuse education immediately following the event or when the employee returned to work at the facility. Staff member B stated he did not assess resident #7 for any psychosocial impact related to the incident. Review of a facility document, titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, showed the following: . 7. The individual conducting the investigation as a minimum: . j. interviews other residents to whom the accused employee provides care or services . l. documents the investigation completely and thoroughly. [sic]

Based on observation, interview, and record review, the facility failed to assess and update a care plan with interventions for wandering for 1 (#7) of 9 sampled residents. This deficient practice increased the risk of injury to resident #7 and increased the risk of lack of privacy for other. Review of a facility reported event, dated 3/20/25, showed resident #7 was wandering and opening and closing other residents' doors, causing other residents to become angry. Review of resident #7's electronic health record showed resident #7 had dementia, low vision, and was hard of hearing. During an interview on 6/18/25 at 10:16 a.m., staff member B stated, Interventions for resident #7 are to work with the doctor on medication management. We don't do a formal assessment of behaviors. During an observation on 6/18/25 at 2:05 p.m., resident #7 was observed wandering the halls in the facility. She went behind the nursing station and was grabbing items on the desk. During an interview on 6/18/25 at 2:15 p.m., staff member E stated, When she is wandering around or bothering others, we usually give her a drink or take her outside. I think she just wants attention. I would ask a CNA what her interventions are. Review of resident #7's electronic health record showed a wandering assessment was completed on 12/24/24 and showed a score of 2.0; a low risk of wandering. Review of resident #7's nursing progress notes for March through June 2025 showed resident #7 was frequently wandering in and out of other rooms, combative towards staff, and wandering inside the facility. Review of resident #7's care plan, with a revision date of 3/4/25, showed: Focus: The resident is an elopement risk/wanderer r/t significantly intrudes on the privacy or activities. Interventions: .The resident's triggers for wandering/eloping are age, disease and smoking related. The resident's behaviors is de-escalated by (specify). [sic] Review of a facility document titled Wandering and Elopements, undated, showed: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on interview and record review, the facility failed to identify the root causes of falls for 1 (#12) of 17 sampled residents, and the resident continued to fall, and this resulted in the resident sustaining a head injury from a subsequent fall. Findings include: During an interview on 1/29/25 at 9:29 a.m., NF1 stated resident #12 had fallen five times this year. NF1 further stated she had asked why resident #12 kept falling and the facility staff could not tell her why. A review of resident #12's Morse Fall Scale, dated 11/12/24 at 9:59 a.m., showed resident #12's score was 75, and was at high risk of falling. A review of facility documents titled, Post-accident/Follow-up Investigation Form Team Meeting, for falls for resident #12, with dates of 2/2/24, 2/8/24, 3/5/24, 3/21/24, and 9/6/24, showed the Fall Root Cause Analysis portion of the documents were not filled out. A review of a progress note for resident #12, dated 11/13/24 at 2:26 a.m., showed: Note Text: [Staff member M] was sitting nearby while [Resident #12] was in bed. [Resident #12] stood up and fell on the floor hitting her forehead. [Staff member M] stated She was getting up from bed. I didn't get to her in time and she fell , [Resident #12] was saying she was taking her sister to the bathroom, [Resident #12] has a bump from the fall. It's 2X2, egg shaped bump on the left side of forehead, with no LOC. No other injuries noted. V.S B/P 234/116, P 87, R 20, T 98.3, O2 sat 90%. 01:55 [1:55 a.m.] Called [Staff member B], 02:00 [2:00 a.m.] Called [NF3] informed them of [Resident #12's] fall. 02:15 [2:15 a.m.] Called POA [NF2]. 02:20 [2:20 a.m.] Called ER spoke to ER nurse [Intials]. 02:25 [2:25 a.m.] Dispatch called. 02:28 [2:28 a.m.] EMS arrived, 02:30 [2:30 a.m.] [Resident #12] placed on stretcher and transported via ambulance to er. [sic] A review of an Emergency Department Visit Record, for resident @12, dated 11/13/24 at 2:28 a.m., showed: HPI: 82 y/o female from the nursing home who was brought due to fall on her head with concussion with LOC and neck pain. Pt has a hx of DM Type 2 and dementia. On arrival, . [sic] During an interview on 1/29/25 at 11:19 a.m., staff member A stated there was no root cause analysis documentation for resident #12's falls. During an interview on 1/29/25 at 1:14 p.m., staff member B stated falls had not been documented like they should have been. A review of a facility policy titled, Falls and Fall Risk, Managing, with a revised date of March 2018, did not show root cause analysis as a step in the facility's fall prevention process. The policy language did not address how the facility would identify causal factors to attempt to prevent future falls with and without injury.

Based on interview and record review, the facility failed to ensure a resident received timely treatment for [REDACTED].#74) of 22 sampled residents. Findings include: During an interview on 10/30/19 at 2:30 p.m., staff member D stated she received a report of bruising to resident #74 on 9/22/19. Staff member D stated bruises were to be reported to the DON or Social Services upon observing them. Staff member D stated nursing did not report the bruising like they should have. During an interview on 10/30/19 at 3:00 p.m., staff member B stated if a CNA finds a bruise, they are to fill out a pink slip and give it to the nurse. Staff member B stated the nurses are to report to the DON, who then would follow up. Staff member B stated the bruise would be assessed and documented in the medical record. Staff member B stated she had received a report about a bruise on resident #74's shoulder on 9/19/19. Staff member B stated it was first reported as a small bruise on the resident's arm and worsened from there. Review of resident #74's nursing progress notes, from 9/19/19 through 9/22/19, showed the following: -9/19/19 at 6:45 p.m., CNA stated that she had found a small bruise to her Right shoulder. bruise small and approx quarter in size on the upper arm. (sic) -9/20/19 at 3:28 a.m., Resident has a bruise on right shoulder. -9/21/19 at 5:03 a.m., 0800 during showing resident a large bruise on right frontal axilla, reported by the CN[NAME] (sic) -9/21/19 at 6:17 p.m., (Resident name) has a huge bruise from the top of inner right arm to approximately the anticubital area. Unknown cause. Pink slip filled out and turned into the DON. (sic) -9/22/19 at 2:31 a.m., Bruising of RUE, beginning at the top of bicep to above inner elbow. Noted 15cm x 6cm. At top of bicep is a hard raised swelling-measures 7cm x 5cm. measured in an X formation as swelling is not round but oblong in shape. Assessment and configuration of bruising and area of swelling-It appears someone may have gripped res with a hand high up on UE, to pull res by RUE while repositioning or during a transfer from one horizontal surface to another. Swelling location and slight bruising impression similar to thumb placement on inner deltoid give a likeness to such a grip when nurse personally compared hand to bruise to substantiate possibility of this theory. Approx 2215 (10:15 p.m.) res scowling and while UTA and decipher vocalization-the tones were distress in nature. Administered children's IBU as ordered. Effective and assessed 0 pain level. Resting quietly and no distress noted during measuring of trauma of RUE. (sic) -9/22/19 at 6:44 p.m., Noted large bruising on (resident name) inner arm this AM. As CNA putting night gown on (resident name) we discovered more bruising on her neck and back with shoulder looking a little misplaced. Nurse spoke with (physician name) and asked if he could do an x-ray of her shoulder. Nurse has tried to contact her family that live locally unsuccessly (sic) so (family name) her brother who lives out of town was called. His number is (phone number) and he will try to locate local family to inform them of (resident's name) being sent to ER. Nurse left message with DON. (sic) -9/22/19 at 8:51 p.m., Social Services was contacted by (nurse's name) at approximately 7:28 p.m. She explained to the Social Worker that (resident name) had to be sent up to the ER due to bruising that was found on her upper/inner arm, neck, and back. They also notice that she was favoring her right shoulder, so they call the ER Dr. and he told them to send her up so that she can be xrayed. Social Services immediately responded by telling (nurse's name) that she was on her way in. Social Services arrived and it was explained further to her that it was determined by the xrays that her right shoulder is in fact dislocated. ER explained that they would be contacting Law Enforcement. Shortly there after, Officer (officer's name) showed up and began asking questions. He asked Social Services about finding out who works both shifts for the past 2 weeks that he would need a schedule of some sort. About that time CNA (CNA's name) showed up and began answering questions asked by the officer and then he asked Social Services to get everything and he would come back and get everything. Social Services has talked with both reporting CNA's they were helpful in giving names, dates and scheduling that are needed to help complete the investigation. This incident will be reported to Bounds (electronic abuse reporting program), Law Enforcement. Local Ombudsman and Elder Protection and a full investigation will be completed within the five days from today. (sic) Review of a Communication Board form showed the resident had bruising to her buttock and right shoulder on Thursday (9/19/19). All bruises were reported by CNAs on pink skin alert sheets and turned into charge nurses. On 9/21/19 the bruise had grown in size. On 9/22/19 the bruise had grown more and went around her shoulder and her back. On all occasions the CNAs reported the bruising to the nurses. Review of resident #74's progress notes showed the resident received [MEDICATION NAME] on 9/21/19 at 9:24 p.m. and on 9/22/19 at 2:00 a.m. Review of the record failed to show ongoing assessment and monitoring of the resident's pain as a result of the bruising. Review of resident #74's clinical record showed there was a three-day lapse between the discovery of the bruising, and the resident being sent out for treatment. Review of resident #74's medical records, dated 9/22/19 from the hospital, showed the resident had bruising over her right shoulder, right upper arm and eyeballs bilaterally. The right shoulder x-ray imaging revealed mildly displaced [MEDICAL CONDITION] neck of the right humerus. The triage assessment showed the resident arrived from the care center with bruises in multiple stages of healing. Under Orders for Today, the record showed the resident was admitted for further evaluation and protection.

Based on observation, interview, and record review, the facility failed to identify a significant weight loss timely and implement interventions timely; and failed to monitor the effectiveness of interventions for 2 (#s 21 & 22) of 22 sampled residents. Findings include: During an observation on 10/28/19 at 5:02 p.m., residents #21 and #22 were sitting across from each other, at one of the two feeding assistance tables in the dining room. Staff members H and I were distributing meal trays to the residents in the dining room. During an observation on 10/28/19 at 5:29 p.m., Staff members H and I were seated at the two feeding assistance tables in the dining room. Staff H was providing feeding assistance to resident #21. Staff member I stated resident #22 had been shaky, and the nurse had taken the resident out of the dining room to check her blood sugar. 1. Review of resident #21's Admission MDS, with the ARD of 4/12/19, showed an admission weight of 128 lbs. Review of resident #21's EMR showed documentation of the following weights: - 4/9/19 weight 128 lbs. - 5/3/19 weight 130.2 lbs. (Wheelchair) - 6/3/19 weight 131.4 lbs. (Wheelchair) - 7/1/19 weight 124.8 lbs. (Wheelchair) - 8/1/19 weight 125.5 lbs. (Mechanical Lift) - 9/10/19 weight 121.4 lbs. (Wheelchair) -10/1/19 weight 112.8 lbs. -10/29/19 weight 111 lbs. (Wheelchair) Review of resident #21's medical record showed a significant 13.3% weight loss from the time of admission on 4/9/19 to 10/29/19. Review of resident #21's dietary progress notes dated 7/24/19, showed, documented significant weight loss of -7.4 lbs. (5.5%) in the past 30 days; resident is on the dietitian assessment list and doctor was notified. Diet order change was received for (resident #21;) diet was changed to high calorie, high protein, 4 ounce nutritional shakes twice daily. Review of resident #21's medical record did not show any dietary order changes were documented after 7/24/19. Review of resident #21's dietary progress notes dated 9/3/19, showed the completion of the quarterly nutritional assessment completed on 8/31/19 by staff member G. No issues, changes or recommendations noted with next visit planned for November, unless otherwise needed. Review of resident #21's Nutrition Recommendation form, dated 10/10/19, was sent from staff member F to staff member J showed: PROBLEM/CONCERN: Change of condition - significant weight loss x 30 days of 8.6 lbs. (-7.1%); From 121.4 pounds to 112.8 pounds; IBW: 140 pounds per dietitian; BMI: 17.1 per PCC. Staff member J had signed the form on 10/18/19 with no comments noted. Review of resident #21's dietary progress notes dated 10/16/19, showed, Change of condition, significant weight loss of 8.6 lbs. (-7.1%); put a notice in to doctor rounds, will be in Dietitian's rounds. Review of resident #21's medical record did not show any dietary progress notes were documented after 10/16/19. Review of resident #21's medical record showed a PCC (EHR Program) alert dated 10/30/2019 at 1830 (6:30 p.m.), stated resident #21 ate 50% or less for 2 meals in one day. During an observation on 10/31/19 at 8:05 a.m., resident #21 was seated at one of the two feeding assistance tables in the dining room. Staff member K was providing feeding assistance to resident #21 and stated resident #21 was, one of the good feeders. Resident #21 had hot tea, water, orange juice, yogurt and ground meat on the table for her breakfast meal. No nutritional supplement shake was on the table for resident #21. During an interview on 10/31/19 at 8:22 a.m., staff member J stated the facility's nursing staff had told her it was very difficult to get resident #21 to eat. Staff member J thought [MEDICATION NAME], an appetite stimulant, had been ordered for the resident. Staff member J stated resident #21's family did not want resident to get a feeding tube. Staff member J stated she was not sure if nutritional shakes had been ordered for resident #21, but would check. During an interview on 10/31/19 at 8:35 a.m., staff member F stated the PCC alerts are flagged after the CNA staff enters the intake amounts for the residents. Staff member F stated she probably did not look at the residents' intake amounts enough, just as needed, and not on a daily basis. Calls were attempted on 10/30/19 at 11:42 a.m., to staff member G were not returned prior to the survey departure. Resident #21 had a decreased intake, was to be assisted by staff with eating, and had a weight loss that was not identified timely. 2. Review of resident #22's Admission MDS, with the ARD of 8/28/19, showed an admission weight of 139.4 lbs. Review of resident #22's EMR showed documentation of the following weights: - 8/21/19 weight 139.4 lbs. (Standing) - 9/10/19 weight 129.6 lbs. (Standing) - 10/10/19 weight 115 lbs. (Bath) Review of resident #22's medical record showed a significant, 17.5%, weight loss from the time of admission on 8/21/19 to 10/10/19. Review of resident #22's diet order, dated 8/21/19, showed a high calorie/high protein diet with three meals, and snacks provided three times per day, with mechanical altered texture and regular liquid consistency. Review of resident #22's initial dietary assessment, dated 8/31/19, showed: diet order of high calorie/high protein, with plan noted to continue to monitor diet, weight, intake and MD orders regularly and provide nutritional recommendations as needed, resident goal is to consume > 75% of meals per day x 90 days. Review of the facility's Quarterly Nutritional Assessment list for the month of (MONTH) noted resident #22 had a significant weight loss in the comments/concerns section. Review of resident #22's medical record showed an alert dated 10/30/2019 at 1343 (1:43 p.m.), showing resident #22 ate 50% or less for 2 meals in one day. During an observation on 10/31/19 at 8:05 a.m., resident #22 was seated at one of the two feeding assistance tables in the dining room. Staff member L was providing feeding assistance to resident #22 and stated resident #22 kept dozing off at the table, and it was hard for the resident to open her mouth. Resident #22 had cereal, scrambled eggs, 1/2 of a banana, toast, orange juice, water, milk and coffee for her breakfast meal. No nutritional supplement shake was on the table for resident #22. During an interview on 10/31/19 at 8:22 a.m., staff member J stated the facility's nursing staff had told her it was very difficult to get resident #22 to eat. Staff member J stated resident #22 was very difficult, and had dementia with significant emotional problems, and cried a lot. Staff member J stated she would speak with resident #22's son, about a feeding tube, and would check to see if [MEDICATION NAME], an appetite stimulant and a nutritional supplement, had been ordered for the resident. Staff member J thought resident #22 would benefit from a feeding tube. During an interview on 10/31/19 at 8:35 a.m., staff member F stated the PCC (EHR Program) alerts are flagged after the CNA staff enter the intake amounts for the residents. Staff member F stated she probably did not look at the residents' intake amounts enough. Calls were attempted on 10/30/19 at 11:42 a.m., to staff member G which were not returned prior to the survey departure.

Based on observation, interview and record review, the facility failed to prevent the development of a Stage III pressure ulcer, delayed treatment for [REDACTED].#2) of 3 sampled residents; and failed to prevent, monitor, and treat a pressure ulcer timely which worsened from a Stage I pressure ulcer to a Stage II pressure ulcer for 1 (#1) of 3 sampled residents. This deficiency has the potential to affect all residents with potential for skin breakdown. Findings include: 1. During an observation on 7/31/19 at 2:40 p.m., resident #2 was sitting in her wheelchair with a soft, gray boot on her left foot. The foot was on the ground and she propelled herself with her feet. She was not able to converse related to a [DIAGNOSES REDACTED]. Review of resident #2's Nursing Progress Note, dated 1/20/19, showed a purple-reddish color on resident #2's left heel, and the charge nurse was notified. During an interview on 7/31/19 at 2:55 p.m., staff member F stated the look of the heel on 1/20/19 probably meant it was about to break down. Review of resident #2's Wound Observation Note, dated 2/11/19, showed the heel injury was aquired at the facility, and was a suspected deep tissue injury. It showed necrotic tissue was present, and it measured 29 x 32 x 03 millimeters (mm). The current treatment plan showed per MD orders. Review of resident #2's Treatment Assessment Record showed no treatments were provided for the pressure ulcer for the months of (MONTH) and Febuary 2019. Review of resident #2' s Wound Observation Note, dated 2/26/19, showed the area was necrotic, and measured 21 x 31 x 02 mm (millimeters). The current treatment plan showed per MD Orders. Review of resident #2's Medical Visit, dated 2/7/19, showed the resident had a blister on the left heel that had broken open, measured at four centimeters. The plan was to refer to podiatry. Review of resident #2's Medical Visit, dated 2/15/19, showed the heel had black eschar, and podiatry would manage the treatment. No treatment was documented for the heel. Review of resident #2's Nursing Progress Notes from 2/4/19 to 5/14/19 did not document the presence of a pressure ulcer or treatment for [REDACTED]. Review of resident #2's Care Plan, showed the pressure ulcer injury problem and interventions were not initated until 4/30/19. The interventions did not inlcude pressure relief or positioning. Review of resident #2's Nursing Progress Note, dated 5/15/19, four months after the injury was identified, showed the left heel had yellow, greenish drainage and a strong odor. She was sent to the ER and started on an antibiotic for 10 days. Review of resident #2's Nursing Progress Note, dated 5/23/19, showed the heel ulcer still had a very foul smell. Review of resident #2's wound culture results, two months later, dated 7/17/19, [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistent Staphylococcus aureus) in the wound. During an interview on 7/31/19 at 2:55 p.m., staff member F stated she did not know why there was a long delay in obtaining a wound culture, or the delay in a referral to the wound clinic, which occured on 6/24/19. Review of resident #2's Wound Clinic Care Note, dated 6/24/19, showed a Stage III pressure ulcer on the left heel, and measured 0.9 x 1.5 x 0.3 centimeters. The pressure ulcer was debrided. During an interview on 7/31/19 at 2:55 p.m., staff member F stated resident #2's heel had been boggy, and she had fallen and broken her left hip, so was in bed for an unidentified length of time. She stated the facility put the resident on doctors rounds for the pressure ulcer. She stated the facility could have focused more on turning and repositioning for the resident, along with better hydration. She stated the pressure ulcer was currently smaller. She did not know why the podiatry visits did not result in treatments for the pressure ulcer. 2. During an interview on 7/31/19 at 1:47 p.m., staff member [NAME] stated the registered nurse does pressure ulcer treatments. Upon discovery, the registered nurse identifies what the pressure ulcer care needs are off of the type of wound it is. During an interview on 7/31/19 at 1:56 p.m., staff member D stated the charge nurse does wound care. The nurse is to chart, notify the physician on doctor rounds, and let the Assistant Director of Nursing or Director of Nursing know of the pressure ulcer. During an interview on 7/31/19 at 2:00 p.m., staff member F stated wound rounds are completed every week and are assessed on the doctor rounds if changes have been noted. The interventions they use are turning and repositioning, air beds, hydration, and nutrition. Intervention that were in place for resident #1 were turning and repositioning, hydration, monitoring his blood sugars close to the parameters set by the physician. During an interview on 7/31/19 at 2:08 p.m., staff member B stated the charge nurse, the Assistant Director of Nursing, or Director of Nursing are responsible for pressure ulcer care. Staff member B stated the expectations of care to pressure ulcers are to monitor the pressure ulcer, follow physician orders, and refer out to the wound care clinic if necessary. Review of resident #1's Braden Scale for Predicting Pressure Sore Risk showed: -On 11/28/19, resident #1 was at risk for developing a pressure sore with a score of 15. - On 2/21/19, resident #1 was at moderate risk for developing a pressure sore with a score of 13. Review of resident #1's progress notes showed the following: -On 3/11/19, small breakdown was noted on resident # left buttocks approximately half inch long and was placed on doctor rounds. -On 3/20/19, redness was noted by the nurse. Review of resident #1's Wound-Weekly Observation Tool dated 3/21/19, showed: -3. Special Equipment/Preventative measures (i.e. gel mattress/pad, special bed/Mattress, side rail pads etc.) was blank and did not specify what preventative measures were in place for the resident at the time of his pressure ulcer assessment. - 4. Resident is on turning and repositioning routine, was not checked in the box provided. - Under the section Observation/Data showed the location of the pressure ulcer to be on the left buttock. It indicates the wound was a facility acquired on 3/11/19 and the type to be pressure as a Stage I pressure ulcer. The visible tissue had granulation and was moist. The extent of necrosis and/or slough in the wound bed was sixty percent. There was no drainage or odor noted. The wound measured 7 mm in length, 19 mm in width, and 01 mm in depth. The peri-wound tissue was well defined. There was no inflammation of the wound noted. -Treatment was resident placed on doctor rounds for assessment this week and the current treatment plan was resident has order for butt paste to area tid. Review of resident #1's Medical Visits dated 3/29/19, showed the resident was seen by the physician rounding in the facility with no mention of a evaluation of the pressure sore of the left buttock. Review of resident #1's Treatment Administration Record showed: -March 2019, Butt paste to scrotum area tid three times a day for rash. There was no mention of treatment administered to the resident's left buttock pressure ulcer. -April 2019, Butt paste to scrotum area tid three times a day for rash. There was no mention of treatment administered to the resident's left buttock pressure ulcer. Review of resident #1's Visit Detail, dated 4/1/19, showed, -Redness-ulceration to left buttock. abd placed to site. -Warm, normal turgor, [MEDICAL CONDITION], abrasions, sacral decubitus ulcer (approx 2.5 cm x .5 cm) left buttocks, generalized abrasions on bilateral extremities, left elbow healing abrasion, healing lesion between fourth and fifth toe, right foot second toe nail missing. -Risk for impaired skin integrity related to admitted with sacral decubitus ulcer (approx 2.5 cm x .5 cm) left buttocks, . Review of resident #1's Visit Detail, dated 4/12/19, showed, Warm dry, normal turgor old sacral duoderm dressing changed today had two quarter sized areas of brown drainage, the proximal aspect of the sacrum has a 2.5 cm x .5 cm Stage II decub .

Based on interview and record review, the facility failed to evaluate and monitor a resident after multiple choking and aspirating events during meals for 1(#1) of 3 sampled residents. This deficiency has the potential to affect all residents. Findings include: During an interview on 7/31/19 at 2:41 p.m., staff member F stated the procedure for choking and/or aspiration is the [MEDICATION NAME] maneuver, monitor lungs and breathing for change of condition [MEDICATION NAME] 24 hours, and to keep the resident up and out of bed. Staff member F stated if needed send the resident to the hospital or have the doctor asses the resident or if resident was to aspirate, she would call the emergency room and ask them what to do. During an interview on 7/31/19 at 2:42 p.m., staff member B stated if a resident choked or aspirated, the procedure would be to call the doctor or send to the emergency room if needed, notify the family member, get a doctor order for a swallow evaluation, and then schedule the swallow evaluation as soon as possible. Staff member B stated the staff is to monitor the resident and the consistency of the food or drink that cause the event to happen and revise the diet as needed such as upgrading or downgrading the diet texture. Staff member B stated that following an event of choking or aspirating it should be documented in an incident assessment called the sbar communication note. Staff member B stated there were no sbars for resident #1. During an interview on 7/31/19 at 3:36 p.m., staff member C stated she had not experienced anyone choking or aspirating in the facility but if it did happen, she would check to make sure there was not anything in the resident's mouth then you would do the [MEDICATION NAME] maneuver. During an interview on 7/31/19 at 4:55 p.m., staff member D stated if a resident was choking or aspirating, she would perform the [MEDICATION NAME] maneuver and lean the resident forward and rub their back. Staff member D would then do a lung assessment on the resident and document in a progress note. Staff member D would monitor the resident for the rest of her shift then pass along to the night shift. Staff member D would notify the emergency room doctor and get instructions on what to do from the doctor. Review of resident #1's Orders- General Note from eRecord showed the following: -3/3/19, showed (resident #1) had an aspiration event today at the noon meal. NF1 requested a swallow evaluation for resident #1. - 3/4/19, showed .taking a drink of coffee caused resident number one to start coughing as if resident was almost choking CNA's and Rn (sic) sat resident up all the way resident was able to check breath and able to swallow when he spit resident has spit out lots of green mucus, will continue to monitor will place resident on Dr. Rounds. -3/5/19, showed resident started coughing as if he aspirated on food or drink, while resident was coughing he started spitting up very green mucus. Resident #1 was placed on doctor rounds for further assessment and the family requested the doctor to see the resident. Review of resident #1's Nutrition Recommendation Form dated 3/6/19, showed Recommendation for down grade texture to pureed, d/t decrease in oral intake and coughing and choking. No mention of aspiration or change in liquids were addressed. Review of resident #1's diet card dated 3/28/18, showed for texture mechanical altered (level 2) and for liquids necter-like liquids. Review of resident #1's Health Status Note dated 3/13/19, stated the doctor had ordered a swallow study on 3/8/19. Review of resident #1's Nutrition/Dietary Note dated 3/14/19, showed Notified the POA of the recent diet texture down grade of pureed, on 3/8/19. Will revisit (resident #1) after he receives a swallow evaluation (referral is in, no appointment date yet). Review of resident #1's Medical Visits for (MONTH) 2019 showed the following: -On 3/8/19, resident #1 was diagnosed with [REDACTED]. Vital signs once a day to include temp and oxygen saturation. -On 3/29/19, resident #1 showed resident 1 had a swallow evaluation on Tuesday (4/2/19). Review of resident #1's temperature log showed the last temperature taken on 2/28/19. No temperatures were taken in (MONTH) 2019 as the physcian had ordered. Review of resident #1's Appointment Clinic Notes dated 4/1/19 showed resident #1 was Per his daughters he aspirated real bad and since then does not want to even drink water. Resident #1 was diagnosed with [REDACTED]. The resident was transfered to the emergency room after the appointment for further evaluation and admitted to the hospital.

During a complaint survey, an Immediate Jeopardy situation was announced by the surveyor at 2:50 p.m., on 11/2/16, at Blackfeet Care Center. The administrator and director of nursing were notified that an Immediate Jeopardy situation existed in the areas of Resident Behaviors and Facility Practices. After acceptance of the plan for the removal of the immediacy, the scope and severity of the F224 tag was reduced from J to G. PLAN TO RESOLVE THE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on 11/3/16 at 3:40 p.m. A summary of the plan included: A. Prior to any nurse working the floor, the DON would educate the nurse on: -Fall Assessment Policy and Procedure; -Comprehensive assessment of the resident after each fall; -Neuro checks; -Investigation into the root cause of each fall, and resident needs assessed; -After each fall, the care plan for that resident would be reviewed, and updated as necessary; - Communication with a physician and care team; and, -The DON and Administrator would review the care plans for all current residents at risk for falls, and review residents who had experienced an actual fall. B. The Administrator would be directly involved in oversite of these resolution measures. Based on record review and interview, the facility neglected to assess, and provide for the supervision needed to reduce the risk of injury for 1 (#1) of 3 sampled residents. The failure to provide the needed supervision lead to resident #1 experiencing a major injury. Findings include: A review of nursing notes, dated 6/1/16 to 10/1/16, showed resident #1 had a history of [REDACTED]. The resident had falls on 7/25/16 and 9/29/16, which did not result in significant injury; and, three falls on 10/1/16 which lead to the resident experiencing a major injury. Fall #1 on 10/1/16 Review of an Incident/Accident Report dated 10/1/16 at 4:48 p.m., showed resident #1 was sent to the ED with, back of head bleeding, after being found near the closet in his room. Review of a document from the local hospital titled, (Facility) Care Center, and dated 10/1/16, showed a [DIAGNOSES REDACTED]. Review of a nursing note, dated 10/1/16, at 7:30 p.m., showed resident #1 returned from the ED with, 5-6 staples in the back of his head, and F/U-Head CT scan for follow up tomorrow. Dr. (name). Fall #2 on 10/1/16 Review of the Transfer Form, dated 10/1/16, with a departure time of 11:05 p.m., showed resident #1 had experienced a previous fall on the day shift, had 5-6 staples, was unresponsive, his collar bone was swollen, he had fallen hard enough to break a table, and was unresponsive. The form also showed injuries of a laceration, hematoma, and swelling. Resident #1's pupil sizes were: on the right, a 4, and on the left a 2. He had blood in his mouth. The form showed the nursing staff had been advised by the doctor, who was reached by telephone at the ER, to monitor the resident. The record showed staff had contacted the ER two times (at 9:50 p.m. and 10:35 p.m.), and called for the ambulance two times (at 10:35 p.m. and 10:50 p.m.). A review of the resident's Licensed Nurse Progress Notes, dated 10/1/16, at 9:50 p.m., showed the resident had fallen when he was by himself in his room. It also showed, CNA's were getting other residents to bed. Checked on resident, on floor in room. Fall mat had been by bed. Bedside table broke in half. Called (physician). VS 183/100, 77, R24, T97.4, right collar bone is swollen. Discussed with (physician) of res falling again. Per (physician) monitor. Explained that resident possibly knocked himself out, his head was bleeding. (Physician) asked use restraints on res. This nurse explained we can't use restraints, family has to sign papers, but we don't use them. (physician), 'Just monitor until tomorrow when CT scan is done. Send anytime tomorrow.' Res checked on frequently, this nurse did not feel right about 'just monitor' res status. Res was put in bed by Hoyer lift, @ 2200, 2210, 2215 (sic) (10:00 p.m., 10:10 p.m., and 10:15 p.m.) res still unresponsive to painful stimuli. Had day shift nurse come in to assess res, @ 2230 (sic) (10:35 p.m.) VS -183/101 P77, R22, T97.1%. Called (physician) @ ER, Son was aware of fall earlier, explained no fell again (sic). Called (physician) @ 2250 (sic)(10:50 p.m.) that sending res up, right collar bone swollen, breathing irregular, pupils unresponsive to light, has blood in mouth, R-4, L-2 pupil size. Called ambulance @ 2235 (sic) (10:35 p.m.) again @ 2250 (sic) (10:50 p.m.) arrived at 2300 (sic) (11:00 p.m.) departed with res @ 2305 (sic) (11:05 p.m.). Fall #3 on 10/1/16 Review of the resident's clinical record lacked evidence to show the facility assessed or documented any data regarding the third fall event, or outcome of the fall. During an interview on 11/1/16 at 4:21 p.m., staff member I said, After he came back from the ED (on 10/1/16 at 7:30 p.m.) We were staying with him for about a half hour each. At about 7:00 p.m., people started calling and wanting to go to bed. We had to check frequently on resident #1. (Staff member F) was putting (another resident) to bed when (resident #1) fell . She heard him fall. She said he had been sleeping. He would only sleep for a little while and then he would wake up and say, 'I have to go.' He just wouldn't stay in that bed, he just kept getting up. On the second fall, after he returned from the ED with the staples in his head, he was just knocked out. During an interview on 11/1/16 at 12:49 p.m., staff member F said, When he got back we sat with him, and we took turns sitting with him. I sat with him for about an hour and I thought he was sleeping. I went across the hall and helped another resident get ready for bed. I heard a crash and went running. I found him lying on the floor on his stomach, like he had tried to catch himself. He was trying to get up and was wide awake. After the nurse looked at him she said to just get him in bed and get his vitals. I believe that (staff member I) was with me. (Staff member I) sat with him while I went and got others ready for bed. She thought he went to sleep and left to help others. Staff member F said, After a while she (staff member I) went down to check on (resident #1), and he was lying flat on his back and he was snoring and it looked like he was knocked out. (Staff member C) came and check him out again and then she made a phone call to IHS. She said, (Staff member C) called IHS a few times. The second time she was told to use restraints. After the second fall (staff members E and G) came in and sat with (resident #1). We had to use a Hoyer lift to transfer (resident #1) to the bed, because the ER doctor had told (staff member C) to use restraints and monitor him. So (staff members E and G) monitored him for the rest of the evening. After the second fall, we shook him, rolled him, rubbed his chest, we could not rouse him. It was like he was sleeping. Staff member F said she was the one who found (resident #1) when he fell the second time, That's when he broke the table. During an interview on 11/01/16 at 1:32 p.m., staff member C said resident #1 had fallen two times after returning from the ED. After the first fall is when the CNAs started sitting one-on-one with (resident #1). She said she had written a second narrative note regarding the third fall, but could not locate the narrative. I don't know why I didn't fill out a second fall report, just to be honest. During an interview on 11/2/16 at 10:48 a.m., staff member C said staff member B had been unable to find the addendum she had completed regarding the third fall for resident #1. Refer to F323 for additional information relating to the resident's accidents.

During a complaint survey, an Immediate Jeopardy situation was announced by the surveyor at 2:50 p.m. on [DATE], at Blackfeet Care Center. The administrator and director of nursing were notified that an Immediate Jeopardy situation existed in the area Quality of Care. After acceptance of the plan for the removal of the immediacy, the scope and severity of F323 was reduced from J to G. PLAN TO RESOLVE THE IMMEDIACY The facility submitted an acceptable plan to remove the immediacy on [DATE] at 3:40 p.m. A summary of the plan included: I. Prior to any nurse working the floor, the DON would educate the nurses on: -Fall Assessment Policy and Procedure; -Comprehensive assessment of the resident after each fall; -Neuro checks; -Education would be provided into the investigation of the root cause of each fall, and assessment of resident needs; and implementation of interventions; -After each fall, the care plan for that resident would be reviewed, and updated as necessary; - Communication with a physician and care team; and, -The DON and Administrator would review the care plans for all current residents at risk for falls, or who had experienced an actual fall. II. The Administrator would be directly involved in oversite of these resolution measures. Based on interview and record review, the facility failed to ensure a resident, with a known level of confusion secondary to his diagnosis, was safe after experiencing a fall with an injury to his head, and after he experienced a second and third fall upon returning to the facility with a head injury. The resident experienced the major injury, and later expired at a hospital. This was found to have occurred for 1 (#1) of 3 residents sampled residents. Findings include: A. During an interview on [DATE] at 11:25 a.m., staff member D said, We did not complete a Significant Change assessment for (resident #1) in July. She said, He has this thing where his ammonia levels go up and down, and things were pretty much the same for him. He would change and then come back out of it. When we did the Sig-Change it was because he was going into these states and staying there longer. During an interview on [DATE] at 8:02 a.m., staff member G said (resident #1) had fallen on [DATE]. He was sent to the ER, and was confused. She said, As noted in the nursing notes, he was confused prior to the fall. He had been confused all day. Resident #1 returned to the facility with a small bump on the back of his head. Staff member G said, (Resident #1) had started to get to where he did not want to take the lactulose (a medication). Once the ammonia levels would get high, it did not come down very fast. She said, (Resident #1) would just wander around when his ammonia levels were high. Like he would go to the dining room and back to his room. Staff member G said, When it comes to this (fall), I wouldn't have changed anything on the care plan. We have nursing report and the twenty-four hour book. That would be our continuation of care. Staff member G did not feel it was an expectation that she would address the care plan, or update the resident's care plan. Staff member G said when resident #1's ammonia levels were high, He just wandered, and we couldn't make him do what was in his best interest always. She said, If we got him to do something, like lay down, he would be back up in just a few minutes. His gait was not steady and his confusion was high. During an interview on [DATE] at 8:40 a.m., staff member C said, (Resident #1) returned from the ER at 7:30 p.m. (from a fall earlier that day on [DATE]), and he was somewhat alert, but not fully. The CNAs kept checking on resident #1 because he kept trying to get up. She said, They were taking turns sitting with him while the other CNA would answer call lights. He was still alert at this time, but confused. About 9:45 p.m., the CNA's thought he was sleeping and went to finish their rounds. The fall mat was in place. I was called to the room. He was on the floor and he looked like he had fell again. He looked like he had fallen forward on the over-the-bed table, and it was broken in half. Staff member C said, After assessing him on his right collar bone, that it was swollen, and his head was bleeding. It had been still bleeding slightly from earlier, but when he fell I think he hit his head again. It was bleeding more than it had been bleeding prior. He was unresponsive. She said, We got his vitals, and I told the girls that we had to send him back to the ER. I started getting the paperwork ready, and about 9:50 p.m., I was on the phone with Dr. (name). The girls stayed in the room with him while I was on the phone. I explained that he had fallen again, and he was unresponsive, and his collar bone was swollen. That is when Dr. (name) started telling me that a CT was going to be done tomorrow. I felt like Dr. (name) was not listening to me. He started saying that we could use restraints, and I told him that we cannot use restraints without family approval. I was really upset because I felt that he was not really listening to me. We had sent (resident #1) up several times due to his high ammonia level, and I felt like they just didn't want to deal with him. I was angry. I did call (staff member G) and asked her to come in and take a look at (resident #1). Ten minutes later she had come in, and at that moment, we went and checked on (resident #1), and he still wasn't responding. I was yelling loud at (resident #1) to try to wake him up and so did (staff member G). I had already called for the ambulance, and called Dr. (name) and told him (resident #1) was being sent back. (Resident #1's) eyes were not really responding to the light. We waited for the ambulance. When they (the hospital) feel they know a resident, then they sometimes assume they know what the problem is. While we were waiting for the ambulance, a night shift CNA was outside, and said the ambulance was circling the block but finally came to the care center. I had already had to call twice for the ambulance before they arrived. Staff member C said, After a person comes back from the hospital we usually put neuro checks in place, for (resident #1) it (neuro checks) wasn't implemented that day. Every day is busy, and with him I just didn't grab the paper and start it. It was more one-on-one with him. We should review the care plan after a fall. I did not review the care plan after this fall. Staff member C said, Prior to sending (resident #1) back to the hospital I did call the son and let him know that he was going back to the hospital. He called a little after midnight and said they were sending (resident #1) to Great Falls. He said they had done a CT, and told him that the first CT showed nothing, but the second one did. He was going to meet his dad in Great Falls. During an interview on [DATE] at 12:40 p.m., staff member F said, on [DATE] she had found resident #1 after his first fall. She said, We let the nurse know and then she comes down and observes them and gets vitals, and gets them ready to be transported. Staff member F said that resident #1 had left, and later came back to the facility. She said she was on lunch break when he came back. Staff member F said resident #1 had only been back about a half hour when he fell the second time. He was trying to get up and leave his room. She said she had not been given any special instructions regarding the care of resdent #1, after he returned from the ED. Staff member F said, When he got back we sat with him, and we took turns sitting with him. I sat with him for about an hour and I thought he was sleeping. I went across the hall and helped another resident get ready for bed. I heard a crash and went running. I found him lying on the floor on his stomach, like he had tried to catch himself. He was trying to get up and was wide awake. After the nurse looked at him she said to just get him in bed and get his vitals. I believe that (staff member I) was with me. (Staff member I) sat with him while I went and got others ready for bed. (Staff member I) thought he went to sleep and left him, to go and help others. Staff member F said, After a while I went down to check on (resident #1), and he was lying flat (on the floor) on his back and he was snoring and it looked like he was knocked out (which occurred with the third fall). Staff member F said, (Staff member C) came and checked resident #1 out again, and placed a call to IHS. Staff member F said, (Staff member C) called IHS a few times. The second time she was told to use restraints. Staff member F said, After the 2nd fall (after resident #1 had returned to the facility, which was technically the 3rd fall), (staff members E and G) came in and sat with (resident #1). We had to use a Hoyer lift to transfer resident #1 to the bed. The ER doctor had told (staff member C) to use restraints and monitor him. So (staff members E and G) monitored him for the rest of the evening. Staff member F said, After the second fall we shook (Resident #1), rolled him, rubbed his chest, and we could not rouse him. It was like he was sleeping. Staff member F said she was the one who had found resident #1 when he had fallen the second time. She said, That's when he broke the table. During an interview on [DATE] at 4:04 p.m., staff member H said resident #1 had fallen [DATE] at 4:48 p.m. (first fall.) She said, He was lying on the floor and he was bleeding. We put a bandage on the back of his head and did not move him at all. We called the ambulance and they came and got him. The doctor called me back and asked why (resident #1) was not given his lactulose enema. I had given him the lactulose a little earlier (orally), because he was confused. She said she told the doctor that (resident #1) was not 'out' when the EMT's picked him up. The doctor told her he was 'out' at the time of their phone call. Staff member H said, The doctors, before they will accept him up at the hospital, will ask if you have given him his enema. When the doctor saw that he was 'out' at the ER, he asked why I hadn't given him the enema. Staff member H said she, Told (the doctor) it was because resident #1 wasn't 'out' at the time, and was able to drink it p.o. She said, I wasn't here when he came back, so I didn't do neuro checks. After he fell I didn't even move him from that position on the floor. Staff member H said, I write notes in the chart and do an incident/accident report and give it to staff member B, and the doctor reviews the report. She said, I don't change the care plan. That's my procedure and I think it's everybody's procedure. I am not too sure when the care plan is changed, but she assumed it was changed when the care plan team met. During an interview on [DATE] at 4:21 p.m., staff member I said that throughout the morning resident #1 had been really shaky. She said, He kept coming out of his room and going into the dining room. He kept trying to pull his pants down in the dining room. He will sometimes just start pacing. When he talks, his words are not clear. She said, When he answers you he just says 'ya.' Staff member I said, After he came back from the ED (on [DATE] at 7:30 p.m.) We were staying with him for about a half hour each. At about 7:00 p.m., people started calling and wanting to go to bed. We had to check frequently on resident #1. (Staff member F) was putting (another resident) to bed when (resident #1) fell . She heard him fall. She said he had been sleeping. He would only sleep for a little while and then he would wake up and say, 'I have to go.' He just wouldn't stay in that bed. He just kept getting up. On the second fall, after he returned from the ED, with the staples in his head, he was just knocked out. During an interview on [DATE] at 1:45 p.m., staff member G said she went in and sat with resident #1 when she came in to work the evening of [DATE]. She said staff member C had to call the ER a couple of times because they didn't seem to realize how serious it was. During an interview on [DATE] at 9:31 a.m., staff member B said staff member C had told her she had made an addendum to the records, and documented the second fall (on staff member C's shift, or 3rd fall that day) for resident #1. Staff member B had been unable to find the addendum. Staff member B said, none of the nurses had recorded or assessed the neuro status for resident #1, for the three falls on [DATE]. A request was made to provide any documentation for the physical assessments and investigations done for resident #1, for all of his falls dating back to May of 2016. Staff member B said, in addition to the accident/incident reports, there was a fall assessment that should have been completed. During an interview with staff member B, on [DATE] at 10:33 a.m., a second request was made for fall assessments and investigations for resident #1. Staff member B said she had been unable to find more documentation, and would continue to look. During an interview on [DATE] at 10:48 a.m., staff member C said that staff member B had been unable to find the addendum she had completed regarding the third fall for resident #1. She also said the other fall assessment (she had mentioned) was the one that nursing completed on a quarterly basis, which was the fall risk assessment. She said, this assessment was not completed with each fall. She said, other than the incident/accident report, there was not another fall assessment done after a fall. A review of the three Incident and Accident Reports, nurses notes, and care plan, that were completed for the fall on [DATE], and two falls on [DATE], showed a lack of evidence that the root cause of the resident's falls was identified, that a thorough investigation was completed, or that a need for a change in the resident's care was addressed. The facility did not to provide documentation of any kind prior to the end of the survey, pertaining to the third fall, which resident #1 had on [DATE], by the end of the survey.

Based on observation, record review, and interview, the facility failed to adequately assess, identify, provide non-medication related interventions prior to PRN medication use, and adequately document pain, and interventions for pain for residents with cognitive deficits, and who did not openly voice, or who were able to recognize pain, and who exhibited behaviors, for 2 (#s 3 and 4); and failed to identify and report the increased use of PRN pain medications over the last four months, and assess routinely the effectiveness of PRN pain medications or include pain locations as part of assessment. Facility documentation failed to demonstrate [MEDICATION NAME] Patches were routinely administered as ordered for 1 (#7) of 14 sampled and supplemental residents. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During an observation on 5/24/16 at 3:50 p.m., staff member I was assisting the resident in the bathroom. The resident was able to stand, but quickly lost her balance and to catch herself she sat down quickly on the commode. The resident did not lock her wheelchair brakes prior to the transfer. The resident stood again as the CNA assisted with removing the resident's brief. The resident made exasperated sounds with movement, and grimaced when she lowered herself to the commode. Staff member I stated the resident had hip pain, and would not verbalize the pain. She said you could tell when she stood, or sat down that it hurt her. Staff member I was unable to specifically say what symptoms the resident exhibited in relation to pain, or what symptoms she was aware of that the resident may have exhibited relating to pain. Staff member I was unable to state what the resident's individualized care plan showed for pain. The resident stood up from the commode, and again grimaced with the movement which was very shaky, and cursed as she was assisted with her brief. The resident sat back in the wheelchair and appeared more comfortable. A review of the resident's Care Plan showed the resident had dementia, which affected the resident's activity, behavior, safety, thought processes, decisions, and communication. The care plan lacked evidence to show if the resident had any issues related to pain. A review of the resident's Physician order [REDACTED]. A review of the resident's Medication Administration Record [REDACTED]. The record lacked evidence to show if the medication relieved the resident's pain, or why the resident needed the medication. The medical record lacked non-medication related interventions prior to PRN medication being given. Four of the seven doses were given between 7:00 p.m., and 11:30 p.m., During an interview on 5/24/16 at 8:43 p.m., staff member K stated the resident would increase her activity when in pain. She stated she will go up and down the hall more, go into other residents rooms, and not appear comfortable. During an observation on 5/24/16 which began at 7:25 p.m., and continued intermittently until 8:43 p.m., the resident was going up an down the hallway in her wheelchair. She would stop at the doors of other residents and peer in. Staff did not attempt to assist the resident during her wandering, and she appeared to be looking for something. When asked, the resident was unable to state what she was looking for. She asked a question about a cat's location, and referenced it being 6:00 a.m. The resident was not approached by the nurse to determine if the resident was having pain during the observation. A review of the resident's Behavior Intervention Flow Record for May 2016 showed the resident was monitored for a flat affect, being withdrawn, and crying. The monitoring record lacked interventions identified for use if the resident displayed the behaviors. During the month, the resident's record lacked documentation to show any of the specific behaviors were documented. During an interview on 5/25/16 at 9:45 a.m., staff member G stated she did not typically review the resident's pain information when determining the cause of behaviors the resident exhibited. Staff member G stated she was unsure of how pain affected the resident's behavior patterns. When determining the behaviors to monitor, staff member G stated the nurses would decide. A review of the Behavior Assessment and Monitoring policy showed as part of the comprehensive assessment, staff should evaluate the resident's usual patterns of cognition, mood, and behavior. Factors to review included pain, hunger, thirst, fatigue, fear, anxiety, and stress, and physical discomforts. The staff would identify, and document the duration, intensity, and frequency of the behavior, and relevant factors relating to the behavior. A review of the resident's Nursing Notes from admission until the date of the survey showed the resident displayed refusals of care, combativeness toward staff, wandering, exit seeking, refused to go to bed, intruded on other residents, would refuse to comply when the nurse would need to assess the resident, and displayed restlessness, agitation and anxiousness. The resident also had five falls which caused minor injuries and pain (Refer to F323). The resident's medical record lacked evidence to show if the behaviors were related to pain, or if the resident was able to adequately verbalize her pain. A review of the resident's Admission (1/4/16) and Quarterly MDS (4/8/16) showed the resident had severely impaired cognition, and she was able to make herself understood some of the time, and was able to understand others some of the time. The MDSs showed the resident was documented as not having any non-verbal expressions of pain exhibited. 2. Resident #4 was admitted to the facility on [DATE]. A review of the resident's Quarterly MDS, with an ARD of 3/11/16, showed the resident was coded as having severely impaired cognition. When assessed, the resident's pain documentation showed she had a rating of 4 out of 10 on a pain scale. The resident was not documented to have any non verbal signs of pain. For the Annual MDS, with an ARD of 12/11/15, the resident showed her pain intensity was severe. During an observation on 5/24/16 at 10:50 a.m., the resident was unsteady as she was walking to her bed, and making exasperated groaning sounds. The CNA came up and assisted the resident, asking if she was ok. The resident asked where she was. The CNA stated she was in the nursing home. The resident verbalized incoherent words, and the CNA was unable to understand what the resident said and asked for clarification. The resident spoke again and the CNA shook her head in misunderstanding. The resident then covered her head to go back to sleep. During an interview on 5/24/16 at 3:55 p.m., staff member I stated the resident had pain, but staff member I was unable to give individualized pain symptoms the resident exhibited, or symptoms she would watch for to determine if the resident had pain. Staff member I was unable to state interventions identified for the resident based on the resident's individualized care plan for pain or comfort. A review of the resident's Care Plan showed she had multiple sensory impairments, impaired cognition, communication deficits, diabetes, depression, falls, poor nutrition, and chronic pain. The pain care plan was updated on 3/6/16, and showed she continued to suffer from pain. The goal was documented as the resident would verbalize relief of pain, cope with pain, and not have discomfort. The only intervention for pain was to have the pain relieved by medication. The care plan lacked information relating to non-medication related interventions to reduce pain for the resident. A review of the resident's admission orders [REDACTED]. Both medications were ordered to be given as needed. Routine orders for pain management included Tylenol and [MEDICATION NAME], both also to be given as needed. A review of the resident's Medication Administration Record [REDACTED]. All of the medications were given between 12:28 p.m., and 9:00 p.m. The resident was also given the scheduled medications - [MEDICATION NAME] twice a day for [MEDICAL CONDITION] pain, and [MEDICATION NAME], twice a day, for pain. The resident also received [MEDICATION NAME] eight times in the month, and [MEDICATION NAME] five times in the month, also for pain. The PRN flow record lacked evidence to show what interventions were utilized prior to the medication being given, if the medications were effective or not, or why all of the as needed medications were given, however, the nurses had documented pain for some. A review of the resident's medical record lacked evidence to show if the facility assessed the resident's pain, or if it was related to her behavior, or inability to communicate the pain effectively. A review of the resident's Nursing Notes showed she exhibited complaints of not feeling well, complaints of pain, inability to sleep, combativeness with care, anxiety and restlessness, refused care, and the inability to get comfortable when in the chair/bed. The nursing notes also showed: - On 5/3/16 the resident came to the nursing station at 2:00 a.m., and requested a pain pill and a sleeping pill. She stated she had not slept all night, and her knees hurt. The nurse documented she gave the resident Tylenol, and the resident went back to bed. The resident was sleeping soundly an hour later. - 5/3/16 the resident again complained of pain at 9:00 p.m. The nurse gave the evening medications. The resident returned one hour later and complained of continued pain and inability to sleep. The resident was holding her shoulder and rated the pain at 7 out of 10. The nurse documented the resident was given a [MEDICATION NAME] tablet. During an interview on 5/26/16 at 9:00 a.m., staff member B stated the resident had long standing pain, and would become upset when she had pain. She stated the facility needed to improve how the staff were able to anticipate the resident's pain, prior to the resident exhibiting symptoms of pain. During an interview on 5/25/16 at 2:50 p.m., contractor S1 stated it was difficult to show if the resident's pain medication regimen was adequate due to the lack of documentation completed by the nurses. He stated the pain needed to be assessed each day to really show the resident's pain, and if treatment was effective. 3. Resident #7 was admitted to the facility with dementia and chronic pain. During an observation on 5/24/16 at 10:11 a.m., resident #7 was in her room, crying out and grimacing from her bed. Resident #7's MDS assessments reflected: -The quarterly MDS, with an ARD of 8/27/15, reflected minimal hearing loss. She received scheduled and PRN medications. Resident #7 had two pain indicators - vocal and expressive. Pain frequency was not documented. -The quarterly MDS, with an ARD of 11/24/15, reflected she sometimes understood others, sometimes was able to make herself understood, had unclear speech, and moderate hearing loss. She received scheduled and PRN medications. Resident #7 had three pain indicators - verbal, vocal, and expressive. Pain frequency was not documented. -The admission MDS, with an ARD of 2/24/15, reflected she sometimes understood others, was sometimes able to make herself understood, and had minimal hearing loss. She received scheduled and PRN medications. Resident #7 had four pain indicators - verbal, vocal, expressions, and body/posture. Pain frequency was not documented. Review of resident #7's Medication Administration Record [REDACTED] FEBRUARY 2016 -[MEDICATION NAME] 325 mg by mouth, give i-ii tabs as needed every four hours, one dose administered. -[MEDICATION NAME] 200 mg by mouth, give i-ii tabs as needed every eight hours, zero doses administered. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth, give as needed every four hours, 30 doses administered. Review of the PRN and Medications Not Administered form reflected 11 [MEDICATION NAME]-[MEDICATION NAME] doses were evaluated for medication effectiveness, and five included the location of pain. MARCH 2016 -[MEDICATION NAME] 325 mg by mouth, give i-ii tabs as needed every four hours, one dose administered. -[MEDICATION NAME] 200 mg by mouth, give i-ii tabs as needed every eight hours, zero doses administered. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth, give as needed every four hours, 24 doses administered. Review of the PRN and Medications Not Administered form reflected 10 [MEDICATION NAME]-[MEDICATION NAME] doses were evaluated for medication effectiveness, and nine included the location of pain. APRIL 2016 -[MEDICATION NAME] 325 mg by mouth, give i-ii tabs as needed every four hours, eight doses administered. -[MEDICATION NAME] 200 mg by mouth, give i-ii tabs as needed every eight hours, zero doses administered. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth, give as needed every four hours, 35 doses administered. -[MEDICATION NAME] Patch 75 mcg/hr to be applied [MEDICATION NAME] every 72 hours (with removal of old patch) The record reflected 120 hours between patch changes between 4/9/16 and 4/14/16. Review of the Nurse's Notes reflected crying episodes on 4/9/16, 4/13/16, and 4/14/16. Review of the PRN and Medications Not Administered form reflected 20 [MEDICATION NAME]-[MEDICATION NAME] doses were evaluated for medication effectiveness, and 13 included the location of pain. MAY 2016 -[MEDICATION NAME] 325 mg by mouth, give i-ii tabs as needed every four hours, zero doses administered. -[MEDICATION NAME] 200 mg by mouth, give i-ii tabs as needed every eight hours, zero doses administered. -[MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth, give as needed every four hours, 49 doses administered. [MEDICATION NAME] Patch 75 mcg/hr to be applied [MEDICATION NAME] every 72 hours (with removal of old patch). The record reflected 48 hours between patch changes on 5/6/16 and 5/8/16, and 96 hours between patch changes on 5/17/16 and 5/21/16. Review of the PRN and Medications Not Administered form reflected 21 [MEDICATION NAME]-[MEDICATION NAME] doses were evaluated for medication effectiveness, two included the location of pain, and one non-verbal with pain at 8/10. Review of resident #7's current care plan reflected resident #7 had chronic pain, with goals of adequate relief or able to cope with incomplete pain relief. Interventions included evaluate the effectiveness of pain interventions, to include notification of unsuccessful interventions. During interviews with staff, resident #7 was identified as having pain issues: -On 5/24/16 at 9:35 a.m., staff member M stated resident #7 was always crying out, she tensed up when repositioned, had facial grimacing, and refused to sit in her chair because of leg pain. Resident #7 verbalized her pain complaints, at times. -On 5/24/16 at 11:25 a.m., staff member F stated resident #7 cried a lot, and she could tell she was really hurting. -On 5/24/16 at 2:40 p.m., staff member J stated resident #7 was always crying and calling, but often unable to say what she needed. -On 5/24/16 at 2:50 p.m. staff member P stated if her PRN pain medications were spaced too long, she would have increased yelling. She has come to work in the morning, and been told that no pain medications were given during the night. -On 5/24/16 at 3:30 p.m., staff member H stated before the pain patch needed to be changed, she had increased pain. If the nurses did not keep on top of her PRN pain medications, she will be in pain. -On 5/24/16 at 8:00 p.m. and 8:20 p.m., staff member K stated resident #7's pain was not well managed. The resident had bad arthritis and contractures. The resident groaned a lot. The nurses needed to make sure to give her PRN medications routinely. Review of the facility's policy for Pain Assessment and Management reflected: -Re-assess the resident's pain and consequences of pain at least weekly for chronic pain. -Monitor the resident's response to interventions, status of underlying causes of pain, and presence of adverse consequences of pain to determine if pain was being adequately controlled. -Document the resident's status of pain with adequate detail to gauge the effectiveness of interventions. -Report to the physician prolonged, unrelieved pain despite care plan interventions.

Based on observation, record review and interview, the facility failed to arrange a timely Wound Care Clinic evaluation after referral, complete a Braden Scale assessment after admission, complete weekly wound measurements, assist with bed position changes every two hours, or initiate the dietician's recommendation of a nutritional supplement change to Boost Breeze for 1 (#2); and failed to utilize an intervention recommended for a pressure ulcer to the heel for 1 (#10), and the resident had further breakdown of the heel, out of 10 sampled residents. Findings include: 1. Resident #2 was admitted to the facility with a pressure sore. Review of resident #2's MDS regarding bed mobility reflected: -On 12/10/15, required total assistance of two persons or more. -On 3/10/16, required limited assistance of one person. During an interview on 5/26/16 at 10:05 a.m., staff member M stated resident #2's strength had not changed significantly since March of 2016. Review of resident #2's Braden Scale (skin pressure risk) was initially completed on 4/6/16, four months after admission. During an observation on 5/23/16 at 2:45 p.m., staff member H provided resident #2's wound care. Staff member S assisted resident #2 into a side-lying position and held her position for the wound care. During an observation on 5/24/16 at 7:20 a.m., resident #2 was lying in bed on her back with her head slightly elevated. During an interview on 5/26/16 at 7:20 a.m., staff member B stated the facility needed to improve their system of wound care assessments and measurements. The nurses write their assessments in the Nurses Notes. Wound assessments have not been standardized. Review of resident #2's Nurses Notes reflected: -On 12/2/15, the sacral pressure ulcer was measured at 2 cm round, 3-4 cm deep, and had tunneling. -On 12/3/15, the sacral ulcer had a small amount of drainage on the old dressing. -On 12/5/15, the old sacral ulcer dressing had a small amount of dried drainage. -On 12/14/15, the sacral ulcer was very pink, healthy looking, except had a foul odor. -On 12/18/15, the sacral ulcer was shrinking in size. -On 12/19/15, the sacral ulcer was shrinking in size and had very little drainage. -On 12/22/15, resident #2 requested the Wound Care Clinic appointment be changed to January. Resident #2 wanted a family member to be present during the appointment. -On 12/27/15, the sacral ulcer had no drainage or odor, and was shrinking in size. -On 12/28/15, the sacral ulcer had no drainage or odor, and closing. -On 1/9/16 through 1/19/16, the resident was hospitalized . -On 1/25/16 - 1/26/16 (7pm-7am), the resident is compliant with frequent position changes. -On 1/26/16 - 1/27/16 (7pm-7am), wound bed clean and pink, minimal amount of serosanguinous drainage, area around wound macerated and red. The resident is compliant with frequent position changes. -On 2/2/16, the sacral ulcer appeared white and moist on the opening surface. -On 2/6/16, the sacral ulcer was clean and odor-free. -On 2/7/16, the sacral ulcer was clean and odor-free. -On 2/17/16, the sacral ulcer is larger than last week, required seven inches of packing gauze. -On 2/18/16, the sacral ulcer required seven inches of packing gauze. -On 2/21/16, the sacral ulcer had a small to moderate amount of serosanguinous drainage. Resident #2 reported the wound was tender. -On 2/24/16, the dressing change to the sacral ulcer was increased from daily, to twice daily. -On 2/27/16, the sacral ulcer was clean and had no redness. -On 3/11/16, resident #2 was non-compliant on changing position off sacral ulcer. -On 3/11/16, the sacral ulcer was clean, without signs of infection. -On 3/14/16, the sacral ulcer required ten inches of packing gauze. -On 3/26/16, the old sacral ulcer dressing had small to moderate amount of serosanguinous drainage. -On 4/26/16, the old sacral ulcer dressing had moderate amount of serosanguinous drainage. -On 4/27/16, the sacral ulcer was odorous, resident complained of wound pain, periwound area partially white and moist. Required 12-15 cm of packing gauze. The ulcer was not getting better. Wound request a medical assessment. -On 5/8/16, the old sacral ulcer packing gauze was six to seven cm long. -On 5/16/16, the old sacral ulcer packing gauze was ten inches long. During an interview on 5/24/16 at 2:40 p.m., staff member J stated resident #2 used her bed side rails, and was able to change her position pretty well. Staff member J stated the resident would ring her bell if she wanted help. During an interview on 5/24/16 at 2:50 p.m., staff member P stated resident #2 called when she wanted her attends changed. She was able to use the partial bed rails to change her position in bed. During an interview on 5/25/16 at 4:30 p.m., staff member Q stated she did not change resident #2's position every two hours. Resident #2 could use the bed side rails to change her position somewhat. Resident #2 would call if she needed help positioning. During an interview on 5/26/16 at 9:15 a.m., staff member R stated resident #2 would let her know if she needed help with position changes. During an interview on 5/23/16 at 3:00 p.m., resident #2 stated she had an old fracture to her right shoulder that never healed, was very painful, and had little functional mobility. Resident #2 stated she could change her position in bed by using her side rails, but not very well. Review of resident #2's medical record reflected a lack of education on the risks of not changing her position every two hours. Review of the Dietician's Notes from 4/1/16 reflected a supplement switch of two scoops of protein powder at lunch and dinner to Boost Breeze twice daily between meals. The current orders did not reflect the dietician's recommendation of Boost Breeze. During an interview on 5/26/16 at 11:35 a.m., staff member C stated she was going to look into the dietician's recommendations and the current orders for supplements. Staff member C did not return with an explanation. Review of resident #2's physician assessments reflected: -On 12/2/15, the Admission Health and Physical reflected a referral to the Wound Care Clinic. -On 3/17/16, the Physicians Progress Note from the Wound Care Clinic reflected a stage IV pressure ulcer located on the back-buttocks-hip related to immobility syndrome ([MEDICAL CONDITION]). The wound was full-thickness with exposed subcutaneous and muscle tissue. The resident presented to the clinic with a urine soaked dressing. Undermining of ulcer located at 12 o'clock was 2.2 cm long. Post debridement measurements were 1.4 cm X 1.3 cm X 2 cm. Recommend twice daily dressing changes, and to continue pressure relieving off loading measures. -On 5/13/16, the Physicians Progress Note reflected a stage IV pressure ulcer located on the back-buttocks-hip related to immobility syndrome ([MEDICAL CONDITION]). The resident presented to clinic with a urine soaked dressing. Undermining from 1 o'clock to 5 o'clock measured at 3.5 cm long. Measurements post-debridement were 1 cm X 1 cm X 2 cm. Continue pressure relieving off loading measures. Review of resident #2's current care plan reflected: -The resident had an unstaged sacral pressure ulcer. -The resident needed assistance to turn/reposition at least ever two hours, more often as needed or requested. -Include weekly treatment documentation of measurements (width, length and depth), type of tissue and exudate. 2. Review of resident #10's record showed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of a 3/27/16 nurses note reflected a large scab came off the left heel. No redness or swelling was noted. It appeard to be completely healed. No pain. No discomfort. Review of a nurses foot evaluation dated 3/29/16 reflected (left) heel ulcer appears to be healed, zero open areas, drainage, right pinky toe gone (right) ankle - pink pigmentation. Under the section titled Recommendations/Interventions it reflected Keep boot on (right and left) foot, adequate fluid intake. Review of the 4/15/16 progress note reflected a physician had seen the resident at the nursing home and there was a new foot pressure wound to the back of the left foot. In an interview by telephone on 6/1/16 at 8:30 a.m., staff member A said she would have the DON fax any documents they had regarding the recommendation dated 3/29/16 to use the boots. Review of the information faxed to the State survey agency on 6/1/16 did not include evidence of use of the boots.

Based on observation, record review and interview, the facility failed to ensure residents had all medications the physician ordered for 2 (#1 and 2), and failed to monitor. Specifically, to complete neuro checks after falls with head trauma and to update the care plan for 1 (#2) of 8 sampled residents. Findings include: Falls 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's significant change MDS, with an ARD of 5/6/15, reflected a BIMS score of 2, meaning severely impaired cognition. Review of the incident/accident reports reflected resident #2 had recently fallen on 5/22/15, 5/28/15, 5/29/15, two times on 6/10/15, 6/14/15 and 6/16/15. Review of the nurse's progress notes, dated 5/28/15, reflected the nurse heard a thump while in another resident's room and found the resident lying on his right side, half way under the sink. The resident had stated he was trying to go to the bathroom and fell . The resident had complaints of his head hurting and he hit his head on the heater under the window. He had a small bump on the top of the right side of his head and bruising at the right hip area. The resident was sent to the emergency room for further evaluation. Upon returning from the emergency room , an addendum to the nurse's progress notes reflected neuro checks were started per the physician's orders [REDACTED]. Review of the hospital emergency room notes, dated 5/28/15, reflected the resident had hit his head and right hip with no bruising and complaints of pain. The emergency room note reflected the resident had a bruised right hip with a possible fracture, no pelvic fracture, and a CT scan was negative for head bleed or fracture. Review of the nurse's progress notes, dated 5/29/15, reflected the resident was dragging his chair from the dining area and tripped over his chair and was found on the floor. He stated he wanted to sit in the smoking room. He did not lose consciousness or have any open areas from the fall. The nurse's note reflected continuous monitoring and to send the resident to the emergency room if any changes. Review of the nurse's progress notes, dated 6/10/15, reflected the resident's son was waiting at the medication cart when the nurse came out and stated that the resident had fallen. He was found lying on his right side, just off of the fall mat. CNA stated the resident was trying to go to the bathroom. The nurse stated to place the call light within reach. The resident was later found by the CNA sitting on the floor below his wheelchair. When asked what had happened, the resident stated he had slipped out of his wheelchair. Review of the incident/accident report, dated 6/14/15, reflected the resident had went to his room and staff heard a thump and found him on the floor on his right side. There was no nurse's progress note pertaining to the fall. Review of the nurse's progress notes, dated 6/15/15, reflected the resident fell in his room.hit his head on the floor. Per ER (physician name) neuro checks times 24 hours. See incident report. Review of the nurse's progress notes, dated 6/16/15, reflected the resident was found on the fall mat in his room. Per resident did not hit his head. He was disoriented prior to falling. A bed alarm and continuous monitoring was ordered and to send the resident to the emergency room if condition worsened. Call light was placed within reach of the resident. During an observation on 6/15/15 at 1:10 p.m., a sign was posted on the resident's wall in his room that documented the resident was non-weight bearing at all times, he had a right hairline [MEDICAL CONDITION], and a fall mat was to be on the resident's floor. Review of the nurse's progress notes, dated 6/9/15, reflected an order by the physician for non-weight bearing status. During an interview on 6/17/15 at 11:43 a.m., with staff member D, MDS coordinator, stated resident #2's care plan information may not have gotten to the chart or been received by her yet. She stated she had not received the information and could have been her only reason why the resident's care plan was not revised. Staff member D stated that falls were updated in the care plan and if there were changes, for example a fall mat, it would be added to the care plan. She stated resident #2 was to be checked on every hour and that was usually put on the care plan. She stated care plans were revised as needed and when changes happen and updates were hand written. Review of the resident's care plan, initiated and revised on 5/27/15, did not reflect the physician's orders [REDACTED]. The care plan did not reflect review and revision after the falls from 5/28/15 to 6/16/15. Neuro Checks Review of the neuro check flow sheets, provided by the facility for 5/28/15 and 6/14/15, were incomplete and three neuro check flow sheets were undated and incomplete. The facility was unable to provide neuro checks for the fall that occurred on 6/15/15, when the resident hit his head. Review of the neuro check policy implemented June 2015 reflected: 3. Neuro checks will be performed 15 minutes times 2 intervals, then 30 minutes times 2 intervals, then 1 hour times 4 intervals, then every 4 hours thereafter for 48 hours. 4. The nurse will monitor vital signs and pupil, motor power, eye opening, best motor response, and verbal response per neuro check sheet. 8. The nurse is responsible to ensure all information is current and filled out on the neuro check sheet. 9. The DON will check daily to ensure that the documentation is completed by staff members. During an interview on 6/17/15 at 2:03 p.m., staff member A, DON, stated after a resident fell , the CNA checked the resident's vital signs and the nurse was responsible for the assessment and neuro checks. She stated the neuro checks were done every 15 minutes times 2 intervals, then every half hour times 2, then hourly times 2, then every 4 hours for 48 hours unless the physician wanted the resident assessed longer. Staff member A, stated she did not have a policy and neuro check intervals needed to be clarified and a new policy written. During an interview on 6/17/15 at 2:55 p.m., staff member B, LPN, stated if a resident fell and hit their head, they were sent to the ER to be evaluated. She stated when the resident returned to the facility, neuro checks were completed every half hour for the first hour times 2 hours, then every hour times 2, then every 4 hours. Medication Error Resident #2 returned from theER on [DATE] at approximately 4:45 p.m., with [DIAGNOSES REDACTED]. During an interview on 6/15/15 at 4:37 p.m., staff member A, DON, stated the resident had pneumonia and would be returning to the facility from the ER with a bag of IV fluids and one time dose of antibiotics and the rest of the resident's antibiotics needed to be sent to them from the pharmacy. During an interview on 6/15/15 at 4:45 p.m., staff member B, LPN, stated the resident returned to the facility with an IV bag of [MEDICATION NAME] Ringer's and no antibiotics. She stated the facility would need to wait for the antibiotics and the DON was going to call the pharmacy. She stated the pharmacy closed at 6:00 p.m. Review of the physician's orders [REDACTED]. Review of the nurse's progress notes, dated 6/15/15, no time, reflected the resident returned to the facility with [DIAGNOSES REDACTED]. Review of the resident's MAR, dated June 2015, reflected the resident received [MEDICATION NAME] 875/125 mg by mouth on the evening of 6/15/15 and morning of 6/16/15. During an observation of the medication pass on 6/16/15 at 7:33 a.m., staff member B, LPN, gave the resident two [MEDICATION NAME] 500 mg capsules by mouth. The medication bottle read [MEDICATION NAME] 500 mg one capsule by mouth twice daily. During an interview on 6/16/15 at 2:10 p.m., staff member B, LPN, stated the medication was filled by the ER the night of 6/15/15 and the courier picked it up. The courier was not given any documentation on what medications he was picking up and wouldn't know he picked up the wrong medication. She stated she should have looked at the medication the resident received better. She stated when a resident returned from the ER, the resident would bring paperwork back with them, which informed the facility what the resident was diagnosed with [REDACTED]. Staff member B, LPN, stated the resident was supposed to receive [MEDICATION NAME] 875/125 mg. During an observation on 6/15/15 at 2:12 p.m., staff member B, LPN, went into the medication room and grabbed the bottle of [MEDICATION NAME] and placed it into the med cart. During an interview on 6/16/15 at 2:55 p.m., staff member H, courier, stated the charge nurse told him to go to the ER to pick up antibiotics for the resident. He stated the nurse did not give him written documentation or the name of the medications. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nurses' progress notes showed: - 5/28/15 Called pharmacy on [MEDICATION NAME] injections. Pharmacy stated 'nothing is in yet.' Driver brought med list up on 5/23/15, 5/26/15, 5/27/15 and today 5/28/15 and [MEDICATION NAME] not filled. Drive (sic) will go back to pharmacy in the morning. This nurse called at 1715 (5:15 p.m.) to check if med filled. Pharmacist stated 'no nothing yet.' Passed into (sic) the noc nurse of no injections for resident. Will continue to monitor. -6/14/15 All meds/txs given as prescribed [MEDICATION NAME] not given as prescribed. Patient out. We have been trying to get this from (facility name). Runner to go to (facility name) tomorrow. Review of resident #1's MAR's for May and June 2015 showed: a. [MEDICATION NAME] 60 mg/0.6 ml injection was not available on 5/27/15 for one dose, 5/28/15 for two doses, 5/29/15 for one dose, 6/13/15 for one dose and 6/14/15 for two doses. Review of the PRN/Withheld/Refused Explanation sheet showed: - 5/27/15 at 2215 (10:15 p.m.) [MEDICATION NAME] 60 mg/0.6 ml SQ unavailable for admin (sic) on order 5/26 and 5/27. - 5/28/15 at 0800 [MEDICATION NAME] 60 mg/0.6 ml SQ unavailable for admin (sic) on order waiting for pharmacy. - 5/29/15 at 0800 [MEDICATION NAME] 60 mg/0.6 ml SQ unavailable for admin (sic) waiting for pharmacy to fill. - 6/13/15 at 2200 (10:00 p.m.) [MEDICATION NAME] 60 mg/0.6 ml unavailable to admin (sic) on order for Monday 6/15/15. - 6/14/15 at 800 [MEDICATION NAME] 60 mg/0.6 ml unavailable - have been trying to get from (facility name). - 6/14/15 at 2150 (9:50 p.m.) [MEDICATION NAME] 60 mg/0.1 ml unavailable for administration on order for tonight. Review of the Order Recap Report, dated 5/1/15-6/30/15, showed [MEDICATION NAME] Solution 60 MG/0.6 ml inject 60 mg subcutaneously two times a day for right upper extremity [MEDICAL CONDITION] take [MEDICATION NAME] medication until 6/30/15. The start date was 5/4/15. Review of the (facility name) Physician Medication Request form for June 2015 showed [MEDICATION NAME] for resident #1 had been ordered on [DATE] and a second request on 6/14/15 and there were 4 refills left. Review of the care plan dated 5/22/15 showed: The resident will remain free of complication related to anticoagulation therapy. During an interview on 6/16/15 at 10:30 a.m. staff member A, DON stated the pharmacy was notified 5 days in advance for a refill request. During an interview on 6/16/15 at 11:10 a.m., staff member B, LPN stated the driver would bring the order sheet to the pharmacy and when the facility would call to see if the medications had been filled, the pharmacy said the orders had not been put in yet. We try to make sure we get the orders to them 7 days in advance of the medication running out. During an interview on 6/16/15 at 11:50 a.m., staff member H, driver stated he would take a photo copy of the medications that were ordered and take it into the pharmacy. The pharmacy would tell him which orders needed to have written refill orders and then the driver tried to find the doctor to write the refill order. The pharmacy had a sign posted, stating a 72 hour notice was required for refilling medications. If I am able to find the medical director, he will write the refill prescription so I can bring it to the pharmacy. During an interview on 6/17/15 at 11:25 a.m., the medical director stated he was not sure why a prescription was not refilled, if it had refills available. On 6/16 and 6/17/15 the pharmacy was contacted and a message left to return a call. At the time of exit, the pharmacy had not returned the call. b. Review of the MARS and PRN Medications Not Administered sheets showed resident #1 did not receive [MEDICATION NAME] 15 mg from 6/2/15 through 6/11/15. On 6/2, 6/4, 6/8, 6/9 and 6/11/15, the PRN Medications Not Administered sheet showed that [MEDICATION NAME] was not available for administration and was on order. Review of the Order Recap Report, dated 5/1/15-6/30/15, showed [MEDICATION NAME] Tablet 15 mg. Give 15 mg by mouth at bedtime for malnutrition. The start date was 5/4/15. During an interview on 6/16/15 at 10:30 a.m., staff member A, DON stated there was a lack of communication. The staff should have told me he was out for that many days. Review of the policy for Notification of Missing Medication showed: 1. Medication that is ordered (sic) is not refilled per pharmacy, will be reported to the Medical Director, after one day from the time it is requested. 5. The DON, Administrator, and Medical Director will be notified of medication availability to ensure there is no break in the system of receiving resident medications in a timely manner.

Based on record review and staff and resident interviews, the facility failed to ensure that 3 (#s 1, 13, and 14) of 10 sampled residents received adequate supervision and assistance to prevent accidents; and secure an oxygen tank in order to ensure the residents' environment remains as free of accident hazards as is possible. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident had been court ordered to the facility related to "adult in need of care." Per the petition from an outside entity, the resident was unable to make competent decisions regarding his medical condition and "unable to care for himself and is a threat to his own safety." On 6/22/10, resident #1 signed the Policy on Intoxication agreeing that he had read and agreed to follow the regulations listed on the policy. The Policy on Intoxication read: "Any person(s) becoming intoxicated, will be assessed...A decision will be made by the Director of Nursing, if the resident will be allowed to stay at the facility or if discharge planning should begin." Yet, this policy was not consistently applied by the facility as evidenced by the following information. The most current MDS with an ARD of 7/6/12, section G0110D, determined the resident needed assist to walk in the corridor. B0700, usually makes self understood and B0800, usually understands others. Section C0500 BIMS (brief interview for mental status) score was 12, indicating moderately impaired cognition. The resident's care plan, with a goal date of 12/30/11, addressed the resident's ADLs with respect to impaired mobility related to and evidenced by an unsteady gait and at risk of falls. The interventions included "Maintain a consistent, clear path for walking at all times. Assess for environmental hazards every shift." The goal for the fall risk was to not have any falls. However, the care plan did not address the resident leaving the facility and drinking alcohol. An entry, dated 9/11/11, by a licensed nurse in the licensed nurses' progress notes revealed the resident had left the facility without signing out and had received calls from an individual asking if the resident could be picked up because "some persons were picking on him in front of (bar name)." On 3/8/12 at 12:50 p.m., a nurse's entry documented the resident was reported being seen at the bar. At 1:45 p.m., the nurse documented that the resident was down by the bar and calls were coming from the public with concerns about the safety of the resident. At 7:00 p.m., the nurse's entry revealed the resident was intoxicated and was being transported to the hospital via ambulance. According to the record, the patient's discharge instructions from the hospital, dated 3/9/12, revealed the resident had a [DIAGNOSES REDACTED]. when the resident did leave the facility. A licensed nurse documented the following information on 4/11/12 at 1:40 p.m. the resident checked himself out of the facility. At 6:10 p.m., the resident was returned to the facility by a police officer. The resident was intoxicated. Per the writer, the facility would not allow the resident into the facility while he was intoxicated. At 10:45 p.m. the nurse documented the resident fell over on the side walk and hit his head. The resident went to the emergency room . Per the writer, since the facility would not take the resident back while intoxicated, he was placed in the hospital waiting room. On 4/12/12 at 1:00 a.m., a police officer came to the facility stating the resident was in the middle of the street and was close to being run over. The officer insisted the facility accept the resident's return. There was no documentation in the record that an assessment was done to address the resident's safety when the resident did leave the facility. According to the record, a licensed nurse documented on 5/15/12 at 1:00 p.m. that the resident checked himself out of the facility, returning on 5/16/12 at 9:45 p.m. He smelled of alcohol and had urinated on himself. A half full bottle of "whiskey" was found on the resident. Staff assisted the resident to bed. The resident became combative with the assisting staff. There was no documentation in the record that an assessment was done to review the incident and reevaluate the interventions on the care plan addressing the safety of the resident. A licensed nurse documented on 7/25/12 in the a.m. the resident checked himself out. At 5:00 p.m., a call came to the facility to make the staff aware the resident was at the local bar and intoxicated. At 11:30 p.m., the resident returned to the facility. He smelled of alcohol. The writer informed the resident he could not stay at the facility while he was intoxicated. He agreed, got his coat, and left the facility in his wheelchair. The DON was notified of the situation and told the nurse that the "resident could not return tonight." The DON advised the nurse to call law enforcement to have resident #1 arrested, and informed the nurse the facility could take resident #1 back after 8:00 a.m. As evidenced by an entry in the record, the resident did not return to the facility on his own volition. The entry in the record, dated and timed as 7/26/12 at 3:15 p.m., described the writer and 2 staff going to the local bar. The writer "didn't feel comfortable leaving resident on street due to his safety." The resident stated someone had taken his money. The resident was taken to the facility by staff. The social service progress notes were reviewed. An entry dated 7/26/12 revealed the the writer had seen the resident downtown, "intoxicated" on the 25th. On 7/30/12, social services documented that resident #1 asked for money for boots, cigarettes and personal items. Social services informed resident #1 that "he can't come back here drunk because it is not fair to the other residents that live here." For each of the described incidents, there was no evidence in the record that the facility staff did assessments to address the resident leaving the facility, drinking and becoming intoxicated. As a result, he was vulnerable of having personal effects stolen, at risk for being hit by a car, hurt when falling in the street, the police officers returning the resident to the facility. On 8/30/12 at 9:00 a.m., staff members B and F stated they realized there were safety concerns with resident #1. 2. On 8/28/12 at 8:50 a.m., staff member E was observed leaning an oxygen tank up against the wall in the room behind the nurses' station where the residents' medical records are stored. The oxygen tank was not secured appropriately. 3. On 8/28/12 at 8:20 a.m., staff member H was observed in the dining room assisting resident #13 to stand to walk to his table for breakfast. Staff member H did not use a gait belt to assist resident #13 to stand. The staff person put her arm under resident #13's armpit. At 8:30 a.m., a communication board in the chart room behind the nurses' station read, "Gait belts on all residents."? 4. On 8/29/12 at 8:00 a.m., staff member I was observed providing care to resident #14. Staff member I assisted resident #14 to stand by putting her arm under resident #14's armpit. The staff person did not use a gait belt to assist resident #14. According to Hegner and Gerlach, due to the risk of resident injury, staff should never place their hands under a resident's arms during a transfer. A transfer belt should be used unless it is contraindicated.? ?Hegner, B.R., & Gerlach, M.J. (2007). Assisting in long term care (5th ed.). United States: Thomson Delmar learning.

Based on observations, clinical record review, administrative record review, and staff interview, the facility staff failed to notify the attending physician for 14 (#s 2, 4, 5, 6, 8, 9, 11, 12, 13, 15, 16, 17, 18, and 23) of 29 residents, when prescribed medications were not available for administration; and further failed to follow an order to notify the physician of a weight increase for 1 (#4) of 10 sampled residents. Findings include: Based on an observed medication pass on 8/16/11 at 8:00 a.m. and a review of residents' MARs from July 2011 and August 2011, the facility failed to maintain adequate medication inventory for residents. Consequently, many (489) medication doses were not administered. The omitted medications included drugs to manage diabetes, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], nausea, depression, pain, [MEDICAL CONDITION] disease, and gout. The clinical records lacked documentation that the attending physicians were notified of missed medication doses and the possibility of needing to alter treatment or commence a new treatment. (refer to F309) On 8/17/11 at 1:40 p.m., as a result of these findings, a determination was made that the residents were in immediate jeopardy. Per an on-site visit completed on August 23, 2011, the Immediate Jeopardy was abated.

Based on observations, clinical record review, administrative record review, and staff interview, the facility staff failed to provide prescribed medications to 15 (#s 1, 2, 4, 5, 6, 8, 9, 11, 12, 13, 15, 16, 17, 18, and 23) of 29 residents. Findings include: 1. On 8/16/11 at 8:00 a.m., the medication pass observation task was initiated. Five of eight residents did not have one or more of their morning medication doses. The missing medications were: Resident #6 [MEDICATION NAME] Resident #18 Potassium chloride and [MEDICATION NAME] Resident #9 [MEDICATION NAME] and [MEDICATION NAME] Resident #23 [MEDICATION NAME] Resident #2 [MEDICATION NAME], and [MEDICATION NAME] When questioned regarding the missing morning medication doses, staff member K stated we have "so many meds that don't come down." 2. After identifying concerns during the morning medication pass, the medication administration records were reviewed for all residents. The following additional concerns were identified on 8/16/11 at 9:00 a.m.: Resident #1 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. All doses were missed from 8/1 to 8/16/11. Resident #2 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. On 4/20/11, the physician prescribed sliding scale insulin for specific blood glucose values, three times a day. During the month of June 2011, on 17 occasions the resident had a glucose value that warranted sliding scale insulin coverage. Eight of 17 occasions for sliding scale insulin coverage were not administered to the resident. During the month of July 2011, on 22 occasions the resident had a glucose value that warranted sliding scale insulin coverage. Ten of 22 occasions for sliding scale insulin coverage were not administered to the resident. The physician also prescribed [MEDICATION NAME] 50u insulin to be given at bedtime. During the month of June 2011, ten bedtime doses of insulin were not given by the licensed nurse. During the month of July 2011, eight bedtime doses of insulin were not given by the licensed nurse. 3. Due to depleted drug inventory, the following medications were not administered: [MEDICATION NAME] 30 mg. QD missed from 7/5 to 7/13 and 8/13, 8/14, 8/16; [MEDICATION NAME] 0.6 mg QD from 7/1 to 7/7 and from 8/8 to 8/16; [MEDICATION NAME] 10 mg AC HS missed all doses for August to date; [MEDICATION NAME] 100 mg HS from 7/2 to 7/6 and from 8/6 to 8/15; and, Simvastin 80 mg HS from 7/2 to 7/6. Resident #4 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medications were not administered: [MEDICATION NAME] 50 mg. QAM from 8/3 to 8/13, and, [MEDICATION NAME] 40 mg. QAM from 8/10 to 8/13. Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. On the February 2011 MAR, the licensed nurse documented that the resident's anti [MEDICAL CONDITION] medication ([MEDICATION NAME] 500 mg every morning and [MEDICATION NAME] 600 mg ever morning), were "out." The resident did not receive the [MEDICATION NAME] on 2/16 or 2/17/11. The [MEDICATION NAME] 600 mg doses were not given on 2/15, 2/16, 2/17, and 2/18/11. The resident's clinical record included a nurse's note dated 2/18/11 stating the resident had "been having small petit mal [MEDICAL CONDITION] last night (and) today. She has missed several doses of [MEDICATION NAME] as it is not in stock." Additionally, the resident did not receive [MEDICATION NAME] 24 mcg BID from 8/7 to 8/16/11. Resident #6 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medications were not administered: [MEDICATION NAME] 150 mg Q AM from 8/1 to 8/8, and HCTZ 25 mg Q AM from 8/9 to 8/16. Resident #8 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medications were not administered: [MEDICATION NAME] 600 mg TID from 7/11/11 to 7/31/11; 8/1 to 8/5; [MEDICATION NAME] 40 mg HS from 7/4/11 to 7/31/11; 8/1 to 8/6; [MEDICATION NAME] 25 mcg Q AM from 7/8/11 to 7/11/11; [MEDICATION NAME] .4 mg BID from 7/7/11 to 7/15/11; and, [MEDICATION NAME] 50/200 mg QID from 7/29/11 to 7/31/11. The resident had a confirmed urinary tract infection on 7/15/11. Bactrim DS BID was ordered by the physician on 7/15/11. The resident received 7 days of Bactrim treatment. Thereafter, the Bactrim was out of stock and Bactrim DS BID doses were missed from 7/22/11 to 7/31/11; 8/1 to 8/8/11. The resident was febrile (7/29/11: 101?F, 7/30/11: 99?F, 8/7/11: 102.3?F) during the time between when the Bactrim was out of stock and he was hospitalized . The resident was hosptalized on [DATE] and remained hospitalized at the time of the survey, 8/15/11. Resident #9 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medications were not administered: [MEDICATION NAME] 20 mg Q PM missed 7 doses in July; [MEDICATION NAME] XL 5 mg QD missed 17 doses in July; [MEDICATION NAME] ER 5 mg QAM from 8/10 to 8/16; and, [MEDICATION NAME] 75 mg QD from 8/12 to 8/16. Resident #11 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medications were not administered: Resperidone .25 mg QD from 8/10 to 8/15, and, [MEDICATION NAME] ER 10 mg. QD from 8/2 to 8/4 Resident #12 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. [MEDICATION NAME] 4 mg TID from 8/12 to 8/16. Resident #13 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medication was not administered: [MEDICATION NAME] 6.25 mg BID from 8/12 to 8/16. Resident #15 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medication was not administered: [MEDICATION NAME] .25 mg Q HS from 7/1 to 7/12. Resident #16 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medication was not administered: [MEDICATION NAME] 10 mg BID from 8/1 to 8/10. Resident #17 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Due to depleted drug inventory, the following medication was not administered: [MEDICATION NAME] 50 mg Q HS from 7/1 to 7/4. 4. On 8/16/11 at 3:30 p.m., the DON stated prior to the previous weekend she was not aware of the problem with medications not available for administration. On 8/13/11, the DON covered a nursing shift and noted the multiple missing medications. 5. On 8/16/11 at approximately 2:00 p.m., staff member L, a pharmacist from the contracted pharmacy was telephoned. The pharmacist stated he was aware of an ongoing problem with maintaining medication inventory at the facility. Several contributing factors were discussed that included the facility's use of transitional ([MEDICATION NAME]) staff, varying resident payor sources, and problems with securing written prescriptions. 6. The pharmacist's drug regimen review summary was reviewed. In April 2011, the Executive Summary of Consultant Pharmacist's Medication Regimen Review included the following observations, "There are many cases where medications are not available for administration. In several cases the medications unavailable are for antidepressants. This results in poorly managed care and a great deal of distress for the patients. There must be consistent availability so as to maintain patients well-being . . . " In July 2011, resident #s 2, 9, 15, and 17, missed medication doses due to depleted inventory. The consultant pharmacist noted on the executive summary for July 2011, "Compliance with medication availability is excellent." On 8/17/11 at 1:40 p.m., as a result of these findings, a determination was made that the residents were in immediate jeopardy. Per an on-site visit completed on August 23, 2011, the Immediate Jeopardy was abated.

Based on observations, clinical record review and staff interview, 2 of 18 administered medications were incorrect. Findings include: 1. On 9/26/11 at 4:00 p.m., staff member A, an RN, was observed performing a medication pass in the facility dining room. Resident #5 received [MEDICATION NAME] 500 mg, one tablet, by mouth. The physician's orders [REDACTED]. Resident #7 received one dose from a [MEDICATION NAME] inhaler. The physician's orders [REDACTED]. 2. On 9/27/11 at 10:00 a.m., staff member C, the DON, was informed of the two medication errors. The DON verified the [MEDICATION NAME] for resident #7 was not an active order. Out of 18 medications, two medication errors resulted in an error rate of 11%.

Based on clinical record review, administrative record review, and staff interview, the facility failed to resolve pharmaceutical issues that affected resident care for 15 of 29 residents. Findings include: The facility failed to provide prescribed medications to 15 (#s 1, 2, 4, 5, 6, 8, 9, 11, 12, 13, 15, 16, 17, 18, and 23) of 29 residents. (Refer to F309) On 8/16/11 at approximately 2:00 p.m., staff member L, a pharmacist from the contracted pharmacy, was contacted by telephone. The pharmacist stated he was aware of an ongoing problem with maintaining medication inventory at the facility. Several contributing factors were discussed that included the facility's use of transitional (traveler) staff, varying resident payor sources, and problems with securing written prescriptions. The pharmacist's drug regimen review summary was reviewed. In April 2011, the Executive Summary of Consultant Pharmacist's Medication Regimen Review included the following observations, "There are many cases where medications are not available for administration. In several cases the medications unavailable are for antidepressants. This results in poorly managed care and a great deal of distress for the patients. There must be consistent availability so as to maintain patients well-being . . . " The consultant pharmacist noted on the executive summary for July 2011, "Compliance with medication availability is excellent." However, in July 2011, resident #s 2, 9, 15, and 17, missed medication doses due to depleted inventory. On 8/17/11 at 1:40 p.m., as a result of these findings, a determination was made that the residents were in immediate jeopardy. Per an on-site visit completed on August 23, 2011, the Immediate Jeopardy was abated.

Based on observations, clinical record review, administrative record review, and staff interview, significant medication omission errors were made on 13 (#s 2, 4, 5, 6, 8, 9, 11, 12, 13, 15, 17, 18, and 23) of 29 sampled residents. Findings included: 1. On 8/16/11 at 8:00 a.m., the medication pass observation task was initiated. Five of eight residents did not have one or more of their morning medication doses: Resident #6 [MEDICATION NAME] Resident #18 Potassium chloride and [MEDICATION NAME] Resident #9 [MEDICATION NAME] and [MEDICATION NAME] Resident #23 [MEDICATION NAME] Resident #2 [MEDICATION NAME], and [MEDICATION NAME] 2. The medication administration records were reviewed for all residents. Numerous omitted medication doses were discovered that included medications to manage diabetes, [MEDICAL CONDITION], gout, nausea, depression, pain, hypertension, [MEDICAL CONDITIONS] disease, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 3. The following additional concerns were identified on 8/16/11 at 9:00 a.m.: 1. Resident #2 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. During the month of June 2011, on 17 occasions the resident had a glucose value that warranted sliding scale insulin coverage. Eight of 17 occasions for sliding scale insulin coverage were not administered to the resident. During the month of July 2011, on 22 occasions the resident had a glucose value that warranted sliding scale insulin coverage. Ten of 22 occasions for sliding scale insulin coverage were not administered to the resident. The physician also prescribed [MEDICATION NAME] 50u insulin to be given at bedtime. During the month of June 2011, ten bedtime doses of insulin were not given by the licensed nurse. During the month of July 2011, eight bedtime doses of insulin were not given by the licensed nurse. The following medications were not administered: [MEDICATION NAME] 30 mg. QD missed from 7/5 to 7/13 and 8/13, 8/14, 8/16; [MEDICATION NAME] 0.6 mg QD from 7/1 to 7/7 and from 8/8 to 8/16; [MEDICATION NAME] 10 mg AC HS missed all doses for August to date; [MEDICATION NAME] 100 mg HS from 7/2 to 7/6 and from 8/6 to 8/15; and, Simvastin 80 mg HS from 7/2 to 7/6. Resident #4 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medications were not administered: [MEDICATION NAME] 50 mg. QAM from 8/3 to 8/13; and, [MEDICATION NAME] 40 mg. QAM from 8/10 to 8/13. Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident did not receive [MEDICATION NAME] on 2/16 or 2/17/11. [MEDICATION NAME] 600 mg doses were not given on 2/15, 2/16, 2/17, and 2/18/11. The resident's clinical record included a nurse's note dated 2/18/11 stating the resident had "been having small petit mal [MEDICAL CONDITION] last night (and) today. She has missed several doses of [MEDICATION NAME] as it is not in stock. " Additionally, the resident did not receive [MEDICATION NAME] 24 mcg BID from 8/7 to 8/16/11. Resident #6 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medications were not administered: [MEDICATION NAME] 150 mg Q AM from 8/1 to 8/8; and, HCTZ 25 mg Q AM from 8/9 to 8/16. Resident #8 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medications were not administered: [MEDICATION NAME] 600 mg TID from 7/11/11 to 7/31/11; and 8/1 to 8/5; [MEDICATION NAME] 40 mg HS from 7/4/11 to 7/31/11; and 8/1 to 8/6; [MEDICATION NAME] 25 mcg Q AM from 7/8/11 to 7/11/11; [MEDICATION NAME] .4 mg BID from 7/7/11 to 7/15/11; and, [MEDICATION NAME] 50/200 mg QID from 7/29/11 to 7/31/11. Bactrim DS BID was ordered by the physician on 7/15/11. The resident received 7 days of Bactrim treatment. Thereafter, the Bactrim was out of stock and Bactrim DS BID doses were missed from 7/22/11 to 7/31/11; and 8/1 to 8/8. Resident #9 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medications were not administered: [MEDICATION NAME] 20 mg Q PM missed 7 doses in July; [MEDICATION NAME] XL 5 mg QD missed 17 doses in July; [MEDICATION NAME] ER 5 mg QAM from 8/10 to 8/16; and, [MEDICATION NAME] 75 mg QD from 8/12 to 8/16. Resident #11 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medications were not administered: Resperidone .25 mg QD from 8/10 to 8/15; and, [MEDICATION NAME] ER 10 mg. QD from 8/2 to 8/4. Resident #12 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. [MEDICATION NAME] 4 mg TID from 8/12 to 8/16. Resident #13 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medication was not administered: [MEDICATION NAME] 6.25 mg BID from 8/12 to 8/16. Resident #15 was readmitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medication was not administered: [MEDICATION NAME] .25 mg Q HS from 7/1 to 7/12. Resident #17 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The following medication was not administered: [MEDICATION NAME] 50 mg Q HS from 7/1 to 7/4. 4. On 8/16/11 at approximately 2:00 p.m., staff member L, the contract pharmacist stated he was aware of an ongoing problem with maintaining medication inventory at the facility. On 8/17/11 at 1:40 p.m., as a result of these findings, a determination was made that the residents were in immediate jeopardy. Per an on-site visit completed on August 23, 2011, the Immediate Jeopardy was abated.